The Welfare of Healthcare Workers amidst COVID-19 pandemic in Sub-Sahara Africa: A call for concern.

As the fight against the dreaded Coronavirus disease 2019 (COVID-19) continues, the virus has infected about 7,949,973 people, and about 434,181 confirmed deaths across the globe as of 15 June 2020 [1]. This is barely 6 months of its emergence, yet still counting. Healthcare workers (HCWs) such as medical doctors, nurses, laboratory scientists, drivers, housekeepers, and morticians are usually in charge of delivering round the clock healthcare and services to sick and ailing individuals during a disease outbreak either directly or indirectly [2]. This makes them predisposed to infections and diseases, although many see them as super-beings that are immune to illnesses or injuries [3]. HCWs are therefore considered by the Occupational Safety and Health Administration to be at high risk of exposure to novel influenza viruses during a pandemic [4].

The tireless efforts of the healthcare workforce to put an end to the menace of the COVID-19 pandemic have led to the global recovery of about 3,799,143 patients as of 15 June 2020 [1]. Sadly, the World Health Organization (WHO) reported healthcare workers are being infected with the Coronavirus during duty [5]. Therefore, if a catastrophe will be averted, the health care delivery system must be safeguarded. The health and safety of healthcare workers must also be well-taken care of to sustain public health and recoveries.

History had it that four influenza pandemics had taken place since 1918 with each having its damaging effects on the populace [6]. The Centers for Disease Control and Prevention (CDC) analyzed that, during the 2009 pandemic, close to 89 million people contracted the novel H1N1 strain of influenza and about 18,300 died as a result in the United States [6]. However, the Coronavirus disease 2019 seems to have more mortality than any seasonal flu recorded. In any pandemic, hospitals usually experienced a surge in the number of patients with signs and symptoms of the disease. Such increases usually placed an additional burden on the health system. This was experienced in the United States during the pandemic (H1N1) 2009 influenza virus that started in the spring of 2009. Approximately 40,000 cases and about 300 deaths were reported by the CDC in the United States. These overwhelming pressures usually pose the risk of contracting the disease by the health workers [4], [6].

As of 21 April 2020, more than 35,000 healthcare workers were reported by the WHO to have contracted COVID-19 globally [5]. This is indeed worrisome. In China, about 3000 healthcare workers have been infected and at least 22 have died of the COVID-19 as of March 2020. Likely transmission between asymptomatic health workers and family members was also reported [7]. During the Ebola virus disease (EVD) outbreak 2014 in Sub-Saharan African countries, about 140 African healthcare workers were reported to be infected, with about 80 deaths [8]. In the course of the Severe Acute Respiratory Syndrome (SARS) in 2003, seventy percent (70%) of patients with suspected cases in Ontario (Canada) was announced to have contracted the disease in healthcare settings, out of which (45%) were health workers [9]. The WHO also confirmed 8098 cases and 774 (9.6%) mortalities during the SARS outbreak in 2002 out of which 1707 (21%) cases were healthcare workers [10].

Recently, there has been a rise in the reported cases of healthcare workers contracting COVID-19 in the line of duty. A case was reported in a hospital in Wuhan city of China where an asymptomatic COVID-19 patient undergoing surgery infected 14 healthcare workers [10]. Such reports are not new when it comes to infectious disease outbreaks. During EVD in Sub-Saharan African countries in 2014, there were reported cases of infections from health facility centers. Health care facilities are also without trained staff, personal protective equipment (PPE), and well-equipped isolation units; hospitals then became a transmission center for its spread. This resulted in patients avoiding hospitals for treatments but preferred staying at home [8].

Currently, there are designated centers for testing and managing COVID-19 cases with a team of specially trained health workers. However, the phobia of being diagnosed for COVID-19 seems to make some sick individuals to deliberately remain in the community rather than going to the hospital for treatments. Besides, those with access to hospitals seem to be providing a false medical or travel history [11]. Also, there have been cases of patients running away from isolation centers after being tested positive to the COVID-19 virus and seek solace in private health facilities that are not equipped to manage COVID-19 cases. This seems to expose many HCWs to the risk of getting infected. It was reported in April 2020 that a larger percentage of the 113 healthcare workers infected with Coronavirus in Nigeria are working in private health centers [12]. At this juncture, it is important to emphasize the need for correct dissemination of information and updates on the COVID-19, campaigning against the stigmatization of infected individuals, and that being tested positive is not a death sentence. Flyers, stickers, billboards, digital screens, awareness campaigns to rural areas, and other channels of communication should portray messages of hope about the virus and not otherwise.

The resource scarcities occasioned by the high influx of people with the COVID-19 cases on hospitals was unprecedented. No healthcare system in the world was adequately prepared for an outbreak of this magnitude. Italy and the United States healthcare system are among the highly recognized accommodated healthcare system globally. Italy has a capacity of 3.2 hospital beds per 1000 people while the USA has 2.8 [13]. However, it has been challenging for them to simultaneously meet the needs of so many critically ill patients during this COVID-19 pandemic. Resources were rationed by given preferential treatments to patients with high chances of survival [13].

Healthcare delivery systems in most of the African countries are far below standard, even before the emergence of COVID-19 outbreak. It has always suffered neglect, deficiency of human and technical resources, underfunded, and healthcare management information systems (HMIS) below par [14], [15]. Meeting up with the requirements following the proposed six basic pillars of healthcare delivery by the World Health Organization (WHO) in 2007 remains bleak to date [14]. In Equatorial Guinea, the ratio of medical doctors to patients is 3:10,000 [15]. The average spending on healthcare in African countries as of 2010, amounts to US$ 135 per unit of population. This amount is too low when compared with other middle high-income countries across the globe that spent an average of US$ 3,150 on healthcare delivery [14]. Poor management and misappropriation in the healthcare systems in Africa have led to the ramshackle state of their healthcare systems [15]. The financial hurdle to healthcare services, ineffective national health insurance systems, and poor service integration is also a major setback [14]. Consequently, this had lead to the vogue of medical tourism abroad at the expense of developing and upgrading their resident hospitals [14]. For instance, a report had it that over 5000 Nigerians are leaving the country per month for various forms of treatment abroad under the guise of medical tourism. This has resulted in spending about US$ 1.2 billion yearly [14]. However, in this COVID-19 pandemic, there is no proof or evidence that any African country can handle the pandemic in case there is a similar spike in the outbreak as was obtained in Italy and the USA. Travel ban restriction order has crippled medical tourism during this COVID-19 period. This has left both the rich and the poor to the fate of their rotten healthcare delivery system.

COVID-19 pandemic has indeed exposed some lapses in the global health sector, especially those considered lowest in global development. To meet up with the increase in demands for combating the COVID-19 pandemic, some countries need to rededicate and redesign their healthcare system while others, especially the sub-Saharan African countries need complete overhauling. The health and safety of healthcare workers must also be prioritized if the healthcare system will be sustained especially during disease outbreaks. This must be in line with the SARS Commission's second interim report that “the health and safety of emergency workers is a fundamental element of every emergency response” [9]. Therefore, to obtain a positive result in healthcare delivery during this COVID-19 outbreak, health workers must feel secure with whatever policy enacted by the government or their employer [9]. Healthcare employers should also provide quality insurance schemes as well as sufficient financial support and hazard allowances to their employees during this time. This will help to revitalize and re-energize them for better team performance [7], [9]. Even though, some African countries like Nigeria, Ghana, and Tanzanian have health insurance schemes in place, yet, it remains unaffordable by an average citizen. Most of their hospitals still insist on payment before giving medical attention, even in emergencies [14].

In clinical settings, all safety precautions should be taken seriously during this global COVID-19 pandemic. Personal protective equipment (PPE) such as face mask, hand gloves, an apron, and eye protection for HCWs is vital for safety. The social distancing between healthcare workers and patients must be maintained except during clinical examinations. Hospitals, residential aged care facilities, and other healthcare facilities should put up all necessary measures and precautions in their facilities whether designated for the management of the COVID-19 or not.

In the Sub-Saharan African countries, some health facilities are still using traditional water taps to provide water for hand hygiene during this COVID-19 pandemic. If care is not taken, this can lead to a touch point cross-contamination. The use of automatic touchless water dispensers, sensor liquid soap and hand sanitizer dispensers and hand dryers are hereby advised to be put in place at strategic locations in the health facilities. This will help alleviate fear and anxiety that is usually exhibited by health caregivers and other visitors in contracting the virus from the healthcare facility center.

Safeguarding healthcare systems and health workers alone is not enough. Frequent industrial strike actions, professional competitiveness, and failure to implement relevant policies and agreements between government or employer and healthcare workers have consequently hindered ideal healthcare delivery in most African countries [14]. A report had it in Nigeria that Doctors are on indefinite strike due to nonpayment of salaries and allowances amidst COVID-19 pandemic. Sadly, the government is threatening with a ‘no job no pay’ directive instead of providing solutions [16]. If this tussle continues, what will be the fate of COVID-19 active patients?

Pending the time a vaccine for Coronavirus would be developed and rolled out globally, the health and safety of the health workforce must be sustained. Healthcare workers exhibiting any symptoms related to COVID-19 must cease to engage in treating patients and should be redeployed or isolated immediately. Any sick HCWs should be excluded from work with sick leave policies and incentives that will encourage them to stay at home with the assurance of job security and not the fear of losing their job [7].

Conclusively, COVID-19 has no doubt uncovered some flaws in the global healthcare delivery system as the mighty are falling. This serves as a wake-up call for global health reformation, redesigning, and preparedness against future occurrences. It is high time for Sub-Saharan African countries to embrace and improve on their technology-based health care systems such as telemedicine, telemonitoring, virtual consultations among others; in case of a future disease outbreak that might be deadly than COVID-19. Governments should also provide quality and affordable insurance schemes for their citizens.

In the COVID-19 context, all health facilities should be equipped with the basic equipment that can handle at least mild COVID-19 cases. All healthcare workers in either undesignated or designated health centers for COVID-19 treatment should be trained in handling COVID-19 cases. Proper education and training on the appropriate use, removal, and disposal of all necessary PPE are vital to prevent reinfection. As the high influx of patients usually puts pressure on health facilities during pandemics; however, HCWs should not be overworked but be given adequate rest and time off for personal issues and recreational activities.

Governments and employers of health workers must ensure timely payments of salaries and allowances to avoid industrial strike actions. Moreover, we recommend adherence to cashless policy at various cash points within the health facilities to avoid indirect contact transmission. Lastly, it will be wise for everyone accessing any healthcare facility to have their facemasks, pocket hand sanitizers, and other PPE to checkmate safety. As findings revealed many COVID-19 carriers might be asymptomatic, therefore, no chances should be taken. Everyone should be on guard, as the exact expiry date of the COVID-19 pandemic remains unknown.

Disclosure of interest

The authors declare that they have no competing interest.