Response to the Novel Corona Virus (COVID-19) Pandemic Across Africa: Successes, Challenges, and Implications for the Future

Background: The COVID-19 pandemic has already claimed considerable lives. There are major concerns in Africa due to existing high prevalence rates for both infectious and non-infectious diseases and limited resources in terms of personnel, beds and equipment. Alongside this, concerns that lockdown and other measures will have on prevention and management of other infectious diseases and non-communicable diseases (NCDs). NCDs are an increasing issue with rising morbidity and mortality rates. The World Health Organization (WHO) warns that a lack of nets and treatment could result in up to 18 million additional cases of malaria and up to 30,000 additional deaths in sub-Saharan Africa.

Objective: Document current prevalence and mortality rates from COVID-19 alongside economic and other measures to reduce its spread and impact across Africa. In addition, suggested ways forward among all key stakeholder groups.

Our Approach: Contextualise the findings from a wide range of publications including internet-based publications coupled with input from senior-level personnel.

Ongoing Activities: Prevalence and mortality rates are currently lower in Africa than among several Western countries and the USA. This could be due to a number of factors including early instigation of lockdown and border closures, the younger age of the population, lack of robust reporting systems and as yet unidentified genetic and other factors. Innovation is accelerating to address concerns with available equipment. There are ongoing steps to address the level of misinformation and its consequences including fines. There are also ongoing initiatives across Africa to start addressing the unintended consequences of COVID-19 activities including lockdown measures and their impact on NCDs including the likely rise in mental health disorders, exacerbated by increasing stigma associated with COVID-19. Strategies include extending prescription lengths, telemedicine and encouraging vaccination. However, these need to be accelerated to prevent increased morbidity and mortality.

Conclusion: There are multiple activities across Africa to reduce the spread of COVID-19 and address misinformation, which can have catastrophic consequences, assisted by the WHO and others, which appear to be working in a number of countries. Research is ongoing to clarify the unintended consequences given ongoing concerns to guide future activities. Countries are learning from each other.

Introduction

COVID-19 and Key Risk Factors

The novel coronavirus named SARS-CoV-2 causing COVID-19 was first reported in Hubei Province in China in December 2019 (Guan et al., 2020; Li Q. et al., 2020; World Health Organisation, 2020a; Wu and McGoogan, 2020), and has subsequently spread to all continents (WHO, 2020a). COVID-19 is transmitted from person to person through respiratory droplets as well as directly through touching surfaces and other fomites (Chiang and El Sony, 2020; Huang et al., 2020; Perencevich et al., 2020; WHO, 2020b; World Health Organisation, 2020b). Initial observations from China suggested a case fatality ratio (CFR) of 2.3% (Wu and McGoogan, 2020). In their July 1, 2020 report, the World Health Organization (WHO) suggested a case fatality ratio (CFR) of 4.91% based on 10,357,662 confirmed cases worldwide and 508,055 recorded deaths (WHO, 2020a).

Increased morbidity and case fatality from COVID-19 is associated with a number of underlying health conditions, alongside male gender and older age. These include hypertension, cardiovascular disease (CVD), diabetes, obesity, chronic kidney disease, chronic obstructive pulmonary disease (COPD), and history of smoking and shortness of breath, as well as some immunosuppressive conditions and potentially blood type (Basu, 2020; Bode et al., 2020; CDC COVID-19 Response Team, 2020; Centre for Disease Prevention and Control, 2020; Di Lorenzo and Di Trolio, 2020; Dietz and Santos-Burgoa, 2020; Docherty et al., 2020; Du et al., 2020; Ellinghaus et al., 2020; Fang et al., 2020; Hamid et al., 2020; Huang et al., 2020; Inciardi et al., 2020; Khunti et al., 2020; Kirby, 2020; Kluge et al., 2020; Matos and Chung, 2020; Richardson et al., 2020; Ryan et al., 2020; Shah et al., 2020; Vardavas and Nikitara, 2020; Williams et al., 2020; Zheng Z. et al., 2020). Ethnicity, particularly for people of Black Afro-Caribbean origin alongside those from South Asia, has also emerged as a significant factor associated with a higher mortality risk versus the white population in Europe and the United States of America (USA) (Bambra et al., 2020; Khunti et al., 2020; Kirby, 2020; Pan et al., 2020; Pareek et al., 2020; Public Health England, 2020). However, it is currently not fully understood how ethnicity, poverty and deprivation, cultural and behavioral differences, as well as underlying health, interplay in morbidity or mortality risk especially with currently lower mortality rates in Africa at the end of June 2020 compared with a number of European countries and the USA (WHO, 2020a).

Prevention and Treatment of COVID-19

Response activities to the COVID-19 pandemic typically included personal protection through physical distancing and hand washing coupled with respiratory precautions through face covering (Courtemanche et al., 2020; Ng et al., 2020; WHO, 2020b; WHO, 2020c; WHO, 2020d; World Health Organisation, 2020b). Increased testing and screening with contact tracing are fundamental to transmission control, and this has been variably combined with “locking down” of public places including educational establishments, retail outlets, factories and offices combined with closure of borders and quarantining suspected persons (Nussbaumer-Streit et al., 2020; Rajendran et al., 2020; WHO, 2020d). Case management of patients includes supportive care with supplementary oxygen coupled with ventilatory support for those most severely affected (Berlin et al., 2020; Marini and Gattinoni, 2020; Matos and Chung, 2020; Meng et al., 2020; Nigeria Centre for Disease Control, 2020a; World Health Organisation, 2020b). Depending on the threshold for hospital admission, it is estimated that up to 17% of hospitalized patients will require intensive care, with an appreciable proportion needing mechanical ventilation (World Health Organisation Europe, 2020; Docherty et al., 2020; Mahase, 2020a; Richardson et al., 2020). This is a concern even in high-income countries where there have been challenges with the availability of critical care beds, appropriately trained staff and personal protective equipment (PPE) (Di Lorenzo and Di Trolio, 2020; IHME, 2020a; IHME, 2020b; Lacobucci, 2020; Massonnaud et al., 2020).

An encouraging example of a positive response among low- and middle- income countries (LMICs) is Vietnam where multiple activities including extensive testing, contact tracing, and social distancing, under the government slogan “Fighting the epidemic is like fighting against the enemy”, have been successful in limiting the tranmission of COVID-19 with only 355 confirmed cases by the end of June 2020 and no recorded attributable mortality (Hall, 2020; Jones, 2020; Ministry of Health, VietNam, 2020; Pearson and Nguyen, 2020; Thai et al., 2020; WHO, 2020a).

Currently, there does not appear to be a cure for COVID-19; however, there are a number of medicines undergoing trials including antivirals, steroids, antimalarials, immunomodulators, and herbal medicines, some of which have shown positive findings although there have been concerns with the trial design of a number of studies (Das et al., 2020; ECDC, 2020a; Geleris et al., 2020; Luo L. et al., 2020; Mehta et al., 2020; Pradhan et al., 2020; Recovery Collaborative Group, 2020; Sanders et al., 2020; Scavone et al., 2020; Zhong H. et al., 2020).

The most promising therapeutic breakthrough to date has come from the UK-based adaptive randomised Recovery trial (ECDC, 2020a; Recovery Collaborative Group, 2020). The low cost corticosteroid dexamethasone has recently been shown to significantly reduce mortality in the most severely affected patients with COVID-19; patients with an oxygen requirement and those requiring ventilatory support (Recovery Collaborative Group, 2020). Other recent studies have also shown benefit from corticosteroids in critically ill patients increasing the number of days alive and free of mechanical ventilation as well as reducing mortality (Sterne et al., 2020; Tomazini et al., 2020). The prescribing of 6mg of dexamethasone daily for 10 days is now recommended for widespread use in the UK unless contraindicated for other reasons as well as endorsed by the National Institute of Health (NIH) in the USA (NIH, 2020a; Rees, 2020). However, currently optimal dosing and duration of dexamethasone in COVID-19 is unknown; consequently, current recommendations reflect those used in the Recovery trial.

Initial studies with remdesivir failed to demonstrate clinical benefit over placebo although these were underpowered (The Guardian, 2020a; BMJ Best Practice - Coronavirus disease 2019 (COVID-19), 2020; Wang Y. et al., 2020). More recently, larger scale studies conducted by NIH in the USA have shown encouraging results including a reduction in the time to recovery and a trend towards lower mortality (hazard ratio for death = 0.70) leading to the issuance of an Emergency Use Authorization by the US FDA as well as endorsement by the European Medicines Agency and the NHS in the UK (Beigel et al., 2020; EMA, 2020; NIH, 2020b; UK Medicines & Healthcare products Regulatory Agency, 2020; US Food and Drug Administration, 2020). However, further studies are needed before the prescribing of remdesivir can be fully endorsed.

However, much controversy surrounds the use of chloroquine and hydroxychloroquine with or without azithromycin for both the prevention and treatment of COVID-19. Following initial studies in China, coupled with the findings of Gautret et al. (2020) (Boulware et al., 2020; Das et al., 2020; Cortegiani et al., 2020; Gao et al., 2020; Gautret et al., 2020), its use was endorsed among a number of governments and medical societies (Bokpe, 2020; Channnel News Asia, 2020; East African, 2020; Rich, 2020; Sciama, 2020; Tilangi et al., 2020). However, the lack of a comparator arm in the initial studies has been heavily criticised coupled with concerns with side-effects including cardiac side-effects with hydroxychloroquine (International Society of Antimicrobial Chemotherapy, 2020; Gautret et al., 2020; ISAC/ Elsevier, 2020; Borba et al., 2020; Ferner and Aronson, 2020; Littlejohn, 2020) as well as reports of fatal overdoses (Abena et al., 2020; Das et al., 2020; GuruGamer, 2020; Nga et al., 2020; Politi, 2020). Recent studies have failed to demonstrate any clinical benefit for both the prevention and treatment of COVID-19 (Boulware et al., 2020; Geleris et al., 2020; Recovery Trial, 2020a; Rosenberg et al., 2020). The study by Mehra et al. (Mehra et al., 2020) also showed increased mortality with chloroquine or hydroxychloroquine; however, this has now been retracted subject to external auditing (Mehra et al., 2020; The Lancet, 2020). The European Medicines Agency now advises caution with the prescribing of hydroxychloroquine outside of clinical trials (European Medicine Agency, 2020a), and the WHO has halted the hydroxychloroquine arm in its ongoing Solidarity Trial with the NIH in the USA also halting the use of hydroxychloroquine in its studies (WHO, 2020e; ECDC, 2020a; NIH, 2020c). In South Africa, the South African Pharmacy Council has also warned against the misuse of hydroxychloroquine for the treatment of COVID-19, which builds on concerns from the regulatory agency given the lack of evidence (Masango, 2020; SAHPRA, 2020a).

The antiretroviral treatment (ART) lopinavir-ritonavir, which showed activity against MERS-CoV, has also been recommended for treating COVID-19 patients alongside arbidol (Cao et al., 2020; Kumar et al., 2020; Mitjà and Clotet, 2020; Zhong H. et al., 2020; Zhu et al., 2020). However, there have also been contrasting data regarding its effectiveness in COVID-19 patients, with most studies failing to show any clinical benefit including the UK Recovery study (Cao et al., 2020; ECDC, 2020a; Ford et al., 2020; Recovery Trial, 2020b). Consequently, lopinavir-ritonavir cannot currently be recommended for use outside of clinical trials and more recently the WHO has discontinued the lopinavir-ritonavir arm in the Solidarity Trial (WHO, 2020e). A recent study though by Hung et al. (2020) found that early triple antiviral therapy with interferon beta-1b, lopinavir/ritonavir and ribavirin alleviated the symptoms and shortened the duration of viral shedding and hospital stay compared with lopinavir/ ritonavir alone in patients with mild to moderate COVID-19 (Hung et al., 2020). Any positive findings though with combination therapies need confirmation before they can be endorsed. Studies regarding the potential effectiveness of nasal irrigation are also ongoing (US National Library of Medicine - ClinicalTrials.gov, 2020a; US National Library of Medicine - ClinicalTrials.gov, 2020b). This follows a pilot randomised study showing improvements in the duration of symptoms and viral shedding in patients with upper respiratory tract infections (Ramalingam et al., 2019), with a post-hoc re-analysis with a focus on those infected with coronaviruses also showing benefit (Ramalingam et al., 2020).

A number of other treatments focusing on the late inflammatory complications of COVID-19 (Gaborit et al., 2020; Jose and Manuel, 2020; Monteleone et al., 2020) are also under review. These include tocilizumab, which is widely used in rheumatoid arthritis and blocks Interleukin-6 (IL-6), a combination of emapalumab, anakinra and sarilumab (Clinical Trials Arena, 2020; Di Lorenzo and Di Trolio, 2020; Luo et al., 2020; Roumier et al., 2020; Toniati et al., 2020; Xu et al., 2020; Zhang C. et al., 2020), and interferons (Andreakos and Tsiodras, 2020; Prokunina-Olsson et al., 2020; Shalhoub, 2020; Tu et al., 2020). These are currently not recommended for use outside of clinical trials. Ongoing studies are also using the plasma from affected patients along with prior titration of neutralising antibodies (Bloch et al., 2020; ECDC, 2020a; UK Department of Health and Social Care, 2020; Tu et al., 2020; Wu et al., 2020), and anticoagulants for hypercoagulability states (Cunningham et al., 2020; Paranjpe et al., 2020; Shi et al., 2020; Tang et al., 2020; Xu et al., 2020). Again, these experimental therapies cannot be recommended until more clinical trial data becomes available.

There has also been controversy surrounding BCG vaccination as possible protection against COVID-19 (O'Neill and Netea, 2020; Schaaf et al., 2020). The WHO is warning against claims of effectiveness based on current ecological studies, with the South African Government and leading scientists also warning against diverting stocks away from neonatal vaccination programmes given concerns with shortages until more trial data becomes available (Medical Brief, 2020a; SAHPRA, 2020b; Schaaf et al., 2020; WHO, 2020f).

There are also concerns with the inappropriate use of medicinal plants to prevent and treat COVID-19, which such use particularly prevalent in some sub-Saharan African countries as this can cause more harm than good (Ekor, 2014; Liwa et al., 2014; Nkeck et al., 2020; Nordling, 2020; Yang, 2020). Safety fears are enhanced by the lack of data when used to prevent or treat COVID-19 along with other treatments that patients may be taking including antivirals, antibiotics as well as medicines for non-communicable diseases (NCDs) (Nkeck et al., 2020; Yang, 2020). We are aware that some herbal medicines are showing promise based on in vitro and small-scale clinical studies (Ang et al., 2020; Luo E. et al., 2020; Luo L. et al., 2020; Vellingiri et al., 2020; Yang, 2020; Zhang L. et al., 2020). However, their use outside of such studies is a concern until more data becomes available especially if their use causes delay in patients seeking appropriate care from healthcare professionals as their symptoms develop (Yang, 2020).

The controversies and issues surrounding a number of the treatments, the redaction of recent studies, as well as concerns with trial design in a number of studies (Bae et al., 2020; ECDC, 2020a; International Society of Antimicrobial Chemotherapy, 2020; ISAC/ Elsevier, 2020; Mehta et al., 2020; The Lancet, 2020), means it is essential that treatment recommendations should only be made once the results of robust trials are known (Council for International Organizations of Medical Sciences, 2020; Godman, 2020).

Consequences of Lockdown and Other Measures to Prevent and Treat COVID-19

There are a number of unintended consequences arising from COVID-19. These include Governments diverting personnel and resources away from priority diseases including both infectious and non-infectious diseases. Reducing antimicrobial resistance (AMR) is a key activity across countries especially among LMICs as it increases morbidity, mortality and costs (Founou et al., 2017; Cassini et al., 2019; Hofer, 2019; Khan et al., 2019). However, diverting attention away from AMR, including ongoing efforts to reduce inappropriate self-purchasing of antibiotics, which is prevalent across many countries, as well as routine immunisation programmes for existing infectious diseases, will inevitably have a significant impact on future patient care (Ghosal and Milko, 2020; World Health Organization, 2020c; Health 24, 2020; Kalungia et al., 2016; Auta et al., 2019; Kalungia and Godman, 2019; Godman et al., 2020a; Hofman and Goldstein, 2020; Jerving, 2020; Lorgelly and Adler, 2020; Thornton, 2020; UN News, 2020; World Health Organisation, 2020d). Self-purchasing of antibiotics is a particular concern with the clinical presentation of COVID-19 overlapping with other infectious diseases including tuberculosis (TB), viral and bacterial respiratory tract infections, and pneumonia, making a differential diagnosis challenging exacerbated by limited diagnostic facilities in most communities (Godman et al., 2020b; Kasozi et al., 2020; Ongole et al., 2020). In hospitals, establishing antimicrobial stewardship programmes and other activities (Mendelson and Matsoso, 2015; Ghana Ministry of Health, 2018; Schellack et al., 2018; Anand Paramadhas et al., 2019; Afriyie et al., 2020; Godman et al., 2020b) can improve antibiotic prescribing where there is little evidence of bacterial co-infection (Godman et al., 2020a; Seaton, 2020; Zhou et al., 2020). Consequently, it is essential that such activities be introduced where necessary to guide future antibiotic prescribing among suspected COVID-19 patients (Seaton, 2020).

We are aware that the Ebola outbreak in Guinea, Liberia, and Sierra Leone between 2014 and 2016 resulted in as many people dying from HIV/AIDS, TB, and malaria as Ebola due to reduced access to health care (Parpia et al., 2016; Ghosal and Milko, 2020; Krubiner et al., 2020). There are also concerns that an appreciable reduction in the distribution of protective bed nets (75%) and medicines for treating malaria due to lockdown measures, combined with no media campaigns, could result in up to 18 million additional cases and up to 30,000 additional deaths in sub-Saharan Africa alone compared to 2018 (Cash and Patel, 2020; Krubiner et al., 2020; World Health Organisation, 2020c). Whilst the latest evidence suggests that HIV positive patients do not have a higher COVID-19 infection rate, or a significantly different disease course than HIV-negative individuals (Blanco et al., 2020; Guo et al., 2020; Härter et al., 2020; Tarkang, 2020), patients’ fears of contracting COVID-19 when they attend clinics, as well as limited access to health facilities and treatment during lockdown, will negatively impact on treatment and adherence to medicines as well as initial diagnosis (Africa News, 2020a; Chaiyachati et al., 2014; Mbuagbaw et al., 2015; Jerving, 2020; Krubiner et al., 2020; Tarkang, 2020). Medicine supplies can potentially be addressed through differentiated service delivery and other programmes (Jerving, 2020; Tarkang, 2020; Wilkinson and Grimsrud, 2020). Telemedicine and other technologies could also potentially help with consultations, with mobile technologies helping with tracking and tracing COVID-19 patients (Cohen et al., 2020; IOL, 2020; LinksCommunity, 2020).

There are also concerns that lockdown measures will negatively impact of the management of patients with non-communicable diseases (NCDs) (Kluge et al., 2020). This includes a lack of support and access to facilities to improve lifestyle management, monitor patient and regularly provide essential medicines (Kluge et al., 2020). Ongoing national plans to reduce morbidity and mortality due to NCDs, especially CVD and diabetes, across continents including Africa (Mensah et al., 2015; Amegah, 2018; Godman et al., 2020c; Godman et al., 2020d) could also be compromised by reduced access to medicines, cancelled or missed appointments due to patients' reduced access to facilities and fear of coming into contact with COVID-19 patients in healthcare facilities, and not following lifestyle advice (Kabale et al., 2020; Kluge et al., 2020; Nachimuthu et al., 2020). However, we are aware that governments are committing extra resources to try and minimise these unintended consequences (Ebrahim and Lakay, 2020). Issues relating to medical supplies can again be addressed by measures to extend prescription lengths (Al-Quteimat and Amer, 2020; Republic of South Africa Government Gazette, 2020; Lakay, 2020) as well as home delivery of medicines, with concerns with consultations potentially addressed through technologies such as telemedicine (Africa Health IT News, 2020a; LinksCommunity, 2020; Webster, 2020).

Other serious consequences include the exacerbation of mental health conditions during lockdown, the implications for frontline healthcare workers in terms of their health and wellbeing, and anxiety of citizens about their health (Brooks et al., 2020; Cullen et al., 2020; Endomba et al., 2020; González-Sanguino et al., 2020; Habersaat et al., 2020; Hwang et al., 2020; Kaufman et al., 2020; Li W. et al., 2020; Rajkumar, 2020; Ren et al., 2020; Wang C. et al., 2020a; Wang C. et al., 2020b; WHO, 2020g; Xiang et al., 2020). Patients with COVID-19 are also at increased risk of requiring psychotropic medicines because mild-to-moderate illness may result in adverse psychological effects from the diagnosis, from the symptoms, the need for forced isolation, any associated loss of income, and the potential risk of death. This might trigger new psychiatric symptoms or exacerbate underlying psychiatric conditions. In moderate-to-severe clinical situations, there is a risk that patients could develop altered states of consciousness such as hypo- or hyperkinetic delirium, which may require treatment with psychotropic medications (Reade and Finfer, 2014). In addition, some of the medical treatments that have been proposed for COVID-19 could contribute to onset or worsening of psychiatric symptoms. These include psychiatric disturbances with antivirals and steroids as well as depressive-dysphoric experiences with interferons (Tamam et al., 2003; Warrington and Bostwick, 2006; Manfredi et al., 2010; Kenna et al., 2011).

In addition, patients with existing mental illnesses may well have difficulties with accessing regular help during the pandemic unless pro-actively addressed (United Nations, 2020a; Yao et al., 2020). This includes continued access to medicines and treatments for those with long-term mental health conditions since sudden discontinuation should be avoided (WHO, 2020g). Worsening of mental health may be greater in patients with conditions such as schizophrenia with challenges in continuing active case management in the community during the pandemic as well as concerns with administering long-acting injections where pertinent, and performing regular blood tests in patients prescribed clozapine (Kozloff et al., 2020). Pro-active and timely support is needed for all patients with mental health conditions to avoid deteriorating conditions (Endomba et al., 2020; Salum et al., 2020; WHO, 2020g; Xiang et al., 2020). There are also reports of an increase in gender-based violence across countries, including African countries, as a result of lockdown measures, which also needs addressing going forward (Campbell, 2020; Chandan et al., 2020; Mahase, 2020b; SADC, 2020; United Nations., 2020b).

Specific Challenges of COVID-19 in Africa

COVID-19 poses a particular challenge for the African continent because of existing high prevalence rates of other infectious diseases including human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS), TB, cholera, and malaria, along with high rates of AMR and a disproportionate burden of poverty (UNAIDS, 2019; World Health Organisation, 2019; WHO, 2019a; Ataguba, 2020; Godman et al., 2020a; Simpson, 2020; United Nations Economic Commission for Africa, 2020a; WHO, 2020b; WHO, 2020c), with ongoing infectious disease initiatives appreciably challenged by COVID-19 (Mendelson and Matsoso, 2015; Ghana Ministry of Health, 2018; Godman et al., 2020a; Kowalska et al., 2020). The presence of multi-morbidity with NCDs will aggravate the situation further (Oni et al., 2015; So-Armah and Freiberg, 2018; Achwoka et al., 2019; Chang et al., 2019; Kansiime et al., 2019; Woldesemayat, 2020), with already high rates of CVD and diabetes a growing concern across Africa (Mensah et al., 2015; Godman et al., 2020b; Godman et al., 2020c).

Alongside this, there are ongoing challenges with available financial and human resources across Africa (Craven et al., 2020; Glied and Levy, 2020; Jayaram et al., 2020; Shepherd and van der Mark, 2020) including more limited availability of healthcare personnel and hospital beds including intensive care unit (ICU) beds (Murthy et al., 2015; Bates et al., 2018; Godman et al., 2019; El-Sadr and Justman, 2020; Godman et al., 2020c; Godman et al., 2020d; Martinez-Alvarez et al., 2020; United Nations, 2020b). Reports suggest there were just 1.8 hospital beds per 1,000 people across Africa before the pandemic, less than a third of those in France (Bavier, 2020). Oxygen is also not widely available and single room isolation can be a rarity making nosocomial transmission a concern. Overall, there appeared to be less than one ventilator and less than one ICU bed per 100,000 people in Africa compared with up to thirty times that number in the USA before the pandemic (Houreld et al., 2020), although there is regional variation (Murthy et al., 2015; El-Sadr and Justman, 2020; Shepherd and van der Mark, 2020; van den Heever, 2020). The availability of PPE across Africa was also a challenge in the early stages of the pandemic putting healthcare professionals at risk (Aljazeera, 2020; Lapolla et al., 2020; Le Roux and Dramowski, 2020; Saba and Jika, 2020). However, this is changing with increased local production of PPE, new local designs for face masks and ventilators (Bissada, 2020; Kenyatta University, 2020; Mining Review, 2020; Nyavor, 2020), as well as improved procurement processes enhanced by the recent launch of the pan-African medical supplies platform (South African Government, 2020a).

Most challenging though is over-crowding and lack of running water (and therefore a lack of hand washing) among the population, with an estimated 34% to 36% of people in Africa having no access to basic household washing facilities and 30% having only limited access (Bavier, 2020; El-Sadr and Justman, 2020; United Nations Economic Commission for Africa, 2020b). This is a particular concern among refugees, who require additional efforts to help prevent the spread of the virus including education on the rationale behind lockdown activities where pertinent (Associated Press, 2020; UNHCR, 2020).

Given these multiple issues and concerns, the UN Economic Commission for Africa (UNECA) initially estimated that the COVID-19 pandemic could potentially lead to 300,000 deaths across Africa and push 29 million people into extreme poverty (Bavier, 2020). In mid-April, the WHO warned that there could be up to 10 million cases of COVID-19 in Africa within six months (Aljazeera News, 2020a), rising to between 29 million and 44 million in the first year, with up to 190,000 deaths if containment measures failed (United Nations Africa Renewal, 2020). By the end of June 2020, there were over 303,000 COVID-19 cases among the WHO African countries with over 6000 deaths giving a CFR of 2.02% (WHO Regional Office Africa, 2020a). Consequently, absolute numbers of COVID-19 related deaths to date are still lower in Africa compared with other continents including the Americas and Europe (WHO, 2020a); however, this is changing as prevalence rates rise. There are also concerns with the reliability of the data among some of the African countries due to limited detection capacity and reliable tests as well as under-reporting of both deaths and prevalence rates (Ashly, 2020; Bruton and Edwards, 2020; Chiang and El Sony, 2020; Houreld and Lewis, 2020; McCaffrey, 2020; Mules, 2020; Shepherd and van der Mark, 2020; United Nations, 2020; WHO, 2020h). For instance, there has been no official data released from Tanzania since 8 May with the President stating the pandemic has largely been defeated despite concerns with truck drivers testing positive at borders and continued ongoing concerns with under-reporting (Houreld and Lewis, 2020; Mules, 2020; Mwai and Giles, 2020). Having said this, there have been concerns with the reliability of testing equipment (Aljazeera News, 2020b).

Other potential factors for currently lower prevalence rates and deaths in Africa compared with other continents could be a comparatively younger population as well as rapid instigation of lockdown and other measures. which build on experiences with other infectious diseases aided by the African Union, WHO Africa and the African Centre for Disease Control (CDC), as well as sensitivity of the virus to ambient temperatures (Africa CDC, 2020; Cash and Patel, 2020; EAC Secretariat, 2020; Lancet editorial, 2020; Pilling, 2020; WHO, 2020h; WHO, 2020i). The African CDC has been actively coordinating a strong multilateral response amongst African governments and other stakeholders towards COVID-19 building on the activities by the WHO in Africa and others (WHO Regional Office Africa, 2020b; WHO, 2020i; WHO, 2020j). The establishment of National Public Health Institutes among many African countries has also improved the response to public health threats (Nigeria CDC, 2018). Activities across Africa include developing laboratory expertise, training a volunteer health workforce, and risk communication. As mentioned, these built on Africa´s experience in dealing with other infectious diseases including Ebola, HIV, malaria and TB (El-Sadr and Justman, 2020; Nkengasong and Mankoula, 2020; Payne, 2020). The United Nations has also established a knowledge hub for COVID-19 to help African countries learn from each other (United Nations Economic Commission for Africa, 2020b). Testing has also appreciably increased in recent weeks across Africa (Burke, 2020) helped by Africa CDC and the WHO Africa, who have provided testing kits and training, with 48 African countries able to test for COVID-19 by 29 April 2020 compared with just two countries at the start of the pandemic (Ighobor, 2020; Simpson, 2020; WHO Regional Office Africa, 2020c).

Most African countries also rapidly instigated lockdown measures as well as social distancing to reduce the spread of the virus (Bavier, 2020; Dyer, 2020; United Nations., 2020b; United Nations Economic Commission for Africa, 2020a; WHO Regional Office Africa, 2020d). Similar to several African countries, Ghana early on began testing travellers on arrival in the country and isolating positive cases, as well as instigating testing among its citizens. Overall, Ghana has one of the highest testing rates in Africa having performed between 110,000 and 120,000 tests by the end of April 2020 (Di Caro, 2020). The Government of Ghana also established five key objectives to reduce the spread of the virus (Ghana News Agency, 2020; Zurek, 2020). Similar to most African countries, South Africa declared a national state of disaster in terms of section 27 (2) of the Disaster Management Act, 2002, and implemented a phased approach to lockdown with stage 5 introduced on March 27 2020, easing to stage 4 with effect from May 1 2020, which remains in place (Abdool Karim, 2020; South African Government, 2020b). Lockdown measures have now been eased among several countries following concerns about the economic and other issues including the potential for increased violence, whilst still maintaining an active response should the need arise (Moore, 2020; Shepherd and van der Mark, 2020; Tih, 2020). However, this situation is being actively monitored in case of a spike in prevalence rates.

Medicine shortages are an increasing concern across countries (Acosta et al., 2019) and are a particular issue in Africa where typically up to 94% of its medicines are imported (N Gage Consulting, 2017; Bavier, 2020; Dugmore, 2020), and supply issues can be exacerbated in countries with ongoing conflicts (ALCED, 2020). However, African countries are already taking steps to address concerns with shortages before and during the pandemic including suggesting potential alternatives (Chigome et al., 2019; Medical Brief, 2020b; Modisakeng et al., 2020; Review Online, 2020; Tomlinson, 2020). There are also ongoing programmes to address the quality of medicines across Africa. The potential for substandard and falsified medications is exacerbated when prices appreciably increase and shortages occur following endorsement of potential treatments for COVID-19 in the media (Abena et al., 2020; Haque et al., 2020; Kindzeka, 2020; Knott, 2020; World Health Organisation, 2020e). Government activities are likely to accelerate with the launch of the Lomé initiative placing falsified and substandard medicines on the highest political agenda with ongoing measures to strengthen the legal response to these medicines (WHO, 2020k).

COVID-19 has accelerated discussions on local pharmaceutical production in Africa (GhanaWeb, 2020a) with, for instance, the East African Community States seeking to support local production of essential medical products and supplies. Products include masks, sanitizers and ventilators, to address shortages in the region (EAC, 2020). In addition, several local companies have come forward to produce medical equipment and other products to manage the pandemic, and this will continue (Defy, 2020; Kaine and Nwokik, 2020; Nyaira, 2020). This is in line with the philosophy to develop regional hubs involving several African countries to address issues of economies of scale (Conway et al., 2020).

Rationale Behind the Paper and the Objective

Given the multiple issues and challenges facing African countries, we believe there is an urgent need to consolidate knowledge of ongoing activities across Africa to address the COVID-19 pandemic and to understand its impact. Similarly, there is a need to evaluate the impact of re-directing activities away from the care of patients in other priority disease areas in Africa towards COVID-19 activities given the likely consequences on increased morbidity and mortality alongside the economic and social impact (Cash and Patel, 2020; Lancet editorial, 2020; Thornton, 2020).

We are aware that several regional financial institutions, including the African Development Bank and the African Export-Import Bank, have announced significant financial support for this purpose (African Development Bank, 2020; Okonjo-Iweala et al., 2020). The commitments of the World Bank and the International Monetary Fund also provide additional mechanisms, including suspending debts, to free resources towards the COVID-19 response (Ataguba, 2020). These measures should help address existing concerns regarding the financial impact of government measures including lockdown measures on the livelihoods of African citizens, with many currently working in the informal sector (Bonnet et al., 2019; Ataguba, 2020; Cash and Patel, 2020).

Containing the spread and impact of COVID-19, including the substantial economic impact, will though require a multipronged approach and co-operation among all key stakeholder groups going forward, including patients, with countries learning from each other (Ataguba, 2020). Ongoing activities include addressing the considerable misinformation about COVID-19 and potential treatments including vaccines and herbal medicines (Anna, 2020; Brennen et al., 2020; Forrest, 2020; Gallagher, 2020; Haque et al, 2020; Larson, 2020; Neil and Campbell, 2020; Newton and Bond, 2020; Nkeck et al., 2020; Serwornoo and Abrokwah, 2020; Smith, 2020; The Guardian, 2020; World Health Organisation, 2020f; Yang, 2020). The current controversies surrounding chloroquine/ hydroxychloroquine is just one example. As a result, there is a recognized need for scientific integrity and credibility when developing and discussing possible treatments for COVID-19 in line with recommendations from the Council for International Organizations for Medical Services (Council for International Organizations of Medical Sciences, 2020; Godman, 2020). This is to ensure future public and physician trust in treatment recommendations, which forms an integral part of effectively dealing with COVID-19 (Pitts, 2019; Abena et al., 2020; Goodman and Borio, 2020; Perry Wilson, 2020; Pitts, 2020; Rubin et al., 2020).

We are aware that early in the pandemic, Africa CDC, as well as WHO Africa and their partners, spearheaded efforts to train and sensitize African governments on the need to effectively counter and reduce the levels of misinformation (Budoo, 2020; Davis, 2020; Media Foundation West Africa, 2020). Their activities included training on risk communication and regular briefings to heads of state as well as relevant sectors of government. Additional efforts have also been provided by groups such as the International Alliance of Patients' Organizations (IAPO), which have developed resource hubs to provide reliable and updated information to mitigate against misinformation and promote preventative activities (International Alliance of Patients' Organizations, 2020).

Education among patients can also help reduce any stigma associated with COVID-19 for recovering patients and their families as well as any mistrust by the people in their governments (Adusei, 2020; AFP-JIJI, 2020; Habersaat et al., 2020; IFRC, UNICEF and WHO, 2020; Lubega and Ekol, 2020; United Nations, 2020b). We know that countries and governments have the potential to learn from the evidence base of HIV-related stigma interventions to help address such issues, as well as previous pandemics as seen with Vietnam (Logie, 2020; United Nations., 2020b; WHO, 2020a). Potential activities among patients and their organizations include active discussions around how stigma affects different communities, reflections on personal biases, and the instigation of institutional support programmes (Logie, 2020; He et al., 2020). This is important as the COVID-19 pandemic has already provoked stigmatisation and discriminatory behaviors against people of certain ethnic backgrounds as well as anyone perceived to have been in contact with or recovered from the virus (AFP-JIJI, 2020; GhanaWeb, 2020b; IFRC, UNICEF and WHO, 2020; ). Having said this, we have seen reasonable knowledge, attitudes and practices towards most aspects of COVID-19 among the public in China, Nepal, Pakistan and Paraguay although still room for improvement (Rios-González, 2020; Hayat et al., 2020; Singh et al., 2020a; Zhong B. L. et al., 2020). Surveys in the UK and US have also shown that participants generally had good knowledge about the main means of transmission and the common symptoms of COVID-19 (Geldsetzer, 2020). In Cameroon, the population is also aware of the disease and preventive measures (Nicholas et al., 2020). Further research is ongoing regarding why some people fail to adhere to suggested preventative measures, and we will be monitoring this (Chan et al., 2020).

Consequently, the objective of this paper is to summarise and consolidate our knowledge of current activities across Africa related to COVID-19 to help provide future guidance to all key stakeholder groups. This includes following up on clinical trial activities across Africa since an early concern was that few clinical trials were being conducted across Africa (Mabuka-Maroa, 2020; Roussi and Maxmen, 2020). This is beginning to change, building on examples in Burkina Faso, Kenya, Nigeria, South Africa and the WHO Solidarity Trial across several African countries (Anna, 2020; Coulibaly, 2020; Olafusi, 2020; WHO, 2020l). By doing so, we believe we can support African countries' efforts to continue to work together to tackle the pandemic, including jointly pursuing loan waivers to help protect against the financial consequences of COVID-19 (Phiri, 2020; President Republic of Kenya, 2020a).

This will be the first paper in this series as more information and findings become available. This builds on a recent systematic review regarding the importance of viral diseases in Africa, and the fact that different approaches will be needed across Africa to tackle COVID-19, depending on current circumstances (Chauhan et al., 2020; Mehtar et al., 2020; Shepherd and van der Mark, 2020).

Methodology

We adopted a mixed methods approach. This initially involved conducting a narrative review of the published literature as well as papers awaiting publication and internet references known to the co-authors. We did not perform a systematic review. We were aware that some systematic reviews have already been conducted and published in this area including potential treatments despite the lack of data from robust clinical trials (Alqahtani et al., 2020; Castagnoli et al., 2020; Chowdhury et al., 2020; Cortegiani et al., 2020; Das et al., 2020; Ford et al., 2020; Huang et al., 2020; Nussbaumer-Streit et al., 2020; Sarma et al., 2020; Singh et al., 2020b; Vardavas and Nikitara, 2020; Zheng Z. et al., 2020). A number of the publications surrounding COVID-19 are also currently only available in pre-publication form and not peer-reviewed. Alongside this, much of the information regarding ongoing activities across Africa are from internet sources, and it is too early to assess the impact of these, especially as COVID-19 cases appeared later in Africa than in either China or Europe.

We also did not systematically review each paper for its quality using well-known scales such as the Newcastle-Ottawa scale or the Cochrane risk of bias tool as our emphasis was on contextualizing the findings rather than performing a systematic review (Marra et al., 2016; Almeida et al., 2018; da Silva et al., 2018; Ong et al., 2018; Saleem et al., 2019). However, the publications and internet sources were filtered by the co-authors to add robustness to the present paper and its suggestions.

In view of this, and to provide direction for the future, we supplemented information from the literature and internet sources with additional current information from co-authors across Africa. The co-authors include senior level personnel from governments and their advisers, lecturers and researchers from academia, and clinicians, as well as those involved with activities to enhance the rational use of medicine, undertake Health Technology Assessment (HTA), document medicine shortages, and involved with patient organizations from across Africa and wider. The co-authors were asked to provide information on the following themes or topics, where known, in their own country to supplement the ongoing literature:

● Details about the current epidemiology of COVID-19 including CFRs, national responses to date and an assessment of the effectiveness, if known

● The socio-economic impact as well as the impact on healthcare delivery in other priority disease areas including medicine and equipment shortages as well as attendance at clinics. This includes any information on the unintended consequences of COVID-19 in other disease areas if known

● How issues such as medicine shortages are being addressed and the implications for local manufacturing in the future

● Current medicines and other approaches to treating patients with COVID-19 as well as ongoing studies that address issues such as false claims and hopes. In addition, ongoing activities to address falsified and sub-standard medicines

● Key lessons for the future for all key stakeholder groups

The same questions were asked of each co-author, with country-specific replies typically consolidated where there were multiple authors in a country. The information was subsequently consolidated by two of the authors (OO and BG) and checked with each co-author during manuscript preparation to add robustness to the findings and suggestions.

We also documented ongoing technology innovations across Africa, which we believe is important as Africa seeks to become self-sufficient in the management of patients with COVID-19 and beyond.

Documented prevalence and mortality rates will typically be based on WHO date for consistency and reliability as there have been challenges with generating up-to-date data among a number of African countries due to the availability of testing facilities and testing kits, as well as concerns with some testing kits; however, as mentioned, this is now being addressed with the help of the WHO and others (Aljazeera News, 2020b; Burke, 2020; Simpson, 2020; UNICEF, 2020; WHO Regional Office Africa, 2020c).

The African countries chosen reflect a wide range of geographies and population sizes. We did not divide them into low- or middle-income countries as COVID-19 is likely to affect all African countries and they can learn from each other.

Statistical analysis of the different measures and initiatives and their possible impact on the epidemiology, morbidity and mortality rates, has not been undertaken as this is too early given rising prevalence rates across Africa. In addition, our principal aim was to provide a comprehensive analysis of the current situation across Africa, including the potential implications for other infectious and non-infectious disease areas within the African continent, to stimulate ongoing debates regarding potential future activities. This is important across Africa with high prevalence rates for both infectious and non-infectious diseases, We have successfully used this dual approach in previous publications to stimulate debate in important healthcare areas and situations to provide future guidance as countries seek to improve the quality and efficiency of their approaches to medicine use, including during pandemics (Godman et al., 2014a; Godman et al., 2014b; Godman et al., 2015; Ermisch et al., 2016; Bochenek et al., 2017; Ferrario et al., 2017; Moorkens et al., 2017; Godman et al., 2018; Godman et al., 2019; Godman et al., 2020b; Godman et al., 2020c; Godman et al., 2020d; Miljković et al., 2020).

Findings

The findings and activities are divided into sections to meet the study objectives. These include documenting the epidemiology among a range of African countries principally based on epidemiology data provided by the WHO. The aforementioned precedes discussing ongoing strategies to limit the spread of COVID-19 as well as their subsequent impact on morbidity and mortality in populations across Africa.

The impact of COVID-19, including the unintended consequences on the healthcare system and patients, along with financial and socioeconomic issues, will be explored before documenting the subsequent impact on increased local production of pharmaceuticals and other supplies as well as any ongoing clinical studies and innovations across Africa aiming at improving future care. Finally, potential ways forward will be debated among all key stakeholder groups based on the experiences of the co-authors to provide future guidance. This includes key issues of shortages, unintended consequences, and misinformation as well as the role of patients and patient organizations in preventative measures and other interventions.

Epidemiology

There is considerable variation in the number of recorded cases, deaths and CFRs across Africa following the first reported case on February 14, 2020 (United Nations., 2020b), with some countries yet to record their first deaths due to COVID-19 and some countries recording only a few deaths to date (Table 1), potentially reflecting different approaches and circumstances (Tables 2 and 2A). Table 1A in the Data Sheet gives further details of the epidemiology over time as well as recovered cases where known and documented.

TABLE 1

Table 1 Current epidemiology of COVID-19 (up to 30 June 2020) across Africa unless stated.

TABLE 2

Table 2 Ongoing activities across Africa to help prevent the spread of COVID-19 including dates and examples.

Ongoing Activities to Address COVID-19 and Their Impact

Different activities are ongoing across Africa to try and limit the impact of COVID-19. These are summarised in Table 2, with Table 2A in the Data Sheet giving additional details for those interested. As seen, prevention and treatment approaches remain broadly similar among the African countries, with a number of African countries combining approaches to provide joint guidance and updates on suggested activities, such as the East African Community (EAC Secretariat, 2020). There are concerns though with limited activity in some countries, e.g., Tanzania, as well as fears that if lockdown measures are released too early due to financial and resource issues for citizens and governments these will appreciably enhance future prevalence rates (Schroder et al., 2020).

Health and Social Impact of COVID-19 Including Impact on Other Diseases

Measures to limit the spread of COVID-19 are having a considerable impact on other disease areas including both infectious and non-infectious diseases. Table 3 contains details of the considerable healthcare and financial impact of COVID-19 as well as ongoing activities among African countries to address these. We will be examining unintended consequences in more detail in future research projects. Similarly, there are considerable financial and socioeconomic consequences which are also being addressed, with countries having the opportunity to learn from each other.

TABLE 3

Table 3 Healthcare, financial, and socioeconomic impact of COVID-19 across Africa up to June 2020.

Shortages of Medicines and Activities to Address This

There are shortages of medicines across Africa as most medicines are imported (Table 3A). We are likely to see local production increasing as part of future strategies to address ongoing shortages as a result of COVID-19, and we will be monitoring this in the future.

Table 3A in the Data Sheet contains details of ongoing shortages across Africa with countries starting to implement robust strategies to help deal with these in the future.

Clinical Trial Activities

As mentioned, there has been limited clinical trial activity across Africa compared with higher income countries; however, this is beginning to change:

● In Botswana, there are currently no on-going clinical trials on COVID-19; however, the University of Botswana (a government-funded institution) has called for proposals on COVID-19 research, which was open until May 15, 2020.

● Egypt appears to be undertaking several clinical trials with currently 14 registered clinical trials granted expedited approval by review boards utilizing different medicines and treatment modalities (US National Library of Medicine, 2020).

● Currently there are no known clinical trials commissioned in Eswatini with no demonstrable commitment to commissioning COVID-19- related clinical research activities given the current pressure on resources.

● In Ghana, there currently appears to be no clinical trial research activities related to COVID-19. However, some medicinal plants with potential antiviral activity have been identified and submitted to the Centre for Scientific Research into Plant Medicine and Noguchi Memorial Institute for Medical Research for the commencement of studies/screening on their potential therapeutic anti-COVID-19/SARS-CoV-2 activities.

● Kenya is currently involved in WHO clinical trials for three medicines used in combating COVID-19. A vaccine clinical trial is envisaged in the next two or three months at the Kilifi KEMRI/Welcome Trust collaborating research site. The Institutional Review Boards have established electronic systems for protocol submissions and review feedback and expediting the review process (3-4 days for first response) to facilitate implementation.

● Three clinical trials have been registered in Nigeria but currently none have started recruiting (Global Coronavirus COVID-19 Clinical Trial Tracker, 2020). However, Nigeria has been included in the WHO SOLIDARITY trial with five treatment centres participating.

● A number of clinical trials are currently ongoing in South Africa for both pharmaceutical and non-pharmaceutical interventions with the Institutional Review Boards in South Africa having established electronic systems and expediting the review process to facilitate these. This includes the SOLIDARITY WHO trial with the South African research team being led by senior academics and clinicians from eight medical schools (Baleta, 2020) as well as the BCG vaccination trial programme for healthcare workers (NIH ClinicalTrials.gov, 2020a) and the South African Ox1Cov-19 Vaccine VIDA-Trial, the first clinical trial for a vaccine against Covid-19 in South Africa with the first patients enrolled the week of June 23, 2020 (NIH ClinicalTrials.gov, 2020b; Wits University, 2020a).

● Zimbabwe is also involved in the WHO SOLIDARITY Trial.

Technical Innovations Regarding COVID-19 From Across Africa

There are many ongoing innovations across Africa to tackle COVID-19, and these are expected to continue. In Senegal, the Institut Pasteur, with support from the WHO, developed a US$1 COVID-19 Rapid Testing Kit to enable the country to undertake considerable testing with the government currently seeking approval for their kits to be used in other African countries (Kavanagh et al., 2020; LaMarca, 2020; Roberto, 2020). Scientists and industry partners in Ghana have also developed a test for COVID-19, a finger-prick blood test to rapidly detect antibodies, which is seen as beneficial among asymptomatic cases to reduce the spread (Nyavor, 2020).

Students at the Jomo Kenyatta University of Agriculture and Technology in Kenya developed a Mobile app to help with contact tracing, triaging and case management of COVID-19 patients (JKUAT, 2020a), with other students in Kenya also developing and making ventilators to address shortages (JKAUT, 2020b; Kenyatta University, 2020; University of Nairobi, 2020). A multidisciplinary team at Wits University in South Africa used their design and engineering skills to create face shields (Wits University, 2020b). A multi-disciplinary team from Honoris United Universities from across Africa, including doctors, engineers, and students, have developed a prototype for a new non-invasive respirator alongside face shields and splash protection masks, which can be quickly and affordably manufactured via 3D printing to address current shortages (Bissada, 2020).

Scientists in Uganda have also developed hands-free hand sanitisers and rapid testing kits with a team at Makerere University involved in manufacturing low-cost ventilators to bolster the country's capacity in case demand increases (Achan, 2020; Daily Monitor, 2020; School of Public Health Makerere University, 2020).

The Gauteng Department of Health in South Africa has introduced an app (Mpilo) based platform that supports improved service delivery and improved patient experiences in Gauteng Health facilities (Matshediso, 2020). The University of Pretoria in South Africa has also produced an interactive app with real-time data on COVID-19 infections to help with management (Gower, 2020). The governments in Egypt and Ghana have also recently launched apps to help with tracing people who have come into contact with COVID-19 positive patients as well as provide advice on management (El-Sabaa, 2020; Ministry of Communications, Republic of Ghana, 2020).

Scientists in Ghana have also successfully sequenced the genomes of SARS-COV-2 from 15 of the samples obtained from confirmed COVID-19 cases through active collaboration using the Next Generation Sequencing (NGS) Core and High-Performance Computing system (University of Ghana News Release, 2020). Whilst there have been some differences in the strains between countries, all 15 genomes typically resembled (>92% similarity) the original strain isolated from China (University of Ghana News Release, 2020). Scientists from the Nigerian Centre for Disease Control (NCDC) and others from across Nigeria, including from Lagos University Teaching Hospital, have also reported sequencing of the SARS-CoV-2 from the first confirmed case of COVID-19 in Nigeria (Pauloluniyi, 2020).

Key Lessons Among Individual African Countries and Implications for the Future for Key Stakeholder Groups

Tabel 4A (Data Sheet) summarises key lessons learnt among a number of African countries going forward in the management of COVID-19 and other disease areas based on their experiences.

Boxes 1–6 consolidate potential activities that could be undertaken across Africa to improve the future care of patients with COVID-19 building on existing activities (Tables 2 and 2A). However, we need to be mindful of a range of healthcare issues including the unintended consequences on both health and socioeconomic circumstances. This builds on Table 3, as well as Tables 3A and 4A, for individual African countries combined with recommendations for all key stakeholder groups in Africa going forward in the management of both infectious and non-infectious diseases as well as clinical and economic issues surrounding fixed dose combinations (Godman et al., 2019; Godman et al., 2020a; Godman et al., 2020b; Godman et al., 2020c; Godman et al., 2020d).

Box 1. National/ regional governments and authorities.
Leadership and Governance

● Instigation of national/ regional pandemic planning. This includes the need for active surveillance with appropriate personnel and facilities as well as ensuring necessary healthcare workforce and structures including adequate supplies of PPE and other necessary equipment, and communication including all key stakeholder groups with reserved funds for such health emergencies. In addition, a phased approach to easing restrictions when pertinent (Habersaat et al., 2020). Such activities have worked well across countries (Jones, 2020; Wang C. J. et al., 2020)

● Development and implementation of occupational health and safety protocols, policies and legislative frameworks taking cognisance of the risks and mechanisms of COVID-19 infection. Such protocols, policies and legislative frameworks should be consistent with national and international workplace safety policies and guidelines. Effective enforcement and monitoring mechanisms should be put in place

● Planning should take account of the impact of COVID-19 on the mental health of patients and healthcare professionals as well as other priority disease areas and potential ways to address these. This requires a sound understanding of investment/ priority decision making and activities including HTA EBM principles

● Actively plan for misinformation building on the considerable levels of misinformation already seen by end June 2020 (Habersaat et al., 2020)

● Good communication and financial planning are vital to address concerns with any lockdown/ curfew measures especially in countries with high levels of informal sector workers/ high level of workers dependent on a daily wage for their survival

● Lead the development of care guidelines nationally as well as take part in the development of any Pan-African care guidelines. This builds on HTA/ EBM approaches

● Ensure longer term that all healthcare professionals have the necessary training to improve the management of patients with infectious diseases as well as likely co-morbidities especially among African patients. This includes instigating antimicrobial stewardship programmes as well as Infection Prevention Control groups in hospitals where these do not currently exist

● Enhance collaboration between African countries, especially those with shared borders. This builds on ongoing collaborations including the East African Community with their shared plans to tackle COVID-19 (EAC Secretariat, 2020)

● Explore telemedicine and other similar approaches to help with diagnosis of infectious diseases and address unintended consequences especially in patients with chronic NCDs (Africa Health IT News, 2020b; Bonner, 2020; LinksCommunity, 2020; Webster, 2020) as a consequence of any lockdown, alongside investigating the potential of robots for care delivery

● Continue with measures to reduce the extent of falsified and sub-standard medicines within Africa as well as measures to address concerns with misinformation. Alongside this, seek ways to enhance local/ regional production of medicines, PPE and other equipment to reduce reliance on imports

Health Care Workforce (HCW)

● Strengthen health care systems including ambulatory care systems as well as policies and initiatives to improve identification and management of COVID-19, as well as other high priority disease areas (capacity building)

● Instigate practices to ensure that essential health services offered by the private healthcare sector are not compromised

● Seek to address shortages of physicians where applicable including training and utilising of other healthcare professionals. This can include task shifting including a greater role for other professionals such as pharmacists (Box 4). As part of this, develop medium to long term epidemic/pandemic training for healthcare personnel to improve their preparedness and capacities for such health emergencies

● Enhance the professionalism of HCWs including initiatives to reduce inappropriate prescribing of antimicrobials where this occurs (Godman et al., 2020a; Khan et al., 2020)

● Strengthen community systems through capacity building of community owned resources including community extension health workers as well as voluntary healthcare workers as these are typically the first point of contact in communities

● Ensure HCWs continue to have access to PPE as well as additional training (where relevant) in dealing with pandemics as the safety of HCWs and patients is critical during pandemics

● Seek to share basic best practices across countries, including what works well in COVID-19 case management, infection, prevention and control.

Financing/Socioeconomic issues

● As most African currently countries rely on foreign input, governments need to find alternative sources of income in the future through agriculture and technology advances building on current innovations

● Minimize the socioeconomic impact through enhancing national solidarity and prioritization of social cohesion.

● Seek to protect vulnerable populations including the benefits and privileges of low-wage workers as well as address access to healthcare and support for all to reduce the burden that makes vulnerable people less able to follow public health directives

● Make it possible for small-scale business to survive periods of economic downturns occasioned by public health crisis. This can include facilitating the disbursement of interest loans to SMEs as well as reward local companies in the country with tax incentives/guaranteed bank loans to enable them recover post COVID-19

Research Including Unintended Consequences for Both Infectious Diseases (including AMR) and non-infectious diseases

● Promote and fund operational/national research on the impact of COVID-19 on infectious diseases (including AMR) and non-infectious diseases especially the unintended consequences (Table 3). This is particularly important in Africa where national programmes are just starting to address AMR as well as NCDs including CVD, diabetes, and mental health (Mendelson and Matsoso, 2015; Keates et al., 2017; Ghana Ministry of Health, 2018; Godman et al., 2020a; Godman et al., 2020b; Godman et al., 2020c)

● Continue to promote research into potential risk factors for morbidity and mortality among African patients given the differences that can exist between patients in Africa and those in high income countries

● Continue with research programmes aimed at mitigating against infectious diseases (including AMR) and non-infectious diseases across countries to add to the debate about the potential impact of unintended consequences

● Instigate research into new ways to manage patients with both infectious diseases and NCDs where there are constraints on patient access including better use of new technologies including telemedicine and consultations through the internet/ mobile telephones

NB: AMR, Antimicrobial Rsistance; CVD, Coronary Vascular Disease; EBM, Evidence-base medicine; HTA, Health Technology Assessment; NCDs, Non-communicable diseases; PPE, Personal Protective Equipment; SME, Small and Medium size enterprise.

Box 2. Health technology assessment/ evidence based medicine.
Short Term

● Continue reviewing emerging medicines that could be used in the management of COVID-19 to inform and update clinical protocols

● Disseminate findings via Ministry of Health and other websites to address current levels of misinformation

● Continue to undertake research for evidence-based interventions given the current controversies surrounding a number of suggested treatments for COVID-19, and encourage greater collaboration between governments, healthcare professionals and patient organizations researching and disseminating the findings

● Strengthen HTA capabilities especially when Ministries of Health are confronted with different potential interventions to address COVID-19 coupled with limited resources. This builds on existing initiatives across Africa including Ghana, Kenya and South Africa as well as the recent cost-benefit analysis on social distancing in Ghana and ICU versus care in general wards for patients with severe COVID-19 (Ghana Prorities Project, 2020; Hernandez-Villafuerte et al., 2016; Mueller et al., 2017; Hollingworth et al., 2018; Southern African Health Technology Assessment Society (SAHTAS), 2019; SAMRC, 2020)

● As part of this, upgrade research into priority decision making especially given the many competing healthcare needs among patients in Africa including those with infectious and non-infectious diseases as well as co-morbidities

Longer Term

● Seek to invest in personnel and resources to enhance HTA/ EBM capabilities within countries where currently limited personnel and resources to enable greater critique of evidence based alternatives

● Seek to establish HTA collaborations across African countries to avoid duplication building on experiences in Europe (European Observatory, 2016; KCE Report, 2017; Vella Bonanno et al., 2019)

NB: EBM, Evidence-base medicine; HTA, Health Technology Assessment.; ICU, intensive care unit.

Box 3. Physicians (hospital and ambulatory care).
Short Term

● Deployment of higher number of physicians where possible to help deal with the pandemic as well as other priority disease areas. Ensure physicians are motivated emotionally, mentally and financially to help deal with the pandemic especially given the likely impact of the virus on their mental health. Educational interventions and psychological support will be needed to ensure greater understanding of COVID-19 and its implications including better coping strategies. Psychological support could include development of support systems among all stakeholders and the general community.

● Physicians need to be provided with adequate PPE and training to address current fears, with hospitals provided with adequate logistical support (PPE, ventilators, medication, non-consumables)

● Embrace alternative ways of working including devolved responsibilities as well as the use of new technologies that help improve the care of all patients during pandemics

● Introduce greater opportunities for the training and re-training of ambulatory care physicians in the management of patients with COVID-19 and any co-morbidities given the challenges that can exist with differential diagnosis. As part of this, push for the instigation of antimicrobial stewardship programmes as well as IPC groups in hospitals where these do not currently exist

● Work with others to address concerns with misinformation as well as falsified and sub-standard medicines. In addition, concerns with potential shortages of medicines and equipment and alternative approaches

Longer Term

● Building on current experiences and collaborations on the best way to treat patients with COVID-19 and the aftermath including concerns with mental health disorders

● Focus on training of sufficient physicians from non-public health or circulatory medicine specialities to ensure a higher number of staff with transferable skills relevant to a pandemic that can be rapidly re-deployed

● There is an urgent need generally to employ more health personnel to augment current inadequacies across Africa. This includes exploring measures to attain and retain physicians

NB: IPC, Infection, prevention and control; PPE, Personal Protective Equipment.

Box 4. Pharmacists (hospital and ambulatory care).
Short Term

● Seek ways to ensure that medicines, or suitable alternatives, that are deemed helpful to patients with COVID-19 are routinely available coupled with medicines for other priority disease areas

● Work with Government agencies when falsified or sub-standard medicines are suspected to reduce their supply

● In hospitals, seek to ensure that hospital pharmacists are part of COVID-19 treatment teams including ASPs and IPC teams. This means that hospital pharmacist must keep abreast on current treatment research and protocols for COVID-19 and be familiar with EBM techniques given ongoing controversies (Al-Quteimat and Amer, 2020). In addition, should be provided with any necessary PPE including face shields and googles

● Hospital pharmacists should be involved in educating patients/staff on COVID-19 management especially on non-pharmacological and pharmacological interventions

● Where appropriate, pharmacist should be encouraged to prepare cost-effective WHO-recommended hand sanitizers for their facilities

● In the community, pharmacists have a vital role as they are often the first healthcare professional that patients contact regarding respiratory/ influenza diseases especially in countries with high patient co-payments, concerns with access to ambulatory healthcare facilities as well as issues of affordability to pay for a physician and their medicines (Markovic-Pekovic et al., 2017; Mukokinya et al., 2018; Adunlin et al., 2020; Al-Quteimat and Amer, 2020; Godman et al., 2020a). This includes encouraging self care/ hygiene measures including the supplying and wearing of masks and the need for regular hand washing as well as trying to protect patients against stock-outs of pertinent medicines (Al-Quteimat and Amer, 2020; Amariles et al., 2020; Haque et al., 2020; Ung, 2020)

● Community pharmacists can also discuss appropriate treatments including arguing against the need for antibiotics where this is a concern and encouraging appropriate referral where possible (Mukokinya et al., 2018; Amariles et al., 2020; Godman et al., 2020a)

● Community pharmacists and others can also push for extended supply of medicines where appropriate as well as help engage in discussions regarding adherence to medicines using different technologies especially given ongoing concerns with adherence to medicines without regular input from pharmacists and other professionals (Al-Quteimat and Amer, 2020; Kretchy et al., 2020; Zheng S. Q. et al., 2020).

● Pharmacists can also suggest alternative approaches during times of medicine shortages including potential OTC treatments (Cadogan and Hughes, 2020).

● They can also help improve stock controls to reduce potential shortages of key medicines with associated price increases, which is important in LMICs with high patient co-payments (Haque et al., 2020; Godman, 2020).

● Community pharmacists can also be involved in vaccination programmes given current concerns, as well as help administer a vaccine for COVID-19 when available with research suggesting that when pharmacists provide immunizations, they substantially increase the number of vaccinated people in the community (Hedima et al., 2020)

Longer Term

● Increase the training of Pharmacists at both hospital and community levels to be prepared/actively involved in management of COVID-19 patients as well as addressing unintended consequences including the use of technology to address issues with adherence

● Pharmacists should be part of appropriate relevant training and the development of emergency plans and workflows to deal with future pandemics and their consequences (Aruru et al., 2020)

NB: ASPs, Antimicrobial Stewardship Programmes; EBM, Evidence-based medicine; IPC, Infection, Prevention and Control; PPE, Personal protective equipment.

Box 5. Other healthcare professionals in ambulatory and hospital care.
Short Term

● Work with other professionals to identify optimal methods to deal with the care of patients with COVID-19 both in hospitals and in the community

● This includes making sure that healthcare professionals have the necessary PPE and equipment to deal with COVID-19 patients

● Seek to instigate training regarding the proper donning and removal of PPE during routine duties and in the management of suspected/positive COVID-19 cases if not in place

● Be part of ongoing plans to help improve the management of high priority disease areas outside of COVID-19 to make sure these patients are not neglected

● Work with necessary professionals to ensure the mental health of healthcare professionals and patients is not neglected during and post the pandemic. This includes helping to address issues of stigma

Longer Term

● Be part of elaborate plans to improve the management of patients with COVID-19 and other priority disease areas including re-distribution of activities to address shortages with physicians and other HCPs

● Seek to work with universities, companies and other groups to develop in-house/ in-country technologies to treat COVID-19 patients and be less reliant on imports in the future

NB: HCPs, Healthcare Professionals; PPE, Personal protective equipment.

Box 6. Suggested activities among patients/patient organizations.
Short Term

● Mobilize and engage with traditional, cultural, and other leaders who are respected and listened to in their communities to disseminate important health messages including hygiene and social distance measures associated with COVID-19 to help address current low levels of health literacy in a number of African countries. This includes addressing current misconceptions about the importance of using face masks, and how to use them appropriately, as many patients do not appreciate the need as well as helping acknowledge that some people with respiratory problems may have difficulties using masks for long, which needs to be effectively tackled

● Engage with various channels to help reassure COVID-19 patients that they pose no threat to the community after treatment, and should continue with their lives, as well as help address issues of stigma and discrimination against COVID-19 patients when these arise

● Work with government bodies to help address issues of misinformation about vaccines and treatments including misconceptions about vaccines and the consequences (Anna, 2020). In addition, work with all key stakeholder groups to help address the mental health issues that will arise from the current pandemic

● Patients organizations should work with regulatory authorities and professionals generally to strengthen ethical conduct and professionalism post the pandemic including promoting only evidence-based approaches across social and other media given concerns with the level of misinformation during the pandemic (Godman, 2020)

● Recovered COVID-19 patients can be used as ambassadors to sensitise the populace about the reality of the pandemic, and the need to avoid stigmatization

● Social media has proved useful and can provide an efficient means for patients and patient organizations to effectively communicate with their communities. However, this needs to be carefully managed to reduce the level of any misinformation and subsequent adverse consequences. This builds on activities with traditional, cultural, and other leaders

● Empower patients on medication safety and polypharmacy concerns as well as educate patients about self-management generally of their conditions especially patients with chronic NCDs in the absence of routine clinics

● Help explore possible telemedicine approaches to reduce reliance on clinic attendance, which in itself can be problematic outside of the pandemic if this involves extensive travel and waiting times

Longer Term

● Seek to develop patient-level data bases to routinely collect data on patients to help with future planning and care delivery

● Enhance the role of patient organizations within countries where pertinent as they can play a long-term role regarding advocacy and the spreading of information not only on COVID-19 but also other diseases and concerns. Patient organizations also have a key role generally to encourage changes in behaviors that promote good underlying health to support health outcomes and reduce the risk of severe symptomatic responses to a pandemic

A key area will be patients especially in view of their necessary compliance with any lockdown and social distancing activities as well as considerations for the unintended consequences of COVID-19. These include mental health considerations, managing maternal and childbirth challenges, the identification and management of other NCDs as well as other infectious diseases.

HTA will also be a crucial area especially given concerns with the extent of misinformation regarding COVID-19 and the implications. In addition, the need for governments to prioritise their limited resources across disease areas (Hatswell, 2020; Allen and Mirsaeidi, 2020), rather than devoting appreciable personnel and resources to one area to the detriment of others as seen currently with activities regarding COVID-19 (Tables 2, 2A, and 3). However, there are challenges including available personnel and resources as well as typically a greater focus on medicines among HTA units rather than other technologies (Hernandez-Villafuerte et al., 2016; Bijlmakers et al., 2017; MacQuilkan et al., 2018; Fasseeh et al., 2020). This is changing with studies in Ghana evaluating the cost-benefit of moderate social distancing policies (Ghana Prorities Project, 2020) and the cost-effectiveness of different prevention measures (Asamoah et al., 2020) as well as groups in South Africa HTA evaluating the cost-effectiveness of ICU versus care on general wards with patients with severe COVID-19 (SAMRC et al., 2020).

HTA and EBM will also be important in the development of clinical guidelines for Africa considering the costs involved with developing de-novo guidelines. Africa could certainly gain from a Pan-African guideline for the management of COVID-19 as knowledge grows to provide scientifically-based recommendations, similar to initiatives for NCDs (Okwen et al., 2019). Global evidence communities including the BMJ under its Best Practice series are already adopting this approach for knowledge generation, synthesis, and translation to facilitate evidence-based decisions (BMJ Best Practice - Coronavirus disease 2019 (COVID-19), 2020; McMaster University. COVID-END, 2020), and any Pan-African initiatives should build on this. Groups such as IAPO are also important with their resource hubs to provide robust, reliable, and updated information to help improve the care of patients (International Alliance of Patients' Organizations, 2020). In the meantime, we are beginning to see African countries taking steps to reduce the level of misinformation and this is likely to grow (Budoo, 2020; Davis, 2020).

Discussion and Next Steps

We believe this is the first study to comprehensively document ongoing activities throughout Africa to tackle the health, financial and socioeconomic consequences of COVID-19. This is important given the high prevalence of both infectious and non-infectious diseases in Africa, the high number of people at or below the poverty level compared with other continents and higher income countries, as well as concerns with the lack of personnel, hospital beds and equipment (Murthy et al., 2015; UNAIDS, 2019; WHO, 2019a; World Health Organisation, 2019; Ataguba, 2020; Godman et al., 2020a; Godman et al., 2020b; Houreld et al., 2020; Martinez-Alvarez et al., 2020; Simpson, 2020; WHO, 2020c).

There have been different activities across Africa to prevent the spread of COVID-19 and reduce mortality rates (Tables 2 and 2A). African countries have broadly followed similar multiple approaches in terms of prevention including closing borders and instigating lockdown measures including travel restrictions, social distancing and testing. Closure of borders and quarantining along with other public health measures appear successful in reducing the spread of the virus (Nussbaumer-Streit et al., 2020), and this certainly appears to be the case among a number of the African countries. Encouragingly, to date there have been no or very few reported deaths among some of the African countries (Tables 1 and 1A), mirroring for instance the situation in other LMICs including Vietnam (WHO, 2020a). Encouragingly as well, there have been a number of innovations coming from the African continent to help with identification and management of patients with COVID-19, which includes local production of hygiene equipment as well as low-cost ventilators (Section 3.6). Alongside this, initiatives to enhance the production of medicines in Africa to reduce their reliance on imported medicines and other essential supplies. This bodes well with dealing with future pandemics in Africa. We will continue though to monitor prevalence and mortality rates across Africa as well as potential reasons for the limited mortality up to late June 2020, certainly when compared with a number of European countries and the USA, including potential issues around ethnicity and other factors.

However, extensive lockdown and other measures to help control the spread of the virus have been at a cost including the negative impact on other disease areas as well as financial and socioeconomic consequences (Table 3). This includes an increase in mental health disorders exacerbated by issues of stigma. Table 3 shows clearly the need to strengthen or enhance existing healthcare infrastructures in many countries to respond to such pandemics and indeed promote better population health and underlying lifestyle behaviors. While good health system infrastructure does not guarantee better health outcomes it increases the opportunities for these to happen (Donabedian, 2005).

Groups such as IAPO are important to reduce any stigma associated with COVID-19 (IFRC, UNICEF and WHO, 2020; Lubega and Ekol, 2020). In the process of stigmatisation, people are being labelled, stereotyped, separated, and/or experience loss of status and discrimination because of a potential negative affiliation with the disease. Stigma can drive people to hide their illness to avoid discrimination, which potentially prevents them from promptly seeking help, and could discourage them from adopting healthy behaviors, which is concerning (Thornicroft et al., 2007). This is because such barriers could potentially contribute to more severe health problems, ongoing transmission, and difficulties with controlling infectious diseases. As a result, there are ongoing strategies to address these challenges including a greater role for patient organizations (Kaufman et al., 2020).

There are real concerns though if lockdown policies are eased too early due to financial and socioeconomic pressures (Schroder et al., 2020), and we will be following this up in future research projects. We will also be following up the unintended consequences of COVID-19 on other infectious and non-infectious disease areas as well as vaccination programmes. In the meantime, Boxes 1–6 provide direction to African countries going forward as they start to ease their lockdown restrictions and address the unintended consequences of the pandemic.

Limitations

We are aware that we have not undertaken a systematic review. This is because, as mentioned, a number of quoted papers have not been formally peer-reviewed and a great deal of information regarding country activities is currently only available on the internet. In addition, cases of COVID-19 started later in Africa than in China and Europe, and it is too early to formally assess the impact of polices. A number of clinical trials regarding possible treatments for COVID-19 have also only recently started.

However, we believe the strength of our paper lies in its comprehensive approach including ongoing and planned activities from across Africa and next steps from senior level personnel, which we will be building upon as more data becomes available. This includes activities against COVID-19 and future activities to re-balance the care of patients with other infectious diseases as well as NCDs.

Conclusion

There have been multiple activities across Africa to try and reduce the spread of COVID-19 with its subsequent impact on morbidity and mortality with the help of international and national groups including the WHO and African CDC. This is despite concerns with available resources, personnel and equipment compared with higher income countries. To date, mortality rates appear appreciably lower than seen in a number of European countries and the USA possibly due to early lockdown and other measures including early closure of borders and quarantining of returning travellers, which is encouraging given initial concerns in Africa. However, infection rates continue to rise which is a concern especially as lockdown measures are being eased in a number of African countries. Encouragingly, multiple activities were typically introduced early across Africa building on the experiences with other infectious diseases, with countries continuing to learn from each other. However, there are a number of unintended consequences which are likely to result in increased morbidity and mortality of other infectious diseases and NCDs. Activities are ongoing to try and reduce the impact, and we will be monitoring these in the future.

Orcid Numbers

Olayinka O. Ogunleye, orcid.org/0000-0002-8921-1909

Debjani Mueller, orcid.org/0000-0001-7796-982X

Nenad Miljkovic, orcid.org/0000-0003-1282-3883

Julius C. Mwita, orcid.org/0000-0002-5947-3684

Godfrey Mutashambara Rwegerera, orcid.org/0000-0002-5896-6065

Bene D Anand Paramadhas, orcid.org/0000-0002-8204-1417

Mohamed Hussein, orcid.org/0000-0003-0349-7262

Wafaa M. Rashed, orcid.org/0000-0001-7531-2840

Loveline Niba, orcid.org/0000-0002-5938-4913

Melaine Nsaikila, orcid.org/0000-0003-2335-3768

Adefolarin A. Amu, orcid.org/0000-0003-3212-2283

Daniel Afriyie, orcid.org/0000-0001-8859-3565

Seth K. Amponsah, orcid.org/0000-0001-7411-0972

Israel Sefah, orcid.org/0000-0001-6963-0519

Tebello Violet Sarele, orcid.org/0000-0002-5874-6599

Refeletse Keabetsoe Mafisa, orcid.org/0000-0001-9713-466X

Felix Khuluza, orcid.org/0000-0002-8334-0160

Dan Kibuule, orcid.org/0000-0002-6908-2177

Francis Kalemeera, orcid.org/0000-0002-4320-5087

Mwangana Mubita, orcid.org/0000-0002-8732-8644

Tshegofatso Maimela, orcid.org/0000-0002-8554-1329

Joseph Fadare, orcid.org/0000-0002-5641-1402

Johannes Hugo, orcid.org/0000-0002-9406-8801

Ibrahim Chikowe, orcid.org/0000-0002-8231-9140

Johanna C. Meyer, orcid.org/0000-0003-0462-5713

Enos M. Rampamba, orcid.org/0000-0002-3492-9104

Abubakr Alfadl, orcid.org/0000-0002-3014-1408

Elfatih M. Malik, orcid.org/0000-0002-8071-8092

Ombeva Malande, orcid.org/0000-0002-1840-7402

Aubrey Kalungia, orcid.org/0000-0003-2554-1236

Chiluba Mwila, orcid.org/0000-0003-0160-1222

Ioana D. Olaru, orcid.org/0000-0003-3392-9257

Trust Zaranyika, orcid.org/0000-0003-4363-7709

Blessmore V Chaibva, orcid.org/0000-0001-7858-3814

Nyasha Masuka, orcid.org/0000-0003-4653-8626

Corrado Barbui, orcid.org/0000-0003-1073-9282

Ruaraidh Hill, orcid.org/0000-0002-2801-0505

Tomasz Bochenek, orcid.org/0000-0001-9915-7267

Amanj Kurdi, orcid.org/0000-0001-5036-1988

Stephen Campbell, orcid.org/0000-0002-2328-4136

Thuy Nguyen Thi Phuong, orcid.org/0000-0001-7939-5276

Antony P Martin, orcid.org/0000-0003-4383-6038

Brian Godman, orcid.org/0000-0001-6539-6972

Author Contributions

OOO, DB, JF, and BG developed the concept of the paper and undertook the initial literature review. OOO, JF, JMe, ACK, and BG developed the draft questionnaire. All authors subsequently contributed to the development of the paper including country activities as well as critiqued subsequent drafts before submission.

Conflict of Interest

AM is employed by HCD Economics.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. However, a number of them are employed by national or regional governments in Ministries of Health or are advisers to them.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fphar.2020.01205/full#supplementary-material

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