On January 17, Ghanaian President Nana Akufo-Addo issued a sober warning to his country: “Our COVID-19 treatment centres have gone from having zero patients to now being full because of the upsurge in infections. At this current rate … our healthcare infrastructure will be overwhelmed.”
Ghana’s early response to the pandemic was deemed a success, gaining praise for taking decisive actions to stop the spread of the virus, including lockdowns and social-distancing measures. But in light of a new uptick in confirmed cases, policy makers need to carefully introduce response measures to control the spread. In doing so, they need to consider its impact on other aspects of daily life, such as employment, food availability and essential health services, to design interventions and social support that provide multi-faceted relief to communities in need.
In this blog post we take a closer look at the primary and secondary effects of the pandemic in Ghana by leveraging our Africa COVID-19 Community Vulnerability Index (CCVI): a modular vulnerability index to inform COVID-19 planning and response. The Africa CCVI maps vulnerability to COVID-19 at a sub-national level, allowing for a nuanced understanding of why and where regions will feel the greatest health, economic and social consequences of the pandemic.
Ghana averted a second wave until January 2021
As confirmed COVID-19 cases near 3.5 million in Africa, countries like Morocco and, more recently, Tunisia and South Africa, became epicenters of the pandemic’s second wave in late 2020, with over 200 cases per million inhabitants being reported daily in mid-January.
Ghana, seemingly untouched by a second surge in cases and having maintained a low case fatality ratio all of 2020 (0.5% of confirmed cases end in death), has seen an uptake in cases in the first weeks of 2021 that threatens to overwhelm an already strained health system. Though the rate of newly confirmed cases is still below that of the first peak (Fig 1), this surge could be responded to with measures that might unintentionally compromise livelihoods in an already contracted economy — Ghana’s GDP growth has fallen from an estimated 6.5% to 1.9% this year.
This brings us to three important questions:
- What challenges are Ghanaian policymakers facing when evaluating the primary and secondary effects of the pandemic?
- How can the Africa CCVI be leveraged to better design targeted responses to the public health impacts?
- In what ways are the Ghanaian regions differently vulnerable to the secondary effects of the pandemic?
Figure 1. Weekly new cases for selected African countries. Source: Our World In Data, January 25, 2020.
Challenges: limited data complicates an objective evaluation of the pandemic impacts
Just three COVID-19 deaths were reported in Ghana in November 2020, compared to 880 to 975 monthly deaths attributed to malaria. Such low mortality levels warrant careful examination: is Ghana testing sufficiently? Are COVID-19 deaths being adequately registered?
These low numbers of reported deaths could be in part due to insufficient testing (with only 2k samples tested per 100k population as of January 25, 2021). The test positivity is no longer under the WHO-recommended level of 5%; yet remains significantly lower than other countries like South Africa, which has performed about 12k tests per 100k inhabitants since the start of the pandemic (Fig 2). But Ghana is using pooled testing, which, in addition to general concerns about the interpretation of positivity rates, complicates the comparison to other countries, and even to the WHO-recommended test positivity level.
With these complications about testing data in mind, we turn our attention to death registrations, which can help estimate the actual health toll of the pandemic. While an excess deaths analysis — such as those done for South Africa — could help shed light on this issue, Ghana’s reliance on a centralized, hand-written vital statistics system and on verbal autopsies complicates assessing the true death toll of the pandemic in a timely manner.
Figure 2. 7-day average test positivity for selected African countries. Source: Our World In Data, January 25, 2020.
Northern and southern regions should prepare for and respond to the second wave differently
Over 55% of the 51k cases to date have been confirmed in Greater Accra, a low overall vulnerability region where half of the 15 accredited testing labs are located (Fig 3). Governmental policies to prepare for and control a second surge must be tailored to each region’s needs. Our index shows that regions in southern Ghana, like Greater Accra and Ashanti, are vulnerable due to population density and epidemiological factors, and accordingly, could be targeted with social distancing measures and lockdown policies (Fig 4). Because of the high population density, increased spread in these regions can quickly overwhelm the health systems capacity, even when they possess the strongest infrastructure in the country. On the other hand, regions like Savannah, Upper West, and Northern are more socio-economically depressed and lack health systems and housing infrastructure and, in the event of increased spread, would need scale-up of supplies like testing site availability, treatment and isolation sites, as well as mobile health units (Fig 4).
Figure 3. COVID-19 Vulnerability and cases by region in Ghana. COVID-19 vulnerability is assessed via the Africa COVID-19 Community Vulnerability Index. Source: Caseload figures were calculated from Humanitarian Data Exchange (EDX) data.
Figure 4. COVID-19 vulnerability in Ghana shows a strong north-south divide, whereas individual drivers of vulnerability show differing patterns. Source: Africa COVID-19 Vulnerability Vulnerability Index (CCVI).
In what ways are the Ghanaian regions uniquely vulnerable to the secondary effects of the pandemic?
- Health service disruptions could harm the North East
Among PERC’s survey respondents from Ghana, 45% reported that at least one person in their household delayed medical service, and 40% had difficulties in obtaining medication. Advances made in preventing malaria, the leading cause of death, could be jeopardized as vaccination, fumigation and insecticide-treated net campaigns have been impacted by measures to control the virus. Malaria deaths disproportionately affect children who, in addition to the halt of these malarial strategies, missed 71k vaccine doses during the first quarter of 2020–21,000 for measles-rubella and 50,000 for yellow fever. Our index suggests that regions with high health systems vulnerabilities like the Ashanti, Savannah, Northern and North East (Fig 4) could be particularly affected by COVID-related restrictions and fear-induced decrease in health care use. In the Ashanti region, for example, only 81%, 61% and 13% of the population lives within the WHO-recommended 5 kilometer ratio from a primary, secondary and tertiary health care location, respectively, with inaccessibility being higher in rural districts. Healthcare barriers like distance and money also prevent infants and women from accessing health care in the Savannah, North and North East (previously the Northern region).
2. Rural farm households in the Upper East are more vulnerable to a loss in income
By July 2020, 22 million Ghanaians saw their incomes reduced due to COVID-19 restrictions. In a country where 36% of the GDP comes from exports, the economic impact of border closures to control importations will be long-lasting: farmers who cannot export their products will lose incomes and products, and the retail economy that depends on face-to-face transactions will also be affected. Moreover, the effect of localized COVID-19 restrictions will be felt throughout the country. An economic modeling exercise estimated that an additional 3.8 million Ghanaians temporarily became poor as result of the 3-week urban lockdown in April, and that over a third of them were in rural farm households. Our index suggests that regions like the Upper East, which rely more on farming for income and experience the highest poverty rates, might be particularly vulnerable to these effects.
3. Reduced food consumption could have severe consequences in Oti and Volta regions
Increases in food prices, driven by reduced agricultural activity and food shortage due to trade bans, were the most important household shock of COVID-19 in Ghana. Immediately after the start of the pandemic, food and beverages year-on-year inflation increased by 12% (Fig 5). Nationally, 77% of households were severely affected by price increases and more than half (52%) of households reduced food consumption to cope with the effects of the pandemic. Household food security in the Oti and Volta, and Central regions, where 82%, 77% and 78% of households reported decreased incomes, respectively, will be severely affected by reduced food intake. Our index shows that these regions have high fragility vulnerability due to the prevalence of stunting in children (roughly 1 in 5 children under 5 years old), and anemia in women (49% and 47%, respectively).
Figure 5. Consumer Price Index inflation by month and commodity group versus year prior. The percentages reflect what part of the overall inflation was due to each sector. Note the large increase in food and non-alcoholic beverage inflation. Source: Ghana Statistical Service (2020).
The compounded primary and secondary effects of the pandemic across Africa, but particularly in Ghana, are pernicious and far-reaching, being felt beyond the epicentres of the outbreak. The Africa COVID-19 Community Vulnerability Index is a good start to understanding how the Ghanaian regions are uniquely vulnerable to the unintended, multi-dimensional consequences of the pandemic. However, only high-quality data will ensure that the social support programs — cash transfers, food assistance, assured work days and PPE supplies — are targeted towards the communities that need them the most. These data include, for example, health service utilization and vaccination coverage, agricultural trade and market prices, incomes and employment, and food security. Ongoing efforts that will provide much needed data for targeted interventions include the Comprehensive Food Security and Vulnerability Assessment by Ghana Statistical Services (launched in October 2020), and food prices datasets from the World Food Programme.
With more and better data, we can more fully understand how different regions within Ghana will continue to be affected by the primary and secondary pandemic, and how we can develop support and services to help them.
This work was made possible by everyone at Surgo Ventures, including (in alphabetical order): Rahul Joseph, Peter Smittenaar, and Valerie Valerio.