Decentralize! Decentralize! Decentralize! COVID-19, an opportunity to strengthen community healthcare

As we continue to examine the opportunities provided by the COVID-19 crisis, monumental amongst them is the one for African governments to decentralize healthcare services and strengthen community health.

Most African healthcare systems are weak and amongst the weakest links are healthcare facilities for communities outside large cities.  As African governments deploy responses to COVID-19, there is opportunity to:

To achieve these goals, local government is key.  Enabling local governments to respond to COVID-19 while strengthening their capacity to build community health services is key to developing Africa’s resilience to fight disease and future pandemics.

Municipalities are uniquely positioned to play a leading role in the global response to COVID-19. First, because they are the public institutions closest to the people. Second, because it is at the level of the municipality that it is most feasible to apply recommendations from central government, regional institutions like the Africa Center for Disease Control and global institutions such as the World Health Organization. Third, without coordination at the local level, mobilizing the population to apply measures which for the most part are about information, education and behavior change will be difficult.

I – Reinforcing health governance at local level

To effectively respond to this crisis and reinforce health governance at local level, it is important to develop a coordinated approach based on certain key principles.

Guiding principles of the coordination approach

At least four principles must always be in the minds of decision-makers at the local level in managing this unprecedented crisis and developing a coordinated approach for healthcare in their community.

  • The participation of all or the mobilization of collective intelligence. This crisis as is the case for all healthcare, has an impact on everyone. It is only possible to win against COVID-19 and strengthen community healthcare if the entire municipality is involved in the response. It is necessary to ensure that all categories of the population are consulted and involved. Every group in the society has ideas, resources and skills. All sectors and groups must be mobilized to build the municipality’s healthcare response.
  • Solidarity to ensure the effective protection of all, especially the most vulnerable. We are only as strong as our weakest link. Solutions must be provided to the most vulnerable groups in the community and those most at risk first.
  • Defining global, multisectoral and sustainable solutions. The crisis is not just about health. It also has economic, social and in some cases security implications. It is necessary to determine and provide solutions at all levels. It is important to respond to the crisis of the moment, but in doing so every community must consider the implications on the medium and the long term as well.
  • Integrity in the management of resources. In this approach the resources of the community will be mobilized. It is imperative that they are used efficiently and managed transparently with no hint of corruption or graft.

To implement these principles, the first step is to develop a coordination unit at local level.

The local coordination unit for the COVID-19 response and for community healthcare

The local coordination unit sets the community’s objectives, mobilizes resources, allocates resources, monitors and adjusts the strategy as the situation evolves.  During the COVID-19 crisis, such a unit would be reinforced in human and material resources.  As the town moves out of crisis, the unit would remain with fewer resources, however with the pivotal role of coordinating the community’s healthcare.

A Community Healthcare Coordination Unit could be made up of the following elements:

  • A general coordination team which includes representatives of the municipal executive, decentralized services of the central state (Health, Economy, Transport, Security, Finance, etc.) and leaders of all the other teams below.
  • A medical crisis team, bringing together the town’s hospital directors, district health officials, nurses, doctors, pharmacists, laboratory staff and other branches of the medical community from both the public and private sectors.
  • A communication team, including public, private and online media. This team would be in charge of providing regular briefings to the population as well as information and education campaigns, including the dispelling of fake news.
  • A neighborhood leadership team (quarter heads, village chiefs, religious leaders, etc.) which would ensure the vertical flow of information from grassroots to decision-makers and vice-versa. This will ensure real-time information on the situation and allow continuous adjustment of the strategy. This is the team that ensures community mobilization, without which it is impossible to fight against COVID – 19 or to improve healthcare in general.
  • An economic team, bringing together businesspeople, market managers, managers of financial institutions and all other relevant economic actors. The idea is to assess the economic impact of the health crisis and to proceed, in a concerted manner, to take measures that will ensure the safety of the population, while bolstering businesses and jobs as much as possible.
  • A security team made up of representatives of the Municipal Police, the City Police and volunteer neighborhoods self-defense groups. This team must monitor the security situation and develop an ad-hoc security strategy adapted to the impact of the health crisis on security. In conflict or post-conflict areas, this team is particularly important as armed groups tend to take advantage of crisis.

It is important to note that the people composing these various teams are not new hires.  They are existing city, central government or private sector personnel who already have existing salaries and benefits and who would be taking on these duties as part of their core responsibilities.  While they may require resources for fieldwork and logistics, resources should not be used to pay them additional salaries or benefits.

It is also important to stress that:

  • Work within the different teams must be voluntary.
  • Work should be done as much as possible via internet platforms.
  • Different teams of the local coordination unit must hold daily, weekly, monthly meetings as the crisis evolves
  • This type of coordination will enable local authorities to effectively deploy the prevention strategy for this crisis as well as preventive healthcare in general.

The first task of the Community Healthcare Coordination Unit is to produce baseline information which is essential for evidence-based decision-making to manage the crisis and community healthcare.

Producing baseline information for strategic and operational decision support

In African healthcare systems data and statistics are largely deficient.  A decentralized approach to fighting COVID-19 provides opportunity to collect information at local level which can be used to create viable local databases that can eventually be linked to a national database. Some of the key areas in which it is vital to have accurate and up-to-date information are:

  • Population. Information must be collected or updated fairly quickly on its composition (different categories of the population and their size, different socio-professional categories, ethnic groups, religious groups, etc.), spatial distribution (grid by district and per block) and the different leaders within groups.
  • Assembly points. All places where the population meets in large numbers such as markets, bus and train stations, places of worship, sports arenas, etc. must be identified.
  • Health infrastructure. This is the opportunity to gather precise information on both public and private health facilities, their equipment, personnel, and bed capacity. The crisis enables local governments to collect this information quickly and comprehensively, providing a baseline for the health system in each municipality. Strengths and weaknesses can then be assessed to determine response capacity for COVID-19 and for community health in general.
  • Economic entities. The crisis creates the opportunities to gather accurate information quickly on both formal and informal business entities. As governments devise responses that include economic aspects, it is possible to count and, in some cases, even register businesses within the community. This will enable local governments to integrate formal and informal enterprises as both part of the response and part of the resources they can count on to face the crisis.

It is advisable that a national template for data collection be developed which will facilitate the integration of local information into a national database.  Young tech entrepreneurs in most African countries are desperate to be invited to develop such products and contribute to the fight against COVID-19.

II – Making a quantum leap in access to community healthcare services

Decentralizing the COVID-19 crisis response will enable local governments to tremendously improve both prevention and care in the local healthcare system.

The implementation of a prevention strategy

The implementation of a prevention strategy

The most important aspect of responding to COVID_19 is of course prevention. At the local level, this strategy should be based on the following axes:

  • Communication
  • Masks for all
  • Hand washing
  • Social distancing

The Community Healthcare Coordination Unit would mobilize resources and implement a strategy along these 4 axes.

Axis Key actions
Communication •       Develop a communication strategy adapted to local realities.

•       Train a diverse group of journalists whose media directly reach all segments of the city’s populations.

•       Create dedicated sites and pages on various networks to relay official information and raise awareness.

•       Communicate regularly on the evolution of the pandemic, measures taken and the outlook.

•       Deploy an awareness and training campaign for various segments of the population with channels and language adapted for them.

•       Respond to rumors, fake news and other concerns as they emerge

•       Open a local call center to manage the concerns of the population

Masks for All Masks are essential to the prevention of COVID-19 spread. It is therefore necessary to:

•       Equip all health personnel in the town with masks.

•       Provide each citizen with masks for essential outdoor outings.

To succeed in this, local authorities must mobilize the entire community to:

•       Fund the production of masks.

•       Distribute masks to citizens.

•       Control the wearing of masks in crowded public spaces

Handwashing Local governments will be able to mobilize funds to:

•       Increase the number of handwashing points in the city and makes soap and disinfectant gels available in the short term

•       Improve access to pipe-born water in the medium term. COVID-19 should serve as a wake-up call. Every African government should use resources mobilized to significantly improve access to water.

Social Distancing In Africa, informal economies and community living, make social distancing a serious economic and cultural challenge.  Local governments will need to consult with all segments of the community to define social distancing measures that are adapted to the local situation.  These could include:

•       Organizing rotations in crowded public spaces such as markets, motorcycle taxi points, etc.

•       Individuals to self-organize to conduct an activity 50% of the time.

•       Reduce overloads in public transportation, etc.

Deploying the system for treatment and care

The strategy for treatment and care at local level includes at least five axes:

Once again, COVID-19 provides the opportunity to strengthen these key elements of the local treatment and care system, rendering it more resilient and capable to meet long term community healthcare needs.

  1. Strengthen existing health facilities and build a network

Using the baseline information gathered, it will be important to:

  • List and categorize the different health facilities of the municipality. Then establish basic information sheets on each structure stating its capacities, needs for upgrading and the specific role it can play in the local healthcare system.
  • Identify a COVID-19 focal point in each facility for optimal management of information flows and rapid decision-making.
  • Mobilize funds to rapidly strengthen healthcare facilities.
  • Set up isolation units in selected facilities that can accommodate infected people under conditions that reduce the spread of the virus.
  • Set up facilities that can accommodate patients in critical condition, needing specific assistance such as ventilators.
  • Organize the network of facilities to ensure continuity of care for other patients.
  1. Set up a patient tracing system

Given that COVID – 19 is highly contagious, it remains necessary to develop a system to trace the path of the patient. This tracking system aims to:

  • Identify people with whom the patient may have been in contact and who are in urgent need of testing and isolation.
  • Continuously monitor patients to see the medium and long terms effects of the virus.
  1. Ensure testing and reinforce laboratories

Africa is still testing at levels considerably lower than the rest of the world.  As more tests become available, it will be necessary to make them available through local healthcare systems.

  • Increase testing capacity as much and as quickly possible to get a clearer picture of the disease
  • Build the capacity of local laboratories so they can analyze and provide results quickly
  • Ensure that these laboratories will be able to test and analyze for other common diseases faced in the community
  1. Ensure the health workforce is ready to meet the challenges

In most African countries the health workforce is essential, insufficient, overworked and underpaid.  With COVID – 19 pandemic, they are also among those most likely to contract the disease.  It is important to use this moment to reorganization and reinforce the health workforce.  of health This includes:

  • List and categorize all the city’s medical personnel
  • Recruit more staff wherever this is possible and mobilize personnel that is in training for jobs that require less training.
  • Train health facility managers on the COVID-19 disease.
  • Train medical staff by category.
  • Facilitate access to online training for staff. Much content has been developed by the Africa Center for Disease Control, the World Health Organization and other health institutions to help healthcare workers cope with COVID – 19. It is important to ensure health personnel have access to online training.
  • Provide health personnel with the necessary protection by providing as much material as possible (gloves, masks, clothing, etc.) in sufficient quantity and quality.
  • Provide financial bonuses and other material compensation for the risks taken, the additional workload and the sacrifices healthcare workers are making.
  1. Reinforce the equipment

At this level, it is also important to carry out the following tasks:

  • Identify key equipment available in the community: scanners, respirators, beds, etc.
  • Define protocols to facilitate rapid access to all available material, including that in the hands of the private sector. These protocols may include user fees to be paid by government and guarantees in the event of equipment failure.
  • Call on the expertise and innovation of local / national scientists and entrepreneurs to rapidly develop complementary solutions adapted to the socio-economic realities of the city.

V – Building the trust

Key to managing healthcare and particularly during a crisis, is trust.  All of the steps mentioned above which are developed and implemented with representatives of the population and using continuous communication will reinforce the trust between the population and its local healthcare system. As will providing accessible, quality health services.

In addition to this, two key security aspects must be managed carefully:

  • Community security directly linked to the crisis response
  • Pre-existing conflict situation in the community

Managing community security as part of the COVID-19 response

The restrictions of the COVID – 19 response – ban on gatherings, closures of public venues, confinement, obligatory wearing of masks, etc. will create fear, apprehension and anxiety within the population.  There are negative consequences of these restrictions on the economy – loss of employment, decrease in income, rise in prices, etc. All this increases tension in the community and can result in increase in violence:  domestic violence, violence against children, tensions in the neighborhood, etc. It is therefore important to put into place a strategy to manage community security as a part of the COVID-19 response.

This requires the Community Healthcare Coordination Unit to:

  • Use baseline data to map out places with high population density (popular neighborhoods, markets, bus stations, etc.) were additional security personnel may be needed.
  • Train mixed units (national police, municipal police and district / market / block managers, etc.) to raise awareness and monitor compliance with protection instructions (social distance, dispersal of crowds, prohibition of overloading) without brutality or repression.
  • Ensure that services that ensure protection from domestic violence, child abuse, and provide mental healthcare remain open and functional.
  • Set up systems within neighborhoods that ensure the security and well-being of the populations.

Elected officials must monitor this security team to ensure that there is no abuse of power or violence against citizens.

Monitoring Armed Conflict and Cooperating with National Security

Non-state armed groups tend to take advantage of a crisis during which there may be some laxity in security due to the national focus on the pandemic.  It is important for local governments in zones where there is pre-existing conflict to remain vigilant and monitor the security situation closely. National security forces should be alerted in case of increased activity by armed groups to avoid the crisis being exacerbated by increased conflict and violence against the population.

VI – A system of monitoring, evaluation and regular adjustment of responses

For it to be effective, this proposed municipal approach assumes that certain management principles are applied. These include:

  • Ongoing consultations with all the key stakeholders as well as the population who will have to apply the measures decided upon.
  • Continuous data collection and analysis, taking into account the strong trends that emerge.
  • Evidence-based decision-making accepted by the majority and explained to the target population. Informed decisions at both collective and individual levels are key.
  • Mobilizing resources at both community and national levels and using them effectively.
  • Synergy in implementation. This synergy must be built at the level of city stakeholders. It must also be built with neighboring towns and with the central government.
  • Continuous evaluation and adjustment of the measures based on results obtained in the field. In this type of crisis, proactivity translates into regular anticipation of possible developments in situations, flexibility in implementation and rapid readjustment in the face of new data in the field.


On the strength of all the above, it is obvious that local governments in Africa have a key role to play in turning the COVID-19 crisis into opportunity.  The opportunity to respond effectively to the crisis and in so doing to build strengthened and resilient community healthcare systems.

As resources are mobilized at national, continental and international levels to fight COVID-19 in Africa, it is important that they are used to seize these opportunities. Municipal governments can carry out concrete coordinated action that directly benefits the population.  That is an opportunity which should not be missed!