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 difficult for residents to social distance or stay locked up in their tiny rooms for extended periods of time . 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 difficult 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. The role of community actors therefore becomes even more pertinent given that such settings often rely on them for community sensitizations and mobilization . 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 confirmation of the first 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 . Without trust, people resort to seeking information and data from unconfirmed 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, finding ways to safely live with the virus becomes critical . 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 fight 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 . 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 fight against COVID-19[19-22]. If well trained and armed with protective clothing and equipment, they could play a significant 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 . 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 . 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.
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 . 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. The CHWs fostered agreement to voluntary quarantine in special facilities, and greatly diminished stigmatization of survivors of the EVD . 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 fight against home deliveries or deliveries conducted by traditional birth attendants .
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. 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, 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. Therefore, community actors can already start advocating for vaccines to counter the widespread scepticism against vaccines . 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 . 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 . 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 fight against HIV/AIDS [35-37].