Covid-19 pandemic could expose Africa’s poor water and sanitation infrastructure

(Illustrative image | sources: Unsplash / Fusion Medical Animation / Wikimedia)

A new book by Jakkie Cilliers explains how far the continent is lagging behind the world in critical services, and why it’s a matter of life and death.

Africa has generally not invested nearly enough in the health of its people; neither in direct healthcare, nor in basic infrastructure in its cities, particularly in the supply of drinkable water and water-born sewage.

The result is that African cities are highly susceptible to infectious diseases.

The continent has partly compensated for its infrastructure deficiencies by relying heavily on modern medicine to keep illnesses at bay. 

But the Covid-19 pandemic could yet expose the flaw in this implicit strategy because no medicine is yet available to cure it.

So far, the virus has not raced across the continent as many predicted – and are still predicting. But that is still possible. The numbers and the rate of infection are rising fast.  

“The one lesson that needs to be drawn from the pandemic is the need for Africa to invest not only in better healthcare but also in basic infrastructure such as clean water and basic sanitation services,” says Dr Jakkie Cilliers, chairperson and head of the futures programme at the Institute for Security Studies (ISS)  in Pretoria.  

“Without basic infrastructure, Africa’s rapid urbanisation could be deadly.”

In his book Africa First! Igniting a Growth Revolution, he examines why Africa is so far behind the rest of the world in essential aspects of life and what it needs to do to catch up.

One of the areas he looks at is health, water and sanitation. Though the book was published just before the Covid-19 pandemic struck, it is in many ways prescient in analysing the conditions that might still enable the rapid transmission of the virus across the continent.

Even before Covid-19 struck, Africa was climbing a steep uphill path to deal with its disease burden. For a combination of geographical, climatic, historical, economic and political factors, Africa faces greater health problems than any other continent. 

For example, average life expectancy in Africa in 2018 was 64 for men and 67 for women versus 71 and 76 globally. Most of that is due to Africa’s higher than average prevalence of communicable diseases. So,  in 2018, about 90% of malaria deaths and roughly 80% of HIV/Aids deaths worldwide occurred in Africa. Aids peaked on the continent in 2004–2005 when more than 1.5 million Africans died from the disease in each of those years.

“The continent accounts for nearly 50% of all communicable disease deaths worldwide, despite making up only 16% of the global population … In other words, people in Africa are about four and a half times more likely to die from a communicable disease than people elsewhere,” Cilliers notes. 

The continent also accounts for 34 of the 47 countries prone to yellow fever outbreak and about 40% of the global burden of lymphatic filariasis (elephantiasis). Today, Africa is still home to 16 of the 30 countries listed by the World Health Organisation (WHO) as having a high burden of tuberculosis, though none are in the top five.

Largely because of Aids, life expectancy in sub-Saharan Africa improved by only about 2.5 years between 1980 and 2000, compared to an increase of about 5.5 years globally and close to nine years in South Asia. The Aids pandemic had a dramatic impact on Africa’s ability to improve health, relative to other developing regions, with a serious knock-on effect on economic productivity and with disastrous effects on families and communities, Cilliers writes. 

While life expectancy in Africa has since partly recovered, it still has not properly caught up. In 2018, the gap in life expectancy between Africa and the global average is at around 7.5 years – despite the ready availability of medicines which should have enabled Africa to make much more rapid progress. During the same period, South Asia slashed the gap in life expectancy between itself and the global average from 11 years in 1960 to three years today.

Historically, Africa’s high communicable disease burden has had a significant impact on its particular development trajectory. HIV/Aids increased this burden and distorted the pattern seen in other regions of declining communicable (or infectious), and increasing prevalence of non-communicable diseases.

Africa has a much younger population than other regions in the world and so has suffered a much higher communicable disease burden, including from flu, unsafe water, poor housing conditions and poor sanitation. Ironically, many are hoping that it will be precisely this younger population which now shields the continent from the worst effects of Covid-19 which has proved fatal mostly to older people elsewhere. 

On current projections, Africa’s future health prognosis is gloomy. By 2040, the continent is projected to account for about 95% of global malaria deaths, 80% of global Aids deaths and more than 47% of total communicable disease deaths worldwide. Life expectancy is also forecast to remain significantly below global averages. 

Cilliers warns that as it develops, Africa is facing a dangerous overlap of these traditional infectious communicable diseases and a premature susceptibility to the non-communicable diseases more common in developed countries. 

Infants and children often die of infectious diseases, while elderly people generally die of chronic diseases. As incomes rise, people live longer, eat more processed foodstuffs, and more readily develop heart disease, high blood pressure, diabetes and cancer. 

In Europe and North America, the transition to non-communicable disease as the main cause of death occurred several decades ago. In Latin America and the Caribbean, the transition happened around 1970. In South Asia, it occurred around 2000.

In North Africa, the transition happened around 1980, but is only set to occur around 2034 in sub- Saharan Africa – although almost one-third of all deaths in sub-Saharan Africa are already categorised as being caused by non-communicable diseases.

People in sub-Saharan Africa are, in effect, living long enough to succumb to non-communicable afflictions. Adding to this growing disease burden, many people in poor countries are contracting these “diseases of affluence” at younger ages. So, in sub-Saharan Africa, the transition is happening at lower levels of income and urbanisation than elsewhere.

The result of this approaching double burden of disease, comprising the increased prevalence of chronic non-communicable diseases and the ongoing battle to deal with infectious diseases, is that there will be more sick adults and that poor countries will have to devote more resources to preventing and treating costlier non-communicable diseases.

Cilliers gives a practical example: Providing mosquito nets to every vulnerable person in Africa is one thing, but ensuring that every African has reliable access to insulin, cancer screenings and dialysis is quite another. 

The higher costs associated with non-communicable diseases will pose a major problem for many African countries as their comparatively low average incomes translate into limited state budgets and capacity to provide the necessary healthcare. 

Although infectious diseases in Africa have largely been kept at bay so far by modern medicines rather than expanding water and sanitation infrastructure, “this does not mean that poor access to clean water and sanitation doesn’t present a major crisis,” Cilliers writes.

In 2018, only about 39% of the continent had access to adequate sanitation, versus the global average of about 70%. About 77% of people in Africa have access to drinkable water, versus the global average of more than 97%. In South Asia, about 53% of people had access to adequate sanitation and about 94% to drinkable water in 2018. 

This lack of access to physical infrastructure and basic services constrains Africa’s ability to fully develop its human potential.

Better water, sanitation and health (WaSH) generally help reduce poverty and boost education and gender equality, largely through improving human capital. 

However, there are immense challenges to advancing access to WaSH infrastructure in sub-Saharan Africa. 

Even upper-middle-income countries in Africa are struggling to expand access fast enough, in particular to sanitation facilities. Of Africa’s eight upper-middle-income countries, only Mauritius, Libya and Algeria register access rates above the global average for countries in this category (about 80%).

In the five remaining upper-middle-income African countries with below-average access levels – South Africa, Namibia, Botswana, Equatorial Guinea and Gabon – about 19 million people were still living without access to an improved sanitation facility in 2018.

And the picture on both health as well as access to drinking water and sanitation is not likely to improve much. On current trends, Africa will fall well short of Sustainable Development Goal 6 (SDG), which is universal access to clean water and improved sanitation as well as SDG 3, the complete elimination of Aids, malaria and other communicable diseases, by 2030.

Only half of Africa’s population is projected to have access to adequate sanitation and just over 80% to have reliable access to clean drinking water in 2030. 

Given how far Africa is falling short of the SDGs, Cilliers does not feel it is realistic to calculate what it would take to reach them.  

Instead, he models the impact of a “determined push” to improve health, water and sanitation, based, more realistically, on what has been achieved in South America and South Asia, the two regions most comparable to Africa. 

This push, nonetheless, “would have significant and visible effects on the health situation on the continent. It would also improve productivity and economic growth prospects,” Cilliers writes. 

The “determined push” would increase the percentage of Africans with access to drinking water from just over 80% on current trends, to about 92% while the proportion of those with adequate sanitation would rise from 50% on current trends to about 65%.

In this “Improved Health scenario”, about 105 million fewer people would rely on unimproved water sources in Africa by 2030, and about 86 million fewer people would have to live with inadequate sanitation. Even so, there would still be about 172 million Africans living without reliable access to clean water and more than 500 million living without access to adequate sanitation by the SDG deadline of 2030.

This improved health scenario would also almost halve cumulative deaths from Aids and malaria compared to current trends, by 2030. It would reduce Aids deaths by about 1.4 million people and malaria deaths by about 2.2 million. Yet nearly 600,000 people in Africa would still die in total from those two diseases in that year. 

Although this scenario doesn’t get the continent quite to the finish line in time for the SDG deadline of 2030, a push to combat communicable diseases and improve WaSH infrastructure would still have significant benefits for human and economic development – by 2030 – including decreasing extreme poverty by about 5.8 million people in 2030, and more so by 2040. 

These include, by 2040,  887,000 fewer births on the continent (cumulatively 8.5 million over the period 2020 to 2040); an increase in life expectancy at birth of roughly 1.7 years for Africa’s 2.1 billion people, moving the continent closer to the likely global average of 76.3 years; a decline in infant mortality rate by four deaths per thousand live births by 2040 compared to the Current Path forecast; more than 3.3 million fewer children suffering from undernutrition, relative to the Current Path forecast; and about 4.6 million fewer people living in extreme poverty.

In the Improved Health scenario, the gap between the life expectancy of the average African male and female compared to that in the rest of the world would have declined to seven years by 2040.

The impact of better health on Africa’s economies would also be large.  

The improved health scenario should boost Africa’s average GDP by an extra 0.1% a year, translating into an increased overall GDP – measured at market exchange rates – of $155-billion in 2040. Furthermore, it should drive a $68 increase in GDP per capita – measured at purchasing power parity – by 2040.

For governments, the benefits of the Improved Health scenario would include reducing health budgets by $715-million in 2040, or by a cumulative amount of $45-billion from 2020 to 2040. 

“The Improved Health scenario demonstrates the impact that improvements in one area – basic infrastructure – can have on another sector – health,” Cilliers says. 

“In Africa, providing basic infrastructure such as WaSH facilities and electricity reduces the impact of diarrhoeal and vector-borne diseases, as well as the respiratory harm caused by indoor use of traditional fuels such as dung and charcoal.”

Cilliers stresses the urgent need for urban planning on the continent, which would provide not only for roads, railways and ports, but also more basic infrastructure such as clean water, improved sanitation facilities and electricity as well as better health and education services. International partners, he argues, could play an important role here.

“Africa’s health systems are desperately trying to battle, simultaneously, the world’s worst communicable disease burden, rising rates of noncommunicable diseases and rapid increases in road deaths, personal violence and drug abuse,” he concludes. 

“This is a complex challenge with many moving parts, but a better understanding of the trade-offs in health policy versus investments in providing basic WaSH infrastructure should lead to improved outcomes.” DM