Informal Institutions and COVID-19 Coping in Rural Africa

Introduction and Background

The global outbreak of COVID-19 raises many concerns regarding how individuals and communities living in African countries with fragile health systems cope with the pandemic. During past pandemics, individuals and communities in Africa have relied on customary practices and traditions, also commonly referred to as informal institutions (Moore, 2020). Informal institutions have continued to function in rural and poverty-stricken areas of Africa in response to a lack of adequate support from formal governing bodies and are primarily used at the community level (Azevedo, 2017). There is a plethora of literature on community participation in informal institutions within African communities; however, no known research has explored the experiences of individuals who use informal institutions to cope during a pandemic.

From 1964 to 2000, nineteen armed conflicts took place in Africa (Sollenberg, 2001). Post-conflict Africa has been characterized by a breakdown in central governance and an increase in Western and international aid in an attempt to implement democratic society, economic reform, and formal governance structures (Ogbaharya, 2008). Formal governance structures, also referred to as formal institutions, are most successful when they are complemented by informal support systems such as social and customary practices (Ogbaharya, 2008). Informal institutions are customary practices — socially shared rules, usually unwritten, that are created, communicated, and enforced outside of officially sanctioned channels (North, 1997). In Africa, the marginalized and socially isolated rely heavily on informal institutions to navigate daily life and cope during crises.

During health crises and environmental shocks, local communities in Africa and elsewhere in the developing world turn to their social networks and customary practices for sustenance and support. For example, due to the longstanding fight against communicable diseases such as lung disease and tuberculosis, local communities in African countries have become quite familiar with social distancing and infection control (DW, 2020). They have used these experiences to inform how they cope during pandemics. Notwithstanding the establishment of formal government structures in the colonial and post-colonial era, customary practices remain central to multifaceted aspects of rural livelihood in many parts of Africa. Customary authorities continue to command a level of local legitimacy and can elicit significant community participation in times of crisis (Azevedo, 2017). This is evident in the widely recognized concept of Ubuntu — the word used for humanity and communal life in sub-Saharan Africa.

Ubuntu is an ethical ideology that emphasizes the value of people's relations with, and allegiances towards, each other. The Ubuntu principle is excellently manifested in the dictum "I am because we are, and since we are, therefore I am" (Fagunwa, 2019). This ideology draws its origins from the southern African Xhosa and Zulu languages and was accepted as a guiding ideal for the transition to majority rule in South Africa and Zimbabwe (then Southern Rhodesia). The interim Constitution of South Africa emphasizes the need for Ubuntu as opposed to victimization, and reparation as opposed to retaliation, as the guiding principles for all South Africans in the transition from apartheid to majority rule.

Ubuntu ties to Africanism in several ways. Etymologically, Ubuntu is an abstract word formed from the combination of the words ntu and ubu, the former of which is a common word used to refer to a human being in many sub-Saharan African countries (Fagunwa, 2019). For instance, the word shares a strong relation with muntu, the word used to refer to a human being among the East African Bantu-speaking people; bumutu in Botswana; vumuntu in Mozambique; umunthu in Malawi; and gimuntu in Angola (Fagunwa, 2019). Based on its link to humanism, the Ubuntu concept is largely associated with the art of being human and using one's existence to contribute to the general welfare of others and the greater community (Fagunwa, 2019).

Besides language, the ethos of Ubuntu is also apparent in the cultures and traditions of most African societies (Fagunwa, 2019). The Oromo society of modern-day Ethiopia aptly demonstrates this. The community operates a socio-political system of governance referred to as the Gada system, which operates like a democracy (Asmarom, 2001). Leaders are selected based on their popularity and generational grade — elders — and are inclined to pursue sustainable development, intimacy, peace, and security (Fagunwa, 2019). Under this political system, leaders are chosen by the people and nurtured in the value system of unity, humanity, and togetherness such that they always protect the well-being of the people, making it impossible for a tyrannical leader to exist within an ideal Ubuntu framework (Fagunwa, 2019).

Tied to the very core of African society, Ubuntu is a platform that connects Africans together in a value system emphasizing people's interconnectedness and the need to act morally at all times for the protection of a common humanity. The Ubuntu logo is crafted to represent three individuals holding each other's hands to symbolize togetherness; its concept draws from African language, traditions, and beliefs, and is thus an expression of the very essence of being African (Fagunwa, 2019). The concept of Ubuntu aids in understanding how community participation empowers and increases the competence of citizens (Brager et al., 1987). By participating in the governing of their societies, citizens can exert influence by voicing their opinions on issues and acting for the good of the general public (Poovan et al., 2006).

Informal institutions attracted attention from scholars in the 1990s when the concept of social change gained popularity. While the Western world tested many social and community development initiatives, most failed because Western ideologies did not align with traditional informal institutions (Ostrom and Gibson et al., 2009). Nevertheless, since the late 1990s, many global development organizations, including the World Bank, have insisted on local participation to ensure that community and social development initiatives have a higher likelihood of success (Dongier et al., 2003). As a result, stakeholder participation is highly valued to ensure project sustainability; engaging the community not only ensures sustainability but can also help with community empowerment and capacity building (Brett, 2003; Brager et al., 1987).

While research highlights the importance of community participation among African people, little is known about individual-level experiences with informal institutions when coping during a pandemic. Much of the literature on this topic relevant to health crises has focused on how informal institutions have worsened health crises, mainly because of the lack of science-based information and the many myths used to explain "western" health issues in the initial stages. For example, during the HIV/AIDS epidemic in Africa, many believed that the disease could be transmitted by touch, and many villages were burned in an attempt to eradicate the disease (Chirikure, 2020). Similarly, during the Ebola outbreak in West Africa, reliance on informal institutions led to several adverse effects and further spread of the disease; the WHO reported that approximately 60% of Ebola cases in Guinea were attributed to traditional burial practices (WHO, 2014). Reasons for these adverse effects have been attributed to a complex social phenomenon characterized by various religious and cultural beliefs held by the African people (Manguvo & Mafuvadze, 2015). While this research has advanced our knowledge of the negative consequences of primarily relying on informal institutions in Africa, few researchers have studied the benefits of informal institutions to the African people during a health pandemic. This literature gap justifies the need for additional research on individual-level experiences with informal institutions during a pandemic in select African countries (Marsland, 2006; White, 2015; Worden, 2012).

In Africa, a high number of deaths due to COVID-19 were expected given the fragile health system, lack of access to preventive measures, barriers to testing, and potentially vulnerable populations (Schwikowski, 2020). However, sub-Saharan Africa is the least affected region in the world, with 1.5% of the world's reported COVID-19 cases and 0.1% of the world's deaths (WHO, 2020). These statistics are expected to change drastically given the predicted economic collapse resulting from COVID-19 (Hameed, 2020). The World Bank (2020) estimates that up to 60 million people living in Africa will be pushed into extreme poverty by the end of the year, presenting a multitude of crises across the African continent.

In the past, people living in African countries relied heavily on informal institutions to cope with pandemics (Moore, 2020), despite the availability of support offered by official governing bodies. While helpful for many, there are often gaps in care provided by formal institutions, particularly for underprivileged populations that are socially isolated and low-income (World Economic Forum, 2020). As a result, many Africans rely on informal institutions such as community groups and faith-based groups to navigate crises. Informal institutions are primarily used collectively, meaning that communities and groups fill the gaps formal institutions do not. However, collectivism poses challenges due to the need for social distancing to slow or prevent the spread of disease, as is required during pandemics. Given that much of the research on informal institutions has focused on group-level participation, it would be beneficial to understand the lived experience of coping through the use of informal institutions at the individual level during the COVID-19 pandemic.

This topic is significant to individuals living in rural South Africa, Nigeria, and Swaziland because the COVID-19 pandemic is expected to result in high death rates and economic collapse in Africa, primarily in rural areas. Approximately 60% of the African continent's population resides in rural Africa and depends on informal institutions to cope and survive during crises (Starkey, 2015). Because informal institutions remain mostly unchanged in the African social landscape, it is essential to draw attention to those informal institutions that have a positive impact on the African people. While informal institutions should not replace formal government efforts, they are used widely among communities and cultural groups in Africa. Given the need to socially distance during the COVID-19 pandemic, it is suspected that these informal institutions will need to be adapted for use at the individual level. Understanding the individual-level experience of coping through the use of informal institutions during COVID-19 might uncover successful coping mechanisms that can be shared with individuals living in rural Africa and inform collaborative partnerships between formal governing structures and community leaders.

Conceptual Framework and Theoretical Foundations

According to Imenda (2014), "the conceptual or theoretical framework is the soul of every research project" (p. 185); it determines how researchers formulate their study problem, purpose, and questions, how they investigate the problem, and what meaning they ascribe to the collected data. Studies that use inductive logic (typically qualitative) construct conceptual frameworks and may use multiple theories to guide inquiry (Imenda, 2014). Regardless of the qualitative approach taken, the conceptual/theoretical framework represents "the system of concepts, assumptions, expectations, beliefs, and theories that supports and informs your research" (Maxwell, 2004, p. 33).

A conceptual framework was developed to inform this study based on W. Richard Scott's (2004) institutional theory and Robert Wuthnow's (1975) interpretive theory. Scott's (2004) institutional theory was chosen because it tends to seek a deeper understanding of social norms, it has an authoritative status, and can be used to determine whether these norms are merely imitation or used only when necessary. Interpretive theory was chosen to build on the work of Robert Wuthnow and his sociological study of culture, exploring the intricate interrelation of alternative approaches to cultural analyses and how they overlap. Components of each theory were integrated into a conceptual framework to inform the proposed study (Figure 1).

Institutional theory encompasses the processes by which structures, norms, daily life routines, communal and state rules, and individual habits and expectations become enshrined and institutionalized within a populace, ultimately serving as authoritative guidelines for social behavior (Scott, 2004). Institutional theory provides a suitable sociological lens for interpreting the findings of this study and exploring the experiences of individuals who live in parts of rural Africa and rely on customary authorities — a type of informal institution enforced as norms and networks rather than codified into formal, positive law (Scott, 2004). How individuals restructure and adapt existing informal institutions in times of crisis can also be explained through path dependency, an area of institutional theory (Rose, 1990; Mahoney, 2000; Pierson, 2000).

Institutional theory (Scott, 2004) is rooted in the social sciences, and early research on institutional theory began in the early nineteenth century. It was embedded within the positivism (sociology) and behaviorism (political science) movements (Scott, 2001). Since that time, institutional theory has become widely recognized and researched by social science scholars and organizational management scholars (Scott, 2004). For example, institutional theory has been applied in the study of authority systems (Dornbusch & Scott, 1975) and the effects of technology on classroom and school structure (Cohen et al., 1979). Path dependency and institutional theory have also been applied in the study of how individuals within international health agencies shape an institution's response to changes within and outside the organization (Gomez, 2013). Together, these two theories complement each other in that they explain how individuals, as agents within an institution, can shape an institution's acceptance and resistance of change.

Early versions of institutional theory emphasized cultural-cognitive elements (Douglas, 1986; Zucker, 1977), regulative elements (North, 1990), and normative elements (Parsons, 1990). The normative element represents the values and norms of a culture or institution and allows for the establishment of individual roles (Scott, 2008). The regulative element represents rule-setting, sanctioning, and monitoring activities of a culture or institution as part of an attempt to influence the future behavior of individuals (Scott, 2008). The cultural-cognitive element represents the "shared conceptions that constitute the nature of social reality and creates the frames through which meaning is made" (Scott, 2008, p. 67).

Scott (2004) focused primarily on the regulative and normative elements of the theory because he did not believe the three elements were always aligned, concluding that certain aspects undermined others. Scott (2004) also believed that during times of conflict or change, individual actors within institutions might experience competing rules or schemas, leading to a restructuring of the rules, norms, and beliefs that guide their actions. This belief is echoed in the earlier work of Barley (1986), who studied the response of individuals working in hospitals during the introduction of technology in the healthcare field. Two years later, DiMaggio (1988) purported that an individual's agency — the ability to adapt based on their situation — supported a "bottom-up" view of institutional models. With this view, social scientists began considering how individuals responded in varying ways to outside forces and did not always behave according to institutional beliefs and standards.

Path dependency explains how an individual's cognitive beliefs and prior experiences shape institutions' response to change. An individual's cognitive beliefs can constrain the legitimacy and learning of an institution. Legitimacy is constrained because people often consider existing approaches to be the most legitimate and therefore favor them over new approaches. In addition, as individuals acquire more knowledge and experience with an approach, they become resistant to learning new ones. Furthermore, as time passes, individuals within an institution pass on knowledge to others and new members, making it all the more challenging for the institution to adopt and learn new approaches (Gomez, 2013).

Robert Wuthnow's (1987) interpretive theory complements institutional theory. Interpretive theory can be traced back to the seminal works of Max Weber (1864–1920). The interpretive approach is a general category of philosophy encompassing symbolic interactionism, labeling, ethnomethodology, phenomenological sociology, and the social construction of reality. The interpretive method is more accepting of free will and sees human behavior as the outcome of the subjective interpretation of the environment. Wuthnow (1975) expanded on Weber's work in his seminal text Meaning and Moral Order: Explorations in Cultural Analysis. Wuthnow argued that the study of culture had been ill-served by a subjective orientation that reduces cultural objects to individual beliefs and meanings. He also discussed the issues surrounding cultural analysis, including the problem of meaning, the nature of moral order, the character and role of ritual, the role of ideology, and the function of the state in producing ideology (Wuthnow, 1975).

Seeking an alternative approach, Wuthnow (1987) identified four theoretical schools that inform the work of social scientists — the subjective, the structural, the dramaturgic, and the institutional — and examined the methodological implications of employing each of them. The subjective school encompasses an individual's beliefs, attitudes, opinions, values, ideas, moods, goals, outlook, anxieties, interpretation of reality, and commitments. The structural school encompasses orderly relations, rules, coherence, identity, distinction, and symbolic boundaries. The dramaturgical approach includes the expressive dimension encompassing an individual's communicative properties and interactions with others. The institutional school encompasses organizations as actors.

This study will primarily focus on the subjective component of Wuthnow's (1987) framework, as the study seeks to explore the experience of coping through the use of informal institutions at the individual level. Beliefs and customary practices to combat illness are rooted in culture, which necessitates the involvement and commitment of the individual and is not solely controlled or optimized by groups or institutions. Therefore, Wuthnow's (1975) framework is useful because it has both cultural and material consequences. On one hand, there are apparent social, economic, and financial consequences that result from individual health issues when many people in the community are ill or at risk of becoming ill. Formal and informal institutions must react accordingly; however, the individual underpins both. Through the application of interpretive theory, the researcher will focus on the subjective perspective to highlight the importance of the individual in relation to the community, as well as the individual's reliance on informal institutions.

As shown in Figure 1, each of these components influences an individual's action and coping behaviors during a crisis. With the application of these two frameworks, it can be inferred that an individual's decision-making process during a pandemic is influenced by four perspectives — the normative, cultural-cognitive, regulatory, and subjective — and that an individual's cognitive beliefs and prior experiences may prevent appropriate responses to change. The normative perspective influences the extent to which one perceives their government as capable or just. From the perspective of an individual living in rural Africa who is often a victim of continued, unpunished corruption by governing bodies, there is often a perception of less responsive leadership (Bratton, 2010). Consequently, individuals expect little, if any, assistance from the government during a time of crisis such as a pandemic.

The cultural-cognitive perspective influences the social networks and identities with which an individual aligns and how these influence their decision-making (Linden, 2015). Based on this perspective, an individual's decision-making is influenced by their worldview. With perceptions of government underperformance, the African individual derives most of their support from social networks and makes decisions based on the positions held by those with whom they share essential ties (Linden, 2015).

The regulatory perspective captures the effectiveness of sanctions available to cushion individuals against institutional failure. The court system, which is meant to regulate the functioning of formal institutions, often lacks independence (Amoako, 2018). Consequently, individuals have little confidence in the effectiveness of the formal regulatory system. Sanctions governing informal institutions include shaming, boycotting, ostracism, shunning, gossip, internalized norm adherence, self-enforcement obligation mechanisms, and the use of violence. These sanctions have little support in law and are consequently highly ineffective (Amoako, 2018). Thus, those who live in rural Africa often have low confidence in their ability to regulate and ensure ethical compliance by informal institutions.

The subjective perspective involves an individual's needs, feelings, and attitudes, and how these influence their decision-making during crises. Finally, path dependency explains how these perspectives intersect with an individual's cognitive beliefs and prior experiences with an institution to inform their future actions and coping behaviors.

In the absence of government service delivery and being disconnected from communal programs, individuals who live in rural Africa during a crisis such as a pandemic utilize informal institutions at the individual level as a coping strategy. For instance, due to a lack of access to government-provided healthcare and a lack of funds to seek private healthcare, an individual might choose to use herbs and customary medicine practices. Further, with the loss of employment and a lack of support programs, the city dweller who is unable to pay rent may dispose of their property and return to rural areas.

One resultant outcome of this action is an increased level of coping; the challenges the individual faces during the crisis and the fact that they must cope without participating in a community helps them build resilience to deal with future pandemics. The individual also develops an increased capacity for adaptation as they are forced to create innovative ways to survive based on age-old customs. For instance, they learn to plant food and prepare medicinal herbs as opposed to relying on prescribed drugs, thus increasing self-sufficiency and self-development. Finally, the individual restructures the norms and rules they previously held to align with the reality posed by the crisis.

Subjective school: Encompasses an individual's beliefs, attitudes, opinions, values, ideas, moods, goals, outlook, anxieties, interpretation of reality, and commitment.

Structural school: Encompasses orderly relations, rules, coherence, identity, distinction, and symbolic boundaries.

Dramaturgical approach: Includes the expressive dimension, consisting of an individual's communicative properties and interactions with others.

Institutional school: Encompasses organizations as actors.

Normative element: Represents the values and norms of a culture or institution and allows for the establishment of individual roles (Scott, 2008).

Regulative element: Represents rule-setting, sanctioning, and monitoring activities of a culture or institution as part of an attempt to influence the future behavior of individuals (Scott, 2008).

Cultural-cognitive element: Represents the "shared conceptions that constitute the nature of social reality and creates the frames through which meaning is made" (Scott, 2008, p. 67).

The purpose of this interpretative phenomenological analysis is to understand the coping behaviors of individuals living in rural South Africa, Nigeria, and Swaziland who engage with informal institutions to cope during the COVID-19 pandemic. Informal institutions include but are not limited to religious organizations, community groups, community functions, and social practices. In Africa, customary practices and institutions are often preferred over scientific methods for fighting the spread of disease during pandemics (Manguvo & Mafuvadze, 2015). Informal institutions are adopted at the community level, which is particularly challenging during the COVID-19 pandemic due to the need for social distancing. Understanding this phenomenon at the individual level may provide additional insights to inform the development of awareness campaigns and other relevant measures to help individuals who might not be able to rely on traditional community practices during a pandemic. Therefore, the following research question will guide this interpretative phenomenological analysis:

RQ1: How do individuals living in rural Africa use informal institutions to cope with the COVID-19 pandemic?

This study will employ a qualitative approach using an interpretative phenomenological analysis (IPA) research design to explore the lived experience of coping through the use of informal institutions at the individual level during the COVID-19 pandemic. A qualitative approach is appropriate when a researcher aims to explore and understand, as opposed to confirm and explain, a problem (Creswell & Poth, 2018). Common characteristics of qualitative research include multiple data collection methods, natural setting, the researcher as a key data collection instrument, inductive and deductive logic, various perspectives and meanings held by participants, an emergent design, and a holistic approach (Creswell & Poth, 2018). These characteristics, coupled with the fact that qualitative research methodology focuses on how people understand experiences, make this methodology appropriate for the phenomenon under study.

An IPA design was chosen because it will allow the researcher to explore how individuals living in rural Africa make sense of their experiences using informal institutions to cope with the COVID-19 pandemic. IPA is appropriate for researchers who seek to explore and interpret the human experience with a phenomenon (Smith, 1996). Phenomenological researchers ascribe to the belief that reality is subjective and based on the subjective realities of individuals (Smith, 1996). An interpretative approach, as opposed to a descriptive approach, was chosen because it aligns with the researcher's premise that the human experience cannot be understood without interpretation, whereas descriptive phenomenologists believe that the human experience can be understood by bracketing biases and judgment (Smith et al., 2009). The process of interpreting the human experience is achieved through the hermeneutic process — the process of exploring and making sense of the individual's experiences through the researcher's perceptions (Smith & Osborn, 2007). Given the researcher's personal experiences with informal institutions while living in Africa, this approach is appropriate because it will allow the researcher to interpret individual experiences through their own experientially formed lens (Smith et al., 2009).

Literature Review: Formal and Informal Institutions in Africa

The COVID-19 pandemic poses a significant threat to indigenous people and rural livelihoods with limited access to public health provision in Africa and elsewhere. Indigenous people are especially vulnerable to COVID-19, as they are at higher risk for communicable diseases and experience higher rates of mortality (Lane, 2020). Contributing factors to this increased vulnerability include limited access to clean water, sanitation, malnutrition, and medical care (Lane, 2020). For example, early reports out of Kenya indicate that in the village of Maasai, home to more than a million indigenous people, livestock markets have closed, leading to food shortages and loss of income for many (Wight, 2020). Further, many communities rely on elders for cultural knowledge and practices; because COVID-19 is deadly for older adults, elders are at high risk for death (Lane, 2020). There are numerous other examples of informal traditions that cannot be relied on during the COVID-19 pandemic, forcing individuals to adapt their coping behaviors.

Centuries before missionaries and colonialists arrived in Africa, and before the slave trade commenced, Africans relied heavily on cultural and social practices and mechanisms to alleviate the loss of lives and prevent the spread of diseases (Iganus & Haruna, 2017). Most customary practices were initiated after elders or senior members of African societies met, discussed crises, and suggested ways to cope based on historical knowledge and experience (Iganus & Haruna, 2017). In Ghana, for instance, the failure to recognize and integrate informal institutions into formal government structures resulted in a "silent conflict" among the wealthier demographic, who favor government-funded support systems, over the lower-income and socially isolated demographic, who rely heavily on customary practices to navigate crises (Lozare, 1994). Conflicts between tribes have continued to negatively affect communities long after the actual conflict, as tensions and suspicions continue to linger and have a major effect on how these tribes respond to health crises.

The Anti-Apartheid struggle between 1912 and 1992 was led by the African National Congress to oppose the Apartheid system and its oppression of the majority non-white South Africans (Kurtz, 2009). The minority white South Africans (Afrikaners) used the Apartheid system to monopolize control of the economy and state, excluding the majority non-whites from political and economic power. The immediate effect of the conflict was an attempt by the Afrikaners to intimidate the non-whites by forcibly ejecting them from their homes, relocating them to segregated neighborhoods, banning leaders of the revolt from public life, and imposing martial law.

Informal and formal organizations of governance emerged as a result of the conflict. Informal organizations that arose include political parties such as the ANC and the United Democratic Front; trade unions such as the Congress of South African Trade Unions (COSATU); and religious organizations such as the South African Council of Churches. These informal institutions were used primarily to drive the agenda of non-white South Africans. Formal institutions to aid in governance were also established, including alternative community-based institutions such as legal resource centers, community clinics, and cooperatives that eventually replaced the traditional government institutions at the community level (Kurtz, 2009).

The Nigerian Civil War began in July 1967 and ended in January 1970 after diplomatic efforts failed to bring peace between the Christian Igbos and Muslim Hausas in northern Nigeria. Biafra, comprising mainly of Igbo Christians, seceded from Nigeria under Colonel Odumegwu Ojukwu (Heerten, 2017). Nigeria capitalized on its military strength to reduce Biafra's territory, and the state lost its oil fields — its primary revenue source — leading to a lack of funds to import food supplies (Heerten, 2017). As a result, millions of Biafran citizens starved to death.

The war was characterized by the development of several formal and informal institutions. Formal institutions that arose sought to strengthen the Biafran army and included an advisory committee to advise the head of state on military and political matters, a Food Directorate for coordinating the importation and supply of food items, a transport directorate to coordinate logistics, and a petroleum management board to coordinate the management of fuels, petroleum, oil, and lubricant laboratories (Heerten, 2017). Informal organizations that arose included a voluntary women's service to educate women on the crisis and train them on the rehabilitation of war casualties, as well as civil defense corporations, orphanages, and nurseries (Heerten, 2017).

The onset and spread of TB, Ebola, and HIV/AIDS in South Africa, Nigeria, and Swaziland resulted in the establishment of numerous formal institutions. While these formal institutions have benefited many African communities, there are also significant limitations. Commonly cited limitations include inadequate supportive supervision and leadership, competing political ideologies, lack of funding, and poor support infrastructure. These limitations impede the effectiveness of formal institutions for rural African communities, particularly during health crises.

Governing bodies in South Africa established five key formal institutions to aid in the management of tuberculosis (TB), which affected 649 South Africans per 100,000 people by 2007 (Mhlongo-Sigwebela, 2010). The first, the National Department of Health, was established to improve healthcare delivery through improved access, equity, efficiency, and sustainability. In response to TB, in 1995, the Directly Observed Treatment Short Course (DOTS) strategy was implemented to provide free TB diagnosis and treatment in a bid to increase access to care. Five years later, Parliament established the National Health Laboratory Service to coordinate the provision of public sector laboratory services by conducting research on new testing methods and developing new technologies for diagnoses. The fourth formal institution established in response to the TB epidemic is the South African National TB Control Program, which works collaboratively with other stakeholders to integrate TB treatment with HIV and coordinate community-based strategies for influencing patients to seek and adhere to TB treatment. Finally, the USAID Technical Assistance and Support Project (TASC II TB) was established to partner with academic research institutions to support local health authorities in improving the management of TB support systems and increasing the quality, availability, and demand for TB services.

Despite these efforts, a notable limitation of formal institutions in South Africa is poor stewardship at the policy level and inadequate supportive supervision at the implementation level (Coovadia et al., 2013). The National Department of Health is known for developing promising policies but lacks proper leadership to ensure those policies are adequately implemented throughout the system, meaning most policies rarely reach the people who need them. Human resource limitations, particularly in rural areas, have also hindered the ability of the National TB Control Program to help patients seek and adhere to treatment at the community level. Data released in 2007 indicate that cure rates were 80 percent in Western Cape Province, compared to just 40–50 percent in the rural KwaZulu-Natal province (Coovadia et al., 2013). Inadequate funding has presented yet another challenge, as political ideology has at times driven resource allocation decisions in ways that undermined public health responses (Coovadia et al., 2013).

Nigeria, the most populous African state, has benefited from investment and development and has experienced changes in formal healthcare approaches to reflect modern universal trends (Shuaib et al., 2014). As a result, Nigeria was able to stop the spread of Ebola. Ebola first appeared in Nigeria following the 2014 outbreak that began in West Africa. When a traveler from Liberia traveled through Lagos Airport, the pandemic reached Nigeria. Through contact tracing, Nigerian health authorities were able to identify 72 individuals who were potentially exposed (Shuaib et al., 2014, p. 867). The swift action of the Federal Ministry of Health, overseen by the Nigeria Centre for Disease Control — modeled after the CDC in the United States — led to the containment of Ebola. Because Nigeria had prior experience with disease outbreaks, its national public health institution was ready to respond (Shuaib et al., 2014). However, many informal health institutions in Africa have developed as a result of economic disparities that prevent more impoverished populations from seeking care at formal institutions (Nelissen et al., 2020).

Nigeria also faces a significant TB health burden and is among the 30 high-TB-burden countries in the world (Ogbuabor & Onwujekwe, 2019). In 1993, the Federal Ministry of Health adopted the DOTS strategy to enhance case detection, improve short-course treatment, and increase TB notification. To complement DOTS, the ministry also adopted the Stop TB Partnership, which focuses on addressing multidrug-resistant TB and the TB-HIV co-epidemic (Ogbuabor & Onwujekwe, 2019). Lack of government commitment, poor leadership within the National TB Control Program, and funding limitations have emerged as fundamental limitations of formal institutions in Nigeria (Ogbuabor & Onwujekwe, 2019; Garmaise, 2018).

In response to its HIV/AIDS epidemic, Swaziland established several formal institutions, including the National Strategic Plan for HIV/AIDS, which serves to inform policy, identify objectives and milestones, and provide the basis for budgeting and HIV-related legislation. The HIV Crisis Management and Technical Committee — comprised of experts drawn from government, donor agencies, traditional healers, media, churches, the private sector, and NGOs — is the highest body with the authority to coordinate the national HIV response (HIV Crisis Management and Technical Committee, 2000). The Ministry of Health and Social Welfare also plays a vital role in developing policy and initiatives relating to care for the infected and affected. Of crucial importance is the U.S. government's President's Emergency Plan for AIDS Relief (PEPFAR), whose primary role is to ease the disease burden in Swaziland and South Africa through the provision of antiretrovirals.

A PEPFAR report indicates that limitations in Swaziland include inadequate road systems and poor internet connectivity, which affect the ability of partners to network and collaborate (PEPFAR, 2019). The program also reported a lack of skilled personnel and unreliable baseline data, limiting the ability to adequately track program implementation and assess outcomes. The HIV Crisis Management and Technical Committee faces additional challenges due to its overdependence on the Global Fund, which requires adjustments to purchasing plans when donation streams are affected by uncontrollable events (PEPFAR, 2019).