In the context of the COVID-19 pandemic, policymakers are confronted with decisions that may prove to be among the most difficult of their careers. To contain the COVID-19 pandemic, unprecedented measures are being taken globally. In Africa, at least 42 countries have imposed partial or full lockdowns on the movements and activities of their people. Experience around the world suggests that such interventions effectively suppress the spread of COVID-19. The lockdowns, however, pose considerable economic costs that, in turn, threaten lives, put livelihoods at risk and exacerbate poverty.
The United Nations Economic Commission for Africa (UNECA) issued a report that has identified seven lockdown exit strategies. However, the challenge in Africa is that each state presents a unique and different context that pre-dates COVID-19 i.e. political instability, natural disasters, peace settlements, corruption, health crisis, poor infrastructure, low levels of trust in government, etc.
Lockdown exit options, countries attempting each option and regret score
|1. Improve testing|
|Rapidly scale-up testing to give greater clarity to the geographic extent and growth of COVID-19.||Zero regret|
(Iceland is leading example)
|2. Lockdown until preventive or curative medicines are developed|
|Retain reasonably heavy suppression measures until preventive or curative medicines are developed and distributed. Vaccines could take 12–18 months and considerable efforts in manufacture, distribution and administration. Existing medicines could be tested within 6 weeks, but may have limited, if any, impact on COVID-19.||Low regret|
|3. Contact tracing and mass testing|
|Identify those who have the disease and everyone they have come into contact with, then isolate, test and monitor those people. Typically requires considerable human, financial and logistical resources. Effectiveness could be supplemented with advanced surveillance technology, such as TraceTogether (Singapore). Typically, some technologies require mobile phone bluetooth or GPS data and may be difficult to design and administer in African countries with limited mobile phone penetration.||Low regret|
(Vietnam, China, Taiwan Province of China, Republic of Korea, Iceland, Australia, New Zealand, Israel and Singapore)
|4. Immunity permits|
|Antibody tests to identify and grant permits to those with immunity to return to work. May create perverse incentives for people to contract the virus as a way to get back to work or to forge permits.||Low regret|
|5. Gradual segmented reopening|
|Gradual opening up certain regions or businesses, or restricting lockdowns to certain hours (curfews) or high-risk demographics (shielding). Can be combined with adaptive triggering to reimpose restrictions if COVID-19 cases begin to rise rapidly. However, some modelling suggests that even a gradual relaxing of some suppression measures will see infections quickly spread again.||Medium regret|
(Ireland, Germany, Italy, Spain, Denmark, Austria, Czechia, United Kingdom, New Zealand, Australia, and United States of America)
|6. Adaptive triggering|
|Ease lockdown once infections decline, reimpose when they begin to rise above intensive-care capacity, repeat. Would require regular shutdowns lasting two-thirds of the year, making little difference to permanent lockdown from an economic perspective. African health-care capacity is limited to begin with, meaning capacity would quickly be exceeded, potentially resulting in fatalities. Can be combined with gradual segmented reopening.||High regret|
(Imperial College London Response Team suggestion)
|Gradually allow the infection to spread across the population with some social distancing measures in place. Reportedly working in Sweden, where an estimated 25–40 per cent of Stockholm have contracted COVID-19, but relies on good adherence to basic social distancing measures and strong health-care capacity. Could imply considerable risk in African populations with low health-care access and unknown comorbidities.||Very high regret|
(Sweden, abandoned in United Kingdom)
Nations that have attempted to gradually reopen their economies have implemented measures to curb the spread of the virus, regardless of the exit option they have pursued. The gradual lifting of lockdown restrictions is accompanied by preventive measures, such as requirements to wear face masks in public, hand hygiene and enforced physical distancing. These measures reflect a “new normal” that may remain long after lockdown measures are lifted. The report highlights the fact that testing for the virus is the “revelatory, zero-regret precondition” in order to ensure that risk to the livelihood of a population is minimized. Testing reduces uncertainty in all exit strategy options, which phases out the possibility of regret. The ability of countries to test for COVID-19 is strongly related to their income level.
Due to the fact that a number of African countries are among the poorest in the world, it is no surprise that countries within the continent have some of the lowest testing rates per 1,000 people.
The appropriateness of various exit strategies for any individual country depends on the characteristics and COVID-19 exposure status of that country. Countries in which cases are rising rapidly are advised to hold lockdowns in place or strengthen suppression measures. Although some countries may have the COVID-19 pandemic relatively under control, they may possess critical vulnerabilities that therefore warrant greater caution, such as a high prevalence of HIV/AIDS in their population. Many African countries are plagued with health vulnerabilities that could increase the danger of COVID-19 and make the premature exiting of lockdowns riskier. A large proportion of African countries also have severely limited health care capacity, which could also increase the risk and regret of implementing lockdown exit strategies to early.
Whilst maintaining a lockdown does pose an instant economic risk, it offers two significant advantages. The first advantage is that it allows governments extra time to implement the systems needed to control the spread of the virus and also treat those infected. The second advantage is that it allows time to learn from the countries at more advanced stages in their outbreaks. African countries are at an advantage due to the fact that they are further behind other countries and regions in their infection trajectories. This means that African countries have the luxury of learning from others as they implement exit strategies. This gives leaders of African nations the knowledge of what works and what doesn’t, which minimizes future regret. The UNECA report suggests that as African countries start to reopen, they must do so gradually whilst simultaneously increasing their testing rate. The timing of an exit strategy is of vital importance and reduces the risk of a second spike of infection rates in the future.
Contact-tracing exit strategies are feasible for countries with extensive testing and contained outbreaks. However, the levels of available infrastructure, resources and health facilities on the continent are under high scrutiny, which in effect affects the ability to monitor, observe and evaluate individuals. The contact-tracing method is supplementary of the existing containment measures, and should these measures struggle, governments are more likely to abandon the contact-tracing exit strategy and resort to a gradual and segmented reopening or other strategies. There is a possibility that stable countries on the continent with available infrastructure such as Botswana, Mauritania, Mauritius and Namibia, which have conducted many tests (but show few new cases) could look to the contact-tracing exit strategy.
WHO has recommended (in no-specific order) that, in lifting lockdowns, countries consider six criteria:
- COVID-19 transmissions are under control;
- Sufficient public health workforce and health system capacities are in place;
- Outbreak risks in high-vulnerability settings are minimised;
- Preventive measures are established in workplaces;
- The management of the risk of exporting cases from and importing cases; and
- Communities are fully engaged and educated
The ECA Report argues that many African countries have underlying health, social, political and economic vulnerabilities that could make COVID-19 more lethal, and the premature exiting of lockdowns riskier (should it be considered).
Africa’s infection trajectory versus comparators, as at 5 May 2020
There is no simple exit strategy for each African state however the report has prioritized the need to ensure that there are sound governance strategies that are put in place to respond to COVID-19.