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Millions at risk in poor countries

Delayed action on coronavirus will cost at least 3 million lives in South Asia and Sub-Saharan Africa

As governments around the world struggle to contain the coronavirus pandemic, the importance of early prevention and containment is now widely recognised. For the world’s poorest countries with the weakest health systems and potentially most vulnerable populations, the stakes are very high. Decisive early action to contain and prevent coronavirus would save at least 3 million lives in sub-Saharan Africa and South Asia according to new research from Imperial College. But the modelling behind the research almost certainly understates the number of lives at stake.

The Imperial College modelling compares different scenarios for the Covid-19 response. With early and decisive action to test and isolate cases, promote social distancing, and treat affected populations, the projections point to 800,000 deaths. Delayed action increases that figure to almost 4 million deaths. Mitigating transmissions through population-wide social distancing could reduce the number of deaths by around one third but will still lead to a collapse of the health systems in low-income countries, with peak demand for critical care beds 25 times higher than the available numbers of beds. 

Bar chart showing the impact of Covid19 on poor countries

Data by London School of Hygiene & Tropical Medicine confirms that the window of opportunity for containing the crisis in the poorest countries is closing. Sub-Saharan Africa now has almost 2000 confirmed cases – a fourfold increase over the course of one week. Currently, no country has more than 1,000 cases. By the end of the June, no country will have less than 10,000.

With the world’s weakest health systems and highest levels of poverty, the spread of the pandemic in sub-Saharan Africa is a source of major concern. Half the population has no access to modern health services. Child and adult malnutrition, coupled with endemic malaria, constitute risk factors which could lead to far higher levels of Covid-19 mortality. 

Save the Children believes the Imperial College modelling may substantially underestimate the true effect of COVID-19 on low-income countries. In modelling the global impact of COVID-19, Imperial College does assume that there is no substantive difference in general health prevalence and morbidity between Chinese and other populations. However, with one third of children in South Asia and Sub-Saharan Africa being stunted and the high burden of infectious diseases children and adults face in those countries, populations are likely to be much more vulnerable. Furthermore, the model does not sufficiently consider the low standard of medical care in many of the poorest.

Save the Children is actively involved in providing child and maternal health care across many of the poorest countries in sub-Saharan Africa and South Asia. These are countries with health systems unable in many cases to provide universal immunisation. Millions of children die as a result of the inability of their parents to get treatment for basic diseases like malaria, sepsis and diarrhoea. Over 800,000 children die from pneumonia alone, many of them because there is no medical oxygen available.

Nor does it project the additional numbers of deaths which will occur as a result of health systems failure. Coronavirus is already overwhelming health systems in the world’s richest countries. The effects will be far more severe in the poorest. Public health spending averages just $17 per person in South Asia and $16 in Sub-Saharan Africa (when excluding South Africa) – far short of the $86 per person needed to finance basic health provision. While in Europe and North America there are 31 doctors per 10,000 population, the equivalent numbers in Sub-Saharan Africa and South Asia are 2 and 8 respectively. Simply to provide basic health care the two regions would need an additional 7 million health workers. Meanwhile, the poorest countries have an average of just 7 hospital beds per 10,000 population in both southern regions compared to 49 beds in Europe and North America.

In some of those countries facing the prospect of high COVID-19 mortality rates, health systems are even weaker than the regional average suggest. In India and Bangladesh, the numbers of doctors is significantly below the regional average (4 and 5 doctors per 10,000 population respectively, compared to the regional average of 8). And in Ethiopia, there is only 1 doctor and 3 beds per 10,000 population.

The best defence against coronavirus is universal health coverage delivered through a properly financed health system drawing on a large medical infrastructure. Many countries in sub-Saharan Africa and South Asia have combined under-investment with high levels of inequality in spending provision. Governments in these countries must now learn from their mistakes. But their citizens should not be left to pay the price for those mistakes.

The lethal combination of a weak health system, limited access to care, a high levels of background risk threatens literally millions of lives. Not all of the risks will be carried by coronavirus victims. As health systems respond to Covid-19, resources will be drawn away from the vital health services now keeping many children alive and supporting safe child birth.

This is a global challenge

As countries around the world grapple with coronavirus at home, the emerging picture from the world’s poorest countries highlights the need for global action. Coronavirus must be beaten everywhere or it will be beaten nowhere.

Delaying prevention and containment in South Asia and sub-Saharan Africa will not only claim many lives in those regions, it will potentially fuel the pandemic in Europe, North America and other regions. Failure to act now will increase the numbers infected by coronavirus in South Asia and Sub-Saharan Africa by almost 1 billion. In an interconnected world an undetected and untreated case of coronavirus in a slum in Lagos, a rural village in the Democratic Republic of Congo, or a town in Bangladesh poses risks for people all over the world. 

Prevention is better than cure

The new global data on coronavirus underscores the need for urgent and decisive action nationally and globally. As countries across Europe and the US have discovered, failure to prevent and contain coronavirus costs lives, strains health systems, and creates devastating levels of social and economic dislocation. What happens over the next few weeks will decide whether or not the gains that have been achieved over the past 20 years in child survival, education and nutrition are reversed. There are plenty of uncertainties, but the one certainty we have is that the poorest and most vulnerable will bear the brunt of the coronavirus fallout and the 2030 Sustainable Development Goals will become a total irrelevance.

To avoid this scenario, Save the Children is calling for international cooperation in five areas:

  • A single global plan to get support to the front-lines where it is desperately needed. Preventing the spread of coronavirus requires urgent investment in kits for testing, with early identification, isolation and tracing critical. The provision of protective equipment, drugs and medical oxygen is critical. The WHO has provided the road-map, but it’s global appeal is under-funded. The World Bank has provided leadership in the form of $6bn for health system strengthening. But we need a global Marshall Plan to beat the disease.
  • Global finance for recovery and protection. Rich countries have pumped trillions of dollars into their economies, and billions into health systems and safety nets. The poorest countries have neither the resources nor the fiscal space to act on the scale required. Western governments must now act decisively to deliver resources through emergency IMF credit lines, and by mobilising new resources through the World Bank and regional development banks. Debt payments from sub-Saharan Africa and low income countries in other regions should be suspended to release resources.
  • Putting families and children at the centre. The economic fallout from coronavirus has hurt families and children in the world’s richest countries. The effects will be even more severe in the poorest countries. International and national efforts to respond to the effects of social distancing and economic recession must now place more weight on the poorest and most vulnerable, using cash transfers, targeted spending, and investment in health and education to shield those with the least resources.
  • Education and learning. School closure has already disrupted the education of million of children. As the pandemic reaches and spreads across the poorest countries, many millions more will be affected. In rich and poor countries alike, it is the poorest children who stand to lose the most. For many of the adolescent girls now out of school, there is a real danger that a temporary disruption will lead to early marriage. Refugee children face particularly severe risks given the already limited levels of provision available, high levels of poverty, and insecurity. We need an international plan of action to continue education. 
  • Protecting the most vulnerable. Preventing and containing coronavirus is difficult in any country. For countries in conflict and those with fragile states, the difficulties are compounded many times over. It is critical that the international response supports the global humanitarian system to address the crisis for conflict-affected populations from Yemen, to the Rohingya camps in Bangladesh and northern Nigeria.


Number of deaths due to COVID-19 and the effect of mitigation or suppression strategies are based on the global impact model of Imperial College London, published on 26 March 2020: Patrick GT Walker, Charles Whittaker, Oliver Watson et al. The Global Impact of COVID-19 and Strategies for Mitigation and Suppression, Imperial College London (2020).

London School of Hygiene & Tropical Medicine has developed a projection of the spread of COVID-19 in Africa: Pearson, C., C. Van Schalkwyk, A. Foss et al. Projection of early spread of COVID19 in Africa as of 25 March 2020, London School of Hygiene & Tropical Medicine (2020).

Data on public health financing, numbers of doctors and hospital beds based on WHO’s Global Health Observatory