COVID-19 and health care inaccessibility in sub-Saharan Africa.

The first case of COVID-19, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in sub-Saharan Africa was confirmed in Nigeria on Feb 27, 2020, followed by the first regional death in Burkina Faso on March 18, 2020. Since these initial events, more than 1 million cases and 20 000 deaths have been confirmed in the region. Despite initial fears of catastrophic spread and high mortality of COVID-19 in Africa, mainly because of high frequencies of HIV and tuberculosis co-infections in combination with weak health systems, the toll of the pandemic has remained lower than expected. However, based on previous research showing gaps in health facility accessibility in sub-Saharan Africa,3, 4, 5, 6 populations without access to health care are probably not receiving COVID-19 testing, resulting in under-reporting of the true toll of the pandemic in this region.

In an Article in The Lancet Healthy Longevity, Pascal Geldsetzer and colleagues mapped health facility (in)accessibility among people aged 60 years or older across sub-Saharan Africa. Older people and those with comorbidities are most at risk for negative sequelae and death from COVID-19. Therefore, Geldsetzer and colleagues focused their analyses on this vulnerable population, filling an existing gap in health facility accessibility research in sub-Saharan Africa. 15·9% (95% CI 10·1–24·4) of people aged 60 years or older had travel times longer than 2 h to access any health facility, suggesting minimal linkage to the health system, including COVID-19 testing and diagnosis. Moreover, access to hospitals (locations at which patients with COVID-19 with moderate-to-severe presentations would need treatment) ranged from a median travel time of 41 min (IQR 34–54) in Burundi to 1655 min (1065–2440; more than 24 h) in Gabon. For all adults aged 60 years or older, 9·6% (95% CI 5·2–16·9) had travel times to the nearest hospital of 6 h or longer. These analyses and resulting maps are invaluable for identifying locations where populations might be currently underserved by health-care facilities and where linkage to care could be scant. Moreover, the maps provide a foundation for addressing vaccine delivery challenges for future COVID-19 vaccination efforts. These analyses, paired with investigations of other high-risk groups and insights into facility capacity and readiness, will be instrumental in mitigating the effect of COVID-19 across sub-Saharan Africa.

In addition to identifying and mapping older populations at-risk for COVID-19 underserved by current health facility infrastructure, Geldsetzer and colleagues developed a new database of geocoded public and private health facilities in sub-Saharan Africa, adding to existing records of public facilities for widespread use.3, 8 Although this data source is comprehensive, two datasets were used to produce the list, and the degree of overlap between datasets remains unaddressed. Furthermore, no deduplication processes were reported, suggesting potential duplicative entries within this novel list. If these duplicate entries have differing geocoordinates, travel times will be calculated separately for each entry, resulting in an inaccurate profile of health facility accessibility. Future analyses should consider formally assessing the degree of duplication between the two datasets and removing duplicates to provide the most comprehensive and accurate openly available public and private health facility list for sub-Saharan Africa.

As shown by previous research,5, 9, 10 the ability to prevent, detect, and respond to infectious disease threats (including COVID-19) requires timely access to high-quality health systems. The research by Geldsetzer and colleagues provides vital evidence on physical accessibility to health facilities among at-risk older populations, but scant information exists on the quality of such facilities, capacity to provide essential health-care services, ventilation capacity, and facility readiness for infectious disease treatment and prevention of nosocomial COVID-19 transmission. Future research is needed to identify facilities with ventilation capacity and calculate travel times to such facilities, to identify additional barriers beyond physical access to widespread vaccine delivery, and to better understand facility quality and treatment readiness.