T H E T H I N K E R45 As Covid-19 sweeps across the globe, one of the biggest questions in many minds is ‘how will this crisis affect Af rica?’ (Nyenswah, 2020; Pillay, 2020; Wood, 2020; World Bank, 2020a). Fears abound that the pandemic will multiply and deepen existing socio-economic issues, such as high levels of unemployment, poverty, and inequality. Some speculations are stoked by geopolitical relations and partnerships that underpin the role of foreign powers, such as China, in Af rica (Tremann, 2020). Other predictions consider the socio-cultural dimensions unique to the continent that would likely hamper extrapolations f rom Western or Eastern examples to date (Broadbent and Smart, 2020; Kaseje, 2020). Often these speculations are characterised by a sense of risk and a pessimistic outlook on Af rica’s capacity to respond effectively to the threat posed by Covid-19 (Holmes et al., 2020). In this article we argue that many Af rican governments have so far responded more proactively and effectively to Covid-19 than some governments in High Income Countries (HICs), and that much of this capacity to respond effectively can be explained by an existing culture of using evidence to inform policy decision-making. Decision-Making in the Time of Covid-19 A key challenge for many decision-makers in these uncertain times is the rapidly expanding and changing knowledge and information base on Covid-19. Response strategies to contain the pandemic require a sensitive design that evidence which forces decision-makers to adjust and review strategies and policies on an ongoing basis (Mbuvha and Marwala, 2020). The vast amount of evidence and misinformation can be paralysing for decision-makers and citizens alike. As the world grapples with an overwhelming number of unanswered questions in relation to this pandemic, and a rising tide of often highly- speculative new research, our leaders’ decision- making is in the spotlight. Crucially, the different trajectories of Covid-19 in countries suggest that adopting evidence- informed response strategies contributes positively to controlling the pandemic. Politicians and leaders stress a need for ‘following the science’ and science advisors and governmental advisory committees are in a new, unfamiliar spotlight. Supporting such institutional mechanisms for evidence-informed decision-making is a wider community of global institutions, organisations, By Nasreen Jessani, Laurenz Langer, Carina van Rooyen and Ruth Stewart COVID-19 EVIDENCE FOR DECISIONS IN THE TIME OF COVID-19 Eyes Africa on © S h u tt e rs to ck .c o m 46V o l u m e 8 4 / 2 0 2 0 and individuals that produce policy-relevant evidence and work to increase the use of the best available evidence in decision-making. They specialise in rigorous analysis of the full body of available evidence and help to sort fact f rom fiction, supporting decision-makers to navigate the evidence in almost real time. This evidence community is suddenly needed more than ever in national and global decision-making systems. So, with our eyes turned to Af rica, how is our Af rican evidence community faring in the time of Covid-19, and how is its response helping to shape the impact of the pandemic across the continent? Increased Demand for Evidence Covid-19 is arriving on the continent and into health systems that are significantly different f rom those in the rest of the world. Af rican health systems have both advantages and disadvantages compared to health systems in the wider international community. While the HIV/AIDS and Ebola pandemics have left many Af rican countries with the experience and skills needed to manage large-scale health crises, many basic health system functions – such as vaccinations and supply of medicines – are often underfunded and heavily reliant on donor funding. With the world shifting its efforts and resources to Covid-19 responses (see the Gates Foundation’s massive reallocation of funding), Af rican health systems face a financial risk for essential basic services at the same time as they have to design an effective Covid-19 response. While the world’s – and Af rica’s – focus to date has largely been the pandemic’s case growth and mortality rate, Af rica is facing a pandemic for which our social and economic capacities arguably require greater attention than our health systems. Millions on the continent are already feeling the impact of unemployment, hunger, and social unrest magnified by the pandemic, while few have been affected by the clinical manifestation of the virus. Country-wide lockdowns have a far greater negative social and economic impact in economies with large informal sectors, much smaller social safety nets, and dense urban townships and informal settlements (World Bank, 2020b). The implications of these unique realities are that Af rican decision-makers have a different demand for evidence and need to be able to design a more holistic Covid-19 response that, f rom day one, is more sensitive to the socio-economic risks presented by the pandemic, and builds on the existing expertise and experience of managing previous pandemics. To this twin challenge, Af rica’s evidence community is responding with cross-sectoral research, monitoring, and evaluation to inform decision-making. For example, the South Af rican government has explicitly requested research advice not only in relation to health, but also for education, economic and social policies (Af rica Centre for Evidence, 2020). Af rican researchers are also producing evidence on how to protect and prioritise already existing health interventions which can increase health system resilience and preparedness for Covid-19. For example, Ugandan researchers have produced a rapid evidence review on infection prevention control practices for district health services in Uganda (Centre for Rapid Evidence Synthesis, 2020a). Evidence Generation and Use by Africans for Africa We are seeing Af rican nations take the lead in the generation and use of evidence for decision- making and in the solutions being sought out to tackle the pandemic. Almost immediately after the pandemic was declared, some Af rican nations responded with explicit evidence-informed mitigation strategies. This is in stark contrast to the speed of the response in some other, much better- resourced health systems. In general, some Af rican states implemented strict lockdown policies much earlier than many European and American countries, often adopting such policies even before any deaths had been recorded. These decisions drew heavily on evidence-informed policy advice by the WHO and the Af rica Centre for Disease Control, as well as observations of the emerging data on the effectiveness of lockdowns in other countries at different stages of the pandemic. Crucially, these decisions also drew on local reviews that assessed the transferability of the existing international evidence, such as a rapid review conducted in Uganda on the effectiveness of lockdowns (Centre for Rapid Evidence Synthesis, 2020b). In addition, individual countries such as South Af rica led the world in introducing mass screening by community health workers very early in the manifestation of the pandemic. Universities and other producers of research across the continent COVID-19 T H E T H I N K E R47 mobilised quickly to contribute to the generation of equipment, the development of affordable test kits, and the conducting of multi-arm vaccine trials. These advances have included, for example, the development and trialling of a rapid Covid-19 test in Senegal which can provide results in ten minutes (Haque, 2020), the contactless delivery of samples for testing using drones in Ghana, as well as virtual hackathons to find Af rican digital solutions to combat Covid-19, facilitated by the WHO (Bright, 2020). In response to multiple complex demands for evidence, we have seen a rise in locally relevant rapid production of evidence to inform Af rica’s Covid-19 response. This local supply f rom Af rican academics and researchers of relevant evidence is multifaceted, including responsive evidence syntheses, rapid responses, surveys, advisories, and guideline documents for government decision- makers. The supply is driven by Af rican research organisations and pre-established evidence broker organisations such as the Af rican Centre for Rapid Evidence Synthesis, the Af rica Evidence Network, Effective Basic Services, and the Af rican Institute for Development Policy. For a full list of Af rican organisations supporting the use of evidence, see the continent-wide GeoMap published by the Af rica Evidence Network (2020a). These institutions are tapping into their already established relationships with government and civil society decision-makers to provide responsive evidence services to support national policy and practice. The supply is also informed by continental priority-setting exercises for research, driven by the Af rican Academy of Sciences (2020), and by the participation of Af rican researchers in contributing to global efforts to synthesise evidence through the COVID-END initiative (McMaster Health Forum, 2020). The evidence-informed response across Af rican states has been led by high-level and cross- governmental leadership. For example, President Cyril Ramaphosa of South Af rica has repeatedly stressed that the country’s response is based on the best available evidence, with a range of cross- governmental teams reviewing and analysing health and socio-economic evidence on an ongoing basis. President Nana Akufo-Addo of Ghana and Nasir El-Rufai, Governor of Kaduna State in Nigeria, both spoke publicly in a recent webinar, alongside some of the world’s leading academics, about their policy responses to the Covid-19 pandemic, with f requent references to the evidence bases that guided their decision-making (Af rica.com, 2020). This use of evidence to guide decision-making in response to Covid-19 is in contrast to the approaches of national leaders in other countries – such as the United States, Sweden, and Brazil – who have downplayed the risk of the pandemic and promoted distinctively non-evidence-informed health advice. Leave No African Behind Whilst fears are mounting for those living in poverty across the continent, and manifestations of elements such as data-poverty and technology- poverty are being felt, Af rican governments have taken stronger measures than their international peers to protect the most vulnerable sectors of their populations. From the onset of the pandemic, governments were keenly aware of the risk Covid-19 posed to populations living in overcrowded conditions, with poor nutrition, and with pre-existing conditions such as HIV/AIDS. To protect these populations, governments have gone to great lengths to design tailored Covid-19 response strategies aimed at protecting the most vulnerable. This includes, for example, Ghana using historic pre-paid records and geo-location to deliver food parcels to those most in need, and South Af rica setting up special isolation sites for individuals who test positive for Covid-19 but cannot self-isolate at home. We have witnessed a flurry of activity f rom advocacy organisations in ensuring that the voices of ordinary citizens do not go unheard, and that their needs are met. In Cameroon, for example, the evidence community is mobilising to communicate evidence around Covid-19 at a community level by using local sign language and Whilst fears are mounting for those living in poverty across the continent, and manifestations of elements such as data-poverty and technology-poverty are being felt, African governments have taken stronger measures than their international peers to protect the most vulnerable sectors of their populations. COVID-19 48V o l u m e 8 4 / 2 0 2 0 Pidgin English for people living with disabilities within their communities (eBASE Af rica, 2020). Again, this contrasts sharply with international examples – such as the United States and the United Kingdom – where more vulnerable and marginalised members of the population are experiencing significantly worse clinical outcomes during the pandemic. African Evidence Solidarity In response to the pandemic there is a general groundswell in calls for solidarity; so too with the evidence community in Af rica. Partnerships to assist with evidence production, collation, and use of evidence are appearing nationally, regionally, and globally as the lynchpin for quick but measured evidence-informed decisions. Such partnerships have demonstrated the value of solidarity in times where collaboration amplifies and multiplies the abilities of the entire evidence community to respond effectively. Regional as well as global evidence networks – such as Cochrane Af rica, the Network of Impact Evaluation Researchers in Af rica, and the Af rica Evidence Network – are working to find, appraise, and publicly share the best available evidence and in some cases recommendations for a wide range of Covid-19 relevant issues and decision implications. These efforts produce a multiplier effect, while reducing duplication and redundancy. It is thanks to the long-term commitment to partnerships f rom evidence leaders in Af rica (see Af rica Evidence Network, 2020b) that these networks were already in place prior to Covid-19, with established relationships and trust enabling Af rican solidarity to translate into evidence solidarity for crisis response. Local capacity to provide, share, and use relevant and timely evidence is contributing to evidence- informed solutions to the pandemic in Af rica. While there are 54 countries on the continent, each with its own unique circumstances, there are values, histories, and traditions that connect us. These connections provide the perfect opportunity for leveraging Pan-Af rican networks, capacities, and knowledge – and strengthening these as we prepare for a new future over the many years in which we will feel the continued impact of Covid-19. As we progress through the various phases of the pandemic and its effects on this continent, we should continue to learn f rom each other, support one another, and serve as examples to the rest of the world. Let us draw on the best- available evidence to inform our decisions and monitor their impacts. Let us share our successes, our challenges, our wins, and our losses. Af rican countries, and Af rica’s evidence community, are rising to the challenge of responding to Covid-19 in every way that they can. ■ References Af rica Centre for Evidence, (2020). ACE’s response to COVID-19. [online] Available at: https://www.af ricacentreforevidence.org/ Af rica Evidence Network, (2020a). Who is working on EIDM in Af rica? [online] Available at: https://www.af ricaevidencenetwork.org/en/eidm-in- af rica/#who Af rica Evidence Network, (2020b). Af rica Evidence Leadership Award. [online] Available at: https://www.af ricaevidencenetwork.org/en/learning- space/article/6/ Af rica.com, (2020). This Isn’t the West – How Af rica’s Informal Sector Reacts to COVID-19, Virtual Conference. [online] Available at: https:// virtualconferenceaf rica.com Af rican Academy of Sciences, (2020). Research and Development goals for COVID-19 in Af rica – the Af rican Academy of Sciences Priority Setting Exercise. [online] Available at: https://www.aasciences.af rica/sites/default/ files/2020-04/Research%20and%20Development%20Goals%20for%20 COVID-19%20in%20Af rica.pdf Bright, J. (2020). WHO Af rica hosts hackathons, offers seed funds to fight COVID-19. [online] Tech Crunch. Available at: https://techcrunch. com/2020/04/06/who-af rica-hosts-hackathons-offers-seed-funds-to-fight- covid-19/ Broadbent, A. & Smart, B. (2020). Why a one-size-fits-all approach to COVID-19 could have lethal consequences. [online] The Conversation. Available at: https://theconversation.com/why-a-one-size-fits-all-approach- to-covid-19-could-have-lethal-consequences-134252 Centre for Rapid Evidence Synthesis, (2020a). COVID-19 control: What can research evidence tell us about Covid-19 Infection Prevention Control (IPC) practices for health facilities at the district level. [online] Available at: https:// aenweb.blob.core.windows.net/aenweb/pages/files/Uganda_Rapid_Review_ Infection_control_practices_in_lower_health_facilities.pdf Centre for Rapid Evidence Synthesis, (2020b). COVID-19 control: How can an LMIC implement a jurisdictional lockdown to prevent spread of infection in the community. [online] Available at: https://acres.or.ug/2020/04/23/new- brief-how-to-implement-a-jurisdictional-lockdown/ eBASE Af rica, (2020). Twitter status 28 April 2020. [online] Twitter. Available at: https://twitter.com/ebase_af rica/status/1255176695444918274?s=20 Kaseje, N. (2020). Why sub-Saharan Af rica needs a unique response to COVID-19. [online] World Economic Forum. Available at: https://www. weforum.org/agenda/2020/03/why-sub-saharan-af rica-needs-a-unique- response-to-covid-19/ Haque, N. (2020). Senegal trials begin for $1 COVID-19 test kit. [online] Al Jazeera. Available at: https://www.aljazeera.com/news/2020/04/senegal- trials-1-covid-19-test-kit-200428132313740.html Holmes, C., Lake, A. and Schneidman, W. (2020). It’s time to help Af rica fight the virus. [online] Foreign Policy. Available at: https://foreignpolicy. com/2020/04/29/af rica-coronavirus-pandemic-united-states-europe/ Mbuvha, R. and Marwala, T. (2020). On data-driven management of COVID-19 outbreak in South Af rica. [online] medRxiv preprint. Available at: https://www.medrxiv.org/content/10.1101/2020.04.07.20057133v1.full.pdf Nyenswah, T. (2020). Af rica has a COVID-19 time bomb to defuse. [online] World Economic Forum. Available at: https://www.weforum.org/ agenda/2020/04/af rica-covid-19-time-bomb-defuse/ Pillay, D. (2020). Low COVID-19 death toll raises hopes Af rica may be spared worst. [online] Financial Times. Available at: https://www.ft.com/content/ e9cf5ed0-a590-4bd6-8c00-b41d0c4ae6e0 Tremann, C. (2020). As Af rica prepares to fight Covid-19, China steps up. [online] The Interpreter. Available at: https://www.lowyinstitute.org/the- interpreter/af rica-prepares-fight-covid-19-china-steps-up Wood, G. (2020). Think 168 000 ventilators is too few? Try three. [online] The Atlantic. Available at: https://www.theatlantic.com/ideas/archive/2020/04/ why-covid-might-hit-af rican-nations-hardest/609760/ World Bank, (2020a). COVID-19 (Coronavirus) drives sub-Saharan Af rica towards first recession in 25 years. Press release no. 2020/099/AFR. [online] Available at: https://www.worldbank.org/en/news/press-release/2020/04/09/ covid-19-coronavirus-drives-sub-saharan-af rica-toward-first-recession-in- 25-years World Bank, (2020b). For Sub-Saharan Af rica, Coronavirus Crisis Calls for Policies for Greater Resilience. [online] Available at: https://www.worldbank. org/en/region/af r/publication/for-sub-saharan-af rica-coronavirus-crisis- calls-for-policies-for-greater-resilience COVID-19