Since the first quarter of 2020, the Tony Blair Institute has been working alongside partner governments in 15 countries to support their responses to Covid-19. As part of this, we have provided advice to governments on a range of critical issues from containing the pandemic to promoting economic recovery. Many of our in-country teams have been working on the ground at various levels of the response, from the central committees established to coordinate cross-government efforts and within countries’ national emergency operations centres focusing on day-to-day response efforts, to within the Nigeria Centre for Disease Control (NCDC), supporting coordination of public-health measures in the continent’s most populous country.
From this vantage point we have been able to observe some of the critical elements that have characterised Africa’s containment of Covid-19 and consider what they might mean for the continent’s future. So, for the final publication of the year on Covid-19 in Africa, our Government Advisory team has produced a short compendium of case studies and insights from Africa’s pandemic response.
Covid-19 has taken a radically different course in Africa than anywhere else in the world. Eight months ago, there was concern that the world’s poorest continent, which is often seen as having among the weakest health infrastructures, would be overwhelmed by the emerging pandemic. Today, many are now wondering why Africa, although still paying huge economic and social costs, has comparatively so few cases and deaths.
A young population, relatively low incidence of non-communicable comorbidities, low population densities outside of cities and lower population mobility all seem to provide plausible explanations as to why Africa’s trajectory has been so different from others, and more evidence is emerging. But they all paint Africa as a passive beneficiary of demographic and epidemiological circumstances. They do not account for the actions African countries and institutions have proactively taken – the rapid and decisive policy responses and in some cases innovations, drawing on previous experiences of infectious disease and the continent’s growing strength in technology. Put simply: African leaders and institutions are not being given the recognition they deserve for their notable contributions to limiting the spread of Covid-19 in Africa.
Within little more than 100 days of the Chinese index case (also known as “patient zero”) being recorded, almost every sovereign state had detected at least one case within its borders. Nine months on, more than a million people are dead. Africa’s most internationally connected population centres and major business hubs – Algeria, Egypt, Nigeria and South Africa – were the first to detect Covid-19 cases on the continent.
Early on, Covid-19 was perceived by many in the Global South as a “disease of the rich” – concentrated in well-off neighbourhoods and expat compounds, brought into the region by business travellers and the mobile elite.[_] Sales of protective equipment and diagnostic supplies have been dominated by China as the world’s largest exporter.[_] Vaccine candidates have been pioneered by American, European and Chinese pharmaceutical companies with a disproportionate percentage of their trials located in, and initial production pre-orders coming from, the prosperous Global North.[_] Meanwhile, the interest in certain unproven drug treatments, chief among them the malaria drug hydroxychloroquine, supported by the US president, received global media coverage and doubtlessly contributed to the emergence of black markets across Africa.[_]
Clearly the globalisation of public health is intertwined with the globalisation of trade and economics – and yet the institutions to cope with the former are not nearly as developed as those which have given rise to the latter. The World Health Organisation’s finances have been strained and its legitimacy and value has been questioned by some, including the US.[_] Even well-integrated political unions with high-capacity members, such as the EU, have faced major collaborative hurdles and found weaknesses in their health institutions.[_] Only about half of sub-Saharan African countries are members of the International Association of National Public Health Institutes.[_][_]
Rather than rallying together for a synchronised response, global collaboration on policy and practice has been poor on the whole. This has been disproportionately detrimental to Africa and others in the Global South. Instead of working for equitable distribution of critical supplies, countries with means scrambled, stockpiled and banned exports in such a way that drove prices up and caused disproportionate challenges for the poorest countries. The money committed by the international community to close funding and capacity gaps in the Global South has fallen well short of what is needed. It is within this context that African countries have had to cope with Covid-19 and it provides an important counterpoint to the far more collaborative approach which characterised the response of African leaders.
The African Union (AU), under the leadership of President Cyril Ramaphosa of South Africa, recognised the importance of collaboration between countries within in Africa, given that global cooperation has not delivered the support that would be required. As a result, the AU worked to provide leadership and has coordinated – directly or through its technical institutions – a number of multilateral initiatives.
It became clear quickly that a unified capacity for engaging with the international financial institutions and the private sector would be critical. In March, the AU brought together African finance ministers to write a joint letter to the IMF, World Bank and European Commercial Bank expressing their need for immediate additional resourcing of $100 billion to support the continental effort to tackle Covid-19. By June, President Ramaphosa’s special envoy on Covid-19 – Executive Chairman and Founder of Econet technology group Strive Masiyiwa – mobilised partnerships to support the effort to source PPE and other vital medical supplies, and broker deals for financing.
As part of this effort for coordination, as we set out in a companion case study, the Africa Centres for Disease Control and Prevention has come into its own as a relatively young and ambitious organisation that has carved out a leading role in public-health advocacy and advisory across the continent. It has pivoted quickly to tackle Covid-19 – convening, communicating and advocating on behalf of all AU member states. It has achieved this in spite of its small size and mandate to support countries of generally low public-health capacity amid supply shortages. In light of these achievements and to ensure greater security for the future, whether in relation to Covid-19 or beyond, it should undoubtedly now be strengthened.
Continental leadership has been important, but ultimately each country assessed its own risk and took action that it considered to be appropriate. Analysis of data on the health-protection and viral-containment measures that African countries introduced shows these countries reacted decisively and quickly once the first case was confirmed (we explore this in more detail in a companion article). Their stringent responses have come in spite of the potentially greater risks that restrictions may pose to often informal African economies. In fact, more than two-thirds of sub-Saharan African countries introduced some health and containment measures before the first case in the region had even been confirmed. Once their respective first cases were confirmed, the average sub-Saharan African country introduced more stringent measures and at a greater speed than the average EU country.
The work of national health institutes and biomedical-research bodies also deserves recognition, for the way they have promoted surveillance, led public awareness efforts and navigated delicate relationships with political institutions. As outlined in our companion case study on the NCDC, the leadership of the organisation has been at the heart of the federal response to the Covid-19 pandemic in Africa’s most populous country – while simultaneously containing a number of other outbreaks of infectious diseases. It worked closely with institutions at international, national, state and local levels, and with a number of scientific and political organisations. Its director, Dr Chikwe Ihekweazu, has been clear about the challenges the NCDC has faced and his determination to build on the momentum of the Covid-19 response to create a more sustainable public-health infrastructure for the future by increasing the capacity of local and state public-health institutions and building stronger relationships with the private sector. Meanwhile in Senegal, the Institut Pasteur de Dakar (IDP), led by Dr Amadou Sall, has been instrumental in supporting the country’s response in creating a network of laboratories to process tests. The IDP is now also hosting the new DiaTropix platform which, among other projects, will develop, manufacture and distribute new low-cost diagnostic tests that will bolster the capacity of African countries to test and contain the virus.
While a scarcity of resources has been a defining characteristic of the pandemic response in Africa, many African countries were, in fact, better prepared than the Global North to stand up robust responses to a new infectious disease strain. Systems originating from efforts to control the spread of HIV, or emergency structures arising from the Ebola crisis, could be swiftly repurposed or reactivated in the face of community transmission of Covid-19. Many countries on the continent have implemented an aggressive contact-tracing and isolation regime (we look at this in detail here) using extensive networks of community health workers, among other assets. Important lessons in contact tracing can be learned from effective strategies deployed in Africa, especially as governments around the world seek to loosen mobility restrictions and safely reopen their economies.
This focus on repurposing existing structures has been crucial, and governments and the private sector have had to innovate and evolve as Covid-19 completely changed the economic landscape. Many African countries have struggled with an acute shortage of PPE due to disruption in the global supply, exacerbated by Africa’s heavy reliance on imports for essential medical equipment. At the same time, as lockdowns and more limited purchasing power led to decreased demand in many traditional manufacturing sectors, governments and the private sector have responded to the opportunity that pivoting and repurposing manufacturing presents, to meet national demand for essential medical items and keep the economy and local businesses afloat. As set out in this case study on repurposing manufacturing, while much of this adaptation will undoubtedly be temporary, it does raise questions about whether this could be the beginning of a shift to greater self-reliance in pharmaceutical and medical supply production across the continent, contributing to Africa’s move to further industrialisation, itself a protective factor against future shocks.
Finally, a number of African countries are leading the tech revolution and capitalising on an emerging generation of technologists in the region to develop technology-enabled solutions (we explore these tech innovations here). Cross-sector partnerships are facilitating the rapid development of innovative tech-enabled solutions that are being used for everything from producing evidence-based policy to protecting indispensable frontline workers and enhancing public-service delivery. It is within this context that the Tony Blair Institute and Oracle are supporting sub-Saharan African countries to manage large-scale vaccination programmes against not only Covid-19 but yellow fever, HPV and routine childhood immunisations, using a cloud-based health system that will help revolutionise immunisation campaigns through data.
Together, these case studies provide insight into the efforts African governments and institutions have made to manage the pandemic in spite of the capacity and resource challenges they face and amid weak global coordination. They demonstrate that while Covid-19 is undoubtedly one of the greatest threats the world has faced in recent years, it has also provided an opportunity for greater pan-African collaboration and encouraged the development of more robust and sustainable public-health structures, systems and capacities.
It has been a privilege to support our partner governments through this crisis, and we pay tribute to the leadership many have provided. We hope this compendium brings attention to the lessons learned and provides a fresh perspective on how a public-health crisis can be approached as well as recommendations for the future.
Read the articles and case studies in the Insights From Africa's Covid-19 Response series:
Insights From Africa’s Covid-19 Response: Repurposing Manufacturing
Insights From Africa’s Covid-19 Response: Decisive National Action