Affiliated organization : Mo Ibrahim Foundation
Type of publication : Data and analysis
Date of publication : 30 march 2020
The spread of COVID-19 is accelerating across the world. In Africa, most countries have now confirmed cases and the number of fatalities is rising. If allowed to spread unmanaged, the impact on African citizens and economies will be substantial. At the time of publication (30 March 2020), cases in Africa remain low compared to other regions. According to the data available, this can be attributed to both the average age of African citizens, which is the lowest globally, and factors relating to the continent’s climate – although this has been recently challenged by some experts.
However, Africa may yet be worst hit by this invisible disease. Africa’s already fragile health systems, coupled with a high burden of respiratory and diabetic diseases and densely packed urban agglomerations, are likely to increase the vulnerability of the continent and the lethality of the virus. According to Dr Tedros Adhanom Ghebreyesus of the World Health Organization (WHO), Africa should “wake up” to the COVID-19 threat and prepare for a worst-case scenario.
Home to over a billion people, public health systems across the continent will quickly be overwhelmed if the virus takes hold. The COVID-19 pandemic is a wake-up call for improving Africa’s still weak health structures and related institutional capacity, such as education, infrastructure or national security. It also highlights the urgent need to strengthen data and statistical capacity, notably in relation to health and civil registration.
Covid-19 in Africa: a relatively lower risk of importation, but a higher vulnerability
A lower risk of importation
Following the coronavirus outbreak in China in late December, and its spread to parts of Asia, Europe, the Middle East and the US, Africa seems to have been spared a major outbreak for months, recording its first confirmed case only on 14 February in Egypt. Though Africa has close ties with China, its risk of importation of COVID-19 based on travel exposure to China is lower compared to Europe (1% to 11% respectively) according to The Lancet, perhaps explaining the relatively late spread of the virus on the continent.
But a higher vulnerability
Nevertheless, while there is no common agreement by experts about whether and when the COVID-19 pandemic might or will explode in Africa, there are signals that Africa is particularly vulnerable to the virus and its lethality could be higher in the continent.
Africa appears to have comparative advantages when it comes to COVID-19. One advantage is its demography. Africa is the youngest continent in the world, with a median age of less than 20, and it currently seems that younger populations appear to suffer milder symptoms than older people, who have a significantly higher risk of contracting severe symptoms. Early data from China suggest that a majority of coronavirus deaths have occurred among adults aged 60 years and over, and among persons with serious underlying health conditions. Only 3% of sub-Saharan Africa’s population is older than 65, compared with about 12% in China. Another advantage could be related to its climate. Among the several environmental factors that influence the survival and spread of respiratory viral infections, air temperature plays a crucial role and in tropical climates, influenza and respiratory viruses are transmitted mostly during the cold rainy seasons.
Packed, unregulated urban areas
In 2019 nearly 43.0% of Africa’s population live in urban areas, including in mega cities with populations often bigger than those of countries, like Cairo (20.5 million inhabitants) and Lagos (13.9 million inhabitants). States with densely packed, fast-growing urban areas and high population mobility across borders are more vulnerable to the spread of contagious diseases. Large urban agglomerations also pose a challenge to diseases control due to: reduced opportunities for social distancing, often poor hygiene and sanitation, making it difficult to implement regulations such as regular hand washing and sanitisation, and limited hospitals and healthcare facilities.
The COVID-19 pandemic is a wake-up call for improving Africa’s still weak health structures and related institutional capacity, such as education, infrastructure or national security. It also highlights the urgent need to strengthen data and statistical capacity, notably in relation to health and civil registration
A high level of respiratory diseases
Africa hosts 22 of the 25 most vulnerable countries to infectious diseases, according to the 2016 Infectious Disease Vulnerability Index (IDVI). The incidence of both infectious and non-communicable diseases such as chronic obstructive pulmonary disease (COPD) or asthma is high in Africa. Sufferers of these existing respiratory diseases make up the category most vulnerable to coronavirus, for whom the virus is often lethal. Infectious diseases such as pneumonia, tuberculosis or HIV-associated respiratory illness are amongst the commonest acute illnesses in African populations. Additionally, some African countries are already struggling with fighting endemic diseases such as tuberculosis or malaria and pre-existing infectious diseases such as Ebola or Lassa fever as well as facing a sharp increase of non-communicable diseases, namely diabetes, which also appears as an aggravating factor in the case of COVID-19.
Weak health structures and institutional capacities
Since the beginning of the outbreak in China, several countries on the continent have started implementing strategic plans to deal with the outbreak. The management and control of COVID-19 rely heavily on a country’s health capacity. Triangulating data on air travel from areas in China with active transmissions, as well as on the vulnerability to infectious diseases with the capacity of individual African countries to detect and respond to an outbreak, The Lancet found that “preparedness” and “capacity” of African countries varies greatly. Countries with the highest “importation risk” (Egypt, Algeria and South Africa) have moderate to high capacity to respond to outbreaks. Countries with the second highest importation risk ranking include Nigeria and Ethiopia, with moderate capacity, aggravated by underlying weaknesses such as high vulnerability to infectious diseases and larger populations potentially exposed. Morocco, Sudan, Angola, Tanzania, Ghana, and Kenya have similar moderate importation risk and medium population sizes; however, these countries present variable levels of capacity and an overall high vulnerability, apart from Morocco.
Multiple factors can weaken epidemic preparedness. Preparedness in low-income countries (LICs) is further challenged by the general weakness of health structures: poor quality of healthcare, low human resources capacity, lack of equipment and facilities and vulnerable supply chains. The CSIS (Center for Strategic and International Studies) estimates the financing gap in epidemic preparedness at $4.5 billion per year in LICs and LMICs (lower-middle income countries). The ODI (Overseas Development Institute) also highlights that countries with constrained fiscal resources are less resilient and more vulnerable to epidemics, with less scope for fiscal and monetary interventions.
While most governments across Africa already rely heavily on assistance from donors in the health area, finding domestic resources to pay for the response will become increasingly difficult. UNECA (United Nations Economic Commission for Africa) estimates Africa will be hit by an unanticipated increase in health spending of up to $10.6 billion due to coronavirus and by inflationary pressures due to supply side shortages in food and pharmaceuticals. According to UNECA, African economic growth will drop from 3.2% to 1.8% and the deep global slow-down will most strongly hit African economies, especially resource-dependent ones such as Nigeria’s, which depends on oil for more than half of government revenues and has already seen global oil prices fall by 13% this year. Revenue losses could lead to unsustainable debt.
Current structures for disease control in africa: a rather swift and coordinated response
The Africa Centres for Disease Control and Prevention – CDC (2017) The International Association of National Public Health Institutes – IANPHI (2006) The Africa Taskforce for Coronavirus – AFCOR (5 February 2020) Against the backdrop of the Ebola crisis in West Africa, the African Union (AU) Heads of State and Government recognised the need for a Specialised Agency to support AU member states in their efforts to strengthen public health systems and to improve surveillance, emergency response and prevention of infectious diseases. This resulted in the launch of the Africa Centres for Disease Control and Prevention (Africa CDC) in January 2017. Along with the European Centre for Disease Control and Prevention, Africa CDC is the first public health institute mandated to harmonise infectious disease surveillance and control among a group of independent countries. The Africa CDC has five strategic pillars:
- Surveillance and disease intelligence
- Emergency preparedness and response
- Laboratory systems and response
- Information systems
- Public health research
The Africa CDC started COVID-19 preparedness measures as early as mid-January when it activated its Emergency Operations Centre and Incident Management System, developed an Incident Action Plan and organised an emergency gathering of health ministers to develop a continental strategy.
The International Association of National Public Health Institutes – IANPHI (2006)
At national level, National Public Health Institutes (NPHIs) provide the platform to ensure that the pillars of the Africa CDC are integrated and coordinated. NPHIs are science-based government institutions or organisations who coordinate public health functions and programmes to prevent, detect, and respond to public health threats, including infectious and non-infectious diseases and other health events. Many NPHIs have been created after fragmented and insufficient responses from health systems to previous crises. NPHIs also ensure compliance with international norms and standards such as the WHO’s International Health Regulations (IHR) and the Global Health Security Agenda (GHSA).
The Africa Taskforce for Coronavirus – AFCOR (5 February 2020)
In cooperation with the African Union Commission (AUC) and the WHO, Africa CDC established the Africa Taskforce for Coronavirus (AFCOR), with six work streams:
- laboratory diagnosis and subtyping
- surveillance, including screening at points of entry and cross-border activities
- infection prevention and control in healthcare facilities
- clinical management of people with severe COVID-19
- risk communication
Supply-chain management and stockpiles This has led to the continent notably stepping up its preparedness measures for COVID-19. As of 7 March, at least 43 African laboratories in 43 African countries have already been trained to diagnose the virus while in the beginning of February only two laboratories – in Senegal and South Africa – had been capable to test for the virus. Several training exercises for incoming analysts as well as African experts and countries have been held to prepare for and enhance events-based surveillance. 22 AU member states were trained to strengthen infection prevention and control capacities in healthcare facilities and with the airline sector. Using a free online training course by the WHO 11,000 African health workers have been trained on the virus and the Africa CDC has trained government officials from 26 countries in public information management. In addition, individual countries in Africa are taking necessary steps to enhance their preparedness and to limit the risk of spreading. For example, Nigeria trained rapid response teams in all 36 states which can be deployed in the case of an outbreak, Kenya opened a quarantine centre in Nairobi for suspected cases and Rwanda has put up mobile handwashing sets for public transport passengers.
The elephant in the room: general lack of data and weak statistical capacity
The capacity of African countries to address healthcare challenges remains hindered by a lack of data coverage, stemming from weak statistical capacity. Quality statistics are essential for all stages of evidence-based decision-making and policy formulation, namely in healthcare. However, the lack of funding and autonomy for National Statistics Offices (NSOs) means that they still have inadequate access to and use of data, are unable to use the latest statistical methodologies, and have statistical knowledge gaps in metadata flow and data updating. This represents a significant challenge for the timely production of quality data, crucial in times of epidemic emergency.
Data coverage on health facilities and health outcomes is low The capacity of African countries to address healthcare challenges remains hindered by a lack of data coverage, stemming from weak statistical capacity. Quality statistics are essential for all stages of evidence-based decision-making and policy formulation, namely in healthcare. However, the lack of funding and autonomy for National Statistics Offices (NSOs) means that they still have inadequate access to and use of data, are unable to use the latest statistical methodologies, and have statistical knowledge gaps in metadata flow and data updating. This represents a significant challenge for the timely production of quality data, crucial in times of epidemic emergency.
The lack of statistical capacity thus represents a major obstacle to obtaining quality health data in Africa, consequently making the production of evidence-based policy and responses to health challenges more difficult. Open Data Watch’s Open Data Inventory (ODIN) assesses the coverage of statistics produced by National Statistical Systems (NSSs) as published on the official website of the NSOs. Coverage refers to the availability of statistical indicators in 21 data categories grouped into social, economic, and environmental statistics clusters. The five criteria of coverage assessed are: indicator coverage and disaggregation, data available last five years, data available last ten years, first administrative level, and second administrative level.
Health facilities data
The 2018 ODIN shows data coverage on health facilities has increased on average since 2015 and is the best covered social statistic on the ODIN, with an African average of 43.6%. The best performing African countries are Algeria, Burkina Faso, Burundi, Niger, Mozambique and Sierra Leone with 80.0% data coverage. The worst performing African countries are Guinea-Bissau, Madagascar, Malawi, São Tomé and Príncipe, Somalia, South Africa, South Sudan and Swaziland all with a zero coverage. Concerningly, South Africa and Nigeria, both WHO identified priority countries regarding COVID-19, only score 0.0% and 10.0%, respectively.
Patchy civil registration and vital statistics (CRVS) systems are the first obstacle to efficient health policies
Civil registration is the recommended source for vital statistics. It constitutes the only robust means by which countries can maintain continuous and complete records of vital events such as births and deaths. A civil registration system is a critical element for establishing the legal identity of individuals, providing them with access to public services and securing basic human rights. Civil registration is therefore essential for accessing healthcare.
However, the lack of funding and autonomy for National Statistics Offices (NSOs) means that they still have inadequate access to and use of data, are unable to use the latest statistical methodologies, and have statistical knowledge gaps in metadata flow and data updating. This represents a significant challenge for the timely production of quality data, crucial in times of epidemic emergency
The Coverage of Birth and Death Registration dataset from UNStats paints a similarly bleak picture. Of the 42 African countries with their latest observation in the last ten years of available data (2009-2018), only eight have a birth registration system with a coverage rate higher than 90.0%. The worst performing countries on the African continent are Chad and Tanzania (12.0% and 13.3%, respectively). While the available data points on coverage rate of the birth registration system in Algeria, Libya, Tunisia and Djibouti are higher than 90.0%, they are all outdated (2001 for Algeria, Libya and Tunisia, 2006 for Djibouti).
Any pandemic requires by nature a general coordination of efforts besides national or regional borders, even more so in a globalised world. Epidemics are a reality test for public governance and leadership, not only at country level, but also at regional and continental levels, among African institutions and organisations, as well as in connection with the wider network of multilateral actors and partners. This paper has focused on the immediate health challenges. But we also need to think and act ahead. COVID-19’s global outreach will have a huge economic and wider impact on the entire African continent. Occurring later, it will isolate Africa from other recovering regions. On the continent, the pandemic will widen inequalities within and between countries, worsen already existing fragilities, restrict employment and investment prospects, and potentially fuel additional domestic unrest and conflicts. This requires immediate attention, and calls for adequate, coordinated responses.
Les Wathinotes sont soit des résumés de publications sélectionnées par WATHI, conformes aux résumés originaux, soit des versions modifiées des résumés originaux, soit des extraits choisis par WATHI compte tenu de leur pertinence par rapport au thème du Débat. Lorsque les publications et leurs résumés ne sont disponibles qu’en français ou en anglais, WATHI se charge de la traduction des extraits choisis dans l’autre langue. Toutes les Wathinotes renvoient aux publications originales et intégrales qui ne sont pas hébergées par le site de WATHI, et sont destinées à promouvoir la lecture de ces documents, fruit du travail de recherche d’universitaires et d’experts.
The Wathinotes are either original abstracts of publications selected by WATHI, modified original summaries or publication quotes selected for their relevance for the theme of the Debate. When publications and abstracts are only available either in French or in English, the translation is done by WATHI. All the Wathinotes link to the original and integral publications that are not hosted on the WATHI website. WATHI participates to the promotion of these documents that have been written by university professors and experts.