Ethiopia has 108 confirmed cases of Covid-19 and three deaths. Despite these low figures, as compared to other countries, stringent measures have been implemented since mid-March. Dr Zemzem Shigute Shuka, Dr Getnet Alemu and Professor Arjun Bedi describe the Ethiopian approach of prevention, preparation and mitigation and share reflections on the challenges and opportunities.
Low figures – a window of opportunity
Of the 48 countries in Sub-Saharan Africa (SSA), 46 have reported cases of Covid-19 infection. At the time of writing, the region has close to 11,600 confirmed Covid-19 cases with less than 350 deaths. These figures accounts for a very small proportion of the global Covid-19 infections (0.48%) and an even smaller proportion of deaths (approximately 0.2%).
'...countries with perhaps the most vulnerable health care systems in the world have a window of opportunity to prepare and to potentially prevent community spread of the virus.'
This may in part be attributed to limited testing and poor reporting systems, resulting in a distorted picture. Alternatively, it may reflect the relatively lower integration of such countries in the world economy and the earlier imposition of lockdown-style measures. While it may only be a matter of time before the epicenter of the pandemic shifts again, at least at the moment, countries with perhaps the most vulnerable health care systems in the world have a window of opportunity to prepare and to potentially prevent community spread of the virus.
In SSA the fear of dealing with the virus has led to stringent measures far earlier as compared to other parts of the world.
At the time of lockdown, the number of confirmed Covid-19 cases in Hubei (China) was 400, in Italy 9,000 and in New York 11,000. In contrast, a number of SSA countries imposed lockdown measures when the total number of confirmed cases for the entire continent stood at less than 9,000. In Ethiopia, lockdown-style measures were adopted on 16 March and further sharpened on 20 March when there were only five confirmed cases. On 10 April, a five-month state of emergency has been declared with further restrictive measures. At the time of writing (19 April), there are 108 confirmed cases and three deaths.
Image: Observing social distancing outside a supermarket in Addis Ababa, 15 April 2020. Getnet Alemu
Prevention, preparation and mitigation
The first confirmed case in Ethiopia was a 48-year-old Japanese national who had travelled to Ethiopia via Burkina Faso. To date almost all the confirmed cases are restricted to urban areas with a majority of them (92%) occurring in the capital, Addis Ababa.
Recognizing the potential pressure on the country’s health care system and the density of population in urban areas (21% of the total population) as a risk for community transmission, the Government adopted a raft of preventive measures at an early stage.
These preventive measures include:
• International travel - isolation of passengers arriving from various international destinations and suspension of flights to and from 80 destinations
• Spread of WHO recommended practices - such as frequent hand washing, #SafeHands challenge, avoiding handshakes, elbow sneezing and coughing through mass media (Radio, TV, pamphlets, Twitter and Facebook) and through high level government officials/public figures
• Free provisions - toll free telephone lines for information and free provision of sanitary items such as soap and hand-washing gels to targeted groups in Addis Ababa
• Closures - of schools, universities, bars and nightclubs; suspending public (including religious) gatherings and meetings and issuing stay-at-home orders for all but necessary staff
• Mass disinfection - of critical urban locations (buildings and work areas, transport facilities)
• Avoiding overcrowding - by reducing maximum number of passengers in trains, taxis and busses and by making available government buses free of charge after they have transported essential civil servants to their workplace
• Complete transport lockdown - in some regions of the country except for carriage of essential supplies.
Other measures include testing of prisoners and the release of around 4,000 prisoners who committed minor offences and/or were to be soon released. Perhaps most notably, national elections scheduled for August 2020 have been postponed with the support of the opposition.
'...a key difference is that a majority of Ethiopians live in rural areas...'
While the measures listed above parallel measures taken in other parts of the world, a key difference is that a majority of Ethiopians (79%) live in rural areas with weak transportation and communication links.
To reach these areas, risk communication and community engagement task forces have been established at the lowest administrative units and at health facilities. These units involve health extension workers who undertake the task of household and individual level sensitization and awareness creation regarding Covid-19.
The safety/social distancing measures in rural areas relate to agricultural marketing, avoidance of social gatherings (including network meetings on development issues) while at the same time continuing daily agricultural tasks such as belg (autumn) crop season plantation. Social protection programs such as the productive safety net program (PSNP), which is designed to mitigate the effects of weather-related shocks and requires community labor contributions, have been re-oriented to individual based activities to avoid social contact.
Image: Awareness creation on “corona-cognizant' marketing of goods by Covid-19 village task force member, SNNPR region, 11 April 2020 Mr Ahmed Mohammed Ali
Preparing the (public) health system in Ethiopia and beyond
While widespread testing for the virus is still unavailable, the government is ramping up its capacity to conduct tests within the country. Initially, samples were sent abroad but with the recent acquisition of test kits, the Ethiopian Public Health Institute is now able to perform tests in seven laboratories, of which three are in Addis Ababa. An additional seven laboratories are being set up outside Addis Ababa.
The government’s resource mobilization team together with the Covid-19 health team is distributing testing kits and personal protective equipment donated by Chinese billionaire Jack Ma, both within the country and to other African countries. The World Bank provided $82 million to support the country’s health care needs. Furthermore, Ethiopian airlines and the government are playing a leading role in enhancing access to medical supplies across the continent. Financial and material resources are also being obtained through Ethiopian nationals and through the 2 million strong Ethiopian diaspora. The foreign ministry has issued a request to all Ethiopian missions to raise funds and buy critical medical equipment and ship to the country.
The government’s health care team is working with Chinese health care experts to enhance the capacity and expertise of its health care system. On April 16, a team of Chinese Anti-pandemic medical experts arrived in Addis Ababa.
Mitigating the economic fall-out
To enhance planning with an eye to the economic fall-out, Ministerial teams working on communication, health care, mobilization of financial and material resources and an Economic case team have been formed. In particular, the Economic case team has been charged with the task of identifying the economic challenges including the effect of the decrease in international remittances, identifying vulnerable sectors/populations and designing mitigation measures. Vulnerable sectors and people include tourism and horticultural exports, workers affiliated with these industries, and individuals already taking part in government support programs such as the productive safety net program.
Paralleling the structure at the national level, economic task forces have been set up at the level of each regional state and at the lowest administrative levels. The focus of these grassroots task forces, staffed by development agents, is to ensure that economic activities especially farming can continue while at the same time ensuring that it is done in a “corona-cognizant” manner.
Challenges and opportunities
Image: A challenge - crowded market place in Addis Ababa, 14 April 2020 Mr Ahmed Mohammed Ali
Tactile nation: Preventing social contact in a tactile country such as Ethiopia is very difficult. Ethiopian social and religious practices and daily culture entail (physical) contact, embodied for example in communal eating habits (sharing a plate of Ethiopian bread (injera) and coffee (bunna) ceremonies) and in the way of greeting (involving shoulder bumps with handshakes).
Also, the importance of community both culturally and in the country’s development strategy make it hard to respect social distancing. On top of that, crowded public transportation and market spaces in urban areas remain a challenge.
'Ethiopia has a total of 557 mechanical ventilators and 570 ICU beds for a population of 110 million'
Challenged health system: Gearing up the health care system to meet the needs of patient surges will be extremely challenging if not impossible. Although access to health care has sharply increased in the last ten years and a substantial number of households are covered by a community-based health insurance scheme introduced in 2011, resources are limited. Ethiopia has a total of 557 mechanical ventilators and 570 ICU beds for a population of 110 million.
Image: The youth 'bored' from staying at home, Addis Ababa, 14 April 2020. Getnet Alemu
Young: Ethiopia is a young country with 40% of its population aged 0-14 and only about 8% aged 55 and above. Given the epidemiological profile of the confirmed cases and deaths in the Global North, this may seem positive. However, the country’s young population is not very well nourished, with stunting in 38% of children aged 0-5 and undernourishment of 22% of women aged 15-49.
Population density and distance: The dangers of community transmission loom large in urban areas with high population density, and especially in Addis Ababa (6,516 inhabitants per km2). However, the bulk of the country has a substantially lower population density: the most populous province Oromia has a population density of 124 people per km2. The low population density in rural areas and relatively poor transportation infrastructure which restricts internal mobility might limit the spread of the virus in the rural hinterland.
'...strong community outreach provides a platform to reach the most vulnerable rural populations'
Experience: Ethiopia is no stranger to widespread shocks, although hitherto, most of these have been weather related (droughts and famine) and often confined to rural areas. Since the disastrous 1983-1985 drought which claimed more than a million lives, the government has strengthened its ability to withstand shocks rather than rely on humanitarian appeals.
In the most recent drought in 2016, the government supported 18.2 million people, or 20% of the total population, through food or cash transfers with the PSNP playing a leading role. The institutional infrastructure involving strong community outreach provides a platform to reach the most vulnerable rural populations and can later serve as a conduit for providing economic support and recovery.
On balance, it is perhaps not a surprise that countries with weak health systems (for instance, India) have perhaps been most assertive in terms of imposing stricter and earlier lockdown-style measures. While preventive measures persist and preparations continue, it seems that its best hopes lie in its strategy of early imposition and continued adherence to stringent preventive measures to avoid widespread community transmission of the virus.
 Calculations are based on data from https://coronavirus.jhu.edu/
 For figures displaying the confirmed cases per day and distribution across cities, see, https://en.wikipedia.org/wiki/2020_coronavirus_pandemic_in_Ethiopia).
 The country has 42,000 health extension workers or about 2 health extension workers per village of about 5,000 residents.
 In 2014/15, the International Monetary Fund (IMF) placed the total value of remittances to Ethiopia at USD 3-3.5 billion or 7.4 per cent of GDP. Also see, https://semonegna.com/edtf-emergency-covid-19-mitigation/
 The Ethiopian diaspora plays an important role and the IMF placed remittances at between USD 3 to 3.5 Billion or 7.4 percent of GDP in 2014/15.
 The PSNP provides cash or food transfers to over 8 million food insecure people in food insecure parts of the country in return for work. The program requires labor contributions to build public works focusing on soil and water conservation projects.
 The country has about 69,000 agricultural extension workers or development agents or about a total of 3 development agents per village of about 5,000 residents.
 Our calculations indicate that the stringency measures adopted by Ethiopia place it in the most stringent category. Ethiopia has a score of 85 while India is at a 100. See https://www.bsg.ox.ac.uk/research/publications/variation-government-responses-covid-19.