Insights From Africa’s Covid-19 Response: Decisive National Action

How different countries and regions around the world initially responded to the emergence of Covid-19 seems to have depended greatly on their local political context. China mobilised fairly rapidly at the domestic level, aided by a well-established epidemic response system and a powerful state, though some have questioned how transparent the country was with the international community in the initial stages of the outbreak.^[_] Europe, which responded during the 2009 H1N1 (swine flu) pandemic with what was described in a World Health Organisation (WHO)-supported assessment as a widespread “general weakness in core preparedness capacities”, encountered challenges in increasing its surveillance capacity. Meanwhile, the United States, with its complex federal system, polarised political culture and a president who has talked down the threat that the virus poses, has one of the world’s highest number of cases and deaths per capita.^[_] Here, political party affiliation predicts both the stringency of containment policies introduced by state governors and the extent of individual behavioural change to prevent the spread of the virus.^[_]

Among all of this, relatively little has been said about Africa. And what little has been said about low case and death rates in the region has not been positive. There have been suggestions that governments are concealing data about the true extent of their outbreaks, that they are not testing widely enough for an accurate picture, or that they have been the passive beneficiaries of certain epidemiological or demographical circumstances that make these countries inherently less vulnerable – such as a lower average age, lower incidence of non-communicable comorbidities that increase risk of serious Covid-19 illness, lower population density or lower population mobility.

These reports do not paint a full picture. It is true that testing capacity on the continent has been quite severely constrained: Many countries have much higher test positivity rates than would be expected if testing was being carried out widely enough, and the erratic number of new cases reported from one day to the next implies weaknesses. But we believe that African leaders have taken the virus seriously and sought to rapidly convince their populations of the same.^[_] We have analysed the scores of sub-Saharan African and EU countries on the Oxford Covid-19 Government Response Tracker containment-health index – an aggregated scale reflecting the stringency of lockdown measures in different countries, as well as their policies on testing and contact tracing, described as “most relevant for measuring efforts to break the chain of infection” – at various stages of the outbreak,^[_] which tells a story of how African countries reacted decisively and quickly to the threat of Covid-19, relative to both the date of their first confirmed case and compared with responses from leaders in other countries.

The first confirmed case in Africa was detected in an asymptomatic Chinese national in Cairo on 14 February; the second in an Italian national in Algiers on 25 February; and the third  case (and first in sub-Saharan Africa) in an Italian national in Lagos also on 25 February.^[_]

Dating first cases is, of course, an imperfect science. Limited testing capacity in the early stages of the outbreak combined with poor public understanding of the virus and the asymptomatic nature of a large proportion of cases means the exact arrival date in different regions of the world and specific countries is unclear. Though more than three-quarters of sub-Saharan African countries detected their first cases in the 14 days between 9 and 22 March, it cannot be ruled out that Covid-19 was present in these countries earlier.

Nonetheless, because sub-Saharan African countries were some of the last in the world to detect their first cases, somewhat more was known medically and epidemiologically about the virus by the time these governments could say for certain that it was present in their populations. By this time, there were some emerging schools of thought – both prevailing and dissenting – on how to contain it. In the face of the virus, African states had two major categories of action available to them: border controls to stop the virus being imported (and continuously reimported) from abroad, and domestic measures to stop it spreading once it had arrived. Different categories and combinations of action entail different economic and political costs. While international public-health bodies sought to advise governments and coordinate action across borders, ultimately each country assessed its own risk and took action that it considered appropriate.

A number of milestone moments could have catalysed government action in the initial stages of the outbreak, including the detection of the first case outside China on 13 January, detection of the first case outside of Asia on 20 January and the WHO’s declaration of a Public Health Emergency of International Concern on 30 January.^[_] A few African countries seem to have been moved by these developments. In January, 35 per cent of sub-Saharan African countries introduced some, albeit limited, measures, and 60 per cent had introduced some by the time of the first confirmed case of Covid-19 in the region on 25 February.^[_] When it came to introducing containment measures, Botswana was not only the first mover in sub-Saharan Africa but among the first in the world, making its first climb on the containment-health index on 1 January, just one day after the Wuhan Municipal Health Commission in China reported a cluster of cases of a then-unidentified virus. Within days of the first case being identified outside of Asia, further action was taken. Though Botswana now has the highest compound daily growth rate of cases in the region, its initial rapid mobilisation may have paid some dividends, as it was one of the last sovereign states in the world to record a case. The day before their first respective cases, only the Central African Republic, Djibouti, Côte d’Ivoire, Mauritius, Senegal and Togo were at 0 on the index, while the average score on the containment-health index was 15.27.

Twenty-eight sub-Saharan African countries declared some variation of a state of emergency.^[_] Sierra Leone declared a 12-month public-health emergency on 25 March, almost a week before the country detected its first case, and in a televised address the president closely reflected the WHO’s narrative and warnings about the virus. President Bio recognised both the inevitability of its arrival in Sierra Leone and the need for commensurate measures, as well as the likely economic hardship that would arise from those measures. He sought to promote compliance with public-health measures while averting panic.^[_] Malawi, Sao Tome and Principe, and Lesotho also declared emergencies before they had confirmed their first cases, while the state of emergency introduced in Cape Verde was the first in the country’s history.^[_] Almost 60 per cent of sub-Saharan African countries declared an emergency before or within ten days of their first case, with an average of five confirmed cases at the time the declaration was made. About 35 per cent of countries had at least one death by this time, though a number of these countries – including Botswana, Ethiopia, the Gambia, Niger and Sudan – declared their state of emergency almost immediately after their first death was confirmed.

Undoubtedly for the majority of countries, the identification of their own first cases was the biggest impetus for action. In the month after their respective first detected cases, the average sub-Saharan African country acted more decisively than the average EU country – imposing more stringent containment measures overall and more rapidly. The average sub-Saharan African country’s score on the containment-health index on the day of its first case was nine points higher than that of the average EU country; and the average sub-Saharan African country climbed a further 19 points in the five days following. This compares with only five points for the average EU country over the same period. While the rate of increase for the average EU country’s score does accelerate considerably ten days after its first case, it nonetheless takes two and a half times as many days after its first case as the average African country does to reach 50 on the index, showing a slower overall response.

By 30 days after the first case, the average sub-Saharan African country’s score (68) is still about 14 points higher than the EU member country’s score (54). By this stage, more than half of sub-Saharan African countries had a score on the index of 70 or more, considered highly stringent, while only one-third of EU countries had the same. Only one country in sub-Saharan African had what might be categorised as a low score on the index of less than 30 by this time, while more than a quarter of EU countries were within this category.

Table 3 – Comparing the scores of sub-Saharan African and EU countries 30 days after first cases recorded

Some countries made huge leaps in their containment-health index scores immediately after their first cases were declared – including an increase of 45 points in a single day after Madagascar confirmed its first case, an increase of 33 in Eritrea and 35 in the Gambia, indicating a raft of containment policies were immediately implemented. Other significant five-day increases, compensating for earlier delays in reaction, included an increase of 50 points between one and five days after Djibouti’s first case, 48 between 10 and 15 days after Congo’s first case and 42 between 20 and 25 days after Chad’s first case. Meanwhile, countries that identified their first cases comparatively late did not wait before acting. They observed developments on the rest of the continent, acknowledged that it was only a matter of time before they too discovered their first patient and took decisive action. South Sudan and Lesotho were the final two sub-Saharan African countries, and among the last sovereign states in the world, to detect their first cases. But they did not wait until that moment to introduce stringent measures. By the day of their first cases, on 5 April and 13 May, they scored 64.58 and 55.56 on the health-containment index respectively.

Kenya and Uganda both introduced Covid-19 screening for all arrivals at airports on 20 January, the day evidence that the virus had spread beyond the Asian continent was revealed. They did so before any EU country did, while nine other sub-Saharan African nations did so before the WHO had declared Covid-19 a health emergency. These countries were ahead of the European curve of action. In fact, sub-Saharan African countries on average imposed controls on international arrivals earlier in the course of their outbreaks compared to EU countries. They were also more likely to pursue progressively more stringent measures than EU countries. While in the end more than nine-tenths of sub-Saharan African countries completely closed their borders to foreign nationals, only around one-third of EU countries did the same.

Stay-at-home orders were among the most significant measures imposed early on in the pandemic. They were also among the most arduous, especially in Africa where there are large informal economies and where working from home is not feasible for much of the population. Nonetheless, the average sub-Saharan African country first required its residents to stay at home, except for limited and specific reasons, after just 13 confirmed cases and only 13 days after first one was detected. By contrast, the virus was known to have been present in the average EU country for 27 days before governments implemented similar restrictions, having caused 641 known cases by the time a lockdown was imposed.^[_] It seems that many sub-Saharan African governments were aware of their own testing limitations – and therefore conscious of their resulting data blind-spots. They realised they could not delay action and, having observed how the virus was unfolding in other parts of the world, acted comparatively quickly in an attempt to prevent the worst.

It has been argued that some of the African countries that were praised for their initially robust responses early on in the pandemic have since relaxed their health and containment measures too much and too quickly. This, it has been suggested, means they will not be able to sustain the benefits of having introduced stringent measures early on.^[_] We at the Tony Blair Institute for Global Change – among many others – have pointed out that strict lockdowns are disproportionately burdensome for African countries, whose economies are often more informal and whose fiscal capability to cushion the economic pain is weaker.^[_] Yet the data suggests that, on average, sub-Saharan African countries relaxed their measures and declined in their scores on the containment-health index in a broadly similar way to EU countries. While there are some outliers in sub-Saharan Africa, the majority of both sub-Saharan African and European countries reached their peak score on the containment-health index during April and May. As indicated in the figure below, when comparing the average sub-Saharan African and EU country in the five months after they reached their respective highest scores, the sub-Saharan African country’s score remains higher at the 60, 90, 120 and 150 day points. The average sub-Saharan African country had a slightly higher peak score on the index (76) than the average EU country (74). It also reached this peak slightly sooner after its first case was recorded (45 days) compared to the average EU country (56 days).^[_] A full five months after their respective peak scores had been first reached, sub-Saharan African countries had declined on the index by an average 22 points (to 54), compared to the average EU country which had declined by 23 points (to 51).

In Africa, a number of countries retained a high score on the index throughout the duration of the pandemic. Ethiopia’s score on the index five months after its peak score was first reached on 8 April stood unchanged five months later, at 73.61. Angola’s score on the index five months on from its peak was also virtually the same, having decreased by around ten points in the interim period before increasing again. The peak scores of Cape Verde, Chad, Eswatini, Kenya and Uganda have similarly deviated downwards no more than about ten points during the five months after they were respectively first reached.

Among the countries with the highest peak scores in sub-Saharan Africa, Djibouti’s score declined considerably over the ensuing months (having peaked at 97.92 on 10 May), while Rwanda’s (which hit 90.97 on 30 April) declined somewhat but remained one of the highest in the region. South Africa, which also had some of the region’s most stringent measures, maintained them until around September, after which time they were eased. Burundi had the single lowest peak score in the region at 21.53, but this remained fairly static over the following five months. On the mainland, the scores of the Democratic Republic of the Congo, Niger, Senegal and Sierra Leone also declined quite considerably over the five months.

Figure 7

Figure 5 – Scores on the containment-health index for sub-Saharan African countries and EU countries, up to 30 days after their first case recorded

Of course, restrictions still being in place does not mean they are being respected by the public. Some governments have issued warnings to their populations, who they say are failing to adhere to the guidelines – perhaps as a product of both “Covid fatigue” and a failure to understand the continuing threat the virus poses.^[_] Indeed, Perception for Evidence-Based Response to Covid-19 data suggests a significant proportion of the African survey population do not believe they are personally at risk of catching Covid-19.^[_] Given recent surges of cases in specific countries in the region, it might have been expected that more African countries would have latterly increased their score on the index after the earlier period of progressive easing. That this has not happened in most cases may well be a testament to the efforts of governments in the region to balance the pressures of saving lives and saving livelihoods.

The way the pandemic has unfolded, and the precise nature of the response, has varied country to country. More detailed country-level analysis is necessary to enhance our understanding of the likely effectiveness of different combinations of measures at different times in different places. The limitations of the data that is available, and the many ways it can be presented and interpreted, must be acknowledged. But what is clear is that sub-Saharan Africa countries were – in general – as decisive, speedy and sustained in their responses as EU countries were, and in many cases more so. We believe this must contribute to some extent to the comparatively low number of Covid-19 cases and deaths in the region,  in combination with a number of other factors, including epidemiological and demographical explanations.