Africa Update for April 2020

Here’s the latest edition of Africa Update.  I’m going to guarantee you a nearly coronavirus-free edition, because I collect links for the newsletter over the course of roughly a month and can’t put it out fast enough to keep up with the pandemic news.  So here are some other notable things that have been happening recently, plus a few coronavirus links covering underdiscussed aspects of the crisis.

Nairobi’s new skyline is taking shape, via Sam Muchai

West Africa: Cameroon has introduced new ID requirements for making mobile money payments after the services were used to pay ransoms.  Here’s how colonial understandings of the gender binary erased Igbo traditions with a very different relationship to gender.  Meet the Nigerian judge who’s liberating people in jail who have spent more time waiting for a trial than they would have served if convicted.  In Ghana, the question of whether people who are dual citizens with neighboring Togo can vote is hotly contested.  Ghana has legalized marijuana for health and industrial purposes.

Central Africa: Religious conservative organizations from the US have begun setting up “crisis pregnancy centers” which discourage contraception in Uganda.  In the DRC and Uganda, colonial-era understandings of the role of local chiefs are skewing policy interventions.  The DRC is about to pass its first law protecting the rights of people with disabilities.

East Africa: Meet the young Somalis who are changing the fact of the country with online shopping and ambulance services.  Kenya’s flower industry had a bad track record on workers’ rights even before the pandemic basically ended exports. Also in Kenya, a 2015 program to import medical equipment has been criticized after over 1/3 of the equipment ended up in hospitals without staff trained to use it.  East Africa is bracing for another locust invasion in May, even worse than the one in January.

Here’s where the locusts are coming from, via the Mail & Guardian

Southern Africa: In South Africa, the Gautrain project which serves the middle class receives state subsidies, but the minibuses which mostly serve poorer people don’t receive any.  Some women in Zimbabwe are finding new opportunities as bus drivers, while others are moving back to rural areas in order to escape the country’s long-lasting economic crisis.  Why is the insurgency in northern Mozambique getting worse?

Economics: By joining the proposed new eco zone, West African countries might give up control over their currencies in ways that are bad for growth.  Dollar Street is a fascinating new project which shows how families all around the world, including many in Africa, live on different levels of income.  In Uganda, big infrastructure projects have benefited foreign investors while sometimes literally walling off local communities from accessing them.

Interesting map of the oldest companies across the continent, via Ken Opalo

Climate + agriculture: Here’s how women in Kenya are re-introducing traditional crops to promote food security.  How are drought in Australia and floods in Kenya connected?  An American tractor company is working on a plan hailed as “Uber for tractors” in Kenya.  If plans to drill for oil in central DRC go forward, the destruction of the peat bog on top of the oil could release as much carbon as Japan produces in a year.

Research + education: Ugandan kids could learn to read more quickly if they were taught using local plants and animals for phonics lessons, rather than “A is for apple.”  Here’s how to use Shaka Zulu to decolonize the teaching of math in South Africa.  Check out this list of free online academic journals about African issues.

Young women leading the way in Namibia, via Sarah Anyang Agbor

Art + culture: I’m excited to read about all the inspiring women on OkayAfrica’s 100 Women 2020 list.  Did you know that the Senegalese national archives are an unusually good resource for historical research?  Somaliland’s informal national archives started with a crumpled napkin.  Once we can all leave our houses again, do check out the new Yemisi Shyllon Museum for African art just outside Lagos.

Coronavirus: Meet the leader of the Nigeria Centre for Disease Control, who’s dramatically scaled up public health capacity across the country after just two years in office.  One important lesson from the Ebola epidemic in Liberia is that door-to-door canvassing makes people more likely to comply with public health rules.  Research in Sierra Leone during the Ebola epidemic shows that governments are likely to see much lower tax revenues as economic activity drops.  In East Africa, coronavirus has driven gambling revenues down by 99% as people save their money for immediate needs.  Here’s a great list of articles on the pandemic from African authors.

Designing social protection programs for the pandemic

François Gerard, Clément Imbert and Kate Orkin published a useful article on this topic recently at Economics for Inclusive Prosperity.  As the authors write,

Our core argument is that middle-income and lower-income countries can cast an emergency safety net with extensive coverage if they use a broader patchwork of solutions than higher-income countries. These strategies could include:

  1. Expanding their social insurance system, which typically covers a much smaller share of the labour force than in higher-income countries;
  2. Building on existing social assistance programmes, which reach a large share of households in many developing countries;
  3. Involving local governments and non-state institutions to identify and assist vulnerable groups who may not be reached by 1) and 2).

The whole article is really worth reading.  I’ll highlight just a few points about using local leaders and non-state institutions to enroll people in social protection programs, as enrollment has been widely perceive as a stumbling block in these times of social distancing.

range of non-state institutions are also particularly active in giving voice to specific groups or serving populations beyond the reach of the state. [For example,] illegal urban settlements sometimes have recognized local leaders who facilitate access to state services and social benefits and are accountable to local populations (e.g. in urban India[35]). Recognized local NGOs also often provide a range of services and sometimes coordinate their efforts within a geographic area under an umbrella organization (e.g. in urban Brazil[36]); they may have years of experience being accountable to both their donors and their beneficiaries. International NGOs (e.g. BRAC, Oxfam) have a strong presence across a range of contexts. There are also private associations with specific purposes, which can, in some instances, have wide coverage. For example, 24% of Africans participated in community-organised savings groups (Findex, 2014). Membership may be even higher in rural areas: 53% of a rural Kenyan sample were members of a rotating savings group (ROSCA) (Orkin and Walker, 2020). In Ethiopia, over 90% of villagers in two separate samples are members of burial associations (Dercon et al., 2006; Bernard et al., 2014). Another type of private associations are professional organizations, which may be active in sectors that employ many  informal or poor workers. For example, India’s relief package encourages Building and Other Construction Worker Welfare Funds to provide emergency assistance.[37]

What role can non-state institutions play?

Some will likely repurpose themselves to provide emergency assistance in the current crisis spontaneously, an effort that could be leveraged and complemented by governments. Governments could leverage their infrastructure to gather information on the needs of their many beneficiaries. Many have a network of workers in remote areas, who are already part of public health responses, e.g. an NGO trained community volunteers, religious leaders and traditional healers in Senegal to monitor for common diseases in their villages.[38] They could be used to recruit people into government programmes in environments where communication about new programmes is difficult. For instance, Kenya used ROSCAs to enroll participants into its new health insurance scheme (Oraro and Wyss, 2018). India used National Rural Livelihood Missions and their network of Self-Help-Groups (SHG) to advertise and enrol people into many development programmes, such as rural sanitation (Swachh Bharat Mission).

It may be unusual to involve non-state actors directly in provision of state assistance, but unprecedented times may call for exploring new opportunities. Although there may be justifiable concerns about a lack of accountability, institutions with a long history and broad base of membership may be particularly resistant to the capture of transfers (Dercon et al., 2006). They already need to be locally legitimate to sustain their work, as they have no formal legal authority and are regulated largely by social sanction (Olken and Singhal, 2011). The most important concern is that community institutions remain inclusive in times of crisis and share broadly the emergency resources given to them (Gugerty and Kremer, 2008).

Uganda’s economic response to COVID-19: the case for immediate household relief

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Pleased to share that I recently contributed a bit to a smart policy brief from the Centre for Development Alternatives in Kampala about options for economic relief to households during the pandemic.  Some background on who’s likely to need support:

According to the Centre for Budget and Tax Policy, 7 million Ugandans need social protection. The Centre’s report argues that the groups most affected by the economic disruption caused by the pandemic are workers in the informal sector (4 million people), the elderly (2 million), private sector employees (800,000), and low-level civil servants (150,000).

Our estimates of the total number of informal workers are considerably higher than those of the Centre for Budget and Tax Policy, which are based on projections using 2014 data. Last year, CDA looked at at the latest available UBOS data from the 2016-17 National Household Surveys. That study found that there are about 9.1 million employed people in the economy, excluding subsistence farmers. Of the 9.1 million employed, UBOS estimates that 85% are in informal employment. This implies that there are roughly 7.7 million informally employed people (85% of 9.1M) in Uganda – much higher than the estimate of 4 million cited above.

How can people in the informal sector be reached?

The government is already working with Local Councils (LCs) in identifying households for the ongoing food distribution efforts (discussed below). However, this presents some risks. LC leaders are likely to identify those that identify with the local council authority in the area – for instance through some form of registration. But most informal sector workers (e.g. those working in salons, car-wash, tax conductors, vendors, etc.), do not necessarily register with local authorities. Further, LC leaders are often trapped in local level politics and may be prone to politicising the distribution of goods. Involving Community Based Organisations, religious organisations, and NGOs to support the distribution efforts could help act as a check on local politicians while also contributing to the effectiveness of the response.

What sorts of support do people need?

We briefly explore four channels through which protection to households that depend on incomes from the informal economy can be delivered:

  1. Increasing household purchasing power (e.g. cash transfers);
  2. Decreasing the cost of essential goods and services (e.g. rent, utilities, food, soap, cooking fuels);
  3. Distributing essential goods and services for free; and
  4. Maintaining the flow of essential goods.

Do check out the full recommendations in the brief!

 

Interesting academic articles for March 2020

Here are some of the things I’ve found interesting in the last month!  Happily, none of it’s on coronavirus, and probably won’t be for a while.  The types of large, experimental studies or deeply historically grounded studies which interest me don’t have very rapid turnaround times.

Rachel Sweet.  2020.  “Bureaucrats at war: The resilient state in the Congo.”  African Affairs.  

Rebels often portray themselves as state-like to legitimize their rule, yet little is known about their on-the-ground relations with the administrators of state power—official bureaucrats. Drawing on internal armed group records from the Democratic Republic of Congo, this article argues that rebels’ state-like image is more than a simple veneer: Bureaucrats actively sustain state institutions and recruit rebel support during war. It develops a theory of the sources of leverage that bureaucrats use to negotiate with rebels. These interactions entail dual struggles to sustain the structures and symbols of state power and to shape the distribution of control over these institutions during war. On first front, bureaucrats can use their official status to market the symbols of state legitimacy—official certificates, codes, and paperwork—to rebels. On a second, to recruit protection for administrative posts. Pre-existing routines of noncompliance, like parallel taxes and sabotaged information, can use bureaucratic discretion and opacity to limit rebels’ takeover of state structures. This view from the ground demonstrates the real-time continuity of bureaucratic practice through daily paperwork and exchange during war. It contributes to research on rebel governance by illustrating new competitions for wartime statehood and illustrates the empirical practices of states seen as ‘juridical’ or weak.

Jeremy Bowles, Horacio Larreguy, and Shelley Liu.  2020.  “How Weakly Institutionalized Parties Monitor Brokers in Developing Democracies: Evidence from Postconflict Liberia.”  American Journal of Political Science

Political parties in sub‐Saharan Africa’s developing democracies are often considered to lack sufficiently sophisticated machines to monitor and incentivize their political brokers. We challenge this view by arguing that the decentralized pyramidal structure of their machines allows them to engage in broker monitoring and incentivizing to mobilize voters, which ultimately improves their electoral performance. This capacity is concentrated (a) among incumbent parties with greater access to resources and (b) where the scope for turnout buying is higher due to the higher costs of voting. Using postwar Liberia to test our argument, we combine rich administrative data with exogenous variation in parties’ ability to monitor their brokers. We show that brokers mobilize voters en masse to signal effort, that increased monitoring ability improves the incumbent party’s electoral performance, and that this is particularly so in precincts in which voters must travel farther to vote and thus turnout buying opportunities are greater.

Darin ChristensenOeindrila DubeJohannes Haushofer, Bilal Siddiqi and Maarten Voors.  2020.  “Building Resilient Health Systems: Experimental Evidence from Sierra Leone and the 2014 Ebola Outbreak.”  Center for Global Development working paper no. 526.

Developing countries are characterized by high rates of mortality and morbidity. A potential contributing factor is the low utilization of health systems, stemming from the low perceived quality of care delivered by health personnel. This factor may be especially critical during crises, when individuals choose whether to cooperate with response efforts and frontline health personnel. We experimentally examine efforts aimed at improving health worker performance in the context of the 2014–15 West African Ebola crisis. Roughly two years before the outbreak in Sierra Leone, we randomly assigned two social accountability interventions to government-run health clinics—one focused on community monitoring and the other gave status awards to clinic staff. We find that over the medium run, prior to the Ebola crisis, both interventions led to improvements in utilization of clinics and patient satisfaction. In addition, child health outcomes improved substantially in the catchment areas of community monitoring clinics. During the crisis, the interventions also led to higher reported Ebola cases, as well as lower mortality from Ebola—particularly in areas with community monitoring clinics. We explore three potential mechanisms: the interventions (1) increased the likelihood that patients reported Ebola symptoms and sought care; (2) unintentionally increased Ebola incidence; or (3) improved surveillance efforts. We find evidence consistent with the first: by improving the perceived quality of care provided by clinics prior to the outbreak, the interventions likely encouraged patients to report and receive treatment. Our results suggest that social accountability interventions not only have the power to improve health systems during normal times, but can additionally make health systems resilient to crises that may emerge over the longer run.

Wei Chang, Lucía Díaz-Martin, Akshara Gopalan, Eleonora Guarnieri, Seema Jayachandran, and Claire Walsh.  2020.  “What works to enhance women’s agency: Cross-cutting lessons from experimental and quasi-experimental studies.”  J-PAL working paper.

Women’s agency continues to be limited in many contexts around the world. Much of the existing evidence synthesis focuses on one outcome or intervention type, bracketing the complex, overlapping manner in which agency takes shape. This review adopts a cross-cutting approach to analyzing evidence across different domains and outcomes of women’s agency and focuses on understanding the mechanisms that explain intervention impacts. Drawing from quantitative evidence from 160 randomized controlled trials and quasi-experiments in low- and middle-income countries, we summarize what we know about supporting women’s agency along with what needs additional research.

Tom Lavers and Sam Hickey.  2020.  “Alternative routes to the institutionalisation of social transfers in sub-Saharan Africa: Political survival strategies and transnational policy coalitions.”  Effective States in International Development working paper no. 138.

The new phase of social protection expansion in the Global South remains poorly understood. Current interpretations use problematic evidence and analysis to emphasise the influence of elections and donor pressure on the spread of social transfers in sub-Saharan Africa. We seek a more nuanced explanation, testing an alternative theoretical and methodological framework that traces the actual process through which countries have not just adopted but institutionalised social transfers. Two main pathways emerge: one involves less electorally competitive countries, where the primary motivation is elite perceptions of vulnerability in the face of distributional crises, augmented by ideas and resources from transnational policy coalitions. The other entails a primary role for transnational policy coalitions in adoption, before competitive elections and the need for visible distribution drive institutionalisation. Consequently, the latest phase of social transfer development results from the interplay of political survival strategies and transnational policy coalitions.

Karthik Muralidharan, Paul Niehaus, and Sandip Sukhtankar.  2020.  “Identity Verification Standards in Welfare Programs: Experimental Evidence from India.”  NBER working paper no. 26774. 

How should recipients of publicly-provided goods and services prove their identity in order to access these benefits? The core design challenge is managing the tradeoff between Type-II errors of inclusion (including corruption) against Type-I errors of exclusion whereby legitimate beneficiaries are denied benefits. We use a large-scale experiment randomized across 15 million beneficiaries to evaluate the effects of more stringent ID requirements based on biometric authentication on the delivery of India’s largest social protection program (subsidized food) in the state of Jharkhand. By itself, requiring biometric authentication to transact did not reduce leakage, slightly increased transaction costs for the average beneficiary, and reduced benefits received by the subset of beneficiaries who had not previously registered an ID by 10%. Subsequent reforms that made use of authenticated transaction data to determine allocations to the program coincided with large reductions in leakage, but also significant reductions in benefits received. Our results highlight that attempts to reduce corruption in welfare programs can also generate non-trivial costs in terms of exclusion and inconvenience to genuine beneficiaries.

Matteo Alpino, and Eivind Moe Hammersmark.  2020.  “The Role of Historical Christian Missions in the Location of World Bank Aid in Africa.” World Bank Policy Research working paper no. WPS 9146.  

This article documents a positive and sizable correlation between the location of historical Christian missions and the allocation of present-day World Bank aid at the grid-cell level in Africa. The correlation is robust to an extensive set of geographical and historical control variables that predict settlement of missions. The study finds no correlation with aid effectiveness, as measured by project ratings and survey-based development indicators. Mission areas display a different political aid cycle than other areas, whereby new projects are less likely to arrive in years with new presidents. Hence, political connections between mission areas and central governments could be one likely explanation for the correlation between missions and aid.

Using markets and donor support to mitigate the economic effects of coronavirus in African countries

ETA: a shortened version of this post has been published at African Arguments.

One truism about the coronavirus pandemic is that it is amplifying pre-existing vulnerabilities and inequalities.  This comes through particularly clearly in discussions about how African countries should respond to the pandemic. Rich countries have a range of options for containing the virus and mitigating its economic impacts but these solutions often require money or public health capacity which African countries lacked even before the pandemic.

This doesn’t mean that there is nothing to be done, however.  There’s been an outpouring of research on approaches to pandemic control and economic relief which are tailored to African contexts.  In particular, it may be possible to mitigate the economic impacts of the crisis through a mixture of targeted investments in public markets and public transport, and donor-funded cash transfer programs.  

How are rich countries responding to the pandemic?

To generalize a bit, rich countries have considered four different responses to the pandemic.  Most of them are clustering around approaches 3 or 4 at this point, which contain the virus and minimize economic disruption, but require lots of spending and strong public health capacity.

  1. Uncontrolled spread: Letting the pandemic spread mostly unchecked in order to rapidly build immunity in the population. This leads to many avoidable deaths, completely overwhelms the healthcare system, and causes a major economic crash, so that’s clearly a bad idea.  The UK briefly considered this before changing their tune.
  2. Lockdown without income replacement: putting the country on lockdown in order to avoid the spread of the virus, without compensating people for lost income.  This leads to higher rates of infection because many people must violate lockdown to continue working and feeding their families, and leads to an economic contraction as many others lose their jobs.  The US is only replacing a fraction of people’s lost incomes with a one-time $1200 check, so it’s a good example of this approach.
  3. Lockdown with income replacement: self-explanatory.  There are a variety of ways to replace lost incomes, from paying companies to keep their workers on board (like Denmark) to offering direct cash transfers to people who’ve lost their jobs (like Canada).  This approach slows the spread of the virus while preserving people’s ability to access the goods and services they need to stay healthy.  However, it’s also extremely expensive.
  4. Testing and containment: Testing enormous numbers of people in order to contain infections before they spread, and letting people who are not infected continue to work and travel as usual.  This is the Taiwan-Singapore approach, and it’s been successful at constraining the spread of the virus while minimizing economic disruption.  However, it relies on the existence of strong public health systems and access to hundreds of thousands of coronavirus tests.

What are the options for African countries?

Which of these approaches might be useful for African countries? Approach 1, uncontrolled spread, is inherently a bad idea, and many governments are already taking steps to avoid this.  South Africa and Uganda are on national lockdown already, Kenya is encouraging cashless transactions, Ghana is shutting down markets to fumigate them, and so forth.  We can also rule out approach 4, testing and containment, as most countries don’t have the extensive public health infrastructure needed to do this.

This leaves us with approaches 2 and 3, lockdowns without or with income replacement.  Right now, many African countries are defaulting to approach 2, as they’re cutting back on economic activity without replacing lost incomes.  This is clearly not sustainable. Many people are subsistence farmers who depend on markets to access inputs like seeds and fertilizer, or live in poor urban neighborhoods without regular access to water and food even at the best of times. Some governments are already using violence to try to enforce these unpopular lockdowns.  We can’t lose sight of the fact that hunger and violence are also threats to public health.

The best remaining option is approach 3, lockdown with income replacement.  Most African governments can’t afford to massively scale up their welfare systems in a short time.  But with a combination of donor support and targeted interventions to keep markets open while protecting vulnerable people, it may be possible to keep people from going hungry while also lowering coronavirus risk.

Protecting people’s incomes

Let’s start with options to keep people’s incomes stable, as it’s going to be impossible to promote any sort of social distancing if people can’t feed themselves while doing so.  The two options here are promoting a baseline level of regular economic activity, and giving people direct transfers of cash or food.

One option for promoting regular economic activity in a safe way is reconfiguring the physical spaces of retail markets so that people can continue to buy and sell with greater social distance.  This includes expanding the footprint of markets to allow for proper social distancing, installing handwashing facilities, and training retailers in safe product handling practices.  It may also be possible to do staggered lockdowns in various neighborhoods in order to keep markets open while controlling the total number of people entering at any given time.  Public transport remains a point of vulnerability, as many people have no alternative for getting around besides crowded mini-buses or motorcycle taxis, but it may be possible to distribute masks and hand sanitizer at bus stops or via transport unions to lower the risk of transmission.

Even if a baseline amount of economic activity can be safely maintained, many African citizens are still going to lose their livelihoods as demand for things like tourism and agricultural exports drops.  There’s a clear need for direct income replacement from the government. Since most people work in the informal sector, a Denmark-style approach to paying employers to keep their employees on isn’t feasible.  Instead, the best solution is to provide cash transfers directly to individuals.  (If agricultural markets begin breaking down, in-kind transfers of food may also be useful, but these are more difficult to organize than cash transfers, so they shouldn’t be the first step.)

The good news is that almost all African countries have existing social protection programs which offer cash transfers to poor citizens.  These programs do tend to have very limited reach, supporting only small percentages of the poor, but at least the infrastructure exists.  There are also cash transfers run through humanitarian aid organizations and through NGOs like GiveDirectly.  As of March 27, only a few African governments had announced plans to scale up their social protection programs.  However, most countries are early enough in the progression of their pandemics to be able to do this before infections peak.

African governments and aid donors should be immediately focused on scaling up the infrastructure for universal cash transfers.  Many African governments can’t unilaterally afford a huge increase in welfare expenses, and will face falling tax revenues during the period of the pandemic, so this is the ideal time for the major donors to step in and support them — ideally with grants rather than loans.  Time is really of the essence here.  Food prices have already begun rising, and will only continue to do so as imports get delayed or shut down, and domestic food supply is threatened by market failures.  Targeting cash transfers to the poorest also takes time, and in this case many people who were not previously extremely poor are about to lose their incomes, so targeting doesn’t really make sense from an ethical perspective either.

Protecting people’s health

But what about public health in all of this?  If markets and transport remain open, even with social distancing measures in place, there’s clearly still a risk of coronavirus transmission.  Many African countries have only a few dozen ICU beds for millions of citizens, and it’s going to be difficult to scale that up rapidly, given that every single country around the world is trying to procure additional medical equipment on short notice via already-stretched supply chains.  The Africa Centres for Disease Control and Prevention appear to be doing as much as they can to help countries acquire coronavirus tests and protective equipment for healthcare workers, but they can’t compensate for years of low investment in health systems overnight.

A research group at the London School of Hygiene and Tropical Medicine has proposed that public health resources in low income countries should be focused on protecting the most vulnerable populations, rather than trying to stop the spread of the disease generally.  This involves identifying people who are immunosuppressed or over 60 years old, and providing them with a package of services (like a safe place to stay and regular food deliveries) so that they can remain isolated from others during the course of the pandemic.  Younger people can continue to show up to work and keep markets open while they are healthy, and if they become ill, there will be more hospital beds available to them.

This strategy obviously has some limitations.  Coronavirus is posed to spread most rapidly in dense urban neighborhoods, where few people can afford an entire room to themselves and there’s no reasonable prospect of building new shelters.  The prospect of leaving home to go into a state-run quarantine facility is clearly undesirable unless the facility is well-run, which many will not be.  In addition, people with conditions like HIV or TB already face stigma, and may not want to self-identify in order to go into coronavirus quarantine. However, this doesn’t mean that quarantine interventions are doomed to fail.  Research on the 2014 – 2016 Ebola epidemic in West Africa suggests that building community trust is an essential part of developing effective, locally contextualized interventions.  Similar trust-building practices may be necessary to develop successful public health strategies in the age of coronavirus.

 

What’s the risk of coronavirus in Kenya and Uganda?

As the novel coronavirus (COVID-19) has marched through China and Europe, Uganda has avoided any cases to date, and Kenya has only had three cases Like everyone else in the region, I’ve been wondering whether this is likely to continue, and what might happen if the disease did arrive at scale.  I wanted to collect a number of resources that I’ve found useful in thinking about this in a single place.  I am not an epidemiologist and am not making any predictions about the geographic spread of the disease.

Is coronavirus likely to spread to the region?

There are two factors which may play to Kenya and Uganda’s advantage when it comes to preventing the arrival of additional coronavirus cases in the area.  First, the virus has been spreading globally when infected individuals travel between countries.  Both countries have relatively few direct flight links outside of the continent.  Kenya has closed its borders to non-residents as of March 15, and is requiring all travelers to self-quarantine for 14 days.  Uganda is requiring travelers from countries with current coronavirus cases to self-quarantine as well.

World-airline-routemap-2009
Map of global flight paths from Wikipedia.  It’s from 2009, the most recent map available, but the general patterns presumably still hold true today.

Second, in countries currently affected by coronavirus at scale, the disease has also been spreading among communities in contact with an infected person.  However, there’s some tentative evidence that this type of spread is only happening in relatively cool climates. A new paper from Sajadi et al. (2020) notes that all cases of community transmission have been concentrated in a narrow band with temperatures around 10 degrees Celsius / 50 degrees Fahrenheit.  This may be because the coronavirus can’t survive as long outside the body in warmer temperatures.

If this finding holds true, it suggests that if additional infected individuals do travel to Kenya and Uganda, the coronavirus may not spread significantly beyond them.  However, there is still a great deal of uncertainty here, and we shouldn’t trust that warm weather will prevent community transmission.

Are Kenya and Uganda prepared to track the spread of the virus?

There’s reason to be optimistic about public health capacity to track potential coronavirus cases.  Both countries already have infectious disease surveillance infrastructure in place at the international airports due to the recent Ebola epidemic in the nearby DR Congo.  All travelers to Nairobi and Entebbe must report their travel histories, share contact information, and go through a thermal screening at both airports.  Of course, airport screening won’t stop all infected people from entering the country because some may not have symptoms yet, but it’s still useful for surveillance.

In addition, both countries are building on much longer histories of population-level disease surveillance, including those for polio and HIV / AIDS.  As this article from Think Global Health notes,

Because of the robust responses to these diseases, many African countries are starting from a very different baseline than twenty years ago. Although this has not generally included support for ICU-level care that will be required by the sickest people with COVID-19, what these investments have supported are increasingly human resource for health, supply chains, information and surveillance capacities for prevention, detection and long-term response capacity against diverse infectious threats.

Finally, because the onset of the epidemic has been delayed here, both countries have had more time to prepare.  The Africa Centres for Disease Control have been running online trainings for healthcare workers about the coronavirus, and have also developed and distributed coronavirus test kits to most countries across the continent, including Kenya and Uganda.  Both countries have already banned international conferences, and Kenya has also opened a 120-bed isolation center for potential patients. 

What happens if coronavirus does spread within the region?

If community transmission of coronavirus does occur within Kenya and Uganda, one of the main risks is that it may overwhelm healthcare systems with people seeking care.  Taking early preventative measures to slow the spread of the virus makes it more likely that sick people can access care when they need it, as this graph from Our World in Data shows.  Unfortunately, Kenya and Uganda are grappling with weak health systems and poverty, both of which may make it more difficult to contain the virus if it does arrive.

A graph showing that

In both countries, health systems tend to be underfunded.  In Kenya, significant revenue comes from user fees, which discourage poor people from accessing healthcare.  Uganda abolished user fees for healthcare in 2001, but poor people still find it difficult to access care. Kenya is doing fairly well at providing essential medicines, but Ugandan clinics often lack drugs.  The number of intensive care unit (ICU) beds in both countries is low, and only 23% of Ugandan ICUs have ventilators.  On any given day, nearly half of healthcare workers in both countries are absent from their jobs, often because of poor pay and long commutes.  If coronavirus spreads among the population and leaves many people in need of hospitalization, it’s clear that the health systems will struggle to keep up.

Poverty can also make it difficult for people to take other steps to keep themselves safe from coronavirus.  Only 14% of Kenyans have access to soap and water at home, and in Uganda only 8% of families with young children have access to soap and water at home.  Hand sanitizer is available in shops, but not widely used.  Without well-functioning state-run social safety nets, most people also don’t have the luxury of taking time off from work to rest if they are sick.  This both increases the risk that the disease will spread, and makes it more difficult for infected people to recover. Informal insurance within families and religious groups can mitigate this somewhat, but churches have also been vectors for infection in the US and South Korea, meaning that this insurance mechanism could possibly increase the risk of contacting the disease.

Even without cases of coronavirus in the region, the social and economic impacts of the disease are already being felt.  Xenophobic statements about Chinese residents have been reported in Kenya.  And in both countries, an economic slowdown is expected as traders have been cut off from Chinese imports.  The indirect economic effects as people lose their livelihoods may be just as serious as the disease itself.  It’s important for both countries to continue expanding their social safety nets and ensure that healthcare is affordable, even if coronavirus never comes ashore.