Cross Country Synthesis

One of the most critical aspects of COVID-19 response is surveillance—the systematic collection, analysis, and interpretation of data to identify cases, map and explain the disease’s spread, and shape the development of interventions to contain the epidemic.

To inform the development of sustainable testing and surveillance systems for future disease preparedness, this project aimed to identify and explain the testing and surveillance strategies adopted by four low- and lower-middle-income countries in sub-Saharan Africa: the Democratic Republic of the Congo (DRC), Nigeria, Senegal, and Uganda. The research has been led by partners at the Makerere University School of Public Health in collaboration with the University of Kinshasa, Université Cheikh Anta Diop, and the University of Ibadan and was supported and funded by the Bill & Melinda Gates Foundation Africa Team and by Gates Ventures.

This cross-country synthesis presents high-level strategies, lessons, and challenges that emerged from the research, which readers can explore further in the detailed case studies coming soon. These findings are relevant for policy makers, funders, and nongovernmental leaders seeking to understand how governments and implementers have introduced, adapted, and scaled testing and surveillance in the context of COVID-19. They can also inform the development of sustainable testing and surveillance systems for future pandemic preparedness and response.

The four countries included in the study were selected because:

• They demonstrated variation in their COVID-19 responses, both in terms of the scope and intensity of nonpharmaceutical interventions and in their outcomes.
• They had historical experience in managing epidemics of global concern, such as yellow fever, Ebola virus disease, and Marburg virus disease.
• Existing partnerships between local research institutions and government offices eased access to COVID-19 and other health systems data and enabled the translation of research findings to evidence-based policy and practice.
• The mixture of Francophone (the DRC and Senegal) and Anglophone (Nigeria and Uganda) countries enhances South-to-South cross-learning networks and communities of practice.

On February 27, 2020, Nigeria was one of the first countries in Africa to report its first case of COVID-19. Just days later, on March 2, Senegal reported its first case in a traveler arriving from France. Uganda and the DRC identified their first cases later in March.

Like many other African countries, these four experienced a relatively mild first wave of the pandemic (through July 2020). A second wave of cases and deaths followed between November 2020 and February 2021, except in the DRC where the reported burden remained low. Until June 2021, Senegal had the most cases and deaths per capita among the countries profiled; that month, Uganda began suffering a massive wave of infections and deaths.

Compared with other parts of the world, COVID-19 has not been as severe in the WHO Africa Region. Although it is home to about 14 percent of the world’s population, the region has accounted for only about 2 percent of reported cases and deaths. (It is worthy to note that reporting gaps exist in cases and deaths across the world, and they are particularly acute in sub-Saharan Africa due to limited existing infectious disease and mortality surveillance systems.)

Test positivity, or the proportion of COVID-19 tests that are positive, can be used as a marker to indicate how widespread infection is and whether sufficient testing is being done. WHO suggests that a positivity rate of less than 5 percent is one indicator that a country has the spread of COVID-19 under control. At certain points in time, especially during the second wave between November 2020 and February 2021, all four countries’ test-positivity rates were greater than 10 percent, much higher than the WHO benchmark of 5 percent, suggesting a substantial undetected burden of COVID-19.

In Europe and North America, most adults who were willing and able to receive a COVID-19 vaccine have already done so. Now the world is focusing its attention on disparities in vaccine access. Only about 2.7 percent of people in Africa had received at least one dose of the COVID-19 vaccine as of July 1, 2021, compared with more than 40.0 percent in North America and Europe.

Summary of reported cases and deaths due to COVID-19 through July 1, 2021

Location	Reported Cases	Reported Deaths	Population (in millions)	Cases per millions	Deaths per millions
World*	182,600,000	3,960,000	7,737.5	23,400	507.7
Africa*	5,550,000	143,700	1,099.6	4,140	107.2
DRC	41,400	933	87.7	470	10.6
Nigeria	167,700	2,121	214.8	780	9.9
Senegal	43,300	1,168	15.1	2,860	77.1
Uganda	81,000	1,061	41.1	1,970	25.8

*Counts have been rounded

Our World in Data, Johns Hopkins University CSSE COVID-19 Data

Country	Strengths	Challenges	Key learnings
DRC	Mass testing strategy at epicenter and early RDT adoption Continued capacity growth & decentralization throughout the pandemic Leveraged existing surveillance systems Multisectoral engagement across levels of the government	Limited access to testing sites and limited supply of testing kits Inadequate funding and resources to manage multiple outbreaks Heavily paper-based surveillance system	Task-shifting to community health workers for contact tracing Develop hotline for case reporting
Nigeria	Increased testing access & TAT through decentralization Leveraged pre-existing SORMAS software and DHIS2v Strong central coordination to avoid duplication and proactive response before first case was recorded	Low demand, in part from misinformation Difficulty in collecting test results Poor use of data to guide decision making at subnational level and some states faced coordination issues	Leverage experience & systems from past outbreaks Adopt tech solutions that integrate disparate information systems
Senegal	Leveraged existing PCR and GeneXpert capacity, as well as the local production of RDTs Strong collaboration between universities and academic institutes Existing surveillance structures and information systems repurposed	Inadequate testing supplies and funding Overreliance on donor funding and foreign supplies Long turnaround times and limited number of sample collection sites Limited resources for district coordination	Rapid response and proactive action Coordination within lab networks Initiate community surveys Leverage available funding for innovation

While the importance of surveillance efforts has long been understood and accurate tests for COVID-19 have been available since January 2020, challenges can occur at each step of the testing value chain (see  for more detail). The following strengths, challenges, and learnings emerged from the research in the DRC, Nigeria, Senegal, and Uganda. These findings can be leveraged to shape recommendations for COVID-19 response and future pandemic preparedness, as well as to strengthen health systems in general.

The findings are categorized according to the testing, surveillance, and public health action framework .

Moving forward—to later phases of the COVID-19 pandemic, future pandemics, and the future of health systems in general—countries and regional bodies can take several actions to better prepare for the next major disease outbreak. In particular, they can continue to invest in data systems and set up regional mechanisms for supply procurement, disease surveillance, and the validation of test results.

Following the first cases of COVID-19 on the African continent in February and March 2020, the DRC, Nigeria, Senegal, and Uganda demonstrated prompt public health response; instituted national policies, strategies, and plans aligned with World Health Organization guidance; and modified these strategies as local epidemics evolved.

In the initial phases of the pandemic, all four countries were able to leverage preexisting capacities in testing and surveillance. Resource constraints continued to be a challenge for the implementation of these strategies. Moving forward, recommended approaches such as those described above can help stem the further spread of COVID-19 while enhancing readiness for future disease outbreaks.

Note: At the time of publication (August 2021), the African continent was in the midst of the third and deadliest wave of COVID-19. How these recommendations have been implemented, adapted, challenged, or scaled to quell the spread of the Delta variant in the DRC, Nigeria, Senegal, and Uganda is still being understood.