Virus exposes gaping holes in Africa’s health systems
Africa could become the next epicentre of the new coronavirus pandemic, the World Health Organization has said. Across the continent, there is less than one intensive care bed per 100,000 people, a Reuters survey found.
Updated May 7, 2020
Reuters survey of intensive care beds, ventilators, testing and essential personnel
Reuters has sent questions to public health authorities across Africa. Health ministries or independent experts provided answers in 48 out of Africa’s 54 countries.
Reuters was unable to get data on ICU beds and ventilators for Algeria, Benin, Comoros, the Republic of Congo, Sao Tome and Principe, and Tanzania
The continent’s three giants - Nigeria, Ethiopia and Egypt - only have 1,920 intensive care beds between them for more than 400 million people.
Tanzania refuses to tell donors anything about its public health resources.
South Africa and Ghana account for 46% of all tests carried out in Africa so far.
Source: Reuters reporting
Africa has recorded over 51,000 cases of COVID-19, a fraction of the 3.76 million cases recorded globally, according to a Reuters tally. But the number of cases jumped nearly 38% in the past week. The United Nations Economic Commission for Africa (UNECA) has warned that even with intense social distancing, the continent of 1.3 billion could have nearly 123 million cases this year, and 300,000 people could die of the disease.
Low levels of testing make it impossible to know the true scale of infection. Africa has carried out a fraction of the COVID-19 testing that other regions have - around 685 tests per million people, although the rate of testing varies widely between countries. By comparison, European countries have carried out nearly 17 million tests, the equivalent of just under 23,000 per million people.
“We are preparing, but it’s like being in a movie that no one has ever rehearsed, and we didn’t get the script.”
Dr. Juliet Nyaga, chief executive of Karen Hospital, Kenya
Africa’s public health systems are notoriously ill-equipped, but there is also little public data on the resources they have to fight the virus. Reuters sent questions to health ministries and public health authorities across Africa. Health officials or independent experts provided answers in 48 out of Africa’s 54 countries, to create the most detailed picture publicly available on resources including intensive care beds, ventilators, testing and essential personnel.
The findings are stark. Most nations have severe shortages of medical personnel, especially critical care nurses and anaesthesia providers. The continent averages less than one intensive care bed and one ventilator per 100,000 people, Reuters found. This compares with 20-31 intensive care beds per 100,000 people in the United States, according to estimates in a 2012 survey for the U.S. National Institutes of Health.
Many African governments moved quickly to contain the pandemic, mounting high-profile public health campaigns, restricting movement and repurposing factories to produce protective equipment. Donations have poured in from a foundation set up by Chinese billionaire Jack Ma, and the World Bank is helping procure more than $1 billion worth of equipment for Africa.
Nevertheless, the Reuters survey and analysis of researchers’ projections showed that even in a best-case scenario, Africa could need at least 111,000 more intensive care beds and ventilators - more than 10 times the number it has at present.
“We are preparing," said Dr. Juliet Nyaga, chief executive of Karen Hospital, a private facility in Kenya, as she showed Reuters an isolation unit they had set up in a nursing school. "But it's like being in a movie that no one has ever rehearsed, and we didn't get the script.”
INFORMATION DEPRIVATION
Data about national health systems is hard to get. Some countries are overwhelmed; others can’t or won’t say what resources they have.
A man assembles new treatment beds at a field hospital built for COVID-19 patients, Aga Khan University Hospital in Nairobi, Kenya. REUTERS/Baz Ratner
Some leaders may fear public criticism over the poor state of public services, said Michel Yao, emergency operations manager in Africa for the World Health Organization (WHO).
The East African nation of Tanzania, publicly criticised by the WHO for not restricting large gatherings, has sometimes gone for days without updating its coronavirus figures and has refused to tell donors anything about its public health resources, a diplomat told Reuters. A government spokesman said it was not true that Tanzania was not sharing information and referred Reuters to the health ministry for data, which did not respond.
Central African Republic’s Health Minister Pierre Somse was surprised to learn from an aid agency’s press release that the country had only three ventilators – he had no idea they had any, he said. In Madagascar, where the president is pushing a botanically-based remedy untested in an international clinical trial, the health ministry took five weeks to respond to Reuters questions about the number of ventilators in the country.
Some countries gave Reuters data about ventilators, but not about intensive care beds.
Even where information is available, it is often hopelessly out of date. The WHO does not have the funds to carry out detailed surveys on a regular basis, Yao said. "Information is critical for us to better help," he told Reuters. "It's difficult to anticipate their overall needs if you don't have accurate information."
“If you don’t test,
you don’t find.”
you don’t find.”
John Nkengasong, director of the Africa CDC
Not enough tests
So far, 868,227 COVID-19 tests have been carried out in Africa, according to a Reuters tally of official figures reported to the Africa CDC. That means around 685 tests have been carried out per million people - far below the 37,000 per million in Italy or 22,000 in the United States. “If you don't test, you don't find,” said John Nkengasong, director of the Africa CDC.
Testing: How African countries compare
with the world
Africa average
Europe average
68.5
2,271
Tests per 100,000 people
Italy
3,715
Russia
3,056
Germany
3,040
Spain
2,889
U.K.
1,495
South Africa
464
Egypt
91
Uganda
96
Kenya
50
Ethiopia
23
Nigeria
10
3
D.R.C.
2
Sudan
1
Tanzania
Total tests carried out
Russia
4.5 mill
Italy
2.2
Spain
1.3
Africa
0.9
U.K.
1.0
Colour density
represents tests
per 100,000
inhabitants.
Figure and size
of rectangle represent
total tests carried
out by country.
10
COUNTRY
100
00
1k
Ghana
South Africa
129,461
268,064
Ethiopia
Tunisia
Kenya
Egypt
25,135
25,165
26,074
90,000
Nigeria
Senegal
19,512
17,981
Mauritius
Djibouti
Morocco
19,039
14,378
49,570
Zimbab.
11,647
Uganda
41,169
Cameroon
10,265
Rwanda
Zambia
35,992
9799
Source: Africa CDC
South Africa accounts for 30% of Africa’s tests, although it has less than 5% of the population. Nigeria, which has 15% of the population, has carried out just 2% of testing; it began by testing strategically then broadened it out, Health Minister Osagie Ehanire said. Chad and Burundi have carried out fewer than 500 tests each. Chad said it didn’t have enough testing kits and staff after many of them had fallen ill; Burundi did not respond. Tanzania carried out 652 tests and identified 480 cases.
A medical worker takes a swab from a health worker in Machakos county, Kenya. REUTERS/Baz Ratner.
A health worker in a laboratory testing for COVID-19 in Machakos Level 5 Hospital, Kenya. REUTERS/Baz Ratner.
The Africa CDC, set up by the African Union in 2017, worked with the WHO to rapidly roll out testing. In January, only South Africa and Senegal could test for the new coronavirus, but now all African countries can perform tests apart from tiny Lesotho and the island nation of Sao Tome and Principe.
But there is a global shortage of testing materials. Kenya has the capacity to carry out 37,000 tests per day, a Senate report based on information from the health ministry found, but has only carried out about 26,000 in all. It does not have enough laboratory personnel, sample collection kits or supplies, and has also received faulty test kits as donations.
NOT ENOUGH INTENSIVE CARE BEDS
Most people with COVID-19 develop only mild illness, but the sickest will need intensive care, which is scarce.
Intensive care beds available by country
Figure represents
total intensive
care beds in the
country.
Colour density
represents intensive
care beds per 100,000
inhabitants.
COUNTRY
1
00
3
6
10
_
No data
Morocco
Algeria
Tunisia
Egypt
_
1,390
500
1,000
(No data)
Somalia
Mauritania
Mali
Niger
Ghana
Libya
Sudan
Eritrea
_
10
37
64
545
246
110
20
Guinea
Bissau
Guinea
Konakry
Burkina
Faso
South
Sudan
Senegal
Ethiopia
Djbouti
Chad
56
60
570
0
_
_
50
40
Ivory
Coast
Cape
Verde
26
Gambia
Togo
Benin
Nigeria
Cameroon
Kenya
45
8
_
_
518
350
150
Sierre
Leone
Equatorial
Guinea
Gabon
Congo
C.A.R
Tanzania
_
700
_
12
_
_
Madagas.
_
Liberia
Zambia
D.R.C.
Malawi
Mozamb.
_
_
100
60
180
Seychelles
32
Angola
Rwanda
Uganda
Burundi
_
110
60
70
Mauritius
121
SaoTome
& Principe
Zimbab.
Botswana
Namibia
Eswatini
_
113
61
150
_
Comoros
_
South
Africa
Lesotho
10
3,300
Source: Reuters reporting
The WHO estimates around 14% of COVID-19 patients will require hospitalization and oxygen support, and 5% will need a ventilator. Some countries are setting up extra beds for COVID-19 patients in places like sports stadiums or pop-up tent hospitals. The number of those beds can change rapidly, but that’s not intensive care.
The definition varies from country to country, but generally includes equipment for monitoring the patient and clearing their airway, access to oxygen and more intensive staffing. Not all intensive care unit (ICU) beds in Africa have ventilators.
Intensive care beds are expensive, difficult to run, and very unevenly distributed. Chad, an oil-rich but impoverished nation of 15 million people, has only 10, whereas the island nation of Mauritius, a financial hub home to 1.2 million, has 121.
The continent’s three giants - Nigeria, Ethiopia and Egypt - have 1,920 intensive care beds between them for more than 400 million people. Nigeria’s health minister said the country had not had to use most of its equipment yet, but it had still ordered more. The other two nations did not respond to requests for comment.
There are discrepancies between official figures and the experience of frontline medical staff, Reuters found. Uganda said it has 268 ICU beds in public hospitals. But only about 70 ICU beds countrywide have the necessary staff and equipment to function, said Arthur Kwizera, a lecturer in anaesthesia and intensive care at Makerere University College of Health Sciences whose team carried out a study on intensive care capacity late last year. The government did not respond to requests for comment on that point.
Also, many ICU beds are already in use. Kenya has 518 beds in its public and private facilities, but 94% are already occupied by non-COVID-19 patients, said the Senate report.
An engineer works on a ventilator at a factory in Casablanca, Morocco. REUTERS/Youssef Boudlal
A prototype of a ventilator at a polytechnic laboratory in Thies, Senegal. REUTERS/Zohra Bensemra
How much will be needed?
To understand how many ventilators African countries might need, Reuters used estimates of the peak demand for critical care beds by researchers at the MRC Centre for Global Infectious Disease Analysis at Imperial College London and assumed all ICU beds would be available. UNECA based their estimates on the centre’s research.
Under a best-case scenario - what Imperial College researcher Charlie Whittaker described as a complete lockdown for an indefinite time - at least 121,000 critical care beds will be needed at the peak of the pandemic on the continent, Reuters found. That compares with 9,800 at present, according to the Reuters survey.
In the best-case scenario, more than 12 cases could be lined up for each available bed on average. The timing of peak demand will differ in each country, but the figures show the magnitude of need.
Ventilator gap
Some nations, such as Guinea Bissau, have no ventilators at all. Mauritania has one; Liberia said it has six; Somalia has 19. South Africa has 3,300, but about two-thirds are in private hospitals, which the majority of the population cannot afford. The health ministry said the state has the right to use private facilities in an emergency.
Tumane Balde, head of an inter-ministerial commission to tackle COVID-19 in Guinea-Bissau, said the country only had 10% of the equipment it needs. “Our staff are under-equipped and unmotivated,” he said. “We need three times more beds than we have.” Officials at Mauritania’s health ministry, and a representative for Liberia did not respond to requests for comment.
Ventilators
Ventilators that could
be needed during the
peak of the pandemic
according to estimates
by Imperial College
of London
Ventilators available
by country according
to Reuters reporting.
South Africa
3,200
5,362
Morocco
1,640
2,611
Ethiopia
557
9,375
Nigeria
20,325
500
Egypt
400
9,231
Namibia
282
313
Sudan
4,413
300
Kenya
4,511
297
Tunisia
903
250
Algeria
3,637
250
Libya
485
246
Angola
2,682
220
Ghana
2,680
200
Botswana
215
150
Gabon
142
100
Zambia
2,070
100
(No estimates)
Uganda
100
Ivory Coast
1,927
80
D.R.C.
10,103
60
Mali
1,941
56
Cape Verde
48
50
Rwanda
1,588
46
Cameroon
2,422
40
Senegal
971
40
Zimbabwe
1,640
35
Mozambique
3,527
34
3,193
34
Madagascar
Chad
1,928
22
Equatorial Guinea
120
21
Burundi
1,062
20
Guinea
1,542
20
Somalia
1,737
19
113
16
eSwatini
Togo
836
15
Sierra Leone
457
13
Niger
2,177
12
Burkina Faso
1,243
11
Liberia
602
6
Gambia
219
5
C. A. R.
433
3
Mauritania
372
1
Eritrea
191
0
Guinea Bissau
175
0
Djibouti
124
0
Sources: Reuters reporting and MRC Centre
for Global Infectious Disease
Analysis/Imperial College London
Africa has no history of building ventilators. South Africa’s state-owned defence company Denel plans to begin making them, and institutions in Kenya and Senegal have developed prototypes. But authorities in Senegal say they’ve only certified imports before; it could take months to get a prototype certified and mass-produced.
OXYGEN, PEOPLE AND POWER
Ventilators need electricity, medical grade oxygen and trained staff to work and maintain them.
Number of physicians qualified
as anaesthesiologists by country
Per 100,000 population
1
3
6
10
15
20
Sources: World Federation of Societies of Anaesthesiologists
(WFSA)
Oxygen can be supplied from oxygen plants, cylinders or machines. Kenya has nearly 300 ventilators but a “critical shortage” of oxygen, a Senate report found. Recently, the ministry of health implored on Twitter for hospitals to pay their bills to the company that supplies many of them with cylinders.
In many nations like Nigeria, South Sudan and Zimbabwe, electricity is extremely unreliable and hospitals depend on diesel-powered generators. Some health facilities in poorer, often rural, areas are unable to pay for the constant refueling and maintenance they need.
Doctors, critical care nurses, anaesthesiologists and biotechnicians - essential for maintaining equipment - are in short supply, although data from many countries dates back years. Continent-wide, one doctor serves an average of 80,000 people, World Bank data shows. There are more in wealthy Mauritius - 2 doctors per 1,000 - but countries like Liberia, Malawi or Burundi have far fewer.
Anaesthetists run critical care units in many African nations. But only nine countries have one or more physicians qualified to administer anaesthetics per 100,000 people, according to the World Federation of Societies of Anaesthesiologists. Most have staffing levels comparable to Afghanistan or Haiti.
In Uganda, staff shortages have meant many ventilators were idle for years, said Kwizera, the lecturer in anaesthesia and intensive care. He added that only four of the 13 at Jinja Regional Referral Hospital are now functioning - and staff at another of the nation’s 16 hospitals with an oxygen plant said it is working at one-third of capacity due to a shortage of cylinders and technicians. Uganda’s health ministry spokesman said he believed all the ventilators at Jinja were working and another 10 were on the way.
Physicians per 10,000 population
Mauritius
20.2
Algeria
18.3
Tunisia
12.7
Seychelles
9.5
South Africa
9.1
Egypt
7.9
Cape Verde
7.7
Morocco
7.3
Sudan
4.1
Equatorial Guinea
4
Nigeria
3.8
Namibia
3.7
Botswana
3.7
3.6
Gabon
Sao Tome and Principe
3.2
2.3
Ivory Coast
Djibouti
2.2
Angola
2.1
Guinea Bissau
2
2
Kenya
Madagascar
1.8
Ghana
1.8
Mauritania
1.8
Comoros
1.7
1.6
Zambia
Benin
1.6
Mali
1.4
Rwanda
1.3
Congo
1.1
Gambia
1.1
Ethiopia
1
Uganda
0.9
Cameroon
0.9
D.C.R.
0.9
Eswatini
0.8
Guinea
0.8
0.8
Zimbabwe
Mozambique
0.7
Senegal
0.7
Lesotho
0.7
Central African Republic
0.6
Burkina Faso
0.6
Eritrea
0.6
Burundi
0.5
Niger
0.5
Togo
0.5
Chad
0.5
Tanzania
0.4
Liberia
0.4
0.2
Sierra Leone
Somalia
0.2
Malawi
0.2
Note: Libya was excluded since the data
predated the civil war.
Source: World Bank
Equipment and personnel are arriving: For example, the World Bank is helping more than 30 African nations source medical supplies. South Sudan recently received a donation of five ventilators, bringing its total to nine. But the new ventilators have yet to be plugged in because the isolation centre is being expanded, said Matthew Tut, director of emergency preparedness for the Ministry of Health.
He was unclear how many personnel were trained to use and maintain ventilators. "We do have some medical engineers,” he said. “I can't confirm to you how many ... because their training also differs."
A worker outside the COVID-19 isolation facility at Mbagathi County Hospital in Nairobi, Kenya. REUTERS/Njeri Mwangi
Private hospitals are generally better staffed, but their revenues have dropped by an average of 40% since March, mostly due to a decline in elective surgeries and regular outpatient chronic treatment, said the Africa Healthcare Federation, an umbrella organisation for the private healthcare sector. Private hospitals are also having to spend more on protective equipment, and private insurance companies are delaying settling claims in many countries, said Dr. Amit Thakker, the head of the federation.
Some governments on the continent are trying to negotiate access to private hospitals for patients who can’t afford the fees. But most hospitals say they will need some form of payment and - mindful of governments that pay bills late or not at all - some would prefer that an internationally administered independent fund handle the payments.
Additional reporting by: Alexander Winning, Giulia Paravicini, Chris Mfula, Dawit Endeshaw, Lova Rabary, Clement Uwiringiymana, Denis Dumo, Abdi Sheikh, George Thande, Nuzulack Dausen, MacDonald Dzirutwe, Christian Brice Elion, Ange Aboa, Josiane Kouagheu, Alberto Dabo, Boureima Balima, Aidan Lewis, Ahmed El Jechtimi, Hamid Ould Ahmed, Tarek Amara, Victoria Waldersee, Nafisa Eltahir, Alexis Akwagyiram, Brian Benza, Nyasha Nyaungwa, Lunga Masuku, Henry Wilkins, Kissima Diagana, Elias Biryabarema Felix Onuah, Paul Carsten, Julio Rodrigues
Graphic by Samuel Granados
Edited by Alexandra Zavis, Jon McClure and Sara Ledwith
Graphic by Samuel Granados
Edited by Alexandra Zavis, Jon McClure and Sara Ledwith
Sources: Reuters’ survey during April and early May of African health ministries and public health officials; Africa Healthcare Federation; World Health Organization; World Bank, Africa Centres for Disease Control and Prevention; national and international medical professional associations including doctors’ unions, hospital boards and members of the World Federation of Societies of Anaesthesiologists; rescue.co; aid groups including the Norwegian Refugee Council, the International Rescue Committee and International Medical Corps; independent medical experts; Africa Healthcare Federation; U.S. National Institutes of Health; MRC Centre for Global Infectious Disease Analysis at Imperial College London. Algeria, Benin, Comoros, Republic of Congo, Sao Tome and Principe and Tanzania provided either no answers or incomplete ones.
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