COVID-19 and beyond: How can Africa’s health systems cope?

By Riku Elovainio, Consultant in global health and social protection and Alexander Pick, OECD Development Centre

This blog is part of a series on tackling COVID-19 in developing countries. Visit the OECD dedicated page to access the OECD’s data, analysis and recommendations on the health, economic, financial and societal impacts of COVID-19 worldwide.

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The Covid-19 pandemic threatens to overwhelm health systems everywhere. With the virus now present in 52 African countries, will health systems in the region, many of which were under strain before the pandemic and have no reserve capacity, be able to cope? International support will be crucial in helping countries in Africa respond, but efforts to strengthen the region’s health services in the short term confront an array of obstacles that extend beyond the health sector itself. Even a crisis of these proportions should not obscure the long-term priorities for Africa’s health systems, on which depends its capacity to deal with day-to-day demand, let alone the next crisis.

The West African Ebola epidemic of 2014-2016 exposed the affected countries’ limited capacity to deal with a widespread disease outbreak. The lessons for health systems across Africa were understood yet have not prompted a step change in public health services, even in the countries where the Ebola crisis struck. While there is great variation across Africa (South Africa’s health system is clearly very different from South Sudan’s, for example), many countries exhibit the same gaps in their health systems that make it extremely difficult to scale up a short-term response.

In the midst of the current crisis, a large number of OECD countries have increased training, rehired retired health professionals, placed medical students in the front line and redistributed health workers across the country. These options are not available for most, if any, African countries: on average, the World Health Organisation (WHO) calculates that the African region[1] has 1.4 health workers per 1 000 people, versus 12.3 in OECD countries. According to the WHO, Africa needs 63% more health workers to meet the staffing requirements of universal coverage. Building up a reserve workforce for pandemic response is an even more remote target.

Shortages of health workers present a huge dilemma: shifting medical staff to Covid-19 care exacerbates shortages in other areas; these shortages might have consequences that surpass those from Covid-19 (in Ebola-hit countries, there was an important reduction in maternal and child health services during the response). Absent a massive influx of health workers from other countries – a possibility that seems remote while they are dealing with the pandemic themselves – there is no short cut to addressing this situation: health workers need to be trained and deployed, which takes much more time than Covid-19 allows. The strong likelihood of losing health workers to Covid-19 would also have a major impact on Africa’s health provision when staffing numbers are so low to start with.

OECD countries are undertaking major efforts to acquire the critical equipment required to treat Covid-19 complications. While some possess reserves through which equipment can be rapidly mobilised, many are finding it hard to source the ventilators, testing kits, beds or even masks they need. Meanwhile, Central African Republic has three ventilators for a country of 4.7 million people; in Malawi, there are 25 intensive care beds for a population of 17 million. While the price of medical equipment partly explains these shortfalls, logistical and trade barriers are also a constraint, especially when many countries are trying to buy the equipment at the same time. As international bidding wars erupt for something as simple as masks, Africa risks being last in line.

Most countries in Africa cannot scale up their response in the way OECD countries are doing, even if they were presented with a blank cheque: the absorption capacity is not there and Covid-19 has not blown away the structural bottlenecks in health system development. This is not to question the financial support pledged to help developing countries in Africa and elsewhere to fight Covid-19. However, the short-term benefits might be limited; even in a time of crisis, we must not lose sight of the long-term priorities for Africa’s health systems, which go far beyond pandemic preparedness and response. Two imperatives stand out for African countries and the international community.

First, African countries need to keep focusing on strengthening their health systems as a whole. Although it has been slow, progress has been made in this area. The objective of universal health coverage has been gaining traction in Africa, often supported by high-level political will. In this context, more harm than good could come from diverting large amounts of funding through ad-hoc channels that might not be effective or cost-efficient (and which could also offer opportunities for corruption) while bypassing mechanisms for strengthening health systems in the longer term.

Second, we need to reconfigure international co-operation – on health and more broadly. A global funding mechanism that serves as a transnational instrument for responding to health crises and also cross-subsidises health systems between countries at different levels of development is a promising way forward. But the problems that confront health systems in developing countries are bigger than financing and go beyond the health sector. Issues such as trade imbalances (African countries often need to purchase medicine and medical equipment on international markets but are short of the foreign exchange required to do so), loss of health workers through migration, capital flight and corruption are all constraints on health provision in the poorest countries. These challenges are interlinked, and they can only be resolved through a different set of global governance mechanisms than exists today.

So what can be done in the short term? To reduce the spread of the virus, many African countries have been quick to implement confinement measures even when confirmed cases were very low. However, confinement and social distancing will be difficult to sustain, especially in countries without scalable social protection systems. The majority of workers across the continent operate in the informal sector and many survive on what they earn each day through face-to-face transactions. Even acquiring water – so critical for prevention and daily life – requires many individuals to leave their home. Without effective social distancing, testing and contact tracing become less effective or even unworkable. Robust enforcement does not alter this reality; indeed, it risks breeding resentment that renders compliance less likely.

But while it seems that most African countries lack the capacity to address Coronavirus in the same way as countries in other regions, it is worth remembering that Coronavirus will also affect the region differently from other regions. Each country will face its own challenges and each will respond in their own way, just as every other country has done. There will be successes and failures, just as there have been across the world. What is critical in the short term is that countries across the region support each other in dealing with Coronavirus, especially by sharing the lessons they learn, and that the international community responds quickly to support effective responses, even if such measures were not applied in their own countries.

[1] The WHO’s African Region consists of 47 member states,