2021 FORUM REPORT COVID-19 in Africa one year on: Impact and Prospects MO IBRAHIM FOUNDATION 2021 FORUM REPORT COVID-19 in Africa one year on: Impact and Prospects MO IBRAHIM FOUNDATION Foreword by Mo Ibrahim Notwithstanding these measures, on current projections Founder and Chair of the Mo Ibrahim Africa might not be adequately covered before 2023. Foundation (MIF) Vaccinating Africa is an urgent matter of global security and all the generous commitments made by Africa’s partners must now be delivered. Looking ahead - and inevitably there will be future pandemics - Africa needs to significantly enhance its Over a year ago, the emergence and the spread of COVID-19 homegrown vaccine manufacturing capacity. shook the world and changed life as we knew it. Planes were Africa’s progress towards its development agendas was off grounded, borders were closed, cities were shut down and course even before COVID-19 hit and recent events have people were told to stay at home. Other regions were hit created new setbacks for human development. With very earlier and harder, but Africa has not been spared from the limited access to remote learning, Africa’s youth missed out pandemic and its impact. on seven months of schooling. Women and girls especially The 2021 Ibrahim Forum Report provides a comprehensive are facing increased vulnerabilities, including rising gender- analysis of this impact from the perspectives of health, based violence. society, politics, and economics. Informed by the latest data, The strong economic and social impacts of the pandemic it sets out the challenges exposed by the pandemic and the are likely to create new triggers for instability and insecurity. lessons learned. It also points to how the recovery presents In 2020, Africa was already the only continent with increased an opportunity for Africa to build a new growth model that is levels of violence compared to 2019. Against this backdrop, more sustainable and resilient. disruptions to democratic practices and restrictions on civic With decisive action from the African Union and the Africa freedoms are undermining citizens’ trust in their governments. Centres for Disease Control and Prevention, supported by We know that young people with shrinking prospects are strong leadership from governments across the continent, at increased risk of being attracted to criminal and terrorist Africa delivered a swift and unified response to the pandemic. groups, and so the impact of the pandemic on the existing Building on the experience of tackling previous pandemics, youth unemployment crisis is of particular concern. most African countries moved swiftly to contain COVID-19, The pandemic has also laid bare the structural vulnerabilities deploying some of the fastest travel bans globally and quickly at the heart of Africa’s economic growth model. Mainly based rolling out contact tracing capabilities. on primary commodity exports, with a heavy reliance on The first wave of the pandemic was relatively late and mild the supply of key goods from outside the continent, Africa compared to other regions. However, subsequent waves are is highly exposed to external shocks. The global economic proving more devastating, and some African countries are shutdown has driven Africa into recession for the first time already experiencing a third. Africa represents 3% of global in 30 years. With social safety nets on the continent already reported cases, but poor data capacity could be hiding the weak, this is set to lead millions more Africans into poverty, true scale of infections. Meanwhile, the toll from other lethal widen inequalities and further deepen food insecurity. diseases, neglected by the current focus on COVID-19, These are profound challenges, and it would be easy to is high. The refocusing of limited resources towards the become despondent. But within every crisis there is always an pandemic means combined excess deaths from malaria, opportunity. I have been impressed by Africa’s immediate and tuberculosis and HIV/AIDS could exceed one million. collective response to the pandemic and I am convinced that, The pandemic has laid bare the long-standing and evolving harnessing the lessons from COVID-19, our continent can crisis in Africa’s health capacities, resulting from insufficient build a more sustainable, self-reliant and inclusive future. This domestic financial commitment, inadequate infrastructure, must be underpinned by sound governance, transparency and and the pervasive problem of ‘brain drain’. In 2018, sub- accountability, and Africa’s youth, who are the future of our Saharan Africa spent just 1.9% of its GDP on public health, continent, must be at the heart of the plan. the second smallest share in the world. Meanwhile, a fifth It is my sincere hope that this report, and the discussions it of African-born physicians are working in high-income informs at the 2021 Ibrahim Forum, play a role in contributing countries. to this goal. Africa remains squeezed out of the global vaccine market, which is dominated by developed countries and is only at the beginning of its vaccination response. Under the committed leadership of Africa’s continental institutions, and with swift commitments from its private sector, Africa has stepped up its purchasing power to independently secure vaccine doses. These efforts to supplement the currently insufficient international support mechanisms are impressive. Chapter 01. Health: strengthening African health capacity is a priority 1. THE PANDEMIC EVOLUTION OVER THE FIRST YEAR: AFRICA HIT LATER AND MILDER 12 a. Africa: only 3% of global cases, unevenly spread over the continent 12 Africa accounts for 3.0% of global confirmed cases and 3.8% of global reported deaths 12 Northern and Southern Africa hardest hit, Central Africa lowest recovery ratio 12 The first wave hit Africa later and milder, the second significantly stronger, with some countries already into the third one 15 Spotlight | Unpacking the low COVID-19 case numbers in Africa 17 b. Focus on COVID-19 undermines progress achieved in the fight against Africa’s most lethal diseases: malaria, TB and HIV/AIDS 18 Malaria: more excess deaths than from COVID-19? 18 Tuberculosis: back to 2012 levels? 18 HIV/AIDS: back to 2008 levels? 19 Spotlight | Mental Health: a mounting concern, especially among youth 20 2. CONTAINING, TESTING, TRACING: AFRICA’S SWIFT RESPONSE TO THE PANDEMIC 21 a. Containing: speed and commitment, ahead of other regions 21 Containment measures put in place speedily but also quickly eased 21 Robust international travel restrictions were among the fastest in the world 24 b. Testing: a swift upgrade in local capacities 25 Immediate and coordinated efforts to increase continental capacity led by AfCDC 25 Africa priced out of PCR testing 26 Mitigating resource shortages through pooled testing and rapid antigen testing 27 c. Tracing: quick and effective thanks to a long experience 29 A majority of African countries introduced contact-tracing within two days of first confirmed case 29 3. THE MAIN CHALLENGE: THE STRUCTURAL WEAKNESS OF AFRICA’S HEALTH SYSTEMS 31 a. Africa’s health capacities: the lowest at global level 31 Hospital beds and critical care: 135.2 hospital beds and 3.1 ICU beds per 100,000 people 31 Human resources: 0.2 doctors and 1.0 nurses/midwives per 1,000 people 33 Spotlight | Significant brain drain in the health sector exacerbated by COVID-19 35 Prevention, protection, and control of international diseases: Africa performs worst 36 b. Dysfunctional infrastructure environment 38 Energy: reliable electricity in only 28% of sub-Saharan African health facilities 38 WASH: sub-Saharan Africa lags behind other world regions in all key indicators 39 c. Health: a priority overlooked by African governments 41 Health ranks low in African governments’ priorities 41 Spotlight | Universal Health Coverage (UHC): still a long way to go 43 d. Preparing for the next pandemic 44 The need to already prepare for ‘Disease X’ 44 Spotlight | Emerging zoonotic diseases: the concerning health-environment link 45 Lessons learned from COVID-19: prevention and preparedness are measured in billions of dollars, a pandemic costs trillions 46 Spotlight | “Make it the last pandemic” conclusions from the Independent Panel for Pandemic Preparedness and Response 47 4. VACCINES: AFRICA’S CURRENT EXCESSIVE EXTERNAL DEPENDENCY 48 a. COVID-19 vaccine rollout in Africa: no immunity before 2023? 48 A belated vaccine rollout: starting last in Africa, with 8 countries not having kicked off their vaccination campaign as of 3 May 2021 49 A striking inequity: less than 2% of globally administered vaccine doses, for almost 18% of the world’s population 54 A concerning outcome: no herd immunity for Africa until at least 2023? 55 Spotlight | Multiple bottlenecks for vaccine distribution on the continent 56 b. ‘Vaccine nationalism’ vs ‘vaccine diplomacy’: a new geostrategic balance? 57 The danger of ‘vaccine nationalism’ 57 Bilateral alliances: China, India, Russia… ramping up as ‘vaccine donors’ 58 Multilateral initiatives are welcome, but far from enough 59 Spotlight | COVAX rollout in Africa: 28 countries covered in May 2021 61 5. A wake-up call for Africa: strengthening continental vaccine autonomy 65 a. Africa collectively stepping up its purchasing power 65 AVATT: a continental strategy for vaccine acquisition 66 Nigeria’s CACOVID: an example of early commitment from the private sector 67 b. Looking ahead: securing Africa’s own manufacturing capacity 67 The market is there: Africa hosts almost 18% of the global population, but still produces less than 0.1% of the world's vaccines 67 Multiple challenges still need to be addressed 71 Spotlight | The Africa Medicines Agency (AMA): a key institution on the road to vaccine autonomy 74 c. Effective political commitment is crucial 75 Multiple former commitments and frameworks still unmet 75 AfCDC's New Public Health Order: a key boost? 75 Spotlight | AfCFTA: instrumental to make progress 77 2021 Ibrahim Forum and Now Generation Forum - Insights from the discussions 78 Chapter 02.