Managing Director & Senior Partner; Head of Social Impact Practice for EMESA; Member of BCG's Executive Committee
The novel coronavirus has arrived in Africa—and the outbreak will look different there than in other parts of the world. Consider the demographics. COVID-19 has exacted a heavy toll among older patients in most countries, but Africa has a young population, and younger people who contract the disease seem to fare relatively well. However, Africa will face unique challenges, too. Health-care systems on the continent remain weak and will not be able to handle a widespread outbreak. In addition, many people there have serious health issues—such as HIV, tuberculosis, or acute malnutrition—that make them vulnerable to other illnesses. And social distancing will be difficult to establish in Africa, particularly in poor populations that need daily income to survive. As a result, the death toll in Africa is likely to be concentrated among the malnourished, the sick, and the poor.
In facing those challenges in the weeks and months ahead, African governments will have to make some difficult trade-offs. They must find a balance between tackling the disease in an already constrained health-care system and addressing the needs of patients with other health issues. They must also gauge the benefits of containing the spread of COVID-19 against the potential negative impact of preventive measures on the economy, employment and incomes, safety, and food security. And African governments will be managing those tradeoffs at a time when a drop in oil prices and exports puts additional strain on their economies and when stakeholders that have helped respond to previous African health crises are consumed with managing the crisis in other parts of the world.
Some factors work in favor of an effective African response. Governments in the region already understand the magnitude of the challenge, given the toll of the pandemic elsewhere, and some are acting more swiftly than other countries have. Among the actions that some countries on the continent have taken so far are confinement measures, shelter-in-place orders, closure of frontiers, and widespread establishment of handwashing stations. Moreover, some countries and global organizations have improved their pandemic preparedness, especially since the Ebola outbreak of 2014.
Strategies will undoubtedly change as the crisis evolves. But key stakeholders must put the right foundation in place now in order to effectively implement those strategies and avoid repeating missteps that occurred during previous health crises in Africa. Three critical enablers will establish this foundation:
With these steps in place, the continent will be better prepared to execute prevention and treatment strategies, as people learn more about the pandemic’s course, and to mitigate the economic impact.
It is difficult to project with any confidence what trajectory the outbreak in Africa will follow, given the number of countries involved, the range of preparedness and resources across the region, and the potential impact of some early, proactive steps that governments have taken there. Regardless of the rate of disease spread, however, the impact of COVID-19 on patients in Africa will be buffered by some unique factors and magnified by others.
Data from countries that are further along in the pandemic, including China and Italy, consistently indicates a much higher fatality rate among the elderly. If that pattern holds, Africa’s relatively young population could help buffer the continent against the rates of severe cases and fatality observed elsewhere in the world. For example, as of February 11, over 80% percent of the deaths in China due to COVID-19 were among people 60 years old or older. In China, people in that age group account for 16% of the population, whereas in Africa they make up just 5% of the population.
Other factors, however, exacerbate the pandemic’s challenges. First, the weak health-care systems in much of Africa will not be able to give many patients the care they will need. Many health-care systems in the developed world are swamped with severe cases, but African countries are in an even more vulnerable position in this regard because they have significantly fewer hospital beds per capita. For example, the most recent data available indicates that Ethiopia and Niger each have 0.3 beds per 1,000 people, and Tunisia has 2.3, compared to an average of 5.6 in Europe. Africa has constrained tertiary-care capabilities, including critical care units, and limited medical supplies in many places. The region’s relatively small number of ventilators, together with oxygen supply issues, will pose a major challenge in a health-care system that already struggles to meet basic needs.
Second, a significant number of adults in Africa have compromised immune systems, mostly owing to the high prevalence of HIV infection and HIV-tuberculosis co-infection. Data on the fatality rate for immunocompromised COVID-19 patients is limited, but early data indicates that the rate for individuals with certain chronic medical conditions is up to five times higher than the overall case fatality rate.
Third, malnutrition may make children more susceptible to COVID-19. There is a significant level of acute malnutrition, also called wasting, on the continent, including a prevalence rate of approximately 10% in Ethiopia and Nigeria as of 2016. Given that the increased risk of mortality from diseases like pneumonia is up to 36 times higher for malnourished children, COVID-19 puts this population at significant risk.
Around the world, the COVID-19 outbreak is putting significant strain on countries’ health-care systems, economies, and social fabric. In the months ahead, African countries will face many of the same issues, as well as some impacts that are unique to the continent.
Health-Care System. Given the low capacity of the health-care systems in most parts of Africa and the prevalence of other serious illnesses, COVID-19 could quickly overwhelm the system. That’s because the disease has symptoms that are similar to those of other common illnesses treated at the primary-care level, spreads easily through a population, and has high rates of complication and mortality for the elderly and for people with co-morbidities. At the same time, it will be difficult to deploy certain major mitigation measures in Africa. Consider social distancing. In African cities—and particularly in tightly packed informal settlements—keeping people apart is no simple thing. And although people are relatively dispersed in rural areas, communicating information about social distancing in order to change behavior there will be challenging. Furthermore, many people in Africa do not have food supplies on hand and rely on daily wages to survive, making it impossible for them to stay home for an extended period.
If health-care systems in the region become overwhelmed, the consequences could be dire. First, deaths among patients with other illnesses could spike, and other types of public health measures could falter. Second, citizens’ distrust could increase, leading patients who need treatment to avoid seeking care. During the 2014 Ebola crisis, a lack of trust in the health-care system contributed to the spread and lethality of the disease. Third, the capacity of the already weak health-care system could erode further if large numbers of health-care workers fall ill.
Economy. COVID-19 will undoubtedly depress economies in Africa, as it continues to do around the world. An economic slowdown will trigger revenue declines for small businesses and larger companies operating in Africa, including those in the tourism industry. Citizens will face job losses and reduced wages as companies lay off workers, and as workers operating in the informal economy lose income as well. At the same time, foreign direct investment in the continent will likely stall.
The likely impact on the agricultural sector is more complicated. The pandemic could disrupt food supply chains and trade. In particular, misinformation, panic, or unexpected border disruptions could trigger prices shocks—already a risk due to recent desert locust activity. In 2014, during the height of the Ebola outbreak, rice prices increased by more than 30% in the three worst-hit West African countries (Guinea, Liberia, and Sierra Leone). On the other hand, if borders remain open and trade continues to flow reasonably well, countries in Africa could hold up better than economies in other parts of the world because demand for agriculture products across the continent and globally would remain high.
Companies and governments are likely to face shortages of cash and working capital. If African economies slow significantly, tax receipts will drop, limiting government liquidity. That, in turn, could hamper governments’ ability to pay for the workers, infrastructure, and supplies needed for the emergency response and to provide economic stimulus to mitigate a serious economic downturn. Several African countries are already implementing shelter in place or lockdowns, so these liquidity issues could surface quickly.
Society. As COVID-19 cases grow and the health-care system and economy come under intense pressure, several social challenges will emerge. Families may lose incomes and have trouble acquiring food and other basic necessities. Family structures may suffer significant disruption as people are lost to the disease; and community cohesiveness may break down as governments prohibit gatherings, funerals, and other events that reinforce bonds. At the same time, misinformation and conspiracy theories may spread, and unrest and crime may surge as people grow more desperate, intensifying fear in communities.
The disease’s spread could also increase social inequity, in the same way that HIV/AIDS had a major and disproportionate impact on specific vulnerable and marginalized populations. In the case of COVID-19, school closings may disrupt school-based nutrition programs and children’s learning. At the same time, existing socioeconomic inequity will inevitably lead to disparities in people’s access to health care, food, and supplies. And interventions such as shelter in place could exacerbate inequity by reducing wages for workers, especially those in the informal sector.
The strategy and actions needed to combat the COVID-19 outbreak in Africa are still coming into focus. But those measures are likely to fall short unless the right foundation for the response is immediately put in place. BCG has been actively involved in helping to address a number of past humanitarian crises in Africa, including the Ebola outbreak of 2014. In light of those experiences—as well as of work we are doing today with public-, private-, and social-sector organizations to combat the COVID-19 pandemic—we believe that the right foundation for an effective response in Africa requires alignment among stakeholders at three critical levels.
Regional Response. Many governments in Africa are moving quickly to implement a national response to the pandemic. But Africa is a vast continent composed of 54 countries, and porous borders and significant interdependence among countries (with respect to food supply, for example) make regional coordination critical as well.
A strong regional response should have three elements. First, regional and subregional institutions must share information and resources, including data on the spread of the disease, details of their response plans, capabilities such as epidemiological modeling, and material such as health-care equipment. Second, regional and subregional institutions need to ensure that movement of food and essential supplies continues even if borders are closed, since these actions will support food security and help minimize the disruption to economic activity along supply chains. Third, governments and institutions in the region must maintain their commitment to social progress, including ensuring human rights and sustaining advances made on key sustainable development goals outside health, such as gender equality. As the leading pan-African institution for regional cooperation, the African Union has a critical role to play in driving action in all three of these areas.
Coordination Among Global Players. A wide range of groups and organizations will be involved in developing and supporting responses to the COVID-19 outbreak in Africa. That is good news in many ways, but it also increases the risk of poorly coordinated relief efforts, hampered by duplication, significant gaps in coverage, and a failure to share lessons and best practices. Such inefficiency has been the norm in previous global health efforts and is very likely in a situation as large and complex as this one. But it could prove especially costly in Africa today, given the speed with which the coronavirus is spreading and the degree to which resources are constrained as governments everywhere try to quell the outbreak.
The answer is a step-change in the level of coordination among federal governments, donors, the private sector, NGOs, and faith-based organizations that are on the ground in Africa. Improved coordination will enable these groups to align on an effective response strategy, translate that strategy into operational plans, and assign roles and responsibilities to the major global players.
Donors, in particular, need to align on their strategies and on the roles each will be playing—and then reach out in a coherent and unified way to governments and other groups to provide assistance. For example, they should develop a coordinated process for assessing needs within specific African regions and countries and for meeting that demand with the materials and resources available from suppliers, donors, and other providers around the world. The World Health Organization’s creation of the COVID-19 Partners Platform to match country needs with donor funds is a positive step in this direction. Donor organizations can also play a crucial role by funding data and modeling efforts to track the spread of the disease across regions and cities and to identify the potential health and economic impacts of different actions—capabilities that African governments can then share.
Achieving the required levels of coordination may require novel approaches. During the Ebola outbreak, for example, the UN took the lead, setting up the UN Mission for Ebola Emergency Response (UNMEER) to coordinate global action. That move reflected the urgent need for global coordination. The COVID-19 pandemic demands a similar effort to find or devise practical mechanisms for ensuring alignment among global actors.
Community Mobilization. One crucial lesson of the response to the Ebola outbreak is that even the best-designed government response will not work unless people take the mitigating steps that the government recommends. In the Ebola epidemic, initially rampant misinformation and rumors fueled distrust of formal institutions and led communities to resist acting in ways that were critical to their own safety. Eventually, authorities overcame that challenge through insights from anthropologists, who helped adapt the epidemic response to the local context, and through support from community and faith-based leaders and local organizations.
Similarly, efforts to control COVID-19 on the continent must take cultural norms into account and must address the potential stigmatization and isolation of individuals with the infection. In light of the disease’s potential to create social upheaval, a robust community-based response will be critically important now and, likely, for a sustained period. Key organizations and structures—including community- and faith-based organizations, village leaders, and local governments—need to be involved in the effort from an early date to support the response and to help tweak it for maximum effectiveness in each local context.
The entire world is grappling with the unprecedented spread of COVID-19. The outbreak has come a bit later to Africa than to many other places around the globe, but it poses a significant threat there. Quick, aggressive action is essential to ensure that the pandemic does not significantly undermine the progress that the continent has made over the past several decades.
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