COVID 19 - On the Frontlines: Nurses, Doctors, and Midwives

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.”[1] 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.”[2]

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:

  1. Surveillance, including screening at points-of-entry;
  2. Infection prevention and control (IPC) in healthcare facilities;
  3. Clinical management of persons with severe COVID-19 infection.

Medical Doctors Data

Nurses and Midwives Data


[1] World Health Report, World Health Organization, New York City, USA, 2006, online at

[2] Task Shifting and Health System Design, Report of the Expert Panel on Effective Ways of Investing in Health, European Commission, Luxembourg, 2019, online at

IMPORTANT: When Accountability International first began tracking the COVID-19 pandemic, our grading of the number of positive cases had as our worst-case scenario (Grade E) countries with more than 1,000 cases. Since the caseloads have increased significantly, with two African countries surpassing the 5,000 barrier, from May 14th, 2020, we have raised the ceiling for Grade E to more than 10,000 cases and have adjusted the rest of the grading in line with that. Comparisons reaching from before to after May 14th, 2020 must thus rely on the numbers and not the grading.

'Doing what we do best: Using facts and scorecards to build Transparency, Dialogue, and Action in the response to COVID-19 in Africa!'

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

  1. 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.
  2. Highlight the linkages between the various areas of research and how they more acutely affect marginalised people in Africa.
  3. Identify best practices and assist on sharing to increase replication of successful tactics.
  4. For civil society to document the epidemic as it occurs for future learnings and advocacy, and to increase accountability.