Coronavirus Disease (COVID-19) Scorecard for Africa - 2020
It bears restatement that nurses, midwives, and doctors – as well as other emergency and medical personnel from ambulance drivers and paramedics to lab technicians, clinic administrators, and hospital porters – are in the front lines of the fight against Covid-19. Far moreso even than in times of outright war, these personnel across medical disciplines and across the continent are involved in an unprecedented, universalised battle to preserve life. Especially for first responders and first carers, recognition has been widely given that they are undertaking huge personal risks – risks that they might take home to their families – in conducting virus testing, assisting with preventive measures, and health-care of the ill and vulnerable.
We need to especially stress that in this “Year of the Nurse and Midwife” – declared by the WHO in honour of Florence Nightingale, the founder of modern nursing practice – that it is these medical practitioners on whose shoulders the burden of care initially and predominantly falls. Already critical situations have been exacerbated by a brain-drain of medical professionals, caused by a complex set of factors including pull (better remuneration abroad) and push (poor equipment in African treatment centres) elements. Africa as a whole has, according to the WHO, “24% of the [world’s health-care] burden but only 3% of health workers commanding less than 1% of world health expenditure. The exodus of skilled professionals in the midst of so much unmet health need places Africa at the epicentre of the global health workforce crisis.” The Coronavirus epidemic has vastly exacerbated the danger to populations in the majority of African countries that have a critical shortage of health-care providers.
The ratio of nurses and midwives per head of population given in the accompanying table is all the more important given the increasing practice of “task transfer” in which nurses have taken on specific medical interventions normally reserved to doctors alone. Task transfer has been driven both by necessity and by the evolution of health-care policy in different environments. In Africa, where the number of physicians per capita falls well below the global average of 14 doctors / 10,000 people in all but three countries (two of which, Mauritius and Seychelles, are small island states), it has often been by necessity that nurses, particularly in remote rural clinics and even many urban hospitals, have taken on some of the primary medical tasks of junior doctors.
Many countries’ health-care policies attempt to forestall the burden of referral of patient cases to hospitals by doing disease management at nurse-run clinic level. The search for ideal policy frameworks guiding the best distribution of medical resources has also driven task transfer. As noted in a 2019 European Commission study recommending evidence-based task transfer, “Tasks can be shifted from health workers to patients and their carers, to machines, and to other health workers. Where these shifts have been evaluated, they often, but not always, are associated with outcomes that are as good or even better than with the status quo. However,” the study warned, “the results are often context dependent, and it cannot be assumed that what works in one situation will apply equally to another.”
So while most of Africa has a general pattern of critically low medical doctor numbers, for nurses and midwives, the patterns are more differentiated. Still, only two countries (Libya and South Africa), meet or exceed the 2015 global average of 3.42 nurses or midwives / 1,000 people. Given task transfer and the dangerous lack of physicians, this is the professional layer that will need to be the focus of the AU’s African Task Force for Coronavirus (AFTCOR), particularly on the first three of its six technical areas of focus:
- Surveillance, including screening at points-of-entry;
- Infection prevention and control (IPC) in healthcare facilities;
- Clinical management of persons with severe COVID-19 infection.
Medical Doctors Data
Nurses and Midwives Data
 Task Shifting and Health System Design, Report of the Expert Panel on Effective Ways of Investing in Health, European Commission, Luxembourg, 2019, online at https://ec.europa.eu/health/expert_panel/sites/expertpanel/files/023_taskshifting_en.pdf
Governments’ response to COVID-19 has in most cases involved earmarking a significant percentage of Gross Domestic Product (GDP) – the standard measure of a country’s productive wealth – towards fighting the pandemic. Although this is only part of most governments’ broad-spectrum policy response to the disease, it is an important measure as it indicates governments’ level of commitment to responding to the coronavirus disease (COVID-19) pandemic. It must be stressed, however, that different governments face different levels of severity of the pandemic and different projections (depending on a wide range of conditions including the capacity of their health-care systems, the size, distribution and characteristics of their populations rendered vulnerable by poverty, HIV or other factors, and logistical difficulties in meeting essential needs in facing the crisis.)
Earmarking state funds to fight the pandemic has been done in one of two ways: either governments have increased their health budgets, or they have established specific anti-COVID-19 funds aimed at financing a broader response than health alone. It appears from the accompanying data, derived from the International Monetary Fund (IMF), that countries’ response is largely dependent on current budgetary funding as their responses usually focus on 3- to 12-month response plans. Based on the fiscal data, only two countries have estimated (but not yet committed to) the overall response cost to fight Covid-19, namely Togo and Republic of Congo. The differences of approach – budget increase or specific fund, intermediate-term or long-term costings – depends to a degree on considerations including but not only the amount of available foreign aid which can be thrown into the fight.
According to the UN Economic Commission for Africa (UNECA), although the impact of COVID-19 on Africa appears at this stage to be less dramatic, according to reports, than on Europe and North America, the economic impact of the virus in Africa is “disproportionate,” because of its high trade vulnerability to import and export fall-offs due to the pandemic. The continental economy is expected to decline sharply from a 2019 growth rate of 3.2% to 1,8% this year, the loss equivalent to US$29 billion. Predictions are that particularly hard-hit will be oil, tourism, and remittances from African Diaspora communities back to their home countries. In addition, foreign direct investment (FDI) is expected to decline, capital is expected to flee the continent’s markets, and those domestic markets will shrink as spending (on all but essentials) as well as spending-power (with job losses) declines. Also, inflationary pressures are expected to grow as supply-chain disruptions create shortages (including of food and pharma) and undermine market value-creation. Of particular concern, according to the UNECA analysis, is a likely increase in national debt as countries borrow to either fund their COVID-19 responses, or to fund stimulus response packages to subsidize flagging economies (another area that Accountability International is tracking).
These factors, along with tax holidays for individuals and businesses, will all negatively affect GDP – and thus the amount of money available to governments to direct to combating the virus. The case of oil-export-dependent countries is worth examining in a little detail. As the Organization of Petroleum Exporting Countries (OPEC) has attempted to stabilize falling oil prices caused by a fall in demand (caused by significantly reduced air and road travel) by slashing production to prevent a glut on the market, African oil producing member countries have followed suit – which means slashing their collective GDP by US$65 billion, UNECA estimates. But the effect of this on their economies differs depending on oil exports as a share of exports – and as a share of GDP.
According to the UNECA data, the top 10 oil producers in Africa in descending importance, based on 2016-2018 annual averages, are:
- Nigeria at US$42,7 billion in oil exports
- Algeria at US$33,9 billion
- Angola at US$33,3 billion
- Libya at US$15,5 billion
- South Africa at US$9,2 billion
- Egypt at US$6 billion
- Equatorial Guinea at US$4,8 billion
- Congo at US$4,2 billion
- Gabon at US$3,2 billion, and
- Ghana at US$3,1 billion.
Of these, the economy of Libya is likely to be hardest-hit by oil revenue losses – on top of the civil war it is experiencing – because while its share of exports is high (88.4%), oil exports’ share of its GDP is the highest of the top ten (62.1%), meaning its economy is poorly diversified and too oil-dependent. The top oil exporter that is least likely to be hard-hit is South Africa with oil exports’ share of total exports relatively low (10.8%) and their share of GDP very low (2.7%), giving it a more diversified economy which is more resilient to oil shocks. Regardless of export losses, however, most governments are protecting their health expenditure, as the IMF notes for Algeria: “In response to the oil price shock, authorities have announced their intention to lower current spending by 30 percent (8% of GDP or USD 15 bn), while keeping wages intact and protecting health and education spending.”
Despite declining GDP, FDI and other financial stimuli, however, African economies are expected to spend an additional US$10,6 billion on health this year to combat the novel Coronavirus. This is a mixed blessing: higher health-care expenditure is certainly needed to flatten the curve of the viral infection and mortality rates – but such massive unplanned expenditure can be expected to reduce spending on other important areas, even within the health sector, such as sexual and reproductive health and rights (SRHR), another key response indicator that Accountability International is assessing to enable clear, evidence-based COVID-19 policy debates.
 It is a little too early to say, but the reported lower incidence of the virus in Africa is probably related to a range of factors including the later transmission of the virus to African countries which enabled the authorities to respond with earlier lockdowns and positive-case detection than in Europe and North America.
 Economic Impact of the Covid-19 on Africa, UN Economic Commission for Africa, Addis Ababa, Ethiopia, 13 March 2020, online at: https://www.uneca.org/sites/default/files/uploaded-documents/stories/eca_analysis_-_covid-19_macroeconomiceffects.pdf
 Policy Responses to Covid-19, International Monetary Fund, Washington DC, USA, data as of 10 April 2020, online at: https://www.imf.org/en/Topics/imf-and-covid19/Policy-Responses-to-COVID-19#A
A significant part of holding leaders accountable in the Coronavirus disease (Covid-19) response is playing a watchdog role in how human rights are protected or trampled by elected leaders in Africa. Some countries have exhibited enduring respect for human rights and this continues under the epidemic response. Others, as you will read below, have been opportunistic and taken COVID-19 as a moment to secure power, suppress opposition and silence civil society.
Out of the 54 countries in Africa for which data is available, 13 of them (Burundi, Central African Republic, Chad, Congo-Brazzaville, Eswatini/Swaziland, Guinea-Bissau, Libya, Djibouti, Madagascar, Mauritania, Saharawi Republic/Western Sahara, Somalia and Tunisia) have instituted no measures to deal with the spread of the epidemic, according to the International Center for Not-for-Profit Law’s INCL’s) Covid-19 Civic Freedom Tracker but the other 41 countries (75%) have implemented a variety of measures ranging from a state of emergency to special Covid-19-related decrees. The INCL has no data for Comoros, Mauritius, São Tome and Príncipe, and Seychelles.
With the exception of Eswatini (Swaziland), all Southern African countries have implemented legal measures to cope with the spread of the pandemic. In all cases, freedom of assembly has been severely restricted with citizens confined to their homes, and only permitted to travel short distances in order to obtain food, medical assistance, or to deliver essential services. Public gatherings have been limited to less than 100 people, in some cases 50 and, in the cases of Zambia and Zimbabwe to five and two people, respectively.
Human rights activists, policymakers, philanthropists, and public health professionals should pay attention to whether a country’s official response to the novel Coronavirus disease is based on a special act of parliament – in other words, where the response has been scrutinized and endorsed by political parties not in power – or whether based on an order grounded in regulatory, including emergency, powers vested in various government ministries and departments. The rapid onset of the pandemic has seen numerous instances of contradictory rules being issued by different ministers – and also of officials on the ground, especially police, misinterpreting or exceeding their proper remit.
It is important to note that where national authorities overstep the mark in their application of emergency responses to Covid-19, or where civil servants exceed their powers, the people targeted as a result are very often marginalized and excluded populations: women and girls, lesbian, gay, bisexual, trans, and queer (LGBTIQ) persons, people who use drugs, sex workers, people who pass through prisons and other places of detention, migrants and displaced people, refugees, the elderly, the mentally ill, people living with disabilities indigenous people, civil society activists, journalists, and perceived political opponents. To these must be added, as victims of prejudiced Covid-19 responses, the economically excluded because the poor generally are rendered additionally exposed to the virus as a result of inadequate access to decent health-care and sanitary living conditions. Some of these communities have also been demonized by officialdom or sectors of civil society for supposedly spreading the virus.
Key areas of concern:
Press Freedom and Freedom of Expression
Several countries have instituted measures restricting press freedom and freedom of expression under the guise of stamping out disinformation or “fake news” relating to the pandemic and to the state’s response programme. While a number of these already had restrictive laws in this regard and have shut down civic spaces even further (Egypt, Zimbabwe, Morocco: for example, the Moroccan Minister of Culture, Youth and Sports has suspended the publication and distribution of print newspapers until further notice), it is very alarming that relatively open, democratic societies such as South Africa and Ghana have also seen fit to follow suit with punitive measures on freedom of expression.
Zambia’s ruling party has apparently used the outbreak of Covid-19 to settle political scores, closing down The Post newspaper and Prime TV; both media houses are perceived to be supportive of the opposition, and in the case of the television station, it was shut down for allegedly having refused to carry government Covid-19 announcements. In Tanzania on 20 April, journalist Ussi Hamad with the daily Daim a newspaper was suspended from work for six months for merely reporting on the pandemic; this came days after the Mwananchi daily newspaper had its online license suspended for posting a picture of President John Pombe Magufuli shopping, surrounded by people, which provided a debate on social distancing. Meanwhile, Egyptian authorities have expelled journalist Ruth Michaelson of The Guardian after she reported that Egypt has far more coronavirus cases than have been officially reported. In Ethiopia, a months-long internet shutdown in parts of the country aimed at curbing the Oromo separatist group has prevented millions of Ethiopians from accessing information about the pandemic.
Curbs on freedom of expression are keenly felt by artists and cultural workers who are either unable to make a living or travel to safe residencies as a result of lockdowns during the crisis. Also, such creatives are important interpreters of social realities for their communities and broader national societies, so any critiques they produce of state responses to the pandemic are likely to fall foul of emergency rules that curb free expression. Free press and expression and arts rights justice campaigners continue to monitor such issues.
Reports of heavy-handed enforcement of the regulations, including, in some cases extrajudicial killings, by police, army, and security force personnel have been recorded in a number of countries. In South Africa, there have been eight deaths reported at the hands of the police enforcing the lockdown, and there have been many more instances of the police and army subjecting citizens to assaults and degrading treatment for allegedly being in breach of containment regulations. Reports are also emerging of a similar pattern in Angola, Zimbabwe, Namibia, Nigeria, Kenya, the DRC, Senegal, and Uganda.
Prisons and refugee camps
Public health authorities have warned that prisons are one of the greatest risks for the spread of the virus because of the manner in which prisoners are kept in confined spaces. In Africa this risk is further exacerbated by the well documented overcrowding of prisons across the continent, but to date few African countries have released awaiting-trial prisoners or those incarcerated for minor non-violent offences. However, on 5 April, King Mohammed VI of Morocco pardoned 5,645 prisoners in a bid to curb the spread of the virus by alleviating overcrowding, though the prisoners were not released wholesale, but rather in phases based on factors such as their youth and conduct. This represents 7,05% to be released of Morocco’s reported incarcerated population of 80,000 (two of whom tested positive), and 10,200 warders (nine of whom have tested positive). Ethiopia has released 4,000 prisoners, while Cameroon has also announced a limited release of prisoners – excluding those accused of terrorism, separatism and other serious offences.
Amnesty International demanded that authorities in Sub-Saharan Africa “must take urgent action to protect people in detention from Covid-19 including releasing prisoners of conscience, reviewing cases of pre-trial detention, and guaranteeing access to healthcare and sanitation products in all facilities.”
Many of the same concerns relating to prisons can be applied to another form of unfree detention – that experienced by migrants in the continent’s massive refugee camps in countries as diverse as Chad, Uganda, Kenya, Ghana, Burkina Faso, Ethiopia, and Zambia. Because of rudimentary health and sanitation facilities, these camps, which often host tens or even hundreds of thousands of refugees, are exceptionally vulnerable to respiratory infections such as influenza and, if their residents are provided with inadequate health-care could become new epicentres of the pandemic. Most early results of pilot tests regarding the possible transmission of the Covid-19 virus via feces have proven negative, yet implementing Sustainable Development Goal 6, access to water, sanitation and hygiene (WASH), as well as public campaigns for people to regularly wash their hands, will prove critical here. Sudan alone had 1.86 million internally displaced persons (IDPs) as of July 2019, and the African Center for Justice and Peace Studies (ACJPS) has called on both the authorities and separatist rebel groups to jointly under UN auspices come up with an action plan to ensure non-discriminatory inclusion of these displacees in health-care provisions during the epidemic, including access to adequate information on combating the spread of the virus.
In Angola, Amnesty International has reported that NGO workers were assaulted and arrested by security forces when they attempted to deliver health information and essential hygiene products to San communities in the remote parts of Cuando Cubango province. In general, indigenous communities across the continent, from the San in the Kalahari to the Amazigh in Morocco’s Atlas Mountains, report that they have been neglected in the Covid-19 response, owing to their lack of resources, lack of access to basic healthcare, water and sanitation, their geographic remoteness, as well as institutionalised discrimination.
In fact activists and health care workers have been bemoaning the lack of guidelines for health-care personnel on how to continue standard care and visits to remote indigenous communities in the face of the epidemic, as visits to these communities might perpetuate an outbreak in these areas. Some hypothesize these communities may have lower resistance due to lower exposure to coronaviruses generally, which would make them additionally vulnerable to discriminatory health practices. The Indigenous Peoples of Africa Co-ordinating Committee, a network covering 22 countries, warned that while lockdowns appeared effective, they could not be imposed against indigenous peoples because of their nomadic lifestyles.
Communities such as the LGBTIQ community that are already marginalized and vulnerable due to a range of factors including poverty and discrimination, now face further challenges during the pandemic; many are in fact rendered even more at-risk due to the response of authorities under emergency regulations. A now well-known example is that on 29 March on the outskirts of Kampala, Uganda, when the police raided a shelter and arrested 14 gay men, four transgender women, and two bisexual men, charging them with breaking social distancing rules (set at a maximum of 10 people and since reduced to five); equal rights campaigners have countered that the arrests were motivated by homophobia and transphobia and not the emergency regulations.
Concerning reports are emerging that several Southern African states (Botswana, South Africa, Zambia, and Namibia) are deporting hundreds of illegal Zimbabwean immigrants back to Zimbabwe under the guise of quarantine requirements. Given the history and continuation of human rights abuses occurring within Zimbabwe and a shortage of food, water and sanitation within the country, this is a serious issue that undermines the desired inclusiveness of universal access to health-care.
Lastly, it worth noting that the pandemic is, in some parts of the continent, happening in a context of armed conflict. The pandemic is likely to exacerbate and fuel some conflicts: for example, Islamic militants have now (April 2020) launched a fresh offensive in northern Mozambique.
While many African countries have launched epidemic prevention measures, a few have taken the opportunity afforded by the necessary emergency response to the pandemic to achieve ulterior aims. Human rights abuses are occurring across a broad spectrum and these need to be monitored closely. Of particular concern are the economic effects of lockdown and other quarantine measures on economic development and social stability. If social unrest from hunger or disease occurs, there is a possibility of heavy-handed responses from various states. Africa’s governments need to be held accountable through active dialogue in this time of crisis with a broad range of stakeholders to ensure an inclusive health-care response is backed up by respect for universal human rights.
 Covid-19 Civil Freedom Tracker, International Center for Not-for-profit Law (ICNL), online at: https://www.icnl.org/covid19tracker/?location=&issue=&date=&type=
* We have not here differentiated between Somalia and the self-administered yet unrecognized region of Somaliland but are tracking responses to the pandemic under both administrations.
Preventing Mass Famine of the Marginalized: Fiscal Stimulus Packages and Accountability
The impact of COVID-19 is clearly not restricted to medical, health-care, vaccinology, and epidemiological concerns, but has an unprecedentedly broad impact on the global economy and its national and sub-national components. In a dire warning by the International Monetary Fund (IMF), the “Great Lockdown” as it has become known in many quarters, is projected in even a best-case scenario to, in the intermediate term, be the most severe world recession since the Great Depression of 1929-1939. It is therefore imperative that African governments’ dialogues with their constituents, including organized labour, formal and informal sector business, and civil society, on how best to rescue their flagging economies urgently need to be transparent, innovative, and above all inclusive to ensure that starvation due to commercial shuttering and economic shrinkage does not provoke widespread famine.
On April 22, 2020, World Food Program (WFP) chief David Beasley told the UN Security Council that even before the onset of COVID-19 he had warned world leaders that “2020 would be facing the worst humanitarian crisis since World War II” because of factors including “deepening crises in places like South Sudan and… Burkina Faso and the Central Sahel region. The desert locust swarms in Africa… and more frequent natural disasters and changing weather patterns. The economic crisis in… DRC, Sudan, Ethiopia, and the list goes on. We’re already facing a perfect storm.” The WFP chief said that “821 million people go to bed hungry every night all over the world, chronically hungry, and as the new Global Report on Food Crises published today shows, there are a further 135 million people facing crisis levels of hunger or worse. That means 135 million people on earth are marching towards the brink of starvation. But now the World Food Programme analysis shows that, due to the Coronavirus, an additional 130 million people could be pushed to the brink of starvation by the end of 2020. That’s a total of 265 million people.”
Stating that the “magnitude and speed of collapse in activity that has followed is unlike anything experienced in our lifetimes,” the IMF’s Gita Gopinath in announcing its April edition of quarterly World Economic Outlook, took the position that assuming “that the pandemic and required containment peaks in the second quarter for most countries in the world, and recedes in the second half of this year… we project global growth in 2020 to fall to -3 percent.” That compares very unfavourably to the worst economic shock of recent times, the 2009 financial crisis provoked by the sub-prime housing scam in the USA, in which global growth only fell to -0,1% of real annual gross domestic product (GDP) growth. “Assuming the pandemic fades in the second half of 2020,” Gopinath wrote, “and that policy actions taken around the world are effective in preventing widespread firm bankruptcies, extended job losses, and system-wide financial strains, we project global growth in 2021 to rebound to 5.8 percent. This recovery in 2021 is only partial as the level of economic activity is projected to remain below the level we had projected for 2021, before the virus hit. The cumulative loss to global GDP over 2020 and 2021 from the pandemic crisis could be around 9 trillion dollars, greater than the economies of Japan and Germany, combined.”
But in a worst-case scenario, Gopinath warned: “The pandemic may not recede in the second half of this year, leading to longer durations of containment, worsening financial conditions, and further breakdowns of global supply chains. In such cases, global GDP would fall even further: an additional 3 percent in 2020 if the pandemic is more protracted this year, while, if the pandemic continues into 2021, it may fall next year by an additional 8 percent compared to our baseline scenario.” Such a combined 14% drop would make it scarily close to the Great Depression’s 15% fall – the aftermath of which endured for a decade. While emerging markets and developing economies such as those in Africa are expected to collectively suffer smaller annual GDP growth declines than the more precipitate drop expected in the developed world, the IMF’s data for 2019 and its best-case scenario projections for 2020, and 2021 respectively for Sub-Saharan Africa are: 3,1%; -1.6%; bouncing back to 4.1%. For two key economies on the African continent, those 2020 and 2021 predictions are Nigeria -3.4% recovering to 2.4%, and South Africa -5.8% springing up to 4%.
In an attempt to rescue their economies, most countries have implemented emergency financial stimulus packages of one kind or another. These are baskets of financial regulatory interventions by governments and central banks that help boost flagging economies. Normally, they involve complex interpretations of a fairly simple equation: boosting government spending to improve liquidity (the amount of cash in circulation) thereby stimulating the economy as people have more spending power, so increased demand drives production.
In the COVID-19 response scenario, however, there are two differentiated responses that we have seen in Africa:
- in non-oil-export-dependent states, government spending is increased, particularly in health-care: either by subsidizing health-care, raising health-care funding, or creating a special COVID-19 fund; and
- in oil-export-dependent countries, government spending is actually reduced, particularly in imports of non-pharmaceutical, non-food, and non-essential items, while health-care expenditure is either maintained or raised.
Fiscal stimulus packages can also be divided into support for finance, business, and industry and for households and individuals, and thus ranges from boosting liquidity to ensure there is more cash in circulation to compensate for the fall in production and earnings, to subsidizing worst-hit sectors of the economy (particularly manufacturing, retail, hospitality, travel, and tourism, and the freelance and informal sectors), boosting unemployment benefit funds or subsidizing wages for workers standing idle under lockdown, VAT and interest rate cuts to increase spending power, and a range of debt relief measures (housing and vehicle finance, and life, retirement and medical aid repayment suspensions or deferral).
These packages can be enormously expensive, however, so the UN Economic Commission for Africa has warned about the additional debt burden this will place on Africa’s emerging economies if they have to borrow to raise the money. For example, South Africa will implement a ZAR50 billion (US$26,6 billion) fiscal stimulus package, while Nigeria has made US$128,4 million available to rescue its oil-dependent economy – whereas the UN Economic Commission for Africa warns that these countries are already saddled with debt as a percentage of GDP of 55,9% (South Africa) and 55,8% (Nigeria).
So far, it seems the most common financial rescue plans across Africa, select elements of which are noted on the accompanying qualitative table, focus on maintaining payments to workers or subsidizing wages, on freeing up capital to increase market liquidity, and interest rate cuts to improve consumers’ borrowing and buying power. But there is a worrying lack of relief where one would expect it, aimed at the citizenry: “debt holidays,” the temporary suspending or rescheduling of home rental, life, and medical aid payments, and of repayments of loans on homes and vehicles; instead it is feared much emergency support is rather tailored to assist the financial sector and big business, and to further empower the security forces. Clearly these forms of relief, combined with increased spending on, or the creation of social grants (such as old age pensions, disability benefits, assistance for child-headed households, and benefits for unemployed or laid-off workers) should be a key intervention. At the point of the IMF’s measurement (8-16 April 2020) on which our table is based, only 16 out of 54 countries (29%) were providing some form of tax relief. Also, it must be noted that even sound fiscal stimulus packages require adequate implementation – and capacity-building for such implementation if required.
However, of the biggest challenges of fiscal stimulus packages – like that of health-care provision itself – is that of including marginalized populations, especially the poor. According to an International Labour Organization report, in Africa, 85.8% of employment is in the informal sector. In South Africa to cite but one example, the indigenous crafts and curios market alone contributed ZAR11 billion (US$585,6 million) to GDP and employed about 38,000 people – compared to to ZAR2,63 billion (US$139,8 million) and 44,000 jobs in fishing. Living subsidies and feeding and other emergency assistance schemes for the informal sector – denied the ability under containment measures to trade in public markets and often unable to access its traditional supply and sales routes – are critical to the wellbeing of traders and the extended networks of people who survive on their earnings.
Poverty is a cross-cutting driver of vulnerability and marginalization in all societies, especially unequally disadvantaging women and girls who already have lower earning power, and people such as migrants, the mentally ill, people living with disabilities, and lesbian, gay, bisexual, transgender, intersex and queer persons (LGBTIQ) who were even in pre-COVID-19 circumstances pushed to the margins of economic activity. As the WFP’s Beasley stated: “The economic and health impacts of COVID-19 are most worrisome for communities in countries across Africa as well as the Middle East, because the virus threatens further damage to the lives and livelihoods of people already put at risk by conflict.”
Warning that death rates from starvation alone could soar to 300,000/day over the next three months if WFP emergency assistance proved unequal to the task, he stressed: “if we don’t prepare and act now – to secure access, avoid funding shortfalls and disruptions to trade – we could be facing multiple famines of biblical proportions within a short few months.” So while fiscal stimulus packages are supposed to even-handedly help both households and high finance, governments need to transparently engage in dialogue about how to uplift their largest vulnerable population group, the poor.
 Gita Gopinath, The Great Lockdown: Worst Economic Downturn Since the Great Depression, International Monetary Fund Blog: https://blogs.imf.org/2020/04/14/the-great-lockdown-worst-economic-downturn-since-the-great-depression/
 WFP chief warns of huger pandemic as CVID-19 spreads, World Food Program, 22 April 2020: https://www.wfp.org/news/wfp-chief-warns-hunger-pandemic-covid-19-spreads-statement-un-security-council
 2020 - Global Report on Food Crises, World Food Program: https://www.wfp.org/publications/2020-global-report-food-crises
 World Economic Outlook, April 2020, International Monetary Fund: https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/weo-april-2020
 Economic Impact of the COVID-19 on Africa, UN Economic Commission for Africa, Addis Ababa, Ethiopia, 13 March 2020, online at: https://www.uneca.org/sites/default/files/uploaded-documents/stories/eca_analysis_-_covid-19_macroeconomiceffects.pdf
 Given the required rapid evolution of government responses, this is likely to change swiftly from the date of this measurement, however.
 More than 60 Percent of the World’s Employed Population are in the Informal Economy, International Labour Organization, 30 April 2018: https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_627189/lang--en/index.htm
 South African Department of Arts & Culture statistics 2011-2012, the latest available figures.
Risks of Sexual & Gender-Based Violence under COVID-19
Movement restrictions imposed in response to COVID-19 have already resulted in a deadly increase in reported sexual and gender-based violence (SGBV), especially intimate partner violence experienced in the home. Such restrictions include rules of full “lockdown” in which all but essential/emergency travel is outlawed, and “curfew” in which travel by the general public is restricted to certain daylight hours. These restrictions have been enforced in varying degrees of severity, but in many African countries have seen much of the population being cooped up in the close confines of their homes for unusually long periods of time. The psychological toll of living at close quarters has combined with other stresses, particularly job losses caused by the pandemic, to produce volatile domestic conditions.
In positive contrast, there is early statistical evidence that the shutting down of much public social life and the increased security force presence on the streets has seen a sharp decrease in sexual crimes such as rape committed in public spaces by perpetrators who are unknown to their victims. Yet in parallel, there is the risk that helplines and shelters for sexual and gender-based violence will become understaffed – either as a result of helpline services being suspended because staff are viewed as non-essential and are not allowed to go in to work or are redeployed to assist in fighting the pandemic, or as shelters are shut down as potential incubators of the virus. In African countries with alarming rates of SGBV, extra consideration must therefore be given to whether undifferentiated lockdown or curfew policies serve the greater good.
Here we will look at a range of gender-related issues under COVID-19, and have separated out a snapshot study of a case in which an alcohol and tobacco sales ban has had mixed results under a total lockdown regime. We will emphasize that a nuanced and inclusive, rather than one-size-fits-all (and thus unintentionally exclusionary) response to the pandemic will help alleviate the danger posed to vulnerable groups, especially women, girls, and LGBTIQ communities, as well as groups that are discriminated against or criminalized.
An increase in SGBV has already been observed in countries as socially diverse as France, Argentina, and Singapore, where reported incidents increased by 25% to 33% since the outbreak of COVID-19. Domestic violence as also increased dramatically in China, where reported cases have tripled during lockdown. Research prior to the Coronavirus disease outbreak had already demonstrated that in Africa, the occurrence of sexual and gender-based violence varied greatly per country, and so different outcomes of COVID-19-related restrictions in each country are to be expected. Prior to COVID-19, in Equatorial Guinea, for instance, 44% of women between the ages of 15 and 49 had experienced intimate partner violence, whereas in The Gambia, only 7% had (see Table 1). The Ebola outbreak in West Africa in late 2013 provides a deeply worrying prior pandemic-response example, for violence against women soared – while at the same time, it was reported that SGBV was deprioritized, unrecognized, or ignored.
Importantly, stigma and discrimination against LGBTIQ people has seen many of the members of this community reporting higher levels of physical, sexual, and emotional violence during the COVID-19 pandemic. Experiences range from being forced to go and stay with family that are homo-, lesbo-, or trans-phobic, to being denied food or a place to stay, or suffering abusive behavior. Job losses under the pandemic, or insecure accommodation arrangements have forced many to move in with partners, or even ex-partners because of the lack of alternative places to stay. Social discrimination, which had already placed such people in a precarious position prior to the COVID-19 crisis, has seen them put under even more severe stress during the pandemic, yet few local authorities have rallied to support them. In Africa, it has been mostly the LGBTIQ community itself and its allied civil society organizations that have provided support, and some funding and relief.
Differences between African countries in their experiences of sexual and gender-based violence could also be a reflection of the capacity of these states to collect relevant data. Evidence-based research still falls short in many African countries, which limits the capacity of governments to make adequately data-driven decisions. The African Population Health Research Centre has advocated for better coordinated systems to collect data on social welfare, an objective pursued by Accountability International and many other NGOs working in the health-access sector. Another challenge is that sexual and gender-based violence is often committed behind closed doors – and it is not even criminalized in many countries, as is frequently the case with marital rape. Therefore, a full picture of the full impact of the COVID-19 pandemic on SGBV in Africa is unlikely to emerge, even well after the storm has passed. Pre-pandemic data, however, shows the canvas on which incidents during the crisis will be painted.
African Heads of State have been largely silent on the looming threats, despite the dire warnings from the UN and civil society for government to put special measures in place that protect women, girls, and LGBTIQ people. For example, an African Union (AU) Bureau of Heads of State and Government communiqué on the African response does not mention SGBV or gender once, nor does it speak to concerns about the effects of restrictive movement measures on these vulnerable and marginalized groups.
Although the risk of gender-related violence in intimate social circles will undoubtedly increase under COVID-19 constrictions, the imposition of effective lockdowns or curfews, taken together with an increased security force presence, can have a different impact on other gender-related crimes, such as rape and sexual assault where the perpetrators and victims are unknown to each other, or do not habitually reside together. Pre-COVID-19 data from showed that in Sub-Saharan Africa, non-partner sexual violence has been documented in 14,8% of all women between the ages of 15 and 49, which is substantially higher than Europe (9,8%), Latin America (10,2%), and Asia (5,3%). Although COVID-19 restrictions may potentially lessen this threat, the UNFPA warned that violence may magnify in vulnerable populations.
In South Africa, non-partner violence appears to have decreased since the outbreak of COVID-19, due to suppressed social and street activity, heightened police visibility, and the reinforcement of the police by 73,000 soldiers in enforcing an initial 35-day full lockdown (none but emergency/essential travel over 27 March to 30 April). A week after their lockdown policy came into effect, the number of reported rapes had declined by 86% (a decrease of 598 cases). However, there were 2,300 reported cases (in a population of 58,7 million people) of sexual and gender-based violence within the first week of lockdown in South Africa, which emphasizes that statistics don’t always reveal the full picture. Therefore, when looking at the risks that COVID-19 policies can pose relating to SGBV, the focus should primarily be on intimate partners and close social and household circles.
The COVID-19 pandemic is exposing many underlying inequalities in socio-economic systems in Africa, of which sexual and gender-based violence is a primary one. Gender discrimination should be considered in every response to this unprecedented public health crisis. The pandemic is still in its early stages, which allows countries the opportunity to address sexual and gender-based violence, empower women, girls, and LGBTIQ persons, and include them in finding solutions. Agencies such as UN Women and UNFPA have already developed guidelines to incorporate gender considerations into national responses to COVID-19. Primarily, governments must ensure that services to prevent and treat SGBV, such as emergency helpline services and domestic violence shelters, remain available not just to women and girls who are considered socially acceptable, but also to other groups who are discriminated against, for example, women who use drugs, trans-diverse people who sell sex, and queer people who are homeless. The LGBTIQ community must be equally included in the provision of services to combat both SGBV and COVID-19, and this must be up front and central and not done in an ad hoc manner.
The public should be sensitized and educated to prevent SGBV that occurs as a result of discrimination and stigma of any kind, fear of infection, restriction of movement, or economic unrest. We further emphasize that national health institutions should make an effort to engage in transparent and honest dialogues with communities whose marginalization is based on sexual orientation and gender identity and expression – and to collect data on the direct and indirect impacts of COVID-19 on sexual and gender-based violence, to better understand and address how policy decisions impact vulnerable members of society differently.
Snapshot: SGBV & restricted substances in South Africa under lockdown
Because South Africa has one of the most comprehensive COVID-19 responses on the continent, it presents an interesting possible case study – presented here in a brief snapshot – of the complex ways in which lockdown policies interact with sexual and gender-based violence. But it must be cautioned that the country also boasts a better capacity to deal with the pandemic than most other African countries, so this should be taken not as an average, but rather as an extreme example. As mentioned in the main piece, a decrease in non-partner was observed, but a substantial increase in intimate-partner and close-family violence is expected. South Africa has also instituted bans on the sale of alcohol and tobacco products, and has reinforced this policy vigorously. Alcohol consumption is known to increase domestic violence and the ban can therefore help to reduce SGBV, but unintended side-effects of the policy need to be taken into consideration. First and foremost, the ban on alcohol and tobacco has provoked much anger, particularly amongst consumers who have become heavily reliant on these products.
As a result, many people started to engage in home brewing, which poses additional health risks such increased accessibility of poor-quality (and even life-threatening) raw and high-proof alcohols. It also brings with it considerable legal, and physical risks, because the ban has encouraged security forces to act with a heavy hand. An additional concern is for the mental health of alcoholics who depend on substance abuse as a coping mechanism. Even in instances where people are so-called functioning alcoholics and have an addiction during specific contexts or times, a sudden and unprepared lack of access to alcohol could increase withdrawal symptoms such as depression and anxiety. And for people who have alcohol use disorder, in some cases a non-controlled withdrawal can even cause death (delirium tremens). Hence, the ban on alcohol during COVID-19 will undeniably prevent many instances of sexual and gender-based violence, but it may easily provoke numerous others.
Lockdowns and curfews have also disrupted illicit drug supplies, with similar concerns for the mental health of drug-dependent persons and the physical safety of those living in close confines with them. The relative inaccessibility of tobacco, alcohol, and illicit drugs has a particular relevance for the trans-diverse community where these substances are significant factors in coping with prejudice and exclusion. For instance, the LGBTQ community consumes 50% more tobacco than the general population, so they are more likely to seek illegal sources of tobacco. Furthermore, most trans-diverse people have experienced discrimination when attempting to access health-care, sometimes being denied of services completely, which could increase their reluctance to seek medical help during the pandemic. Another concern is that trans-diverse people might be forced back into living with their families during lockdown periods, where they will be more vulnerable to people that do not accept them. In places where LGBTQ rights are still absent or homosexual relationships are illegal, which is the case in many African countries, the pandemic will indubitably make their lives even more difficult.
 Wanqing, Domestic violence cases surge during COVID‐19 epidemic, Sixth Tone, 2020: https://www.sixthtone.com/news/1005253/domestic-violence-cases-surge-during-covid-19-epidemic
 Global Health Observatory data repository.
 Communiqué of the AU Bureau of Heads of State and Government teleconference meeting, 3 April 2020, online at:
 Significant reduction in crime since lockdown, South African Government News Agency, 5 April 2020: https://www.sanews.gov.za/south-africa/significant-reduction-crime-lockdown
 South African police record 2,300 gender-based violence complaints in first week of lockdown – not 87,000, Africa Check, 9 April 2020: https://africacheck.org/spot-check/south-african-police-record-2300-gender-based-violence-complaints-in-first-week-of-lockdown-not-87000/
 What Works to Prevent Violence, Violence Against Women and Girls in Conflict and Humanitarian Crises. (2017). No Safe Place: A Lifetime of Violence for Conflict‐Affected Women and Girls in South Sudan. Retrieved March 30, 2020, from https://globalwomensinstitute.gwu.edu/sites/g/files/zaxdzs1356/f/downloads/No%20Safe%20Place_Summary_Report.pdf
 Buchting et al. (2017) Transgender use of cigarettes, cigars, and e-cigarettes in a national study. American journal of preventive medicine 53(1): e1-e7. https://doi.org/10.1016/j.amepre.2016.11.022
The World Health Organization (WHO) has warned that “if efforts are not made to mitigate and overcome interruptions in health services and supplies during the COVID-19 pandemic, a six-month disruption of antiretroviral therapy could lead to more than 500 000 extra deaths from AIDS-related illnesses, including from tuberculosis, in sub-Saharan Africa in 2020–2021.” It stressed that “the impact of a [mere] six-month disruption of antiretroviral therapy could effectively set the clock on AIDS-related deaths back to 2008, when more than 950,000 AIDS-related deaths were observed in the region. And people would continue to die from the disruption in large numbers for at least another five years, with an annual average excess in deaths of 40% over the next half a decade.”
The intersections between people living with the human immunodeficiency virus (PLHIV) and/or tuberculosis, the most vulnerable of our marginalized communities, and the threat posed by the current global epidemic is underscored by the dangerous paucity of data on the most affected key populations on anti-retroviral treatment (ART). It is particularly important for health-care and human rights advocates to focus here on women, girls, LGBTIQ people, sex workers, persons who use drugs and other people who are vulnerable for a variety of reasons. People from these communities are marginalized, stigmatized, discriminated against, criminalized, brutalized and even killed because of their sexual orientation, gender expression or identity (SOGIE) as well as their bodily autonomy-related choices such as having an abortion or injecting drugs.
Winnie Byanyima, the executive director of UNAIDS, warned in a global teleconference on COVID-19 and HIV on 7 May that the world faced “two colliding pandemics,” stating: “We are fighting Corona-19 – but must hold the ground for people living with HIV – and also the vulnerable.” A citizen of Uganda, Byanyima red-flagged several key issues relating to the care of PLHIV during the current crisis in Africa in her conversation with renowned South African HIV activist Mark Heywood. Drawing comparisons between the HIV and COVID-19 epidemics, Byanyima said that both had no vaccine or cure and had devastated and taken lives, both had seen the number of new cases soar exponentially, and both required public campaigns to curb disinformation as well as stigmatization and criminalization of those testing positive. The most important similarity, however, was that “the people hurt are the most vulnerable…: pandemics feed on existing inequalities…” She stressed that 40 years of knowledge gained by civil society and community groups in the fight against HIV/AIDS would prove to be a significant resource for those combating the novel Coronavirus outbreak.
Key Populations ART coverage data gap
While UNAIDS statistics for the percentage of each African country’s people living with HIV and receiving ART are available for 53 out of 55 African countries, when it comes to specific data on key populations (KPs – those most at risk of contracting HIV), the lack of data is shocking. For instance, for the indicator showing the antiretroviral therapy coverage as a percentage of the main five key populations living with HIV is available for less than a quarter of African states:
- ART coverage among sex workers living with HIV: only for 11 out of 55 African countries.
- ART coverage among men who have sex with men living with HIV: only for 9 countries out of 55.
- ART coverage among prisoners living with HIV: only for 9 countries out of 55.
- ART coverage among people who inject drugs: only for 5 out of 55.
- ART coverage for transgender persons: only 1 out of 55.
This means that on average only 13% percent of possible data is being collected on KP’s ART coverage.
Initial concerns about the potential impact of the COVID-19 pandemic on PLHIV have been somewhat allayed as it seems that people on ART probably face the same risks as anyone else. But the lack of knowledge of ART coverage of these vulnerable groups is of great concern. In addition, Byanyima warned, “if you have infections particularly of the chest” – and here tuberculosis is a very real threat – “and if you have other diseases like diabetes [and] if you have HIV/AIDS, you are not on treatment, your viral load is going down, and you are getting opportunistic infections, you should protect yourself much more, [you] could be more vulnerable than anybody else.”
Diversion of resources
Of greater current concern is the diversion of attention and potential diversion of HIV-earmarked funds and resources away from the virus to fight COVID-19 instead. Byanyima said while that Bill Gates had assured her that the Bill and Melinda Gates Foundation money intended for the fight against HIV would not be moved for the campaign against the novel Coronavirus, UNAIDS was closely watching what funders did with their money under current conditions – and were also monitoring medical manufacturers, to ensure that factories producing condoms did not change to producing masks (and presumably latex gloves) because it was more profitable. The WHO advised PLHIV to stockpile anti-retrovirals for at least one month – but up to six months where possible – in advance because of disruptions to the supply chains, yet it was unclear how this increased demand would be met by suppliers. Byanyima said UNAIDS was as a result closely monitoring supply-chains of both prevention and treatment drugs in Africa – a task made more critical because Africa imports 94% of its pharmaceuticals (worth US$16 billion/annum).
However, Olive Mumba, Executive Director of the Eastern Africa National Networks of AIDS and Health Service Organizations (EANNASO), gave Accountability International an example from Uganda in an interview that whereas pre-pandemic, PLHIV had to restock their own ARVs once every three months, they had to do it every two weeks – in addition, state-imposed travel restrictions made it so difficult for many PLHIV to access ARV treatment. Fear of becoming infected with the novel Coronavirus while going out for their medication put an extra stress on PLHIV seeking treatment. Additional problems she highlighted were that job losses, including among already vulnerable populations like sex-workers and LGBTIQ communities, was putting the nutritional health of many PLHIV at risk as they lacked adequate money to buy food. She gave an example from Botswana where although undocumented migrants (including sex-workers) were legally allowed to access ART as non-citizens, few of them did so as they hid because of police clamp-downs. Additionally, with international borders shut to all but essential cargo traffic, few were able to reach the relative safety of home. Other responses to the current pandemic have had an impact on HIV and TB affected communities: for example, Mumba said, a strike by health-care workers at Malawi’s main referral national hospital over inadequate protective gear and the lack of risk allowances caused services at the hospital to be suspended, which saw patients sent back to regional hospitals which lacked the required specialists.
The most important indicator of a country’s progress in fighting HIV/AIDS is its achievements towards the “90-90-90” agenda launched by UNAIDS in 2014 to end the AIDS epidemic by 2030 by: ensuring that by this year (2020), 90% of people who are HIV infected will be diagnosed, 90% of people who are diagnosed will be on ART, and that 90% of those who receive anti-retrovirals will be virally suppressed. Here the African statistical knowledge is much better – at least as far as the first and second measures are concerned: the percentage of people diagnosed; and the percentage of positive cases on ART. By 2018 Malawi, South Africa, and Zimbabwe had already achieved their goal of 90% of PLHIV knowing their status – which is important as all three countries are considered by many to be epicentres of the disease – while Botswana, Cape Verde, Eswatini (Swaziland), Namibia, and Rwanda had all surpassed that level already. African countries performed better when it came to getting PLHIV onto anti-retrovirals, with 12 topping the 90% target by 2018, but poorly on either achieving or reporting on the percentage of people on ART who achieved viral suppression – the condition in which PLHIV can be considered at equal risk of COVID-19 to anyone else. Only Botswana (91-92-95) and Eswatini (92-93-94) had beat the UNAIDS 2020 targets by 2018.
Co-morbidities between COVID-19 and TB
The intersections between COVID-19 and tuberculosis become obvious, when we understand that both diseases present as potentially fatal respiratory ailments with a nagging cough and high fever as symptoms. This presents a problem because, as Mumba states, “TB patients are stigmatised because they are presumed to have Coronavirus disease.” Also, the pre-existing stigma that TB patients were presumed to be HIV-positive has meant that large numbers have shied away from seeking treatment in the first place. This untracked and untreated “invisible population” of TB patients was highly at risk of contracting the novel Coronavirus because of their respiratory problems. The stigma around HIV, TB, and COVID-19 are compounding and scaring people away from the necessary health-seeking behaviour that is required for them to be tested and treated and for further spread to be prevented. Yet many countries’ quarantine protocols are fatally flawed, Mumba warned, in that all suspected COVID-19 cases are corralled together in communal sleeping and eating spaces, which dramatically raises the risk of people with respiratory and other underlying health conditions contracting the novel Coronavirus.
Nine African countries have achieved a reported 100% of their known HIV-positive TB patients being on antiretrovirals – Comoros, Egypt, Gabon, Libya, Mauritania, Mauritius, São Tomé and Príncipe, Seychelles, and Tunisia – while another 20 countries have achieved in the 90-percentiles. This would bode well for addressing the comorbidities between HIV, TB, and COVID-19 – but the caveat is that this generally solid result (though 14 countries fall under 81%) stands on the shoulders of a much patchier continental achievement record of the percentage of people living with HIV who are on ART in the first place: some countries have a shockingly low showing, including Madagascar (9%), Sudan (15%), and South Sudan (16%) as can be seen in the accompanying scorecards. Additionally, TB mortality is exceptionally high in Lesotho, South Africa, and Namibia – all countries where epidemiologists have warned COVID-19 may entrench itself because of these pre-existing frailties.
Meanwhile, controlled clinical trials are being conducted in various locales around the world to see if various strands of the BCG vaccines used to treat tuberculosis might be of assistance in combating the novel Coronavirus because of their ability to reduce respiratory tract infections by boosting the body’s natural immune system. The initial results appear to be positive according to The Lancet – but are too preliminary at this stage, and the journal echoed the WHO’s warning against the indiscriminate use of BCG vaccines (already in short supply) before any possible efficacy in warding off COVID-19 was clinically proven.
The fightback against HIV, TB, and the novel Coronavirus
One of the largest donors or funding partners on HIV and tuberculosis is The Global Fund to Fight AIDS, TB and Malaria. In mid-May 2020, The Global Fund wrote that programmes against the three diseases would have to continue under COVID-19: “Prevention interventions, case finding, access to medicines, treatment adherence, human rights protections, community engagement and other important aspects of effective disease response must be maintained as we move forward.” An example from Uganda demonstrated how The Global Fund funded local grant activities were combining their COVID-19 funding response with their main programmatic aims: “In support of Uganda's National COVID Preparedness Response Plan, The Global Fund is providing US$4,452,205 to fight COVID-19, shore up critical health systems, and ensure lifesaving HIV, TB and malaria programs continue. As part of the initial response, the Ugandan Ministry of Health has prioritized the purchase of personal protective equipment for health workers and diagnostic tests for COVID-19. Additionally, the Global Fund is coordinating through our main civil society organization partner to strengthen differentiated service delivery models for key populations and people living with HIV in Uganda.”
On 15th May The Global Fund made funding available through a COVID-19 Response Mechanism (C19RM), with an initial allocation of US$500 million, enabling recipient countries/regions to access an amount of up to 10% of their allocation for countries/regions with an existing allocation for 2020-2022. Funding from the response mechanism is in addition to the funding available through grant flexibilities,  as well as support in health product supplies. The Response Mechanism aims to enable recipients “to respond to COVID-19, mitigate the impact on programs to fight HIV, TB and malaria, and initiate urgent improvements in health and community systems.” In addition, under grant flexibilities, the Global Fund has allowed recipients to use up to 5% of their current grant to combat COVID-19 – if there are savings available – and also to reprogram 5% of their current grant: foreseen activities under these guidelines include, but are not limited to, epidemic preparedness assessment, laboratory testing, sample transportation, use of surveillance infrastructure, infection control in health facilities, and information campaigns.” Country and multi-country recipients have been encouraged to use their grant flexibilities first before applying for C19RM funding.
Activists have stressed that it is important for civil society to monitor whether funding to combat COVID-19 – from all donors, across the board – have not in fact been drawn from reserves previously earmarked for HIV and TB. EANNASO’s Olive Mumba said that because most donors’ funding for the current financial cycle had already been allocated, all donors had to be engaged with to ensure HIV and TB funding would not be adversely affected later.
UNAIDS might be monitoring possible resource diversion as Winnie Byanyima promised, but the situation on the ground revealed several instances in which this had already occurred, Mumba warned. Also, she said, “It seems that resources which normally would go into supporting HIV or the TB community, governments are taking that budget to respond to COVID. Our question is ‘are they taking it from the already inadequate health budgets, or taking funding from some other health-related interventions?’” Mumba cautioned that not only funding, but equipment, pharmaceutics, and research were being diverted towards COVID-19: for instance, the US company that manufactured the cartridges used in GeneXpert machines to test for TB and also for HIV viral loads in many African countries appeared to have switched to making cartridges to test for COVID-19 instead.
But she agreed with Byanyima that the current crisis provided health-care workers and advocacy campaigners with a unique opportunity to integrate HIV and TB testing into the novel Coronavirus response. Not to do so – with TB in particular – risks exacerbating the spread and lethality of COVID-19 itself. That window of opportunity is widened, she said, by bringing to bear the decades of experience in fighting HIV and TB: “When it comes to learning from HIV communities – and the TB community is at a high level of learning, and the malaria community just starting to learn – with COVID, it is very true.” She said that the primary lessons which should be applied to the novel Coronavirus were of community mobilization around testing and treatment, of the vital role that grassroots information networks performed in monitoring pandemics, the creation of awareness (including gender and human rights awareness) programmes, the formation of counselling and support groups, and of the importance of social sharing. Also crucially derived from the HIV and TB experience were “community-based monitoring systems,” from survivors who monitor the treatment adherence of patients at home, to mobile apps that monitor stockouts or stigma at health-care centres.
Caveat: Accountability International is critically aware that the statistics that are presented to the Africa CDC or other regional/continental/global organizations on which we base our scorecard grading are not without some problems and can thus not always be taken at face value. Firstly, on a country-by-country basis, we need to have an understanding of the robustness of each country’s reporting mechanisms (are they adequately funded, comprehensive, and statistically sound?). Next, we need to recognise that in rare cases, the temptation of governments to improve their public image by under-reporting the impact of the pandemic may prove too strong: this is clearly the case with Tanzania that dangerously ceased reporting on 31 May 2020, but there may be other less obvious examples that involve under-reporting rather than a total refusal to provide data. Lastly, a pre-existing lack of data, particularly on key populations, undermines an adequate understanding of the impact of the pandemic on the most vulnerable and marginalized.
 The Cost of Inaction: COVID-19-related service disruptions could cause hundreds of thousands of extra deaths from HIV, WHO, New York City, USA, 11 May 2020, online at: https://www.who.int/news-room/detail/11-05-2020-the-cost-of-inaction-covid-19-related-service-disruptions-could-cause-hundreds-of-thousands-of-extra-deaths-from-hiv
 The Potential Impact of the COVID-19 Response on Tuberculosis in High-Burden Countries: A Modelling Analysis, Stop TB Partnership et al, online at: http://www.stoptb.org/assets/documents/news/Modeling%20Report_1%20May%202020_FINAL.pdf
 Q&A: HIV, antiretrovirals and COVID-19, WHO, Geneva, Switzerland, 24 March 2020, online at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-on-covid-19-hiv-and-antiretrovirals
 Economic Impact of the COVID-19 on Africa, UN Economic Commission for Africa, Addis Ababa, Ethiopia, 13 March 2020, online at: https://www.uneca.org/sites/default/files/uploaded-documents/stories/eca_analysis_-_covid-19_macroeconomiceffects.pdf. Africa’s largest importers of pharmaceutics are the European Union (51,5%), India (19,3%), Switzerland (7,7%), China (5,2%), the USA (4,3%), and the UK (3.3%). South Africa is the biggest continental supplier, providing 2,2%. AI interview with Olive Mumba, 11 May 2020.
 UNAIDS data (Treatment cascade) https://aidsinfo.unaids.org/
 Hence our Table indicates “estimated incidences” of aspects of TB.
 Nigel Curtis et al, Considering BCG vaccine to reduce the impact of COVID-19, The Lancet, 30 April 2020, online at https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31025-4/fulltext
 https://news.trust.org/item/20200511120950-6d9rv and Information on the Response to fight COVID-19, The Global Fund to Fight AIDS, TB and Malaria, Geneva, Switzerland, Regional Platform for Communication and Coordination for Anglophone Africa, News and Updates , 14 May 2020.
 The company, Cepheid, is the target of a campaign by, among others, the International Union Against Tuberculosis and Lung Disease, to reduce the price to developing countries of its cartridges for testing for HIV, TB, COVID-19, and other diseases.
A critical aspect of the management of the COVID-19 pandemic in many African countries is whether there are districts or regions that are either entirely un-administered by the authorities or are under-administered, for a variety of reasons. Regions that fall entirely outside the ambit of governments’ abilities to respond to the virus largely embrace those that fall under the control of separatist groups or rebels. Regions that are under-serviced fall into three, sometimes interlinked, categories:
- those which are difficult to reach because of their remoteness or arid/rugged terrain;
- poor rural areas which under-resourced governments battle to serve, even under normal conditions; and
- those from which state services including healthcare are deliberately withheld or restricted because their populations are viewed as hostile to the central state.
Africa’s “lawless” third
These conditions are far more widespread in Africa than is usually acknowledged by the authorities, though concentrated in the Sahara, Sahel, and Forest Belt regions. And as such, they are deeply marked by traditional modes of nomadic livelihood that clash directly with state attempts to curb the spread of the novel Coronavirus by closing borders to all but commercial traffic. Nevertheless, there have been a variety of responses to the challenge posed by the pandemic in these regions, some of them remarkably positive, because human rights imposes a duty of healthcare even on authorities widely regarded as illegitimate. The most notable cases we will examine here of viable alternative healthcare administrations are those of two states with contested legitimacy, the Sahrawi Arab Democratic Republic (SADR) which occupies the eastern third of the Moroccan-ruled territory of Western Sahara, and Somaliland, a Horn of Africa republic that seceded from the north of Somalia.
A hint of the breadth of Africa’s un-, under- or alternatively -administered, regions – which underlines the scope of this crucially unacknowledged issue – was given by a map produced to illustrate a 2015 article in Foreign Affairs and redrawn for the pan-African journal Ogojiii in 2016. The map indicated huge swathes – all of Libya, half of Algeria, much of the Sahara and Sahel, northern Nigeria, the Horn, and a crescent of the African Forest Belt extending from eastern Central African Republic down the eastern border of the DRC – as being beyond central government control. The Foreign Affairs author stated: “By my count, of the 11.7 million total square miles of African continental land mass, roughly four million, or about 34% are out of state control.” By using the term “lawless” third as a catch-all phrase however, it must be stressed that AI does not mean that law is entirely absent in such areas, or that the law is not applicable there – but that it is difficult or impossible in current conditions for recognized governments to assert their authority in such zones.
What is remarkable about the attached map produced by Thomas Heap of HokaHey! for Accountability International based on Warren Roberts and Robyn Swift’s 2015 map for Foreign Affairs is the very close match between the “lawless” third and the regions proving problematic in terms of controlling the novel Coronavirus. This is despite the fact that this zone shifts continually: for example, since 2015, a government has now entrenched itself in Libya around Tripoli thus reducing the “lawless” zone there, while secessionist conflict has broken out in Ambazonia in western Cameroon, extending the “lawless” zone into that country. We believe that if the data was presented at provincial instead of national level, then the areas within the “lawless” third that currently appear to have less of a crisis on their hands – western Mauritania, northern Nigeria, eastern DRC, northern CAR, and northern South Sudan for example – would likely be revealed to in fact have a higher COVID-19 mortality than the rest of their countries and thus more closely conform to the Roberts-Swift map. Regarding the three remaining anomalies, Libya, being embroiled in civil war is likely under-reporting as stated further in this text, while Eritrea is an authoritarian state and is also likely under-reporting; lastly, we will later examine the complex case of Somaliland/Somalia in detail.
Much of this third of the continent remains un-administered or under-administered because of its inhospitable, remote desert/jungle conditions; in particular this affects border controls and attempts at shutdowns where there are both insufficient authorities available to enforce COVID-19 international movement restrictions and where traditional nomadic (and rebel/smuggler) routes bypass or bribe their way through official checkpoints. In addition, travel time and inadequate methods of travel to healthcare facilities is markedly increased in remote areas. Although it is the state’s responsibility to provide adequate and equitably-accessible healthcare to such areas, it is well-known that many African states lack sufficient funds, medical staff, equipment, and pharmaceuticals to properly meet this duty of care.
Governments direct few resources – including health infrastructure, healthcare workers, medical equipment, and pharmaceuticals – to such remote and rural provinces because their sparse and nomadic populations. Exceptions would include far-flung mines such as Niger’s uranium mines which produce valuable raw materials and as such are comparatively well serviced and resourced.
Furthermore, a key study on population densities across Africa, in stressing the correlation of isolation to equitable access to healthcare (and other resources) noted that “existing spatially explicit population data across Africa are generally based on outdated, low resolution input demographic data, and provide insufficient detail to quantify rural settlement patterns and, thus, accurately measure population concentration and accessibility.” Accountability International thus continues to highlight the crucial importance of governments having accurate baseline data on which to plan their healthcare – and now COVID-19 – interventions.
The Sahara, Sahel, and African Forest Belt
The Sahara Desert is an immense expanse of 9,2-million square kilometres that covers all but the Atlas Mountains and Mediterranean coasts of Algeria, Tunisia, Libya, and Egypt, and which also embraces all of Western Sahara and the northern parts of Sudan, Chad, Niger, Mali, and Mauritania, with an average population density of 0,38 people/km² – one of the world’s lowest. Overall, the Saharan countries have fared the worst in Africa in in terms of the documented COVID-19 deaths as a percentage of positive cases (see AI’s Daily Data maps over April-June 2020 for visual evidence of this). The Sahel is the vast semiarid swathe to the south of the Sahara, comprising the rest of Mauritania, most of the rest of Niger, the north of Senegal and Eritrea, and another third each of Mali, Chad, and Sudan, with an average population density of 6 people/km². But these very low average population densities should not be taken as an indication that people do not gather, socialize and interact in significant numbers in certain zones of the Sahara and Sahel and thus do not pose a low risk to novel Coronavirus transmission.
Notably people cluster and move around bodies of water like Lake Chad (2 million people within a 100km radius of the lake’s centre, and 13 million within 300km radius) and along the Nile River (a density of up to 1,165 people/km² along the river’s lower course through Egypt), as well as along the ancient trade routes that traverse the region. Of relevance to COVID-19 is the potential for viral transmission at these points and along these routes. Such population densities in remote, less-developed areas can have very different impacts on access to healthcare: while it improves access in a better-resourced Egyptian Nile valley (Egypt rates 116 out of 189 countries on the UNDP’s 2019 Development Index) – it pushes healthcare beyond reasonable reach in the impoverished Lake Chad region (Chad ranks 187 out of 189). Also, some rural population distributions are counter-intuitive: for example, the Ouargla province of Algeria and the Tombouctou province of Mali – both remote Saharan Desert regions – have high focal population distributions, meaning their rural populations are densely clustered in small settlements, ideal for novel Coronavirus transmission given that these settlements are linked by poorly-monitored/controlled nomadic travel.
Lastly, the African Forest Belt – home to many rebel groups – though mostly sparsely populated, also boasts zones of dense population. Examples include the strife-torn Lake Kivu basin in the eastern Democratic Republic of Congo which has a density of over 400 people/km² - and yet the government only controls half of the North Kivu province bordering the lake’s western shore, the rest being controlled by a patchwork of numerous guerrilla groups. This extreme fragmentation of authority naturally undermines any coherent anti-COVID-19 response (even by the rebels themselves (as we outline below), and even if assisted by international healthcare agencies) in population density conditions which pose a distinct risk of viral transmission in wildly variable and uncontrolled circumstances.
Guerrilla insurgencies: the destruction of healthcare systems
Sparseness of law enforcement, resource allocation, and healthcare access has enabled rebel groups – with a variety of rationales from religious extremism to ethnic separatism – to operate with relative impunity and gives them an opportunity to legitimize themselves by offering the populace alternative services, including healthcare. But this is a rarity: insurgencies usually disrupt and overstress already fragile healthcare infrastructure. An example is north-eastern Nigeria which already had inadequate clinics and too few healthcare workers before the jihadist Boko Haram insurgency began in 2009. The insurgency has to date displaced 2,3 million people (which creates its own severe healthcare challenges including in neighbouring states which absorbed some quarter-million refugees), killed scores of healthcare workers, and destroyed hundreds of clinics, slashing Nigeria’s north-eastern Borno state’s functional healthcare facilities to a third, while a third of its doctors have left the state due to insecurity. Altogether, despite stern countermeasures by the states at the intersection of which it operates – Nigeria, Niger, Chad, and Cameroon – Boko Haram continues to severely disrupt these states’ ability to exercise their duty of care in rebel-controlled areas. In fact, it is feared that Boko Haram and similar groups, in seeking to undermine the legitimacy of their enemy states by spreading unscientific disinformation to counter official COVID-19 containment messages, may create new epicentres for the virus, while their cross-border activities help spread it further.
Similar problems relating to containment of the novel coronavirus can be observed in countries and provinces embroiled in civil war or other severe conflicts such as Nigeria’s Delta, Libya, Central African Republic, Sudan’s Darfur region, South Sudan, and the eastern DRC – although the mortality rates in Libya are North Africa’s lowest, probably because of severe under-testing/reporting in the midst of a bloody civil war that has seen the destruction of healthcare facilities in violation of international humanitarian law. The highest numbers of confirmed cases in Libya have been in the government-controlled enclave of the coastal capital, Tripoli, and in the rebel-controlled desert Sabha province, both under relatively stable administrations which have taken anti-COVID-19 measures – but much of the country is either lawless desert or controlled by the two main competing armies and their allies (currently engaged in large-scale offensives and counter-offensives) as well as jihadist, localist, and tribal militia.
In some cases, such as that in northern Mozambique, rebel groups have taken advantage of the diversion of security forces to lockdown duties to attempt to expand their territories or make fresh claims. Mozambican President Filipe Nyusi stressed that such insurgencies drew resources away from combating the novel Coronavirus: “The state security services will have to prioritise between the… insurgency, the armed threat posed by the Renamo military junta, post-cyclone reconstruction, and any measures which will be implemented in the country in light of the detection of COVID-19 within Mozambican borders.”
In Cameroon’s Anglophone Ambazonia region, a legacy of underrepresentation in the Francophone central government in Yaoundé spilled over into open secessionist conflict; a year ago, Médicins Sans Frontières (MSF) reported that “violence is also restricting people’s access to healthcare, hindering them from reaching medical centres; interrupting supplies of drugs and equipment; causing medical staff to flee; and forcing health facilities to close.” MSF said all parties to the conflict had been involved in attacks on healthcare workers and facilities. Such disruptions render proper COVID-19 responses extremely difficult or even impossible. The reference to MSF is important in indicating the role of international non-governmental healthcare organisations in attempting, nevertheless, to provide healthcare in rebel-controlled areas – and across the frontlines of ongoing conflicts. Accountability International encourages state and rebel forces on all sides of regional conflicts to allow such medical staff to move unrestricted about their life-saving work in conflict zones as provided by international law.
Western Sahara and the Sahrawi Republic
This general picture of lawlessness or fragmented authority imposes some unique circumstances under which the COVID-19 pandemic is being faced across many parts of Africa – but there are instances of stable yet alternate (and thus often unrecognized) territorial authorities with aspirations to formal government and state status. At either extremity of this supposedly “stateless” third of the continent lie the Sahrawi Arab Democratic Republic (SADR, administered by a government recognised by 40 out of 193 UN member states, 20 of which are AU members) – and Somaliland (administered by a government recognised by only three UN member states, two of them AU members). Regardless of whether the international community recognises these states, in reality they are only “un-administered” in the view of the central governments in Rabat and Mogadishu which lay claim to them; in most other respects, they fall under conventional functioning administrations which provide healthcare to their citizens. Where diplomatic recognition does count, however, is whether these contested territories are able to access adequate COVID-19 testing – and donor or funding partner healthcare support.
Given that the pandemic statistics reported by the Africa Centres for Disease Control and Prevention (Africa CDC) derive from recognised governments only, the figures for what Africa CDC calls “Western Sahara” and “Somalia” have had perforce to neglect conditions in the independently-administered SADR and Somaliland territories. In addition, the World Health Organization (WHO) also has no official coverage of either territory by its Regional Office for Africa (AFRO). This provoked some debate within Accountability International on how we would track the pandemic in areas falling beyond the reach of Rabat and Mogadishu – as well as regions un-/under-administered by other capitals. Matters were further complicated by the lack of independent data from the two contested territories; for example, Africa CDC did not initially distinguish between Morocco and Western Sahara (both its Moroccan and SADR-controlled parts) at all, making it difficult to ascertain the incidence of the virus in both parts of the territory. The first four cases reported in Western Sahara, by the UN mission there (MINURSO) on 4 April 2020, were in the Moroccan-controlled zone – but it was only a month later that Africa CDC distinguished for the first time in its COVID-19 reporting between Morocco and Western Sahara – though its usage of the term appears to exclude the SADR territory.
Within SADR’s zone, on 19 March, the Sahrawi government had announced its implementation of COVID-19 countermeasures including the closure of borders with friendly neighbours Algeria (home to a large Sahrawi expat camp populace near Tindouf who were restricted from visiting the city), and Mauritania. It also created quarantine areas, and the imposition of a “stay-in-your-tent” lockdown policy. On the one hand, this indicates a seriousness by the Sahrawi authorities to exercise their duty of care, but the remoteness and relative poverty of their territory meant that at the time of these measures were implemented, healthcare workers had “just 600 pairs of gloves and 2,000 masks for a population of between 180,000 and 200,000 people.” Unfortunately, the SADR response to the pandemic which has ravaged its Algerian and Mauritanian neighbours has become more of a political football, with observers aligned to Morocco claiming SADR ruling party POLISARIO has blacked out reporting on COVID-19 in the camps and SADR-occupied zones.
Like the Africa CDC, the WHO had no cases reported to it in either part of the territory – until the Moroccan two-thirds finally reported for the first time on 25 July 2020. The only reliable reporting appears to be by the MINURSO mission, which “maintains constant liaison with the Moroccan government, POLISARIO and Algerian government to share information and coordinate action.” Its last report, dated 5 June 2020 states: “There have been no new cases in the Tindouf Governorate [of Algeria] since 10 May and still no cases to date in the Saharawi refugee camps or in the Territory East of the Berm,” the embankment that marks the border with Algeria. “The lone death from Covid-19 in Tindouf Governorate remains the only fatal case in MINURSO’s area of operations. All 13 remaining cases in Tindouf Governorate have recovered and been discharged from hospital.” However, the report gives no number of positive cases for the SADR-occupied portion of Western Sahara – and these figures conflict with the supposed zero cases for “Western Sahara” reported by the Africa CDC.
Somalia and Somaliland
On the extreme east of the continent, the widely unrecognized state of Somaliland, which in 1991 broke away from Somalia – itself without a fully functional or authoritative government and state since then – has likewise posed a problem for tracking the progress of the virus, and for attempts to combat it. A report by the Juba-based Rift Valley Institute and its partners warned that this knowledge vacuum, combined with inadequate or inextant health services could turn the Horn of Africa territories into one of the world’s worst epicenters of the pandemic. The internationally recognized government of Somalia in Mogadishu announced the first positive novel Coronavirus case on 16 March and suspended international flights in response, later followed by the suspension of domestic flights. It also tried to prevent the importation of khat (the leaf chewed for its mildly narcotic effects) as a means to limit socializing amongst people who sit together and chew the leaf in close proximity to each other and because actually buying and selling the leaf can lead to virus transmission.
But Mogadishu’s grip on authority is tenuous at best, the government having spent much of its existence in exile in Kenya. By mid-August last year, it could only claim to control the capital and some of the larger cities of the south, with half of the southern towns and most rural areas under the Al Qaeda-affiliated Al Shabab militant Salafist group centered on the town of Jamane – or completely lawless. Most of the central Puntland region (which reported its first COVID-19 case on 19 April) is dominated by the Mogadishu-friendly yet separate unionist armed forces centered on the port city of Bosaso, while Somaliland in the north is under an antagonistic separatist administration based in the city of Hargeisa (with a small hostile Al Shabab and Islamic State presence in the lands between Puntland and Somaliland). The result is that the official Somalia government is unable to enforce any travel restrictions by road – and dogged in its efforts to get COVID-19-related aid to Puntland and even Somaliland (though some of Chinese magnate Jack Ma’s mass donation of testing kits, masks, and protective suits to Africa, having arrived in Mogadishu in late March did reportedly make it to Hargeisa). And the situation is bedeviled by drought, locust storms, flash-flooding, traditional contestation between six major clans, and some 2,6 million people internally displaced due to conflict.
Somaliland reported its first two positive novel Coronavirus cases on 31 March 2020, six days after closing its land borders and ordering incoming airline crews and passengers quarantined for two weeks. On 26 March, it had diverted all developmental funding into combating the pandemic. Khat establishments were closed, mosques issued with social distancing guidelines, social gatherings outlawed, and 574 prisoners pardoned and released, but the crucial lifeline of flights to Ethiopia were maintained. To date, the Africa CDC’s figures have not differentiated between separatist Somaliland and Somalia (including Puntland), with 2,860 positive cases of whom 90 died as of 25 June 2020, though it appears Mogadishu is counting Somaliland in its reporting to the Africa CDC and WHO. Somaliland separately reported at the same date a total of 681 cases of whom 28 had died. On 15 July, Somalia reported 3,083 cases of whom 93 had died, with Somaliland the following day reporting 807 cases of whom 29 had died. Lacking its own testing facilities, the breakaway state has been sending abroad to get test results.
Aid to combat the novel Coronavirus is being sent via Mogadishu – which politically and practically undermines Hargeisa: in late April, the European Union donated €27 million in aid to combat COVID-19 to Somalia, of which €10 million was officially earmarked for Somaliland. Yet it was subsequently reported that in allocating €15 million of the donation to budgetary support in Somalia, €6,5 million for Somalia’s health infrastructure and awareness campaigns, and the remaining €5,5 million to health services at Mogadishu’s Banadir Hospital, Somaliland had been entirely cut out of the donation, despite the EU representative urging civil society to ensure the earmarked portion did indeed reach Somaliland. On 23 June 2020, however, Hargeisa announced the lifting of all anti-COVID-19 measures – though social distancing measures and the quarantining of virus-positive people entering the country remain in force. The government did not give reasons for its reopening of the country but it is likely that its economy cannot longer bear an economic shutdown without external aid – hard to come by as an almost totally unrecognized state. Despite a lack of international support and a precarious health-care system with only half of facilities having essential equipment and only Hargeisa Hospital having any ICU beds at all, Somaliland’s apparent firm commitment to fighting the epidemic – including the raising of $15 million from its tax-base, and a widespread COVID-19 information campaign – should compel the international donor community to put human welfare above politics and send aid directly to Hargeisa.
In a positive development, it was reported on 5 July 2020 that the UK, Denmark, and the Netherlands had approved agreements with Hargeisa under the Somaliland Development Fund to improve critical infrastructure. Notable under COVID-19 was the commitment to improving Somaliland’s “resilience to future pandemics through enhanced water, sanitation and hygiene (WASH) infrastructure”: this involves increasing the water available to Hargeisa by 20% – “enough to meet the needs of an additional 200,000 people,” though deadlines for the water project’s completion were not announced.
Under-servicing and ethnicity
Lastly, we must deal with the fact in many African countries of some regions being deliberately under-serviced by central governments because of their perceived hostility to the incumbent political leadership. This factor is most noticeable in countries where under-serviced regions are the strongholds of ethnicities that are not in power and are thus characterized by the capital as inherently unpatriotic, subversive, or even secessionist. Although in general, normal protest actions have fallen off considerably across Africa under various forms of lockdown or curfew, economic hardship caused by job losses and trading restrictions has seen a resurgence of protest as travel restrictions have eased. Many of these protests – which flout social distancing protections – occur in areas normally seen by governments as “rebellious” such as Algeria’s Kabyle, Zimbabwe’s Matabeleland, or Ethiopia’s Oromia.
Most current reports on healthcare access disparities relating to ethnic minorities focus on conditions in the US, UK, France and other developed countries – ignoring the widespread nature of the problem in Africa. UN High Commissioner for Human Rights Michelle Bachelet warned that under COVID-19, healthcare disparities experienced by ethnic minorities may in part be related to “bias in provision of care [our italics]… People from racial and ethnic minorities are also found in higher numbers in some jobs that carry increased risk, including in the transport, health and cleaning sectors.” Yet in speaking of minorities of African descent – against the backdrop of the #BlackLivesMatter protests – she only mentioned Africans living in minority Diaspora communities outside Africa where COVID-19 death rates are exposing racial inequalities.
Some African ethnicities are privileged with better healthcare access as they have historically held power; some are majorities, yet others are minorities. A study that gave many examples from Sub-Saharan Africa of “large differentials in child mortality among ethnic groups” noted that the “disparities correspond with the prominence of specific ethnic groups in the national political economy. In many countries where heads of state since independence have come from one or two ethnic groups – as in Côte d’Ivoire, Kenya, and Niger – these groups have experienced levels of early child mortality at least one-third lower than those of other groups. In other countries where there have been several transitions in state control, as in Ghana and Uganda, descendants of precolonial kingdoms… have experienced much lower mortality than others. In most countries, the lower mortality of potent ethnic groups – who typically represent small proportions of national populations – is strongly related to economic privilege.”
Such pre-existing ethnicized healthcare access inequalities are only amplified under COVID-19. For example in Burundi, the aftermath of the genocidal civil war between a Tutsi-dominated army and Hutu rebel groups over 1993-2005 that left some 300,000 dead, its healthcare in ruins, and a Hutu political leadership in charge, has seen the authorities enforce 60% Hutu/40% Tutsi ethnic quotas on the staffing of foreign NGOs – including in the healthcare sector. Human Rights Watch noted: “On October 1, 2018, authorities suspended the activities of foreign nongovernmental organizations (NGOs) for three months to force them to re-register, including by submitting new documentation stating the ethnicity of their Burundian employees.”
Some observers have interpreted this move as using affirmative action as cover for reducing civil society space and privileging Hutus within the developmental sector as they have been in government and business. This is also likely to affect Tutsi access to developmental services. The disruption put many healthcare projects months behind schedule, while some NGOs, wary of how the ethnicity data might be misused, exited the country entirely – all of which has undermined Burundi’s COVID-19 response. On 12 May 2020, the Burundian government declared the WHO’s country director and some of its health experts persona non grata as they were critiquing its underreporting of data on the pandemic. A refusal to honestly deal with the data and address the impact of the pandemic amounts, in Accountability International’s view to a deliberate under-administration, under-servicing and thus to a denial of care. On 10 June, President Pierre Nkurunziza, who had refused to take strong measures against COIVID-19 died of a heart attack rumoured to have been brought on by the virus.
Migrants and Internally Displaced Persons
Denial of healthcare in remote borderlands is most often practiced against migrants, refugees, and other non-citizens – as well as internally-displaced persons (IDPs) – even under COVID-19 quarantine. This practice, which is counter to the most basic human rights, is particularly directed at undocumented migrants, for example, undocumented Zimbabwean refugees in South Africa (so-called “medical xenophobia”) – but also in overcrowded, underserviced and under-administered borderland refugee camps in many areas. Often the rationale for this denial of care is that taxpaying citizens supposedly have first right to tax-funded state healthcare – but this is not only a denial of patients’ human rights, but of the universal healthcare (UHC) goals under various international and African health and human rights commitments. An example of this service gap is from Ethiopia where a Reliefweb update on the pandemic in Ethiopia warned that “IDPs living in congested and unsanitary collective centers, spontaneous and planned sites, rental accommodations or shared shelters with relatives in host communities are particularly vulnerable to COVID-19. Migrants and deportees who have recently arrived in Ethiopia currently confined to underserviced Quarantine Centers without basic [non-food items], are similarly at higher risk of transmission.”
Complicating the issue is that most undocumented migrants including asylum-seekers cross international borders not only without going through any proper health checks, but often without even knowing of the existence of the COVID-19 pandemic. For example, the UN’s International Organization for Migration (IOM) reported that just over half of all migrants attempting the exceptionally dangerous crossing into the Gulf States from Somalia via war-torn Yemen were not only unaware of their viral status but had not heard of COVID-19.
The lack of access to healthcare during the COVID-19 pandemic experienced by millions of Africans as a result of living in ungoverned, under-serviced, rebel-controlled, or poorly-supported alternatively-administered regions raises a unique set of problems for governments, donor agencies, and healthcare professionals combating the novel Coronavirus. Accountability International believes that the sheer scale and persistence of this problem has caused many decision-makers at country and international levels to turn a blind eye to it – with the unfortunate result being the avoidance of the duty of care in this troublesome third of the continent. However, under numerous human rights, humanitarian, and healthcare conventions to which Africa’s governments are signatory – and to which alternate administrations and some though far from all rebel groups claim adherence – the people living in these zones deserve equitable access to universal healthcare including adequate COVID-19 testing, treatment, and care.
An urgent starting point is for all armed groups whether state or rebel to allow international healthcare agencies like MSF and the International Committee of the Red Cross / Red Crescent to do their work in remote and conflict-torn areas unhindered. In addition, the international community needs to immediately put human lives over shallow diplomatic considerations – and provide assistance directly to SADR, Somaliland, and any other contested regions the rulers of which, regardless of their official status, have clearly demonstrated their administrative capacity and their resolve to fighting the pandemic and protecting the people under their care. Lastly, African administrations of all stripes and their international supporters must pay significant attention to the most vulnerable population groups languishing in poor, remote, and under-serviced areas across Africa – especially migrants and displaced persons, and key populations most threatened by the novel Coronavirus. Only by adhering to our UHC commitments – and leveraging the remarkable unity demanded by the universal threat of the pandemic – can we advance equitable healthcare access to all now, thereby establishing a legacy of robust care well after the current crisis is over.
Caveat: Accountability International is critically aware that the statistics that are presented to the Africa CDC or other regional/continental/global organizations on which we base our scorecard grading are not without some problems and can thus not always be taken at face value. Firstly, on a country-by-country basis, we need to have an understanding of the robustness of each country’s reporting mechanisms (are they adequately funded, comprehensive, and statistically sound?). Next, we need to recognise that in rare cases, the temptation of governments to improve their public image by under-reporting the impact of the pandemic may prove too strong: this is clearly the case with Tanzania that dangerously ceased reporting on 9 May 2020, but there may be other less obvious examples that involve under-reporting rather than a total refusal to provide data. Lastly, a pre-existing lack of data, particularly on key populations, undermines an adequate understanding of the impact of the pandemic on the most vulnerable and marginalized.
Somaliland COVID-19 Response Timeline
In Accountability International’s view, though the lifting of most anti-Coronavirus measures in Somaliland on 23 June is worrisome, this timeline demonstrates that the Hargeisa government has responded with alacrity to the pandemic and thus deserves the support of foreign donors and governments in combating the threat – a fact apparently accepted by the World Health Organization (WHO), the United Arab Emirates (UAE), and some European governments which committed aid to the secessionist republic regardless of its diplomatic status.
20 Jan: WHO and Chinese government confirm human-to-human transmission of COVID-19
29 Jan: Somaliland Ministry of Health Development (MoHD) convenes a conference on COVID-19
30 Jan: WHO declares COVID-19 an international public health emergency
5 Feb: MoHD delivers equipment to medical staff at Somaliland’s borders
15 Feb: MoHD addresses House of Elders on Somaliland’s Coronavirus preparedness
23 Feb: MoHD meets Ethiopian Health Ministry on combating COVID-19
16 Mar: Somaliland Cabinet meeting showcases social distancing on TV and in newspapers
19 Mar: MoHD issues sanitary and other rules to protect communities from the pandemic
25 Mar: First two cases of COVID-19 detected in Somaliland; all land borders closed
26 Mar: Somaliland diverts all developmental funds towards fighting COVID-19
7 Apr: Hospitals prepared to test and treat Coronavirus patients
8 April: First foreign-donated medical supplies to fight COVID-19 (from UAE) arrive in Somaliland
13 Apr: MoHD starts novel Coronavirus prevention awareness campaign on YouTube
23 Apr: MoHD runs workshop for health professionals on case management guidelines
28 Apr: A total of 6 cases reported
30 April: MoHD launches COVID-19 information website: https://somalilandcovid19.com/
17 May: A total of 103 cases reported; MoHD counters COVID-19 disinformation
28 May: A total of 257 cases reported; MoHD receives a testing machine from the WHO
1 Jun: European Union delivers medical supplies to seven health facilities; caseload hits 332
10 Jun: A total of 479 cases reported
23 Jun: Somaliland lifts all restrictions except social distancing and quarantine for positive cases
25 Jun: A total of 681 cases reported, including 28 deaths
5 Jul: UK, Denmark and the Netherlands approve aid to Somaliland including WASH improvement
16 Jul: A total of 807 cases reported, including 29 deaths, for 199 recoveries, and 4,374 tests
1 Pierre Englebert, The ‘Real’ Map of Africa: Redrawing Colonial Borders, Foreign Affairs, 8 November 2015, online at: https://www.foreignaffairs.com/articles/2015-11-08/real-map-africa; Michael Schmidt, Charting Africa, Ogojiii, Issue 7, April-May 2016.
2 Catherine Lineard et al, Population Distribution, Settlement Patterns and Accessibility across Africa in 2010, published in 2012, online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3283664/.
3 Lake Chad Resilience and Climate Resilience Action Plan, World Bank, New York City, USA, 2014: http://documents.worldbank.org/curated/en/489801468186879029/pdf/Main-report.pdf
4 Yet it must be cautioned that water, sanitation and hygiene (WASH) in combating COVID-19 is a crucial problem in the Nile Valley as it has one of the world’s lowest rates of fresh water availability per capita in the world (660m³/person/year) as most water taken from the Nile goes to agriculture, and is ranked high by the WHO among lower middle income countries in the number of deaths from water pollution.
6 See the December 2017 Kivu Security Tracker map online at https://kivusecurity.nyc3.digitaloceanspaces.com/reports/3/Armed%20Actor%20Area%20of%20Control%20Map%20Eng%20Dec%202017.pdf
7 How is Boko Haram Responding to COVID-19? Tony Blair Institute for Global Change, 20 May 2020: https://institute.global/policy/how-boko-haram-responding-covid-19
8 ‘We are dying’: Residents lament rebel attacks in northern Mozambique, Fidelis Mbah, Al Jazeera, 24 March 2020: https://www.aljazeera.com/news/2020/03/dying-residents-lament-attacks-northern-mozambique-200324115552256.html
9 Médicins Sans Frontières project update on Cameroon 23 May 2019: https://www.msf.org/five-things-know-about-violence-cameroon
10 Sahara Press Service, 19 March 2020: https://www.spsrasd.info/news/en/articles/2020/03/19/25151.html
11 Euronews, 10 April 2020: https://www.euronews.com/2020/04/10/stayinyourtent-covid-19-protective-measures-reach-sahara-desert
12 World Health Organization, 1 July 2020: https://covid19.who.int/region
13 MINURSO, 5 June 2020: https://minurso.unmissions.org/regular-updates-minurso-covid-19
14 Rift Valley Institute, 1 April 2020: http://riftvalley.net/index.php/news/covid-19-looming-humanitarian-disaster-somali-east-africa
15 Political Geography Now map: https://www.polgeonow.com/2019/08/somalia-control-map-timeline-august-2019.html
16 Somaliland Standard, 21 April 2020: https://somalilandstandard.com/eu-supports-somalias-covid-19-response-with-27-million-euros-somaliland-excluded/
17 Somaliland Standard, 23 June 2020: https://somalilandstandard.com/somaliland-lifts-all-covid-19-related-restrictions/
18 British Embassy Mogadishu, 5 July 2020: https://www.gov.uk/government/news/uk-denmark-and-netherlands-approve-agreements-with-somaliland-government-on-critical-infrastructure-to-improve-peoples-lives
19 The disproportionate impact of COVID-19 on racial and ethnic minorities needs to be urgently addressed – Bachelet, Relief Web, 2 June 2020: https://reliefweb.int/report/world/disproportionate-impact-covid-19-racial-and-ethnic-minorities-needs-be-urgently
20 Martin Brockerhoff and Paul C. Hewett. Ethnicity and child mortality in Sub-Saharan Africa, 1998: https://knowledgecommons.popcouncil.org/departments_sbsr-pgy/246/
21 Human Rights Watch World Report 2020: https://www.hrw.org/sites/default/files/world_report_download/hrw_world_report_2020_0.pdf
22 See for example Stef Vanderginste, Ethnic Quotas and Foreign NGOs in Burundi: Shrinking Civic Space Framed as Affirmative Action, German Institute for Global Area Studies, 2019: https://journals.sagepub.com/doi/full/10.1177/0002039719881460
24 Annexure to Update to the 2020 Ethiopia Humanitarian Response Plan, Reliefweb, May 2020, online at: https://reliefweb.int/sites/reliefweb.int/files/resources/hrp_update_june_2020_ethiopia_.pdf
25 Cara Anna, Associated Press, 25 June 2020: https://apnews.com/9c916d80adda68d43a42ccc04390443e
'Doing what we do best: Using facts and scorecards to build Transparency, Dialogue, and Action in the response to COVID-19 in Africa!'
With over 593,100 people dead and over 13.9 million people testing positive for the novel Coronavirus [i] and the International Monetary Fund predicting the most severe global recession since the Great Depression of the 1930s and the World Food Programme the most severe famine since World War II, the global COVID-19 pandemic has become a pivotal moment in human history where equal access to health-care has become internationally recognised as an urgent priority.
The African continent, with its already challenged health care systems, is only now starting to see the first cases of local transmission and the statistics of both new infections and death rates are alarming. Added to this is the fact that each of the challenges we face in this epidemic are more acute for marginalised people.
It is vital to have an independent, civil society driven analysis of the COVID - 19 data for Africa, and one which connects the various issues of health, human rights, socio-economics and accountability to Africa community leaders and human rights activists. Scorecards are what we do, and we wish to support the response to COVID-19 by doing what we do best.
Long term goal
Improve accountability from African governments to respond to Corona Virus pandemic.
Short term objectives
- Provide stakeholders, especially civil society, with data analysis in the form of a Scorecard on Corona Virus outbreak in Africa for their own use and advocacy at country level.
- Highlight the linkages between the various areas of research and how they more acutely affect marginalised people in Africa.
- Identify best practices and assist on sharing to increase replication of successful tactics.
- For civil society to document the epidemic as it occurs for future learnings and advocacy, and to increase accountability.
With over 593,100 people dead and over 13.9 million people testing positive for the novel Coronavirus[i] and the International Monetary Fund predicting the most severe global recession since the Great Depression of the 1930s and the World Food Programme the most severe famine since World War II, the global COVID-19 pandemic has become a pivotal moment in human history where equal access to health-care has become internationally recognised as an urgent priority.
The World Health Organisation’s Executive Director, Tedros Adhanom Ghebreyesus has criticised the African response as being too slow.[iv] Dr. Ahmed Ogwell, deputy director of the Africa CDC, has said “our health systems will not be able to cope” if African countries are not prepared for the numbers being seen in other parts of the world.[v] Ogwell has also stated that the Africa CDC is only able to provide limited support in such outbreaks due to the fact that there is a lack of financial, human and other resources provided to the institution.[vi]
In March 2020, in a candid interview Ogwell spoke about how, “with assistance from the international community and the World Health Organization (WHO), these 13 countries[vii] have had simulations of how to control a disease, but this is hardly enough.” He said: “They passed, but not with flying colours and that is going to need emergency money put aside.”[viii]
Prior to this outbreak, we have seen the exclusion of marginalized people from health care systems in Africa. For example, people work as sex workers, people who are gay, lesbian, bisexual, and trans-diverse, people with physical and mental disabilities, and differently abled persons, people with albinism, people who use drugs, and people living with HIV, as well as many other people on the margins of society.
Most of these facets of a human being usually “intersect”: for example, an HIV-positive person not having an income due to their health status and then perhaps turning to using drugs as a coping mechanism, and then being imprisoned as a result of drug use being criminalized. In the current global COVID-19 pandemic this exclusion of marginalized people becomes even more marked. For example, food security is more difficult for sex workers who are unable to work due to social distancing rules, supply chain issues affect trans-diverse people’s access to hormones, and discrimination affects drug users getting access to potable water. Never more so has it been important for us to see and work on the interconnectedness of these issues and how they affect people on the margins of society than during this pandemic.
The African response requires all stakeholders to play a role in ensuring that we minimise the numbers of deaths and permanent disabilities in Africa as this COVID-19 outbreak and the response to it evolve. It is also vital to examine what health, human rights, and socio-economic policies need to be put in place and implemented. As such AI proposes to do what we do best and have done for over 12 years: use our scorecard methodology, developed by over 100 experts globally over two years, to monitor the outbreak, and work to increase transparency and accountability by sharing this analysis with country-level policy-makers, activists, and other stakeholders for their own use for advocacy at country level.
It is vital to have an independent, civil society-driven analysis of the COVID-19 data for Africa, and one which connects the various issues of health, human rights, socioeconomics, and accountability to African community leaders and human rights activists. Scorecards are our widely-respected speciality, and we wish to support the response to COVID-19 by doing what we do best.
To see the indicators we have already covered, please see our online coverage:
[vii] The 13 African countries considered most at risk due to their being transport hubs: “Egypt, Algeria, and South Africa) have moderate to high capacity to respond to outbreaks. Countries at moderate risk (ie, Nigeria, Ethiopia, Sudan, Angola, Tanzania, Ghana, and Kenya) have variable capacity and high vulnerability.” Gilbert et al, Preparedness and vulnerability of African countries against importations of COVID-19: a modelling study. Lancet 17 Feb 2020. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930411-6
Long term goal
Improve accountability from African governments to respond to Coronavirus pandemic.
Short term objectives
- Provide stakeholders, especially civil society, with data analysis in the form of Scorecards on responses to the COVID-19 outbreak in Africa for their own use and advocacy at country level.
- Highlight the linkages between the various areas of research and how they more acutely affect a wide array of marginalized people in Africa.
- Identify best practices and assist on sharing to increase replication of successful tactics.
- For civil society to document the epidemic as it occurs for future understanding and advocacy, and to increase accountability.
Accountability International acknowledges and is thankful for the financial contribution made by SAA. SAA also plays a role in advocacy on this piece of work.
- Michael Schmidt (Hammerl Arts Rights Transfer, South Africa) research manager for the scorecard
- Delme Cupido and Tristen Taylor (Humanity NPC, South Africa)
- Laura Tensen (The Netherlands/South Africa)
- Michael Asudi (Kenya Adolescents and Youth SRHR/HIV Network)
- Olive Mumba (EANNASO)
- Thomas Heap (HokaHey Design)
- Denis Nzioka (Accountability International)
- Ricki Tshepo Kgositau-Kanza (Accountability International)
- Mats Ahnlund (Accountability International)
- Sheriff Mothopeng (Accountability International)
- Alexandra Ciobica (Accountability International)
- Phillipa Tucker (Accountability International) project manager for the scorecard.