The Potential Role of Community Actors in The Response Against COVID-19: Lessons From Three African Countries, Tanzania, Uganda and Zambia

Objective With the spread of COVID-19 to most low-and middle- income countries, global concerns arise on how to respond to the pandemic. We seek to highlight the early response to COVID-19 of Tanzania, Uganda and Zambia and draw lessons on how community actors could be engaged in the global efforts to prevent its spread and resurgence. This is envisioned to guide COVID-19 prevention efforts as well as implementation of interventions, especially in areas with relaxed, no or partial lockdown measures. Results Community actors can be useful in the promotion of behavioural change including consistent use of face masks, handwashing, social distancing, as well as act as whistle-blowers who identify new residents, report suspected COVID-19 cases and those breaking self-quarantine directives. Furthermore, community actors can encourage adherence to government directives on COVID-19 prevention through integrating COVID-19 information into their routine services. Countries across the globe have the opportunity to tap into the potential role of community actors, especially as we move towards more inclusive health systems. Increased involvement of community health systems is vital in sustaining the gains that have been made in areas where COVID-19 cases have reduced.


Introduction
COVID-19 is a rapidly evolving global health pandemic [1]. Experiences from other highly affected countries such as the United States of America (USA), Spain and Italy have shown that the virus can be devastating. Albeit, advanced healthcare systems, the pandemic took many of these countries by surprise, thereby making its containment even more challenging [2]. With the spread of COVID-19 to most low-and middle-income countries (LMICs), global concerns arise on how to respond to the pandemic [3], particularly in Africa where health systems are fragile [4]. In this perspective, we aim to highlight the response of Tanzania, Uganda and Zambia and draw lessons on how community actors could be engaged in the global ght against COVID-19. Community actors may include local opinion leaders such as politicians, artists, heads of religious or other social groupings, celebrities, community health workers and village health teams (VHTs).
Over the last decades, LMICs have recorded various health gains that have been linked to major contributions by community level actors [5]. Many LMICs have relied on community-based actors to effectively deliver maternal, newborn, child health, malaria and HIV/AIDS interventions among marginalized and hard to reach populations [6]. The use of community actors is not unique to LMICs, high income countries like Sweden are using community actors to activate virtual health rooms for rural communities. In the USA and Australia, the use of community actors to deal with high risk group behavior change has equally been reported [7]. The collective use of community resources to create better health for all has been termed as reactivating the community health systems by scholars [8]. A community health system is de ned as a set of local actors, relationships, and processes engaged in producing, advocating for, and supporting health in communities, but existing in relationship to established health structures [9].
The focus on community health systems in the era of COVID-19 is of paramount importance as re ected in the Policy Brief issued by the World Health Organisation (WHO) on 1 st April 2020, which outlined 16 recommendations for strengthening health system response to COVID-19 [10]. In this Brief, it was stated that the early experience in countries with large-scale community transmission showed that COVID-19 required unprecedented mobilization of health systems. The rst recommendation that health systems ought to consider is expanding their capacity for communication of COVID-19 related information and proactively manage information ow. The use of community actors to supplement such communication therefore comes in handy, and is critical to tackling the widespread miss-information on COVID-19 that is quickly creating another battle eld, referred to as the COVID-19 infodemic by the WHO chief [11].

Main Text
The COVID -19 response in Tanzania, Uganda and Zambia The three African countries generally instituted methods that promote social distancing, although in rather varying ways. While Uganda initially instituted more strict lockdown measures [12,13], Tanzania followed a more "Swedish like" approach. Institutions of learning were closed earlier in the response, while religious gatherings were allowed to continue. Zambia on the other hand instituted measures that lie somewhere in between the two approaches. For instance, gatherings of more than 50 persons were initially banned. The public was largely receptive to lockdown measures in the three countries but left a lot to imagination in places like informal settlements, where measures such as social distancing and frequent handwashing are practically close to impossible. In Kampala for example, 60% of the population lives in informal settlements where sanitation facilities are shared and living conditions are extremely crowded, making it di cult for residents to social distance or stay locked up in their tiny rooms for extended periods of time [14]. Similarly, in Tanzania and Zambia where lockdowns were not instituted, infection control measures such as regular handwashing and consistent use of face-masks have been more di cult to adopt particularly in lower social economic settings. Therefore, the question of how to reach disadvantaged communities with prevention messages in order to build their capacity to prevent COVID-19 is eminent. Additionally, many rural communities in the three countries are remotely detached from information, and may lack the basic prevention tools such as access to water and soap [15]. The role of community actors therefore becomes even more pertinent given that such settings often rely on them for community sensitizations and mobilization [9]. Indeed, in recognition of the role of community actors, Zambia had started involving a few community volunteers in Lusaka district to sensitise communities on COVID-19 prevention measures as early as mid-April 2020, hardly a month after the con rmation of the rst COVID-19 case.
Diaconu et al., 2020 have argued that limited community engagement in public health interventions can inadvertently translate into lack of information, potentially leading to trust issues between the government and communities [16]. Without trust, people resort to seeking information and data from uncon rmed and possibly false sources as is now the case with the infodemic. Consequently, leading to myths, misconceptions and low appreciation of government efforts, thus affecting the community's capacity to adhere to COVID-19 preventive measures. In Zambia for example, the Ministry of Health reported that COVID-19 suspects did not avail themselves to the health authorities during contact tracing owing to this mistrust, disinformation and misconceptions. With lockdowns increasingly becoming unsustainable across the globe, nding ways to safely live with the virus becomes critical [17]. We propose that given the prevailing record of community actors in community sensitization and mobilization, tapping into this resource will make a worthwhile contribution to the ght against COVID-19.

Potential roles for community actors
Evidence suggests that the use of community-based actors to supplement ongoing government efforts to prevent disease spread could potentially help prepare communities to respond better to curb the spread of COVID-19 [18]. Based on lessons from many public health programmes from Tanzania, Uganda and Zambia that have worked with community actors, we believe that community-based actors such as religious leaders, community leaders, traditional healers, teachers, and community health workers (CHWs) can be a critical resource in the ght against COVID-19 [19][20][21][22]. If well trained and armed with protective clothing and equipment, they could play a signi cant role in mobilizing communities to adhere to preventive measures by playing the roles discussed in the subsequent paragraphs.
As role models, they promote behavioural change Several social distancing and infection control measures are being encouraged and made mandatory in some countries; however, community reception and implementation is problematic. We suggest that since community-based health workers, community leaders and other actors such as celebrities are respected and trusted in the communities, if they adopted preventive measures such as wearing of masks, keeping safe distances at shopping malls etc., community adoption of such behaviours could be increased. Similarly, they can play a critical role in delivering culturally sensitive information to counter practices, social norms and misinformation that may propagate the spread of COVID-19 [23]. Lots of misinformation is being spread globally and while governments are doing their best to counter this, community actors could very much enhance these efforts [24]. Celebrities across the globe are already passing on positive messages as is the case of musicians and other artists, whose COVID-19 prevention messages are now on international media making a positive global impact [25].
Acting as whistle blowers toidentify new residents and those breaking self-quarantine directives Community actors being permanent residents in communities, can easily identify visitors and support enforcement of quarantine directives through relevant bodies [26]. The study by Marais et al., 2016 on the Ebola virus disease (EVD) showed that CHWs using indigenous knowledge in administering safety protocols during disease surveillance helped in fostering acceptability of a family member with symptoms to be taken away for admission to a treatment center [27]. The CHWs fostered agreement to voluntary quarantine in special facilities, and greatly diminished stigmatization of survivors of the EVD [28]. Furthermore, working with the community, the CHWs registered substantial victories through informing people about quarantine measures and in identifying suspected EVD cases. In Zambia, reports of vigilant community leaders have been seen in the ght against home deliveries or deliveries conducted by traditional birth attendants [29].
Working alongside the local leaders to encourage adherence to government directives on COVID-19 prevention Community-based actors tend to enjoy support from the community leaders, which creates legitimacy for their services [26]. Based on this pre-existing support and legitimacy systems, we note that if properly engaged, community actors can work alongside community leaders to ensure positive reception of government directives such as handwashing and social distancing. Such community collaborations can result in reduced rumors, fear and mistrust [26], which is detrimental to government preventive and curative efforts. Further, such collaboration is key not only in preventing the spread but also re-occurrence of COVID-19 in those countries where the cases have reduced. In fact, as we move towards the discovery and development of vaccines, community acceptance of vaccines will be critical for them to be effective [30]. Therefore, community actors can already start advocating for vaccines to counter the widespread scepticism against vaccines [31]. Historical experience indicates the key role that community actors have played in vaccine acceptance across the globe [30,32].
Acting as advocates for the continuity of essential health services In many LMICs, there have been reports of decreasing usage of routine health services such as child immunization and maternal health services due to COVID-19 restrictions/ measures [33]. Community actors such as CHWs and VHTs play a major role in community mobilization and sensitization for a vast majority of health services both preventive and curative in low-income-countries [34]. Harnessing this potential to ensure that they continue carrying out their roles in a safe manner will be a game changer in guaranteeing continuation of health service delivery and usage. This will contribute to the building of resilient health systems. Protective wear, basic training and incentives shall be needed to create and sustain this momentum. For example, reports from Uganda, Tanzania and Zambia indicate that community champions and CHWs have been essential in creating positive behavioural change regarding uptake of prevention and treatment services in the ght against HIV/AIDS [35][36][37].

Discussion
The current call by WHO to strengthen health systems response to COVID-19 and in particular promoting the role of the health system in stopping community spread of COVID-19 is timely. From this perspective, we are particularly interested in how the recommendation by WHO on expanding the capacity for communication of COVID-19 related information can be operationalised across the globe given the different contextual realities. We suggest that effective use of community actors will be critical in enhancing the bene ts of a multifaceted approach to communicating behavioural change messages.
Whether it's through the use of celebrities in high income countries or foot soldiers such as CHWs in LMICs, engaging actors and structures that signi cantly in uence their communities will be critical.
Use of the community actors and structures is also important as it may trigger collective action and responsibility towards addressing COVID-19 [38]. This may among other aspects create a better appreciation of the non-discriminatory nature of the pandemic and therefore calling for a consorted ght to defeat it. The use of community structures and actors as collectively envisioned in the de nition of community health systems, creates opportunities for harnessing community resources for the good of society's health and wellbeing. In doing so, it's critical that the community actors are equipped with the right information and tools to stimulate the needed changes.

Conclusion
The use of community actors to back drop the formal health system is a long-standing global tradition. The re-energizing of such community resources in the ght against COVID-19 will expand the needed resources and contribute towards the building of resilient health systems. Additionally, it will trigger a sense of community and common responsibility, which according to WHO is critical in the ght against COVID-19 unlike polarizing acts that have so far dominated the global COVID-19 response [13].

Limitations
The lack of primary data is a major limitation to this study. However, the multi-country nature, wide literature review as well as author experiences on the topic strengthens the paper's contribution to knowledge.

Declarations
The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are a liated.