The COVID-19 pandemic in the African continent

Vaccines were regarded from early on in the pandemic as one of the pillars in the fight against COVID-19 [150, 151]. The first vaccine to receive the World Health Organization (WHO) Emergency Use Listing (EUL) status was the Pfizer/BioNTech mRNA vaccine on 31 December 2020 [152]. To promote equitable access to vaccines for low-middle income countries (LMICs), COVAX was established as a collaboration co-led by Gavi, Coalition for Epidemic Preparedness Innovations (CEPI), and the WHO with UNICEF as the key delivery partner [153]. COVAX’s biggest beneficiaries are countries in Africa and South Americas. The next COVID-19 vaccine to be accessible was the AstraZeneca vaccine, which was granted EUL approval by the WHO on 15 February 2021 [154]. The AstraZeneca vaccine approval was a pivotal moment in efforts to accelerate vaccine access to Africa due to its affordability, easier storage, and transportation [155].

Côte d’Ivoire and Ghana were the first recipients of the first-round allocation by COVAX in Africa on the 1st of March 2021 and more countries soon followed [156]. However, as of 14 February 2022, only 26.1% of the population in Africa had received at least one dose in contrast to 61.8% for the rest of the world’s population [157]. According to WHO, over 670 million doses have been received in the 53 African states to date, with 64% of the doses from COVAX, 29% from bilateral agreements between countries, and 6% from the African Union’s African Vaccine Acquisition Trust (AVAT) [158]. The COVID-19 vaccines have included AstraZeneca (31%), Sinopharm (20%), Sinovac (18%),Pfizer/ BioNTech (13%), Janssen (11%), Moderna (5%), Sputnik (2%), and Covaxin vaccines (0.1%) [158].

Only 26% of the population in Africa has received at least one dose of COVID-19 vaccines in contrast to 62% of the global coverage of at least one dose [158, 159]. This represents a ratio of 11.8 per 100 people that are fully vaccinated with COVID-19 vaccines on the continent. Of the 677 million COVID-19 vaccines received in Africa, about 364 million doses (54%) have been administered and 163 million have completed the primary series doses [158].

In May 2021, the WHO set targets for countries to have 10% of their population vaccinated by end September 2021, 40% of their population by end December 2021, and 70% by mid-2022 [160]. By the end of September 2021, only 16 African countries had met the target to fully vaccinate 10% of their total population eligible for vaccines. Only seven countries achieved 40% vaccination coverage by end December 2021, with Seychelles, Mauritius, and Morocco able to vaccinate over 60% of their population [158, 161]. Majority of the countries (n = 46) missed the 40% target, including some of Africa’s largest populations such as Nigeria, Ethiopia, and Democratic republic of Congo as they managed to vaccinate only <5% of their population. Tanzania and Burundi were the last two countries to commence their COVID-19 vaccination campaigns, due to policy divergence from the WHO recommendations. Following alignment with WHO policy recommendation, the countries began COVID-19 vaccination, in July 2021 for Tanzania using the single-shot Johnson & Johnson vaccine [162] and in October 2021 for Burundi with Sinopharm vaccine [163]. However, Eritrea remains the only African country yet to start their COVID-19 vaccination campaign [158]. Judging from the current trend in vaccine uptake, it is only a few countries that are set to have 70% of their population vaccinated by mid-2022.

The low vaccination coverage and uptake in Africa is multifactorial, but with most of the challenges stemming from inequitable distribution of vaccines [164]. Firstly, the observed low utilization rate of COVID-19 vaccines in Africa is partly due to the expected lag in time between in-country receipt of vaccines and time of vaccination, as there are preparatory and logistical steps at a national level that need to occur. Vaccine rollout is accompanied by key steps that include but not limited to training and supervision of healthcare workers, assessment of vaccine cold chain capacity, and regulatory and safety surveillance [165, 166]. It has been demonstrated that COVID-19 vaccine utilization increases as vaccines are accessible to the general public [158]. Secondly, the inconsistent supply of COVID-19 vaccines to Africa, due to lack of equitable access to vaccines, is a major barrier to vaccine uptake. The vaccine supply challenge was initially caused by agreements between high-income countries and manufacturers where doses were reserved by wealthier nations before the vaccines became available [167]. This was coupled with vaccine hoarding where wealthy countries had surplus vaccines than needed for their population while countries in Africa were still waiting for supplies [168]. Furthermore, exports to Africa of the AstraZeneca (COVISHIELD) vaccine by Serum Institute of India (SII), which had mandate to produce the vaccine for LMICs at lower cost [169], were blocked by the Indian government when the country experienced its second wave that had a high case fatality rate [170]. This led to shortage of supply of vaccines to Africa as SII is one of the main vaccine suppliers to the COVAX facility [171]. Thirdly, across the globe, reluctance of people to receive safe and recommended available vaccines, termed vaccine hesitancy, has slowed down the consumption rate of COVID-19 vaccines. Across the continent, it has been a common trend that the vaccines donated to African countries by wealthier countries have had a short shelf life, which has led to the inevitable expiry and destruction of the vaccines in the recipient country because countries are unable to adequately plan for vaccination campaigns [172]. This has fuelled distrust and perpetuated vaccine hesitancy. In addition, the risk perception of the people on the COVID-19 pandemic, considering the less severe nature of the pandemic in Africa compared to the Americas and Europe [150], has contributed to vaccine hesitancy. Lastly, country-level preparedness has impacted vaccine uptake in Africa. Vaccine arrival in some countries was met by national deployment and vaccination plans that were not updated, which is a pre-requisite for countries to apply for implementation funds [173]. Furthermore, public engagement to encourage COVID-19 vaccination has been suboptimal in reaching rural communities in some countries, this is in contrast to the robust immunization campaigns most African countries are known for, that have led to the high childhood vaccination coverage across the continent [174].

Africa is the second most populous continent [175], yet it remains the only continent that lacks local technological capacity for COVID 19 vaccine manufacturing. The COVID-19 pandemic has been a lesson for African countries to urgently invest in local technological capacity for vaccine manufacturing. This could in part also help solve the problem of vaccine hesitancy, as the recipients are more likely to have trust in locally manufactured vaccines. At a global level, COVID-19 vaccine manufacturers should be incentivized to increase vaccine access through the sharing of vaccine manufacturing technology in order for the vaccines to be locally produced in Africa while maintaining their intellectual property rights similar to the recent agreement between Moderna, WHO, and Afrigen Biologics and Vaccines in Cape Town, South Africa [176]. Recently, Germany’s BioNTech announced plans to send vaccine production units in shipping containers to Africa, with the initial facility expected to arrive in the second half of 2022, and manufacturing starting about 12 months after delivery [177]. As vaccine supply to Africa drastically increased around mid-August 2021, we witnessed a similar rise in vaccine utilization in the region [158]. However, the gap between supply and uptake has exponentially increased since November 2021 [158], which underlines that Africa’s current primary challenge is both supply and uptake. With improved vaccine supply, countries must accelerate uptake through improved demand creation. There should be contextualized and country-tailored support from multilateral partners to understand the challenges faced by each country and their root causes in order to overcome human, financial, and technical assistance needs. Moreover, there is a need for joint coordination efforts between governments in Africa to find data-driven innovative methods to lower vaccine hesitancy and increase uptake, as this has potential to derail the highly successful childhood vaccination programs in Africa.

The authors declare that they have no competing interests.

All authors were involved in drafting, editing, and revising the manuscript and agreed to its publication. All authors read and approved the final manuscript.

Sub-Saharan Africa has the highest burden of public health events, including health and humanitarian emergencies because of its bio-geographical location. Each year, the World Health Organization Africa Region confronts over 100 health emergencies [178]. Public health threats originating from the human-animal and environmental interface occur frequently [179]. Concomitantly, climate-related events, including prolonged droughts, food insecurity, destructive floods, and cyclones, are increasing [180]. The African continent is also affected by many protracted humanitarian crises. Mass refugee migration, internal population displacements, trade practices, and cross-border movements provide opportunities for spreading infectious diseases [178].

The COVID-19 pandemic has unraveled significant gaps in emergency preparedness and health systems resilience worldwide. The pandemic has infected millions of people and caused over hundred thousand deaths in Africa [198]. Early reports from low- and middle-income countries show interruption of critical disease services for HIV, TB, and malaria as well as maternal and child health programs [181, 182]. Additionally, the public health and social measures (PHSMs) to contain the pandemic have significantly interrupted trade and supply chains and hospitality and recreational industries [183]. Consequently, stock markets have plunged, unemployment rates have risen, and economic gains have been reversed [184, 185]. This is a stark reminder about the urgent need to build resilient health systems and strengthen the International Health Regulations (IHR 2005) capacities.

Research on the unintended consequences of Covid-19 on the African continent is still limited; however, emerging evidence shows devastating effects of the COVID-19 pandemic on economies and major disruptions to essential health services, livelihoods, and education, among others [186‐188]. The COVID-19 pandemic has clearly demonstrated how public health emergencies can affect all four interconnected health system performance attributes. COVID-19 has affected access capacity—the ability to overcome barriers (physical, financial, and socio-cultural). It has also affected quality capacity—the ability to provide services as expected. Additionally, it has affected demand capacity—the ability to provide services expected by populations [189]. Importantly, the pandemic has brought to the surface inadequacies in resilience capacity—the ability to sustain the provision of essential health services during shock events. The resilience of a health system is driven by the need to ensure continuity of essential service provision. Resilience brings together the work of emergency preparedness and health systems-health security and universal health coverage (UHC) goals [53, 190].

The fear of COVID-19 affected health service delivery and utilization because health workers and communities avoided going to health facilities [191]. The repurposing and diversion of human, financial, and material resources to the COVID19 response deprived other priority health programs. However, the biggest effects have perhaps been due to the negative consequences of the PHSMs adopted to prevent COVID-19, and the challenges with prioritization of investments in health. Importantly, the PHSMs to contain the pandemic such as the nationwide lockdowns and other movement restrictions, closure of schools, discontinuation of community health service outreaches for immunization, family planning, and other health services, as well as closure of formal and informal services such as trade have created devastating effects on health and other services [192].

Restriction of movement of health service providers led to complete absenteeism or late arrival to duty station. Inadequate infection prevention control (IPC) resulted in COVID-19 infections among health workers and further exacerbated the absenteeism [193]. The disruption of health services was further exacerbated by the fragile health systems and the absence of clear plans and guidelines for the continuity of essential health services [194]. For example, the poor investment in human resource surge capacity led to repurposing of health workers to conduct surveillance, contact tracing, and other activities as part of the COVID-19 response and affected the delivery of the other health services. Space and infrastructure for some health services was repurposed too. In Uganda, for example, mental health wards were used as isolation centers for COVID-19 at the onset of the pandemic while in Cameroon tertiary health facilities where designated to exclusively care for COVID-19 cases, yet these facilities offer other essential health services [182, 194]. Laboratory equipment and personnel across various countries such as the GeneXpert were repurposed to Covid-19 testing [195].

Movement and travel restrictions also affected the delivery of health commodities and supplies across various levels of service delivery, with resultant stockout of essential supplies [194, 195]. The disruption of health services had immediate effects on service utilization, leading to negative outcomes such as increased mortality among women during childbirth, poor coverage of childhood immunization services, loss to follow-up among patients in chronic care clinics such as HIV, tuberculosis, and non-communicable disease clinics, including diabetes and hypertension clinics [194, 196].

Although countries developed policies and guidelines for the continuity of essential health services [196, 197], including data analysis to track and address disruptions, the pace of adoption of these interventions was quite varied, with significant delays, varied levels of disruptions, and outcomes across many countries [197]. To counter the disruptions, health workers were trained, and new service delivery models were adopted or expanded, for example, multi-month drug refills for chronic care patients, home-based delivery of supplies using motorcycles, telephone-based counseling, etc. These interventions led to recovery of the services where they were applied while some services that did not receive much attention lagged [194, 197, 198].

The International Planned Parenthood Federation (IPPF) report of 2021 revealed declines in service delivery evidenced by closure of mobile clinic services globally, with the African region experiencing the largest number of clinic closures (447 closures) [199]. There were reports of vaccination clinics stopped in Zimbabwe and a resurgence of measles in DRC [200]. In Ethiopia, a national level study of effects on reproductive, maternal, newborn, child, and adolescent health and older people (RMNCAAH) services showed minimal disruptions of the RMNCAAH indicators [198]. However, a study in Northern Ethiopia revealed increased institutional caesarian sections and still births and in the number of under-5 children with malnutrition as well as a decrease in HIV testing and enrolment on to antiretroviral therapy among HIV-infected individuals [201]. These national and subnational differences reflect the varied disruptions across regions and different services, and the need for disaggregated analyses within countries for targeted mitigation measures where needed [194]. In Kwazulu Natal, South Africa, there was a 36% decline in clinic attendance and 50% decline in hospital admissions of children in April–June 2020, although the changes were less for the hospital births and testing of HIV-exposed infants. Although short-lived, there was a 47% increase in neonatal deaths in May 2020 [202]. In Rwanda, there was a reduction in malaria testing in health facilities among patients by 4.32 per 1000 population while testing in the community increased by 2.38 per 1000 population monthly, due to challenges and delays in accessing care at facilities [203]. The findings in Kenya were mixed, with declines in some services while utilization of other services increased or did not show significant changes. While bed occupancy reduced by 25%, measles vaccination increased by 44% [204]. In another study, the majority of women in Kenya and Burkina Faso did not change their contraceptive status and were in fact more likely to adopt a method if the status changed (25 and 13%, respectively). Discontinuation was lower at 6 and 5%, respectively [205]. In Cameroon and DRC, several RMNCAAH in 2020 were comparable to 2019 and some where even higher, perhaps due to the service adaptations implemented with a focus on sustaining these services [198].

The disruptions to health and service access were more pronounced among the most vulnerable populations. For example, the absence of a functional referral and ambulance system, yet the poorest communities and families could not afford car hire to access emergency health services [206]. Similarly, with migration to virtual approaches and e-learning, the poorest and most disadvantaged families could not have access to these services because they neither have electronic devices nor internet access to support learners [207]. Limited safety nets for the most vulnerable has further aggravated the inequities within and across countries [190]. Worryingly, despite the major impact of COVID 19 on mental and social welfare, mental health and psychosocial services were not prioritized. Consequently, negative mental health effects including depression, anxiety, post-traumatic stress, and behavior trouble have increased due to the impact of movement restrictions and socio-economic challenges [21, 208‐212].

On the other hand, there were investments to improve critical care capacity, laboratory infrastructure (diagnostics, genomic surveillance, pooled scientific, and other resources, e.g., training in PCR for COVID-19 testing), emergence of pooled procurement and distribution networks, and renewed commitments towards local production and public-private partnerships across the continent [213, 214], which if sustained could lead to longer-term improvements in systems and care across various disease conditions. The longer-term effects of these health service disruptions and investments on the achievement of the sustainable development goals (SDGs) and UHC targets are yet to be fully assessed and are an important area for further research. Additionally, the disruptions of other critical determinants of health including education, livelihood, and increased poverty among the most vulnerable groups may have longer-lasting effects on health and health outcomes and should be further investigated.

An Oxfam report shows an undeniable increase in gender-based violence (GBV) during the COVID-19 pandemic around the world to which too many governments and donors are not doing enough to tackle. The Oxfam report, titled “The Ignored Pandemic: The Dual Crisis of Gender-Based Violence and COVID-19”, showed the number of calls made by survivors to domestic violence hotlines in ten countries during the first months of lockdown. The data reveals a 25–111 percentage surge, in Tunisia (43%), Somalia (50%), and South Africa (69%) [215]. In many households, coronavirus created a “perfect storm” of social and personal anxiety, stress, economic pressure, social isolation, including with abusive family members or partners, and rising alcohol and substance use, resulting in increases in domestic abuse [216]. Worryingly, not enough countries have acted with sufficient seriousness to tackle the GBV pandemic. Even before the surge in GBV cases sparked by the pandemic, in 2018 alone, over 245 million women and girls were subjected to sexual or physical violence by an intimate partner—a greater number than the global total of coronavirus cases (199m) between October 2020 and October 2021 [215].

School closures were instituted across many countries in Africa in March–June 2020, and most of these remained closed for prolonged periods with the longest closure of 22 months and a predicted learning deficit of 2.8 years in Uganda [217]. Burundi on the other hand did not close schools due to Covid-19 while Tanzania closed schools for a few months [218]. In an assessment of school reopening in 40 Global Partnership for Education (GPE) countries, >60% opened after >200 days of closure [218]. While there was increased adoption of e-learning across countries, this mostly favored high-income households in urban areas—those that had access to internet and e-learning tools. Children got involved in creative household work and trade, which may enhance learning but also has the unintended consequences in terms of child labor and exploitation, with some learners dropping out of school due to the attraction to petty trade [218].

Further, there have been widespread reports of early marriages and pregnancies among the girl child, with many young mothers failing to return to school or struggling to cope with the demands of school while caring for their children [217‐220]. Overall, learning was disrupted for most of the learners with a lack of progression to the next level, with reports of anxiety and other mental health issues driven by stress and increased use of alcohol and drugs [217]. There have also been reports of teachers losing jobs due to downsizing or school closures while others opted for more lucrative forms of employment [217‐220].

Although Africa reported the least number of cases and deaths of all the continents, it is our considered view that the COVID-19 pandemic and its related PHSMs have had mixed outcomes in Africa. Major disruptions occurred in the delivery of essential health and other social services, and negative socioeconomic consequences that could reverse decades of economic progress in Africa. Worryingly, the discontinuation of education will have major consequences that need to be tracked and addressed in the medium to long term. Moreover, there have been major effects on household and individual incomes and increasing unemployment. Effects on mental health and gender-based violence will need African countries to carefully build a cadre of mental health experts and increase the number of facilities offering mental health care and addressing GBV.

Finally, some of the effects could be sustained for a long time and potentially affect the attainment of the sustainable development goals and UHC targets if remedial actions are not timely. The lessons from the COVID-19 response should inform future epidemic and pandemic preparedness and response strategies and plans—specifically ensuring resilience of health and other systems to mitigate the negative effects of health emergencies. Continuity of essential health services and mitigation of unintended negative consequences during shock events should be fully integrated into the policies and strategies for health emergency preparedness and response.

Both authors declare that they have no competing interests.

AOT has no conflict of interest. RW and AOT conceptualized the idea, and RW wrote the first draft of the manuscript that was reviewed by AOT. Both authors have reviewed and approved the final manuscript.