Introduction

The COVID-19 pandemic in 2019 led the world to experience a significant global public health threat that pushed the world to the brink of a social and economic meltdown. This threat triggered questions about how well the global public health community is prepared to handle major epidemics and pandemics. The COVID-19 pandemic forced countries to adopt drastic response measures, which included imposing total lockdowns due to its rapid person-to-person transmission rates. This was further exacerbated by weak and poorly resourced health systems with inequities especially across low- and middle-income settings most of which are in sub-Saharan Africa put the whole world at risk. Most of these countries also possess pockets of hard-to-reach areas that are described as places where it would be hardest or take the longest for someone to access basic humanitarian services (such as health clinics and hospitals). This access is further compounded by a lack of functioning transport links and infrastructure, as well as terrain difficulty [1].

To contextualize the epidemic challenge better, it is important to realize that health systems in Low-and Middle-Income Countries (LMICs) are barely able to handle health systems challenges in high-access areas such as urban and more affluent areas. Major gaps exist in key areas like surveillance, emergency preparedness and response, risk communication and effective control and management of points of entry [2]. A WHO evaluation reported that most Sub-Saharan Africa (SSA) countries are not equipped to respond to sudden shocks to health systems, yet the region often suffers isolated disease outbreaks [3]. Worse still, broader dynamics continue to contribute to the emergence and re-emergence of outbreaks of new diseases and antimicrobial resistance [4]. Despite the fact that outbreaks such as Severe Acute Respiratory System (SARS), cholera, chikungunya, dengue fever, Rift Valley Fever and Ebola provided warning signs and tested countries’ ability to respond [5], COVID-19 still found most LMICs unprepared. And the poor emergency response strategy was made worse by inadequate laboratory and epidemiological surveillance systems and economic, social and political disincentives to case reporting [6].

While COVID-19 presented a particularly unique challenge for most countries, it is pertinent to revert to understanding how SSA countries have been responding to other types of outbreaks. We are particularly keen to document immediate (short-term) responses in order to better understand policy agility and capacity to learn, adapt and change when the need does not seem/appear to be urgent. We know that because most SSA countries focus on urgent rather than important matters, their ability to handle COVID-19, which is both an urgent and important matter, was compromised. We argue that by understanding immediate policy response to outbreaks in low-priority areas, we may be able to characterize and deal with the pain points that prevent countries from prioritizing and establishing mechanisms to nip outbreaks in the bud before the major calamity. We also argue that while effort has gone towards examining health sector responses to specific outbreaks, not enough attention has gone towards characterizing commonalities in immediate response to the disease of different kinds and how the immediate actions translate into (or fail to translate into) medium- and longer-term strategies. Examining the causal relationships between the response activities and the broader health system change is crucial if the global health community is to find a lasting solution to disease outbreaks. Moreover, successful strategies for pandemic response and preparedness over the years have been viewed from a vertical lens that is disease-specific, yet it is plausible that if the response was looked at from a health system lens, the response would be quick and more effective. This explicit linkage appears under-addressed by existing literature.

Our scoping review, therefore, aims to provide an overview of existing evidence on immediate health system responses to epidemics in hard to reach areas in SSA and attempt to answer: what is the context of the health system (Service Delivery, Health workforce, Leadership and Governance, Health financing, Medical products and technology, and Health Information Systems) with regards to pandemic preparedness and management in SSA? What is the diversity of approaches in terms of policies, protocols, communication, community participation, and surveillance that were used to manage disease outbreaks? And what were the outcomes of the various approaches and models in the early detection of diseases, reduced disease impact on the population, change in health behavior, and strengthened health system?

Conceptual framework for the scoping review

A conceptual framework has been developed using the Donabedian framework [7] of structure, processes and outcomes as illustrated in (Fig 1). The framework is commonly used to assess the quality of health services. For this review, a modified framework will be used to help in understanding approaches used in the immediate health system responses to disease outbreaks. For the review, Structures will describe the context of the health system and includes the WHO building blocks of Service Delivery, Human Resource for health (HRH), Leadership Management and Governance (LMG), Health financing, Medical products and technology, Health Information Systems (HMIS) [8]. The process will include the functions and the surveillance, policies how to conduct contact tracing, community engagement, and vaccination campaigns, protocols on health messaging and data collection processes, and communication between partners, and outcomes will include surveillance and early detection of disease outbreaks, supply chain management, treatment centers, community engagement, contact tracing, rapid response teams, public health messaging, data collection and analysis, Vaccination campaigns (if applicable), coordination between institutions and different organizations (national, International, NGOs).

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Fig 1. Modified Donabedian framework for the scoping review.

https://doi.org/10.1371/journal.pone.0285916.g001

Aided by this modified framework, we focus on the following review questions:

1. Context of the health system building block: What contextual forces are shaping the health system, and what are the key challenges faced by countries hard to reach areas in SSA?
2. Processes (functions and activities) of the health system: What are the main functions and activities of the health system hard to reach areas in SSA, and what diversity of approaches, models, innovations and tools were used to manage epidemics?
3. Outcomes of the health system: How successful are the various approaches and models in improving preventing and managing disease epidemics hard to reach areas in SSA?

Methodology

The review seeks to describe the short-term health system responses to epidemics across hard-to-reach areas in sub-Saharan Africa. Like other scoping reviews, the purpose is to broadly describe a phenomenon (what is known and what isn’t) and characterize it in ways that contribute towards a more detailed understanding and/or further research. Consequently, we seek to identify and map available evidence from a wide variety of sources, including published and unpublished material. We follow Arksey and O’Malley’s five-stage scoping review framework [9], which proposes the following five stages: identifying the research question, finding the articles, selecting appropriate articles, charting the data, and collating and summarizing the data into meaningful themes.

Stage 1: Identifying the research question

The research question in this review is based on the Joanna Briggs Institute PCC (Population-concept-context) model [10]. An overarching research question was developed to guide the search strategy: “What are the short-term health system responses to epidemics across hard to reach areas in sub-Saharan Africa?”. The question allows us to capture appropriate existing literature and also provides an opportunity for research questions to be added or modified in the course of the study.

Stage 2: Identifying relevant studies

Our approach will include a systematic search of peer-reviewed studies from electronic databases—PubMed, Google Scholar and Cochrane, snowballing from article reference lists to include additional studies that may not have been indexed. We will also search gray literature using Google. Literature search strategies will be developed using medical subject headings (MeSH-terms) and text words related to the population, geographical terms where countries identified as hard to reach areas will be analyzed and phenomenon of interest/intervention, as shown in Table 1.

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Table 1. Search terms used in searching Pub-Med electronic database.

https://doi.org/10.1371/journal.pone.0285916.t001

Stage 3: Selecting articles.

A three-step search strategy will be undertaken. An initial search of three databases will be used that is PubMed, google scholar and Cochrane gray literature will also be accessed through google, this will be followed by an analysis of the text words contained in the title and abstract and the index terms used. The second step will include using all identified keywords and index terms in all the included databases and gray literature. The third step will include a manual review of the reference list of all the studies for additional articles that may have been left out during the initial search. This will be done firstly by searching through the reference lists of all included articles, secondly citation tracking in which we shall track selected articles that cite each one of the included articles, and thirdly similar to the citation tracking, we will follow all “related to” or “similar” articles where data collected does not have the word hard to reach areas, data will be collected based on countries included in the study.

Exclusion criteria

The scoping review will exclude all types of reviews, protocols, book chapters and countries not identified as hard to reach areas in SSA

MeSH terms used to search for CAB Direct included: Epidemic OR disease outbreak, AND Health system response AND hard to reach Countries AND Sub-Saharan Africa; and for Google Scholar, Health system response to epidemics AND hard to reach AND Sub-Saharan Africa

Following the search strategy above, all identified articles will be uploaded onto Zotero, where all duplicates will be removed.

The first screening process will include reading the title and the abstracts to reach the following decisions: (1) if at least one reviewer agrees to include or consider the abstract or title to be inconclusive, the study will be moved to the next level of screening; (2) for any of the studies if both reviewers agree for an article to be excluded, the article will be excluded. All studies at this level will be charted in an Excel sheet.

In the second level of screening, the full texts will be assessed by two independent reviewers. Reasons for any exclusion will be recorded and reported in the scoping review. Any disagreements will be resolved through discussions or with a third reviewer. The results of the search and study selection will be reported in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) as illustrated in the flow diagram (Fig 2).

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Fig 2. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

https://doi.org/10.1371/journal.pone.0285916.g002

Stage 4: Charting data

To answer the research question, a data charting form in Excel with the following features will be created: authors, year of publication, study title, study design, the aim of the study, country of the study, and key findings relevant to the review objective. A draft charting table is provided (S1 Appendix). As a preliminary step, the reviewers will independently extract data from the first five articles using the data-charting table and meet to determine whether the approach to data extraction is consistent with the purpose of the study. The draft data extraction tool will be modified and revised as necessary during the extraction process. Modifications will be detailed in the full scoping review article.

Stage 5: collating, summarizing and reporting the results

The data from stage 4 will be collated, summarized and reported in a manner that aligns with the study objectives. Tabular and graphical representations of the data may be used to illustrate the identified results and will be supported by narrative descriptions of the data. The meaning of the findings and implications for future research and practice will be discussed.

Supporting information