IDC inquiry into Humanitarian crises monitoring:
The impact of the coronavirus
Response by the Tony Blair Institute for Global Change, 17th April 2020
As the Tony Blair Institute (TBI) we are submitting evidence specifically focused on Africa and based on our ‘live’ experience supporting 11 governments across the continent to respond to COVID-19. We draw too on our experience supporting the governments of Sierra Leone, Liberia and Guinea in responding to Ebola.
The key points of TBI's response are as follows:
Our recommendations to the UK government to inform their future response to COVID-19 in Africa are the following:
Leadership and coordination
The Tony Blair Institute for Global Change (‘TBI’) is a not for profit organisation registered as Tony Blair Institute in the UK and working in over 20 countries across the globe. TBI employs over 200 staff delivering programmes across six continents, Africa, Europe, North America, South America the Middle East and South Asia. Our mission is to support political leaders and governments to build open, inclusive and prosperous societies in a globalized world.
We specialise in developing policy and advising governments. Our government advisory work involves helping countries and their leaders in Presidencies and Ministries in 15 countries in Africa to turn their vision for development into reality through effective government. TBI works alongside government to advise them on effective governance best practice, to help them enhance their ways of working, capabilities, and systems to ensure their objectives are delivered more efficiently and effectively. This support to leaders builds on the work previously undertaken by the Africa Governance Initiative, including support to government leaders in Sierra Leone, Liberia and Guinea in responding to Ebola. We have also over the last month focused our efforts on COVID-19 responses following direct government requests for support in the countries where we operate.
TBI is offering a range of services to governments and their leaders in response to COVID-19, which can be adapted to each country context and different stages of the pandemic. Our Government Advisory Practice is directly supporting leaders in their on-the-ground fight against Covid-19 in 11 countries where we work in Africa. This involves the provision of embedded advisory support to help government leaders build strong crisis response systems as well as advise on how to mitigate the social and economic impact of the Coronavirus pandemic in the short and long-term. This includes facilitating connections to meet supply shortfalls, for example making connections with reliable medical equipment manufacturers and suppliers in response to the acute global shortage of PPEs.
Our Policy Futures team is delivering analysis and advice to help countries mitigate the economic impact, source essential equipment, harness the power of technology and position themselves for the rebuilding to come. This includes the development of practical tools and resources for government to use in responding to the pandemic. In this way we provide bespoke support on disease suppression measures, testing, equipment procurement, tech solutions and the economic response. Examples of tools and resources include a Framework for Government Decision-making in a Crisis, Crisis Management Structures and Crisis Communications, and can be found here: https://institute.global/advisory/tools-governments-covid-19
This response to the IDC Humanitarian crises monitoring inquiry into the impact of the Coronavirus on developing countries around the world and the UK’s response builds on our experience and lessons learned from supporting countries and their leaders over the last 12 years, including Guinea, Sierra Leone and Liberia during the West Africa Ebola outbreak. This document also provides an outline of the immediate direct and indirect impact of Covid-19 on health systems and the economies of sub-Saharan Africa, and the importance of government leadership and coordination of the response at national and international level to minimise the risks and threats posed by the pandemic in the immediate and longer term.
This evidence to the IDC inquiry on the impact of Covid is based on our experience and lessons learned from supporting governments in West Africa in responding to Ebola, our experience of providing embedded advice to government leaders in Africa more broadly over the past 12 years, as well as our on the ground experience of supporting countries and their leaders to respond to Covid-19 in 11 countries in Africa. It provides insights of what we are witnessing on a day to day basis during the crisis to inform the response by the UK government to the pandemic in the UK and in developing countries.
The outbreak is taking off in Africa
While data is poor due to limited testing capacity, it is clear that case numbers are increasing rapidly. Confirmed case number increases combined with limited testing suggests that the actual outbreak is therefore much larger. Three governments – South Africa, Ghana and Cameroon – are now starting to conduct wider strategic testing in the community to get a wider picture of transmission. It is early days but these examples are already confirming wider community transmission with some showing large numbers of asymptomatic cases, in the order of 60-80%.
While we simply don’t know the full picture across Africa, we can assume the numbers are higher than the reported figures. This is why TBI is advising governments to focus on getting crisis systems in place and ensure robust surveillance – contact tracing, tracking, isolation and testing – to get as full a picture as possible of the outbreak. Community outreach to search for symptomatic people to test should be combined with some strategic testing where testing capacity is limited, to rule potential hotspots and areas frequented by contacts in or out for further investigation.
Lockdowns have a different purpose in Africa to in Europe – and they must go hand-in-hand with social protection
We have learnt that even in the more developed economies of Europe lockdowns disproportionately impact the poorest and most vulnerable. Yet in Africa, the challenges are compounded by several factors, including poverty, living conditions, global economic disruption and governments’ limited fiscal space. Large urban populations often involve households of up to 10 people sharing limited space, shared communal WASH facilities, and the majority of those populations rely on working for a daily wage to survive
In Europe, lockdowns are being enforced to supress the spread of the virus and ‘flatten the epidemic curve’ so that the numbers of people needing hospitalisation and Intensive Care treatment does not exceed the capacity of the health system. In much of sub-Saharan Africa, health capacity was exceeded even before coronavirus.
Lockdowns can only therefore be a tactic, not a strategy, for Africa – a tactic to buy time to allow governments to prepare for what is coming. This is not about buying time until a vaccine is available – much of Africa cannot afford to suppress economies and livelihoods for so long. Leaders are buying time to prepare their health systems, their economies and their people.
They are creating a pause for countries where health systems are already at capacity, well before the outbreak is approaching its peak, where many people must go out to earn every day to put food on their family table and where governments cannot afford the scale of social protection and service delivery required to keep people safely compliant with lockdowns for long periods.
While all 55 African countries are using a form of border closures to reduce the importation of cases and many are using this time to educate their public on the virus and social distancing, there is a wide spectrum of how lockdowns are being utilised so far. Ghana has undertaken enhanced surveillance, reaching out to communities and deploying testing strategically to create a geographical footprint of the spread of the virus. Many others however remain far behind, with not all contacts traced, some with less than 100 tests conducted and porous borders leading to new importation of cases, particularly in West Africa.
The different socio-economic indicators in Africa also need to be carefully considered, as well as cultural norms, when imposing lockdowns on communities, alongside the impact they have on the non-COVID-19 healthcare system. President Faure Gnassingbé of Togo stated:
‘No matter how effective the developed world’s approach to the Covid-19 pandemic might be in terms of protecting public health, it simply will not work in Africa without social protections. With so many vulnerable low-income households and informal workers, forcing people to stay at home will only create certain poverty. However, my government is trying to go the extra mile to make sure this does not happen.’
To address the social protection challenges his government introduced a 3-month monetary transfer program to support vulnerable members of population, consisting of 10,500 FCAF ($17) per month to men and 12,250 FCFA ($20) per month for women. However, even with such social protection measures many African countries are already seeing some violence and flashpoints as people flout restrictions to seek income or food.
Therefore, lockdowns might be appropriate for short-term containment, to allow for measures such as community surveillance and tracing to be established, but their long-term impact may be more devasting than the virus itself and governments need to use the lockdown time to prepare their health systems as best they can, prepare their economies and their people.
We know from the Ebola crisis in West Africa, how unexpected shocks to already weak health systems can be disastrous. The impact is likely to be felt in a variety of ways.
Health workers by the nature of their work are likely to be disproportionately affected by COVID-19. If infected, health workers will need time away from work either for treatment or isolation, which will affect the overall capacity of the health system to respond to COVID-19 and offer non-Covid care. The impact of health worker absenteeism will be felt even more in developing countries where the capacity of the health workforce is limited. Health care workers are also likely to be overrepresented within COVID-19 mortalities. While this is tragic wherever it happens, in countries like Liberia and Sierra Leone where there is a low number of qualified physicians, this will have a lasting and systemic impact. 
Health worker associations
, are beginning to note the danger, and as this may lead to situations, like with Ebola, where health workers either walk off the job because they are not adequately protected with sufficient supplies of PPE, or demand hazard pay to continue working, which would leave governments needing to make difficult decisions and trade-offs to ensure the health system continues, when there is extremely limited fiscal space.
There are signs that the presence of COVID-19 is having an impact on patient trust in health systems. In Sierra Leone’s main referral hospital, Connaught Hospital, there are reports that the hospital is operating at approx. 20% of its usual capacity, over the past few weeks, which staff associate with reduced health-seeking behaviour from citizens concerns about being exposed to COVID-19. Wider data from Sierra Leone corroborates that this is a trend, with bed occupancy significantly dropping during the period that government was preparing for a national lockdown.
Table 1: Bed occupancy for adult, maternity and paediatric wards in Sierra Leone (prepared by Partners in Health for Ministry of Health, Sierra Leone)
Source: Partners in Health, April 2020
This appears to be borne out too, by the proportions of patients using ambulance services over March.
Table 2: Patients using ambulance services (NEMS) in Sierra Leone (prepared by Partners in Health for Ministry of Health, Sierra Leone)
Source: Partners in Health
If this is a widespread trend then we can expect to see non-COVID-19 mortality rates increasing, as patients who require medical interventions fail to seek treatments. During the Ebola crisis, all affected countries saw both a decrease in the numbers of women attending health facilities for ante- and post-natal care, and for delivery itself. Even where women attended health facilities, one study found that there was a 34% increase in the in-facility maternal mortality ratio and 24% increase in the stillbirth rate, which are attributed in part to women attending late, due to concerns about how safe facilities were.
It is not established whether the young age of African populations will result in lower mortality, as predicted by the Imperial College modelling, and whether the high disease burden, including tuberculosis, HIV/AIDs and acute malnutrition, will exacerbate mortality, or how badly non-COVID-19 healthcare will be affected. Yet it is clear that as public messaging about COVID-19 is shared, and countries are put on heightened alerts through ‘lockdown’ measures, public confidence in their health system’s ability to respond is already being tested.
There have been reports from Kenya of police punishing anyone travelling during curfew, regardless of health exemptions, including accounts of a motorcycle driver beaten to death for taking a woman in labour to hospital and reports of health workers being beaten for going to their shifts. Even where transport can be bought, daily wage earners, in particular, who are likely to suffer a significant hardship in terms of their livelihoods, may not be able to put money together to get transport and seek treatment.
Whilst health services are trying to prepare for COVID-19 and its impact, there are indications that this will be at the expense of regular health service planning. There are also other concerning reports about shortages of chloroquine to treat malaria given it’s rumoured benefit in reducing the severity of COVID-19 symptoms. After president Trump touted Chloroquine as a possible cure for COVID-19, sales in several countries spiked. However, after two people overdosed, the Nigeria Center for Disease Control has warned the public against self-medicating with the drug. In Kenya chloroquine is now only available for those with a prescription, instead of being available over the counter as usual.
Governments are also asking questions around how to efficiently cover existing facilities to isolate the estimated 80% of COVID-19 positive patients who do not require acute care. Due to density of populations, allowing these patients to self-isolate is very likely to intensify spread but putting them in main hospitals will cause people to stop using them, leading to even more adverse non-corona healthcare consequences.
African governments cannot get the supplies they need and there is an urgent need for coordinated and rapid effort to support procurement of essential materials like PPE and testing. According to UNECA, African countries import about 94% of their medicinal and pharmaceutical products, with 52% coming from Europe alone. With current demand as a result of COVID-19 far exceeding supply, and amid export bans in China, the EU and the US, as well as major supply chain bottlenecks, governments of the 15 African countries with whom TBI is working directly have indicated their urgent need for help with PPE (including masks), diagnostic kits, and respiratory equipment, among other critical supplies. While some donations have been made through multilateral, bilateral and philanthropic channels (e.g. WHO, Chinese government, Jack Ma Foundation), these remain largely insufficient to control the spread of the virus across Africa.
A lack of coordination and nation-first approach is also fraying diplomatic relations and leading to equipment seizures. Global support needs to bridge the gap across the supply and implementation chain. Many countries are able to develop testing domestically removing an incentive for global coordination and leaving some countries behind. Some countries have stronger bioindustry bases to draw from e.g. Germany and South Korea.
A combination of factors places African governments in a very difficult situation. These include; a) Financial Constraints b) Low stock levels of medical equipment, c) Limited potential for retooling production lines, d) Lack of coordination and supply chain access, and e) Corruption and leakage.
The health expenditure in Africa is inadequate to meet the growing healthcare demand. The continent has hit an approximately US$60 billion financing gap per year which works out at an average per capita expenditure of less than 10% of the global average.
The shortfall in health expenditure is evident in the scale of the medical equipment shortages across Africa (e.g. 1 ICU bed/100k people in South Africa vs. 35 in U.S.). An estimated 40% of medical equipment in sub-Saharan Africa is estimated to be out of service. In addition, there is also an acute shortage of trained healthcare professionals (1.3 per 1,000 people vs. 4.5 recommended by U.N.).
Technical limitations in repurposing the existing production lines across Africa make it difficult to fill the existing gaps in medical supply needs. Africa has relatively low value-adding manufacturing activities. Manufacturing accounts for only ~10% of GDP share and less than 2% global share. This is combined with a relatively unskilled workforce as illustrated by no African countries being listed in the top 25 most competitive manufacturing countries globally) and an even smaller number (10%) of Africans represented in the total manufacturing workforce.
However, to address global shortages, countries are turning to their domestic manufacturing bases, either by supporting the diversification of existing healthcare manufacturing capacity and/or repurposing other sectors such as the garment and nonwoven industries (e.g. soap, beverages, etc.). Ghana is one of the countries that has successfully implemented some repurposing and investment facilitation into manufacturing of medical equipment and other key sectors (like electronics etc). The country is currently producing needed PPE for health care professionals. As of mid-April, Ghana has reported production of 10,000 masks /day with plans to increase to 20,000/day through to 50,000/day. Ghana also produces 2000 scrubs/day with plans to increase to 10,000/day; 2000 gowns/day; and 5000 headscarves/day.
While the likes of Ghana, Ethiopia and Senegal are filling some of the gaps in manufacturing PPE and other equipment relevant to the response, this is a small part of a larger response need, and the continent is highly dependent on global supply chains (Africa is a net importer for goods and services valued at US$40 billion/year on average) which have become more difficult to navigate as countries priorities fulfilling their own emergency requirements. Moreover, 60-80% of medical equipment in many SSA1 countries is donated or funded by foreign sources due to constrained domestic capacity and supply.
In assessing their needs, governments are using a range of modelling tools while information remain difficult to obtain and verify against current stock levels and ongoing procurement processes. The clearing house established by the WHO across the continent is also not equally accessed by countries, some of whom are not aware of it. As a result, governments continue to engage bilaterally with various stakeholders in parallel to identify available stocks, with varying ability to mobilise fiscal space and meet upfront payment requirements from private suppliers. Most countries are unable to meet these payment terms without support from external partners. For instance, based on WHO estimations, Côte d’Ivoire, Nigeria and Kenya are forecasted to need US$114M, US$164M and US$133M, respectively, to fight Covid-19 over the next 5 weeks. As of today, less than a third of the required funds and equipment is estimated to be either mobilized or available in country.
Table 3: 5-week equipment needs forecast as of April 9
Source: TBI analysis using the WHO COVID-19 Essential Supplies Forecasting Tool (ESFT)
At a time when medical procurement is at an all-time high, African governments must grapple with public procurement spaces that are highly susceptible to leakage and graft. UNECA estimates African countries lose US$148 billion per annum due to corruption and Africa is the lowest scoring region collectively in the Global Corruption Perceptions Index (32/100).
Developing countries present very different sets of challenges to policy makers designing strategic and tactical interventions to combat the virus. Most interventions in places like the UK have been informed by modelling work that has made predictions around the capacity of healthcare systems to cope with the predicted rate of infections, using various detailed socio-economic indicators. The lack of sufficient granular data and no relevant precedent means these have had weak predictive power to aid decision making for African leaders. This includes decision-making on social distancing options and their wider implications. Various worldwide forecasts conducted by leading institutions use national level data, however they are not always accurate. Collecting district-level data is a crucial part of accurate forecasting. African governments also need to work together to share data to inform decision-making.
With better forecasting governments can make better forward planning decisions instead of constantly reacting to the virus. TBI’s support to African government partners include modelling work to ensure more evidence-based decisions and dynamic estimates. For example, our team in The Gambia has worked with the government to model the likely impact on vulnerable populations, which has informed the design of an alleviation programme. The analysis in Gambia looked at sectors that would potentially be affected by factors ranging from how many families receive remittances - over 90% in the Greater Banjul Area to the number of households sharing a water supply and kitchen facilities. Our work with our Gambian counterparts is helping the government design socio-economic mitigation measures for the most vulnerable groups.
In contexts where lockdown doesn’t work for longer periods testing has to be significantly ramped up to keep pace with community transmission, especially to track mild cases in order to anticipate serious cases. This is particularly important in countries where it is difficult to keep entire population in lockdown. However, this has to be done strategically because there are significant shortages of tests.
Governments are considering dealing with their lack of testing kits by considering strategic testing – that involves strategically deploying testing guided by surveillance, identification of probably areas of transmission or hotspots, or innovative methods such as sample pooling. This also includes thinking innovatively around testing waste water and shared toilet facilities in densely populated, low income urban areas to rule areas in or out for further investigation. TBI is also supporting governments to think about options for capturing alerts from the community about potential transmission to inform the deployment of strategic testing, such as through call centres, surveys, and use of technology.
TBI is also helping our partner governments apply technological solutions to the problem of contact tracing. Contact tracing tells you where you are with the virus. If every new case of corona comes from a known list of contacts or associates of a previous positive person you have been monitoring, then you are ahead of the virus. If on the other hand you find cases appearing with no clear idea of the chain of transmission the virus is still ahead of you – you don’t know how it is moving. Good contact tracing is only possible at the beginning and the end of the outbreak, but software provides some useful applications to ease this difficult process.
Recommendations for the UK Government:
WHAT AFRICAN GOVERNMENT LEADERS ARE TELLING US – THE ECONOMIC IMPACT
We cannot look at the health impact of COVID-19 separately to the economic impact. The focus of African governments is on saving both lives and saving livelihoods.
Africa is faced with a hard-hitting combination of factors in the economic response to COVID-19: a) Commodity prices were down pre COVID-19 and continue to fall b) Trade has significantly dropped because of global response to the pandemic and Africa depends on trade much more than other continents, and c) the suppression measures in Africa itself are under strain due to a lack of fiscal space to balance vital economic activity against a health response.
African economies reliant on oil and the export of base minerals have been hit by plummeting market prices and an acute slowdown in global demand. This a harsh blow for Nigeria and Angola where in 2017, oil accounted for 90% of exports and 70% of their national budgets. For economies such as Liberia, Mozambique, Sierra Leone and Uganda heavily dependent on commodities revenue markets have been volatile even before COVID-19. Rubber demand from Liberia for instance, which has been driven by China, is at an all-time low.
More than two in three countries in sub-Saharan Africa are extremely commodity dependant. 33 African countries have an extreme dependence (>80%) on export commodities, while 10 more have a moderate dependence (60-80%).
Overall, the continent relies heavily on imports for its consumption, including of medical equipment and food, and on exports of commodities for its government revenue, jobs etc. To further complicate the impact of the pandemic on the continent, up to 86 countries, mostly outside of the continent, have placed restrictions on exports of food and medical supplies, both key imports for the continent during the COVID-19 response.
Tightly integrated with the concerns in commodities and trade on buying local economies is the impact of the pandemic on the informal sector which accounts for between 30-90% of non-agriculture related employment. Most Africans are vulnerably employed and living day to day. Governments then lack the fiscal space to put in place proper stimulus to support those who are losing their livelihoods and their access to food.
Lack of fiscal space (i.e. lack of funds) is the most pressing concern for governments. Financial resources are needed to:
a) support the healthcare sector as needed
b) provide immediate relief to people (e.g cash transfers and food transfers), while ensuring key sectors like agriculture continue to function
c) provide a proper stimulus package like we have seen in the west (for SMEs, informal sector, key industries like manufacturing and energy production).
To date the focus has been on debt payment relief (IMF has given 25 low income countries debt service relief) and to emergency funding by IMF and WB but it is far from enough. Average stimulus in the West is 8% of GDP, in Africa it is around 0.8%. However the amounts committed to emergency funding to date remain disproportionately low compared to the request from African Ministers of Finance for a US$100 billion stimulus and debt holiday. Even this number is low – the needs could rise to closer to $500 billion.
Many governments have not yet established needed support facilities (crisis support units/funding etc) for SMEs or for key sectors that sustain most jobs and most exports, e.g. cocoa in Ghana. This presents both a coordination/planning gap and a financial gap for many countries on the continent. While some countries including Senegal, Kenya, Cote Ivoire, Nigeria and Ethiopia have focused their immediate thinking on access to food, agriculture supply chains, support to key industries and assets in lower income countries have fallen behind.
Sierra Leone, Liberia and the Democratic Republic of Congo are drawing from their experiences with Ebola. They have however been stifled in their response
in varying degrees due to limitations in fiscal space, coordination management and needed support facilities. The limitations are harder to navigate for low income countries with limited background in managing a public health crisis. Across the continent, cash and food transfers (including the huge risk to large scale hunger especially in landlocked countries like Burkina Faso and Niger ia) will increasingly get attention though there is too little focus on them for now. There is a looming food security crisis in Africa, both because of COVID and also the locust challenge in East Africa. WFP will also be stretched as they scale up their logistics support for the health response itself, where they also face critical funding shortages.
A virus without borders but a divided response - coordination at an international level
International cooperation will be key to mitigating the impact of the pandemic on health and education systems and the economy in the UK as well as overseas. As Bill Gates stated in an article by The Telegraph: ‘If countries can unite, everyone wins. If not, it will come down to a troubling question: who’s the highest bidder?’ (The Telegraph, 12th April 2020). The UK government has an opportunity to spearhead a coordinated, cross-government approach to act as a role model for in the international community in supporting developing countries in effectively responding to the pandemic. This support would complement UK government investments in developing countries, which are also of geopolitical importance.
Finally, we applaud the UK government for its continued support to multilateral agencies such as the WHO, the World Bank and the IMF. We also congratulate the UK government on its support to the Coalition for Epidemic Preparedness Innovations (CEPI). Covid-19 presents an unprecedented situation where there is global demand for a global supply chain. This will require coordination through intranational bodies (WHO, the World Bank etc). The UK has a political role to play in giving these bodies credibility, especially in face of attacks from US government
Recommendations for the UK government:
Consider programmes that:
STRONG LEADERSHIP AND COORDINATION IS AS ESSENTIAL AS EVER
Ending the Coronavirus pandemic depends on effective crisis management by governments across Africa, and of course across the world. The most critical lesson from the Ebola epidemic was the importance of active and visible leadership from Presidents themselves. Preparing for and responding to a public health crisis requires the personal attention and involvement of political leaders to create the right systems for information management, decision making, accountability for action and public communications. Ministers of Health cannot achieve that alone.
Strong leadership from the centre of government is required to set up effective response structures that are led by the right people. Without coordination, scarce resources will not be allocated efficiently, citizens will not get consistent messaging and ultimately governments will be unable to keep up with the outbreak.
Ebola also taught us insights into managing the most important aspect of a vital response – influencing changes in public behaviour to reduce the rate of transmission. We learned from Ebola that the message, the messenger and the medium were crucial for establishing public trust in the government. We found that decentralising the response and engaging communities to own the response (“social mobilisation” in public health parlance) was extremely effective.
Ebola looked like it was just a health problem but as stated by Peter Graaff, Field Crisis Manager for the UN’s Ebola Mission (UNMEER) in Liberia, it was “a systems problem”. The response required more than treatment centres and doctors on the front lines, but a cross-government coordinated response. Guinea, Liberia and Sierra Leone eventually managed their Ebola responses effectively through a national task force or committee. They had different names – the Cellule in Guinea, the National Ebola Response Centre in Sierra Leone and the Incident Management System in Liberia, with local/district/county level structures below for decentralised operations.
Secondly, leadership was key in the Ebola response. “The Presidents were at the centre of this response”, said UN Special Envoy for Ebola at the time, David Nabarro. Country leadership was essential in getting countries through an unprecedented crisis. The Presidents have played three roles, as:
Developing country governments face 3 critical challenges to set up effective crisis response systems:
a) Lack of management and technical capacity
Unlike Ebola, COVID-19 is a global health and economic crisis, affecting all aspects of the economy and society. All hands are already on deck and for governments with limited leadership, management capacity at a senior level and technical expertise, they are quickly over-stretched, and decisions lack the analysis required to be well-informed. There needs to be streamlining to ensure efficiency and good coordination with technical experts from amongst development partners. Nigeria is facing the challenge of coordinating its 10 sub-committees under its structure and as various players push for access to resources, economic sub-committees are weak and adding pressure to the health side. Kenya has established its structure but currently lacks a donor coordination mechanism so donors with funds and equipment can align. Nigeria and Kenya depend on state-level implementation and capacity varies significantly, sometimes leading to inconsistent approaches.
b) The unprecedented nature of this crisis and lack of evidence
Mozambique and Kenya are grappling with how to adapt learnings on social distancing to low-income high-density neighborhoods. Ethiopia is looking for examples of what is working well in different countries in terms of economic response policy measures. Rwanda and Ghana have experienced rapid increases in food prices and are looking to other countries to understand how to manage food supply in lockdowns and with closed borders. There are two sides to this problem 1) this is an unprecedented crisis and we simply do not know how it will evolve in Africa. It is not appropriate to mimic the approaches taken in Europe and Asia, where the contexts, health systems, economies and fiscal space varies significantly compared to Africa. 2) Data is poor because testing is limited and testing capacity will remain low for the coming weeks in almost all cases in Africa. Strategic testing and widespread syndromic surveillance will be the only additional sources of data about the outbreak but remain resource-intensive to achieve.
Countries like Tanzania and Benin are struggling to see how they can apply WHO guidelines on suppression and lockdown given the high risks, e.g. starvation. Some countries lack necessary pressure and support to overcome concerns/biases. Malawi only stopped flights coming in on 31 March and is not quarantining possible cases.
TBI is advising governments on how to structure their response with effective command and control and on information management, providing leaders with indicators and targets to help them identify the problems and measure the effectiveness of various key elements of their response, such as shown in the slide below. It is also offering practical advice on topics ranging through medical equipment sourcing, crisis communications and economic stimulus options.
A coordination management structure for the economic side of the Africa response that complements the structures on the health side is also key. During Ebola, Liberia had 2 structures work in parallel: the Economic Management Team coordinated the economic response, and backstopped the health structure. To manage the gaps in fiscal space, to keep critical infrastructure working (e.g ports) and imports coming in (e.g. rice), to support economic coordination between African countries and then a focus on smart economic stimulus (i.e. the facilities for SMEs, investors, key sectors, adaptation of markets to social distancing etc) are critical.
Unsurprisingly the Ebola response was most effective when international partners supported the governments’ leadership, strategies and plans rather than pushing their own or creating parallel systems. It can be tempting in a crisis for parallel systems to be set up however this is counter-productive and can cause much damage in the long-term.
TBI is available to give further evidence if required.
 TBI Daily briefing, 17th April 2020
 Proportions of health worker infections are already high worldwide. In the UK it is estimated that a quarter of the health workforce is out of work either because they have Covid, or are isolating because a family member is ill. Statement by Richard Goddard, Head of Royal College of Physicians, 30 March 2020.
 According to the Liberia College of Physicians and Surgeons Vice President, Liberia has 1,505 registered Physicians which for a country of more than 4 million, is significantly below the WHO recommended 1:1000 ratio. LCPS Graduates 17 ‘Specialized Doctors’, Liberia Observer, 29 July 2019
During the 2014-15 Ebola outbreak in West Africa Liberia lost 8% of its combined doctor, nurse and midwife workforce to the disease and Sierra Leone lost 7% of its healthcare workers. Centre for Disease Control, 2014-16 Ebola Outbreak in West Africa
 ‘Compared to Ghana, others, Nigerian doctors fighting COVID-19 earn peanuts as hazard allowances’, Punch Healthcare, April 7, 2020
 Women and babies are dying but not of Ebola’: the effect of the Ebola virus epidemic on the availability, uptake and outcomes of maternal and newborn health services in Sierra Leone, Susan A Jones, British Medical Journal Global Health, 2016
 Kenya Coronavirus Curfew: death toll soars from crackdowns, Washington Post 16th April 2020
 Examples of TBI practical Covid-19 resources and tools to African governments can be found here: https://institute.global/advisory/tools-governments-covid-19