Health and economic imperatives for households in the context of the anti-Covid-19 strategy in Cameroon. The case of Yaounde

Introduction

Despite the outstanding advances in medical science and technology in the twentieth and twenty-first centuries, the current coronavirus pandemic (Covid-19) is a stark reminder of the vulnerability of humans to unpredictable and virulent emerging or re-emerging infections. Within 10 months of its outbreak in Wuhan-China, over 34 million confirmed cases of Covid-19 were registered in over 200 countries (WHO, 2020). The virulence and pace of diffusion of coronaviruses are extraordinarily high. For example, the severe acute respiratory syndrome (SARS-CoV), a coronavirus that emerged in China in November 2002, had spread to 37 countries in all continents, resulting in 8,096 infections and 774 deaths by July 2003 (Luo and Gao, 2020; Al-Osail and Al-Wazzah, 2017). In 2012, the Middle East respiratory syndrome, a novel coronavirus code-named MERS-CoV, emerged in Saudi Arabia and by 2015, had reached 1,621 infections and 584 deaths in 26 countries (Al-Osail and Al-Wazzah, 2017).

Like the recurrent Ebola virus disease, coronaviruses have the potential to become very persistent in the twenty-first century. They were first characterised in the 1960s and were associated with common colds, flu and pneumonia (Khan and McIntosh, 2005). Columbus et al. (2020) document four types of coronaviruses, namely, alphacoronavirus (α-CoV), betacoronavirus (β-CoV), gammacoronavirus (γ-CoV) and deltacoronavirus (δ-CoV). They are zoonotic and their animal reservoirs are thought to be bats and rodents for α-CoV and β-CoV; and avian species for γ-CoV and δ-CoV. Recent variants of the coronavirus have been associated with severe illnesses in humans. Although coronaviruses were first isolated in the 1960s, it was the SARS-CoV pandemic of 2003 that placed them amongst major infectious diseases capable of assuming epidemic and pandemic proportions, with the potential to disrupt economic, social and political systems around the world at short notice. As the quest for the earth’s resources including rare minerals and food advances even into the remotest ecosystems, the chance that man will get contact with more and new pathogens remains high. Pandemics and epidemics are fast becoming a permanent part of our everyday lives.

Diseases spread basically through different mechanisms of diffusion. This occurs through the movements of people and goods that result in one of three forms of diffusion as follows: expansion or contact or contagion diffusion; hierarchical diffusion where a disease moves from major zones to infect minor ones; and relocation diffusion involving the transfer of a disease over time and space notably through modern fast travel (Pyle, 1979; Ndi and Nguendo-Yongsi, 2018). The limitation of population movements or quarantining people to their homes constitutes the cornerstone of the strategies adopted by governments around the world to prevent or control epidemics and pandemics. Notwithstanding, emergency strategies involving economic and social lockdowns, as well as national and international border closures, often result in heavy economic and social costs on the countries or places adopting them (Begley, 2013; Garrett, 2007; Burns et al., 2006; Overby et al., 2004; Fan et al., 2018).

This study posits that the success of Covid-19 prevention through economic closures in cities dominated by informal activities is low because of its potential to push more people into extreme poverty and death than would the pandemic in question. It examines the challenges of allocating scarce financial and human resources between health and economic priorities by households in the informal sector of the city of Yaounde between March and May 2020. While some studies have projected the potentially damaging macroeconomic effects of the Covid-19 lockdowns on developing countries (Smith et al., 2018; Jorda et al., 2020; Susskind, 2020; Dabla-Norris et al., 2020; Delivorias and Scholz, 2020), few have illustrated these effects at the micro or household level. As the International Growth Centre (IGC) (2020) notes, blanket quarantine and lockdown measures may not achieve their desired goal because economic, political, social and cultural circumstances vary with context. Given the fragile economic circumstances of countries in sub-Saharan Africa, this study seems relevant to the understanding of the likely pattern of popular response to health emergency measures in informal settings. Such knowledge is important for contextualising the design of successful pandemic responses and health protection policies.

Literature on the health and economic imperatives of Covid-19

Without an efficient allocation of limited resources to health, a people’s quality of life inevitably declines and a sickly population is inimical to a strong economy. Throughout history, infectious diseases and attempts at controlling them have had devastating consequences on economic life. The Black Death, for example, is estimated to have disseminated a third of Europe’s population, leading to a fall in the labour force, a hike in wages which eventually caused the collapse of the manorial system (Martin, 2015). The word quarantine comes from Italian, quaranta giorni, meaning “40 days” (Enfield, 2020). Enfield explains that the Black Death used to kill in a maximum of 37 days from when the disease was contracted, necessitating sea-bound travellers to be quarantined for 40 days in the sea vessel within which time the infectious passengers would have died out.

Less than two years into the Covid-19 pandemic, the amount of published literature on the subject is overwhelmingly large. However, in terms of the impacts of Covid-19 on sub-Saharan, a lot of the literature is still conjectural. Two major trends are discernible from this literature as follows: the analysis of the Covid-19 pandemic as a public health challenge on the one hand and Covid-19 as a factor in economic ruin on the other (Frimpong et al., 2020; Danquah and Schotte, 2020; Delivorias and Scholz, 2020; Gondwe, 2020; Nkengasong and Mankoula, 2020; Boum et al., 2021). Despite the interest in the subject of Covid-19 and its effects on health and economics in Africa, less attention has been accorded to the considerations, perceptions and attitudes of informal sector populations in African cities most affected and how these can influence their responses to pandemic control measures such as business lockdowns, social distancing and interpersonal hygiene. With over 50% of its population now living in cities, Africa is rapidly urbanising, although the phenomenon is dominated by the development of slums. Pandemic control measures can be very difficult to implement effectively in such informal urban contexts where hygiene and sanitation are nearly absent and people’s livelihoods are unstable, ephemeral and insecure.

The analyses of the potentially ruinous effects of Covid-19 on African economies have tended to emphasise the potentially negative effects of the pandemic on African macroeconomics notably in the decline of economic growth rates, per capita income and increased unemployment (Frimpong et al., 2020; Gondwe, 2020; Delivorias and Scholz, 2020). Because of this bias, far less literature accords significance to the microeconomic activities of small firms and individuals. The United Nations Economic and Social Council (ECOSOC) (2015) notes that economic growth in Africa has not been accompanied by sufficient decent wage-paying jobs in the formal sector. The informal sector remains the main source of employment across the continent, accounting for over 70% of employment in sub-Saharan Africa (ECOSOC, 2015). Assessing the potential effects of the Covid-19 pandemic in any sub-Saharan African country from a purely macroeconomic perspective ignores the domineering role of the informal sector in African cities. The greatest effects of the slump in exports and workplace closures are felt by the urban poor who inhabit slums and scratch their living by toiling on a day-to-day basis with limited or no access to health-care or societal safety nets (Danquah and Schotte, 2020; Frimpong et al., 2020). The World Bank and other organisations estimate a loss of 4%–5% global gross national income in the case of a severe pandemic (Fan et al., 2018) and in the current Covid-19 pandemic, the economies of many countries have shrunken and slipped into recession with others recording negative gross domestic product (GDP) growth rates (Delivorias and Scholz, 2020). Governments have been coerced into making hard economic and political choices to protect the health and economic well-being of their populations.

Health and economics are always competing for choices for any country faced with an emergency or pandemic of the magnitude of Covid-19. Irrespective of a country’s level of economic and social development, all people desire to live a healthy life and to enjoy the material and psychological benefits of scientific and technological advancement although differences in resource availability and allocative efficiency make this desire illusionary (Lee and Mills, 1982). That is, why the effects of the Covid-19 pandemic and the response to it, vary amongst individuals, social groups, communities and even countries.

As the WHO declared Covid-19 a pandemic in March 2020, governments around the world have been faced with essentially the same predicaments, namely, ascertaining how much of economic and social activity should be restricted by quarantines and lockdowns to achieve what level of disease prevention and control; how much of economic lockdowns may disproportionately affect the capacity of public financing to keep up with health protection, promotion and routine patient treatment; and how lockdowns may be managed to prevent irreparable damage to the economy, youth and education and social life (Teachout and Zipfel, 2020; International Growth Centre, 2020). When businesses are shot down and movements restricted to control a pandemic, losses result from disruptions to aviation, tourism and leisure, supply chains and heightened absenteeism from work due to sickness or the need for prevention, etc.

Countries enact different policies in times of emergency or crisis. Counter pandemic fiscal policies may include an increase in public and foreign debt, a reduction in the national saving rate, thereby possibly pushing real interest rates to rise and investment to decline (Jorda et al., 2020). Teachout and Zipfel (2020), in a policy brief for the IGC, observe that blanket lockdown policies in poorer countries notably in sub-Saharan Africa may put more people at risk of dying than the unmitigated spread of the virus itself if such measures are not accompanied by massive national and international economic responses. Similarly, in a Covid-19 guidance note issued in April 2020, the IGC posited that as follows:

[…] limiting social interactions to slow the spread of the virus has also limited economic interactions essential to employment and trade, leading to a collapse in economic activity in developing countries, undermining livelihoods and augmenting extreme poverty and hunger […] a functioning economy is crucial to population health, especially in high poverty communities (p. 2).

Simulating the effect of the Covid-19 containment measures in sub-Saharan Africa, Teachout and Zipfel (2020) estimate that 9.1% of the region’s population would slide into extreme poverty and 19.3% would be unable to afford their pre-Covid-19 food consumption level after a two-month lockdown. Nyashanu et al. (2020) corroborate this fact with substantive examples from the informal settlements of Tshwane Gauteng Province of South Africa. The informal sector produces about 30% of global GDP and 30%–90% of total non-agricultural employment in sub-Saharan Africa (ILO, 2018; Alexander, 2019). Assessing the impact of Covid-19 on Africa’s economic development, Gondwe (2020) posited that the pandemic was going to drag African economies to a fall of about 1.4% in GDP with the smaller economies facing a contraction of about 7.8%. The ILO (2020) notes that Cameroon’s labour force is characterised by the preponderance of informal employment and a rapid increase in the labour force with little access to decent jobs. Informal sector workers who are dominated by women have suffered acute health risks and lost incomes due to the current coronavirus pandemic. Economic contraction is likely to cause losses in tax revenues and reduce the capacity of governments to extend the services necessary to respond to the pandemic.

In many countries, routine outpatient care has suffered a setback because hospitals have had to reallocate essential resources to accommodate Covid-19 patients. The prioritisation of Covid-19 care has led to a backlog of non-Covid-19 care of patients with chronic diseases (BMA, 2020). Similarly, severe deterioration in mental health and well-being such as difficulties in sleeping, eating, increased alcohol consumption or substance use has been reported during lockdowns (Panchal et al., 2021; Xiong et al., 2020 and Giorgi et al., 2020). Social distancing, quarantines, loss of employment and income, uncertainty about the future and personal health have led to unprecedented levels of anxiety in people.

While the current literature on the Covid-19 pandemic in Africa has is skewed towards analysing the potentially devastating effects of economic lockdown on the continent’s macroeconomic indicators, relatively fewer analyses have been carried out into the responses to economic closures from the informal sector actors. This study picks on this discrepancy in the literature by surveying the responses to the Covid-19 response strategy amongst informal sector workers in selected neighbourhoods of Yaounde in Cameroon. By analysing the responses from the urban poor in Yaounde to the Cameroon Government’s anti-Covid-19 strategy in 2020, the study demonstrates the weaknesses of applying Eurocentric blanket measures in emergencies notably the inability of such measures to reflect the diverse social and economic characteristics of African cities where bespoke measures may be more suitable.

The health and economics nexus

Health and economics are two sides of the same coin because they mutually reinforce each other. An acceptable level of health may lead to economic growth by reducing working hours lost to ill health; enhance children’s school attendance and learning and make alternative profitable use of scarce resources that would otherwise be spent on disease treatment (Rout and Nayak, 2007). Similarly, a strong economy improves the allocative efficiency of resources to health care at both the institutional and personal levels. The United Nations Organisation (UNO) and its agency, the WHO all recognise this nexus and believe that the best way to achieve health in developing countries is to reduce or eliminate poverty and to increase the percentage share of each country’s GDP spent on health. In an address to the 54th World Health Assembly on 17 May 2001, Kofi Annan, the then Secretary-General of the UNO posited that the biggest enemy of health in the developing world was poverty (UNO, 2001). The typically low resilience of developing countries to disasters is attributable to weak economic production, poor allocation of scarce resources and rampant poverty that renders people more vulnerable to pandemics. Because of this reality, ministries of public health, the WHO and non-state actors invest significant resources in disease prevention and health promotion programmes in these countries.

Conceptual framework

The conceptual framework for this study was inspired by the work of Lee and Mills (1982) on the economics of health in developing countries. Health cannot be dissociated from economics. Samuelson and Nordhaus (1998) define economics as the study of how societies use scarce resources to produce valuable commodities and distribute them amongst different people. The two key ideas in this definition are the facts that resources are scarce necessitating society to use them efficiently. The application of the discipline of economics to the topic of health is called health economics (Kernick, 2003). Because of scarce resources, governments and individuals worldwide, face difficult budgetary allocation choices between health protection programmes on the one hand and multiple competing development programmes on the other hand. Allocating resources to competing uses is even more challenging in a pandemic situation in a developing country context where a lot of spending on social development emanates from bilateral and multi-lateral grants and loans procured with conditionalities at high interest rates. Figure 1 is an illustration of how governments, institutions and households allocate scarce resources between economic and health choices. Health expenditures in sub-Saharan African countries mostly come from out-of-pocket sources, state budgets and private institutions. In this scenario, the context (household or government) must make choices based on their circumstances or priorities.

The framework illustrates the two main competing needs (the economy and health) of households in a pandemic situation. How much of the resources are allocated to each of the two needs depends on the acuity of each need and the allocative efficiency of the resource managers.

In Cameroon, where out-of-pocket health expenditures represent 75.6% of all health spending, outpacing government health spending which is only 6.0% of total health spending, (WHO, 2020), allocative efficiency tends to be even more important for households who mostly work in the informal sector. These workers are mainly women and account for more than 90% of the workforce (ILO, 2020). Jobs are extremely vulnerable and with the constant addition of young school graduates into the labour force every year, many people resort to self-employment in petty trading.

Cameroon Government’s strategy against Covid-19

The first confirmed case of Covid-19 in Cameroon was announced on 24 February 2020 (Minister of Public Health [MoPH], 2020a). From this date, the official number of cases rapidly rose to 14,916 on 6 July and stood at 19,604 on 10 September 2020 with 415 deaths; 18,448 recoveries; and 742 active cases (MoPH, 2020a). This figure is certainly under-reported, as testing was never rolled out on a massive scale within the period. Although the virus spread to all the regions of the country, the Centre and Littoral regions whose capital cities are Yaounde and Douala, respectively, formed the main epicentres of the infection in the country. They accounted for 13,612 or 74% of confirmed cases in the country, with the centre alone accounting for 52% of the cases in August 2020 (Figure 2). They are the largest cities in the country and were almost at par in population in 2017 (Yaounde, 2,969,156 and Douala, 2,954,443) (Institut National de la Statistique, 2017, 2019).

Official government communication on the pandemic in Cameroon started on 17 March 2020 when the Prime Minister presented the country’s response strategy. This aligned with pre-crisis and initial crisis stages of the crisis and emergency risk communication (CERC) model where communication and education are used to inform vulnerable groups of the need for behaviour change in the face of an impending crisis (Reynolds and Seeger, 2005). The salient features of this strategy were as follows:

• The closure of Cameroon’s land, air and sea borders to international movements of people and goods except for cargo flights and vessels transporting essential goods and materials;

• An indefinite closure of all schools in the country from kindergarten to higher education, including school sporting activities;

• The prohibition of gatherings of more than 50 persons throughout the country;

• A curfew on the hospitality activities after 6.00 p.m.;

• A limitation of urban and inter-urban travel to essential movement and commercial vehicles with a prohibition of overloading;

• The potential requisitioning of some private health institutions, hotels and lodging facilities, vehicles and specific equipment to fight Covid-19;

• An encouragement of civil service workers to adopt electronic communication in their work and meetings where more than 10 people could be expected to come together;

• A suspension of all travel by government officials abroad; and

• An urge to step up hygiene, social distancing and face masking.

The government empowered civil administrators and security forces to implement these measures and a Covid-19 task force was instituted in the Ministry of Public Health to monitor, inform and communicate the trend of the virus in the country. It produced regular briefings on the infections and deaths from the virus.

By considering the need for support and cooperation with crisis response efforts including household adaptations to the response measures, the incorporation of regular crisis updates, as well as an evaluation of the strategy and the lessons learned from the process, the framework provides an ideal fit for analysing the responses of poor households to anti-Covid-19 measures in Yaounde.

Methodology

Results

Conclusion

Lockdowns have the propensity to be more effective in the rich countries, where towns and cities are planned; and where people can endure economic stress in the short to medium term with incentives and support schemes for people to stay indoors. Their efficiency is still to be ascertained in the developing and poorer countries despite their importance in public health medicine. Teachout and Zipfel (2020) and Delivorias and Scholz (2020) note that most poor urban households in sub-Saharan Africa live in remarkable proximity because of high room densities and the cramming of many buildings in limited spaces. In such a context, lockdowns may keep people indoors and rather encourage transmission through contact diffusion irrespective of face-masking and handwashing. Social distancing is practically impossible to implement in such contexts. No doubt, many Yaounde city dwellers went about their businesses as if there were no restrictions of movements. The government opted for passivity because it could not provide lockdown support measures to the population.

The near absence of a country-wide address system for residences and streets means that contact tracing is difficult even if digital resources abound. In such a context, the challenge of balancing the level of health protection through lockdown with the level of economic activity is massive. No matter how meticulously the balancing is done, health and economic imperatives in the context of crisis often relate inversely, not directly. There is an urgent need for a progressive and socially inclusive clearance of slums, improvement of communication and local level mobilisation for improved sanitation; provisioning of potable water and better urban infrastructure in Yaounde. Such investment has the potential to reduce the frequency of human contact with pathogens. Bloom et al. (2018) posit that no health system can predict which pathogen will prompt the next major epidemic, where it will originate or how grim the consequences will be. Notwithstanding, if the response to any pandemics must be effective, our living milieux must be rendered convivial and livelihoods strengthened through optimal resource governance.

Implications for policy and future research

Controlling a pandemic through lockdowns or business closures is a historic and effective technique. Notwithstanding, its effectiveness, this policy should achieve better results if it is tailored to reflect the diversity of economic, professional, social and cultural characteristics often found in city populations and neighbourhoods. This is explained by the fact that vulnerability to pandemics may also be determined by social, demographic, cultural and economic factors.

Restricting movements and closing businesses are difficult to implement in urban informal settings because their populations are informal workers who earn a living on a day-to-day basis and have no access to social security and health-care. Respecting lockdowns and staying home in the absence of support from the government is extremely difficult. Successful lockdown policies in these cities should be driven by local governments which manage markets, transport and housing systems. As such, their policies will be more reflective of local realities than those enacted by central government authorities.

The effective use of herbal medicine in pandemic situations is more effective when coordinated with public health policies. This synergy has the potential to boost the confidence of the population in these herbal cures. This can be effective if research in medicinal plants is revitalised and the results valorised for local consumption.

Despite these policy implications, it should be noted that controlling pandemics is not an easy task for any government whether in rich or poor countries. No matter how well-informed an anti-pandemic strategy may be, the perceptions and beliefs of people, as well as their economic realities, make them susceptible to either resist or accept change. Understanding the role of religious beliefs, traditional cultures, levels of education and political activism in emergency contexts is, therefore, crucial. This is one of the directions further research in pandemic control should take.