PP67: COVID-19 in Africa - Vulnerabilities and assets for an effective response

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Policy papers
Robert Mattes, Carolyn Logan, E. Gyimah-Boadi, and George Ellison

Not only did the COVID-19 disease arrive on Africa’s shores (and at its airports) later than in Asia, Europe, and North America (Loembé et al., 2020), but for months the numbers of infections and deaths also appeared to remain relatively low. As of early August, the continent had experienced more than 1 million confirmed cases and 23,000 deaths (Africa CDC, 2020), though these figures were increasing rapidly.

At this point, the causes behind Africa’s comparatively low initial numbers are not completely clear. One reason may be that early and decisive responses on the part of many African governments prevented the virus from gaining an easy foothold (Beech, Rubin, Kurmanaev, & MacLean, 2020; Hirsch, 2020; Levinson, 2020; Moore, 2020; Loembé et al., 2020). Indeed, according to the International Center for Not-for-Profit Law (2020), 46 African countries took some form of official action – in the form of new legislation or executive orders and decrees – restricting or banning travel and public gatherings, enforcing quarantines, or in some cases imposing full “lockdowns.”

But Africa, somewhat paradoxically, may also have benefited from a range of structural factors, such as the continent’s relatively limited international exposure, its relatively low rates of intra- and inter-state air travel (Marbot, 2020), a generally hot and humid climate, relatively lower levels of population density and urbanization (De Waal, 2020; Marbot, 2020), and its substantially younger populations (Binding, 2020). It may have also profited from cultural factors, such as the fact that older people tend to remain with their families, rather than being institutionalized in retirement homes (Marbot, 2020), though this also has consequences for residential density, or that it has a more collectivist, less individualistic culture, which, according to recent research, may make COVID-19 interventions more effective (Frey, Presidente, & Chen, 2020).

Yet most public health experts remain wary, and still expect significant further transmission of the virus across the continent, requiring drastic public health responses and interventions, especially where governments eased initial restrictions and lockdowns. Indeed, some officials have expressed concerns that Africa’s low numbers merely reflect very low rates of testing (Sly, 2020) and even, in some countries such as Tanzania, deliberate under-reporting (BBC, 2020). Some press reports have described instances where local reports of death rates bear little relation to official data (MacLean, 2020; York, 2020).

These concerns appear well-founded given that community transmission is now present in all African countries and the number of infections increased by 50%, and deaths by 22%, in the last two weeks of July (World Health Organization, 2020). And officials at the Africa Centres for Disease Control and Prevention have warned that Africa could well become the next epicenter of the pandemic (Loembé et al., 2020).

If, as these events suggest, early interventions in African countries successfully erected a wall that kept the virus at bay, albeit temporarily, how well prepared are these countries if and when the virus penetrates their initial defenses? A wealth of Afrobarometer survey data suggests that Africans are especially vulnerable, in part due to lack of access to clean water and adequate health care (Gyimah-Boadi & Logan, 2020a; Logan, Howard, & Gyimah-Boadi, 2020). In this paper, we attempt to take the issue of vulnerability a step further by developing a more fine-grained approach, using insights from public health to examine different dimensions and components of vulnerability (Morrell, 2018).

Specifically, we develop three inter-connected indices intended to capture the extent to which Africans might 1) run a heightened “risk of exposure to infection,” 2) face a heightened “susceptibility to illness” (once infected), and 3) face a “lack of resilience” (to recover once they become ill). In addition, a fourth index of “lockdown readiness” estimates the proportion of people who are more (or less) likely to be able to withstand the most severe forms of government health interventions, i.e. lockdowns or “shelter in place” orders,

We then demonstrate how cross-country variations in the extent of exposure and susceptibility, and in the degree to which people are prepared for a lockdown, might help us better understand policy choices that African governments have made, and the extent to which these interventions were able to achieve desired reductions in mobility and contact.

Finally, we briefly explore some of the soft assets that governments can bring to the table, such as legitimacy and trust, that may help increase compliance with restrictions on mobility, especially in countries we have identified as least able to tolerate lockdowns.