Economic implications of COVID-19 for the HIV epidemic and the response in Zimbabwe

Understanding the economic implications of COVID-19 for the HIV epidemic and response is critical for designing policies and strategies to effectively sustain past gains and accelerate progress to end these colliding pandemics. While considerable cross-national empirical evidence exists at the global level, there is a paucity of such deep-dive evidence at national level. This article addresses this gap. While Zimbabwe experienced fewer COVID-19 cases and deaths than most countries, the pandemic has had profound economic effects, reducing gross domestic product by nearly 7% in 2020. This exacerbates the long-term economic crisis that began in 1998. This has left many households vulnerable to the economic fallout from COVID-19, with the number of the extreme poor having increased to 49% of the population in 2020 (up from 38% in 2019). The national HIV response, largely financed externally, has been one of the few bright spots. Overall, macro-economic and social conditions heavily affected the capacity of Zimbabwe to respond to COVID-19. Few options were available for borrowing the needed sums of money. National outlays for COVID-19 mitigation and vaccination amounted to 2% of GDP, with one-third funded by external donors. Service delivery innovations helped sustain access to HIV treatment during national lockdowns. As a result of reduced access to HIV testing, the number of people initiating HIV treatment declined. In the short term, there are likely to be few immediate health care consequences of the slowdown in treatment initiation due to the country’s already high level of HIV treatment coverage. However, a longer-lasting slowdown could impede national progress towards ending HIV and AIDS. The findings suggest a need to finance the global commons, specifically recognising that investing in health care is investing in economic recovery.


Introduction
This article analyses the economic implications of COVID-19 for the HIV and AIDS epidemic and response in Zimbabwe. Virtually all countries have experienced an economic fallout associated with COVID-19. However, the situation in Zimbabwe is unique. At the time the COVID-19 pandemic emerged, Zimbabwe was going through a slow, partial recovery from a deep and sustained economic crisis. These macro-fiscal conditions had enormous implications for the country's capacity to respond to COVID-19 in a manner consistent with continued economic recovery.
Globally, there are currently 38 million people living with HIV (PLHIV) (UNAIDS, 2021). The decades-long fight against the AIDS pandemic has overcome several challenges. The concurrent COVID-19 pandemic is one of its latest challenges. The intersection of these two pandemics has led to disruptions in HIV services and widened inequalities, among other impacts. A body of emerging research has quantified these changes, and predict the new trajectory of the HIV pandemic (Hogan et al., 2020;Maital & Barzani, 2020;Ozili & Arun, 2020;Khan et al., 2021). While considerable cross-national empirical evidence exists at the global level, there is a paucity of such deep-dive evidence at a national level. Using Zimbabwe as a case study, this article addresses this gap. This analysis is timely considering the rapidly changing environment, and the lack of experience with a health and economic shock as intense and universal as the colliding HIV and COVID-19 pandemics.
We find that this context has fundamental consequences for the impact and the response to COVID-19. Throughout the crisis, the government has kept an eye not only on responding to the economic and health care challenges posed by COVID-19, but also on the bigger picture of achieving "sustainable economic recovery" (Ncube, 2020;. Relatedly, the economic context has had implications for the fiscal response to the epidemic. Zimbabwe has been in arrears on its external debt since 1999 and is therefore unable to borrow, or severely constrained in borrowing from external sources. At the same time, the volatile macro-economic situation (with a bout of very high inflation as late as 2019-2020) complicates borrowing from domestic sources. The government has thus largely funded the response to COVID-19 from its own resources (without increasing the fiscal deficit), with some support for the COVID-19 response from external grants. The prolonged crisis has also shaped the capacities of the public sector and of public health care services.
The rest of the article is structured as follows. First, we present the analytical framework that informed the analysis here. Second, we present an analysis of the macro-economic impact, the fiscal impacts, the financing of the response to COVID-19 and the impacts on the household level. This is followed by an overview of the impacts of COVID-19 across the health care sector, looking at evidence which the disruptions have caused, the impacts on PLHIV and an analysis of disruptions to HIV services. Finally, there is a concluding section with policy implications.

Analytical approach
The analysis in this article, adopting a mixed methods approach, is guided by a theoretically informed analytical framework. We draw on Krubiner et al. (2021) and Hevia and Neumeyer (2020), among others. A comprehensive literature review and a re-analysis of secondary quantitative and qualitative data (Coast, 2017) was undertaken. In Figure 1, we present the framework that underpinned the synthesis and analysis in this article. It recognises that HIV and COVID-19 co-pandemics are long-wave events, with their impacts poorly understood and possible serious long-term consequences. To this end, we posit that the choices are clear: either prepare to confront these sometime in the future; or, better, try to avoid them by acting now. It is in this context that policy implications are made.
In a nutshell, the framework reflects five key considerations: First, COVID-19 has fundamentally changed the macro-economic outlook and the external economic environment. The article discusses the macro-economic and fiscal consequences for Zimbabwe amid the large role of external financing in the global HIV response. Second, Zimbabwe is a country recovering from a deep economic crisis which may mask the direct impacts of COVID-19 (for instance, the International Monetary Fund posited that Zimbabwe is one of the few countries where government revenues increased in 2020 as COVID-19 hit). The article anchors this discussion in this unique economic context. Third, the article focuses on the socio-economic consequences of COVID-19 in pushing many households in, or at risk of falling into, poverty and addresses the relevance of socio-economic barriers in access to health and HIV services. Fourth, the article focuses on the economic repercussions of COVID-19, particularly addressing the impacts on health care and HIV services. Finally, the article is policy oriented. It builds on the analysis of the economic

Results and discussions The impact of and response to COVID-19
With the first reported case of COVID-19 in Zimbabwe in March 2020, the reported number of deaths stands at 5 459 as of 8 April 2022 (equivalent to 360 per million). It is plausible that the actual toll is higher because of underreporting and disruptions to and delays in accessing non-COVID-19 health care services. GDP contracted by 4.1% in 2020, compared to an expansion of 2.7% that was expected (IMF, 2019). It is, however, useful to note that this loss is much smaller than the lingering consequences of the economic crisis since the early 2000s, with real GDP per capita still about one-quarter below the level attained in 1998. The economic disruptions have caused the number of people classified as poor in Zimbabwe to rise by about one-quarter between 2019 and 2020. Total COVID-19related spending was estimated at 0.7% of GDP and 1.2% of GDP in 2020 and 2021, of which 0.3% of GDP was financed by external grants in each year. The emerging picture on the impacts of COVID-19 on health care service delivery is consistent with the experiences across countries in terms of declines and delays in access to a wide range of health care services and the adverse impacts on health care workers. Below, in detail, we present an analysis of the health care impacts of and response to COVID, the macro-economic impact of COVID, the fiscal costs of COVID-19 and the response to it, the financing of the response to COVID-19, the household-level impact of COVID-19 and its impact on the health care sector.
First, regarding the health care impact of and response to COVID-19, it is important to note that the first case of COVID-19 in Zimbabwe was reported on 21 March 2020. Since then, Zimbabwe experienced three waves of COVID-19, with daily reported cases (7-day average) peaking at nearly a thousand in January 2021, at 2 200 in July 2021, and at 4 800 in December 2021 (Our World in Data, 2022). The reported number of deaths followed this pattern, with a peak at close to 40 per day in January 2021, 80 in July 2021, but fewer than 20 in January 2022. The relatively lower number of deaths in early 2022 reflects two factors -testing rates and awareness had been increasing, so that the rate of unreported cases in 2022 presumably is lower than during the earlier peaks, and the third wave was dominated by the less lethal Omicron COVID-19 variant ( Figure 2).
Due to low testing rates, especially at the beginning of the pandemic (Figure 3), the number of actual COVID-19 infections is suspected to be significantly higher than the reported number (Chitungo et al., 2020). As of 9 April 2022, the total number of tests conducted so far stands at 146 per 1 000 -lower than in Botswana (925), South Africa (400), and Zambia (178), but higher than in Mozambique (40). Stigmatisation and uncertainty about quarantine procedures has impeded the uptake of testing. Apart from external reasons -e.g. the shortage of test kits and the high prices in the initial stages of the pandemic -the low testing rate is also a consequence of the weakness of the health care system overall. Because of the severe underfunding of the health care system, there was no money in reserve in case of such an emergency, and testing initially relied almost exclusively Reported deaths (right scale) on donor funding and private donations (Dzinamarira et al., 2021). While there were long delays at public health care facilities, a fee of about USD 60 at private health care facilities made voluntary testing unaffordable for a significant share of the population. As shown in Table 1, the total number of reported deaths from COVID-19 of 5 459 as of 8 April 2022 corresponds to an accumulated contribution to the burden of disease of 360 per million, and added about 4% to total crude mortality in 2020 (307 per million out of 7 700 per million). The overall burden of disease has been much lower than in South Africa and Botswana (accumulated COVID-19 deaths at 1 666 per million and 1 120 per million respectively), but higher than in Mozambique and Zambia (68 per million and 210 per million respectively). 37.3% of the population were fully vaccinated against COVID-19 and 23.7% partially vaccinated, as of 8 April 2022, far above the average of the whole population in sub-Saharan Africa (SSA) (16.7% and 12.0% respectively) and among the highest rates in SSA. 1 However, the average number of doses administered per day peaked in late summer of 2021 and has declined since. Vaccine hesitancy is low at 20% and more prevalent in women (24%) than in men (14%) (Mathieu et al., 2021).
Generally, because the risk of experiencing severe forms of COVID-19 and death is linked to age and the presence of several risk factors (many also linked to age), and considering the relatively young populations in most countries, the burden of disease from COVID-19 is comparably low in SSA (Azarpazhooh et al., 2020). Bell and Schultz Hansen (2021) estimate that disability-adjusted life-years (DALYs) lost from COVID-19 in SSA were equivalent to only 11.1% of DALYs lost from tuberculosis, and 5.5% and 7.5% of DALYs lost from HIV and AIDS and malaria respectively. And the contribution to mortality from COVID-19 amounted to 19.2%, 11.7% and 20.2% of the contributions from tuberculosis, HIV and AIDS and malaria, respectively.
A special concern is the link between the pandemic and widespread malnutrition in the country (Mertens & Peñalvo, 2021), indicated by high levels of stunting (23.5% of children under 5 in 2019), anaemia among children between 6 and 59 months old (38%) and pregnant women (32%), wasting (3% of children under 5) and moderate or severe food insecurity (70%; severe: 32%). The limited access to handwashing and sanitation facilities (42%) increases vulnerability to the spread of COVID-19, especially in high-density urban areas.
As one of the first countries in southern Africa to do so, the government of Zimbabwe banned air travel (23 March 2020) and interprovincial travel within the country (30 March 2020) and mandated quarantine and testing for persons   On 27 March 2020, COVID-19 was declared a national disaster, which allowed the government emergency measures against the spread of the virus and the deployment of personnel to health care services. On 8 April 2020, the government declared a lockdown (initially for 21 days, but with bi-weekly and finally indefinite extensions, with measures of different degrees of severity according to the changing situation) and required the population to stay at home, unless going out for food or health care, and to observe social distancing. People were also required to wear masks in public. However, the initial lack of equipment, cultural norms (funeral attendance, church gatherings) as well as necessity (queues at shops, public transport) limited the adherence to such measures.
The COVID-19 pandemic coincided with a severe human resources crisis in the Zimbabwean health care sector. A significant share of doctors and nurses had been on strike periodically because of low renumeration, salaries consumed by hyperinflation and bad working conditions overall. The situation had accelerated the brain drain, the loss of skilled personal to neighbouring or oversea countries, especially to the UK, Australia and New Zealand. For example, 64% of positions in public laboratories as medical laboratory scientists and technicians were unstaffed in December 2019, as well as 92% of laboratory assistants and 100% of trainee/senior scientific laboratory technicians. The MoHCC finalised a national preparedness and response plan for COVID-19 in March 2020. (MoHCC, 2020 The goals of the plan were to minimise the health impact of COVID-19 as well as the adverse socio-economic impacts in a manner that would contribute to a strengthening of the health care system overall. The government released 2 million Zimbabwean dollars (ZWL) for the implementation of the plan, while total costs were estimated at USD 26.4 million for a period of twelve months. The National COVID-19 Response Task Force and the Inter-Ministerial Committee on COVID-19 were established in March 2020 too.
Furthermore, measures were taken to ensure the continuation of essential health care services under the new conditions, e.g. family planning, the promotion of self-injection of the contraceptive DMPA-SC, communitybased distribution of commodities and integrated outreach services. While the number of clients who were counselled for family planning in 2020 started out lower than the previous year for the first quarter and declined rapidly in April 2020, it recovered quickly and was maintained at levels exceeding previous year's figures for the rest of the year. There was a reduction in the uptake of family planning commodities though. Safe abortion and post-abortion services decreased between June and September 2020 (compared to 2019), but not for the period of October 2020 to January 2021 (WHO, Regional Office for Africa, 2021).
In April 2020, the government of Zimbabwe made a humanitarian appeal for international support to address the food insecurity of an estimated 5.6 million people, caused by the concurrence of the COVID-19 pandemic, crop failures and the aftermath of devastating cyclones. By July 2020, the government reported that international donors had committed USD 202 million to support its response to COVID-19. Additionally, the government introduced several measures to mitigate the socio-economic impact of COVID-19, including the provision of food, cash transfers, health system interventions, pension support and subsidising the production of personal protective equipment. Direct food provision (grain) to deprived rural districts preceded the outbreak of the coronavirus and was carried on during the lockdown. The scheme was extended to urban districts, but in the form of cash transfers rather than direct food provision.
Apart from the cash transfers, the government announced another cash transfer programme geared at two million vulnerable households in March 2020 (ZWL600 million, of which ZWL158 million had been spent by June 2020). Furthermore, additional funding (ZWL600 million) for the Ministry of Public Service, Labour and Social Welfare was made available to boost social protection programmes. In May 2020, the government adopted a COVID-19 Economic Recovery and Stimulus Package, valued at ZWL18.2 billion, equivalent to about 9% of GDP. The package sought to ensure economic recovery from the shock of the pandemic and to provide relief to individuals, families, or businesses impacted by COVID-19. ZWL2.4 billion were allocated to the cash transfer programme, which reached about 200 000 beneficiaries by October 2020. However, the amount provided (ZWL180 initially, raised to ZW300) was considered inadequate and the selection of beneficiaries untransparent. ZWL739 million of the stimulus package was earmarked for the MoHCC. Among the interventions were the hiring of an additional 4 000 health care professionals, a tax-free allowance for frontline health care workers and equipping all public hospitals and other health care facilities to accommodate COVID-19 patients. In the 2021 budget, ZWL54.7 billion was allocated to health, increasing the share of health spending to 12.9% of the total budget. In 2022, the budget of the MoHCC was increased to ZWL117.7 billion (12.7% of total).
While the government announced that the pandemic was "under control" in November 2021 after a series of days with no or a very low number of new cases (>10), it reinstated stricter measures on 1 December 2021 in light of increasing numbers of cases and the spread of the Omicron variant, restricting business hours, imposing a curfew, limiting services (restaurants, bars, clubs) to vaccinated persons and restricting public gatherings.
Second, assessing the macro-economic impacts of COVID-19 in Zimbabwe is a challenging task, because the economy has been subject to concurrent shocks (a devastating cyclone in 2019 and adverse weather), andwhile suffering the consequences of and recovering from COVID-19 -the economy is recovering from a much larger and sustained economic depression, and GDP per capita in 2019 -just before COVID-19 hit -was still one-quarter below the level attained in 1998 in real terms ( Figure 4).
Comparing the outlook before COVID-19 (IMF, 2019) and the most recent macro-economic estimates and projections (IMF, 2021) provides a crude indication of the magnitude of the economic costs of COVID-19 (but might also reflect other important policy developments). According to the IMF (2021), GDP contracted by 4.1% in 2020, compared to an expansion of 2.7% expected before that (IMF, 2019). Together with the contraction in 2019, this means that the economy 2020 was 10% smaller than in 2018. While the economy has rebounded somewhat in 2021 (by 5% according to IMF, 2022a, and even 6% was estimated at the conclusion of a recent IMF staff visit), the economy is expected to reach the 2018 level of GDP only in 2023. Also taking into account population growth at a rate of about 2% annually, real GDP per capita has contracted by 13% between 2018 and 2020 and is not projected to reach or surpass its 2018 level by 2026 (the most recent of the projections published by the IMF).
Third, in terms of the fiscal costs of COVID-19 and the response to it, these are not obvious from aggregate trends in government revenues and expenditures. Government revenues increased from 14.4% of GDP in 2019 (a year characterised by severe economic disruptions not related to COVID-19) to 15.8% of GDP in 2020 and 16.6% of GDP in 2021 (according to preliminary fiscal data. These developments represent a recovery following the economic disruptions in recent years, when government revenues often reached levels close to 20% of GDP. From this perspective, the dominant story since 2019 is one of a fiscal recovery. Nevertheless, the IMF (2022b) estimates that various measures taken by the government in support of COVID-19 (allowing companies to delay tax payments and suspending duties and taxes on various essential goods and services) reduced government revenues by USD 483 million (2.2% of GDP) in 2020 ( Figure 5).
In interpreting these estimates, expressed relative to GDP, it is important to bear in mind two further developments. First, GDP has contracted because of COVID-19, so the government commands an increasing share, but of a diminished economy. Second, GDP in US dollars has increased from 19.6 billion in 2019 to 25.8 billion in 2021, and it is projected to increase to 27.8 billion in 2022 (up by over 40% since 2019). This development -with relatively low economic growth -reflects a real appreciation of the currency. That means that inflation (and, for the government, domestic costs) have increased at a higher rate than the exchange rate. Consequently, government revenues in US dollar terms -and the government's capability to procure imported supplies and equipment -have improved.
To address the economic fallout of COVID-19, the government initiated a stimulus package "to save lives and livelihoods" (Ministry of Finance and Economic Development, 2021, p. 22) in mid-2020, with a volume of ZWL18.2 billion, equivalent to about USD 225 million, or one per cent of GDP. 3 The bulk of this spending was aimed at supporting vulnerable populations, with two-thirds of the total allocated to improving food security and supporting vulnerable households, and the bulk of the remainder dedicated to supporting industry and sectors like tourism affected particularly hard by COVID-19. In 2021, the government's focus switched to rolling out vaccinations. As of the end of September 2021, the government had spent USD 127 million (0.5% of GDP) on vaccines. As a result, 40% of the total population had been vaccinated at least once by November 2021, and 31% had received a second dose. As of the end of August 2021, the government estimated that it has spent ZWL38 billion -about USD 470 million or 2% of one year's GDP -on vaccines and COVID-19-related health care measures or social and economic impact mitigation since the start of the pandemic.
The IMF estimates the total costs of the response to COVID-19 at USD 735 million (3.4% of GDP as of September 2021). This number is higher than the government's spending estimates, likely because it also includes the loss in revenues from tax relief measures (estimated by the IMF at over 2% of GDP; see above). However, there is an inconsistency as the IMF figure contains a much lower estimate of health care spending (USD 21 million) than the figures reported by the government. This discrepancy could reflect the role of externally financed procurement (see below) or the extent to which health expenditures are attributed to COVID-19 (e.g. through increased utilisation of in-patient facilities because of COVID-19 not captured in COVID-19-specific expenditure items). Fourth, in terms of financing of the response to COVID-19, the government's decisions in responding to COVID-19 and mitigating the impacts -through spending allocations or tax breaks -are mirrored in the circumstances of and decisions on how this response is financed. Funds allocated to COVID-19 are not available for other purposes, so there is an opportunity cost to consider. Domestic funds are augmented by external grants. And to the extent that the fiscal deficit increases, it needs to be financed either by domestic or external borrowing. Moreover, there is an interdependency between spending and revenue development on one hand, and financing on the other. While spending and revenues dictate financing needs, the availability of financing and the costs of raising funds dictate the scope for spending and revenue measures in response to COVID-19. This channel running from funding opportunities to spending decisions is particularly relevant in the context of Zimbabwe, where access to new loans is restricted by a history of economic mismanagement and the fact that Zimbabwe is in arrears in servicing most of its external debt.
Spending reallocations have been an important instrument of financing the response to COVID-19. This is obvious from the overall estimates of the costs of the response to COVID-19, which considerably exceed the estimates of government borrowing or financial support through external grants. Moreover, identified COVID-19-related spending includes expenditures like purchases of PPE equipment, vaccines and other COVID-19-related supplies, but not the increased utilisation of health care sector resources like personnel and facilities. Recorded COVID-19-related expenditure therefore understates the absorption of government resources by the response to the epidemic (Table 2).
External grants played an important role in financing government services and supporting the response to  According to the OECD (2022), Zimbabwe has benefitted from about USD 500 million in grants annually in recent years (average 2015-2019), equivalent to about 2.5% of GDP. Compared to this, grants received in 2021 (USD 850 million) and budgeted for 2022 (USD 765 million) represent a steep increase, and at least some of the increase reflects grants specifically in support of the COVID-19 response (USD 75 million in 2020 and USD 81 million in 2021, equivalent to 0.3% of GDP). 5 As of now, there is no evidence that the increased government spending necessitated by the impact of and response to COVID-19 has affected HIV funding, or that it has crowded out health care spending in other areas. The bulk of domestic public HIV financing occurs through the AIDS levy as a surcharge on income tax (which surged relative to GDP through 2020 and 2021, following the disruptions in 2019). External funding from the Global Fund was predetermined through the country allocation before the arrival of COVID-19, while the response to COVID-19 in the United States was in the first place funded by increased deficits. Looking ahead, the most concrete risk to the funding of the HIV programme comes from increased public debt and reduced fiscal space in advanced economies, especially as interest rates are increasing.
The situation with domestic public health care spending is less transparent. The government publishes estimates and projections of spending by the ministry in the annual budget statements. These data, however, are not final out-turns and -especially in years when inflation is highare unreliable indicators. The latest such estimate, for 2021, suggests that health care spending amounted to 10.8% of government expenditures in that year -an increase relative to the WHO's estimates for 2018 (8.7% of government expenditures). Importantly, the government exempted the health care sector from a general hiring freeze in April 2020, enabling an increase in health care personnel of 20% (IMF,  2022a). Looking ahead, budget allocations for health care are increasing relative to total government expenditures and as the economy continues its recovery. The government uses domestic borrowing only very cautiously. Improving public financial management is a cornerstone of the government's economic reform programme, and the MoFED recently committed to "limiting issuance of Treasury Bills to the approved budget deficit," and not using the central Reserve Bank of Zimbabwe (RBZ) overdraft facilities to satisfy immediate spending needs (Ncube, 2021). This approach recognises the role that uncontrolled government domestic borrowing has played in destabilising the economy. As Zimbabwe is in arrears with most multilateral and bilateral lenders, its ability to borrow externally from these sources is severely limited. And borrowing commercially from financial markets is constrained by the uncertain economic outlook and perceived country risk. It would also complicate efforts to settle the existing debt. For these reasons, external borrowing has played a minor role in funding the response to COVID-19, the main example is a loan of USD 10 million to support the purchase of protective and laboratory equipment (IMF, 2022b).
However, external financing plays an important role in supporting government operations and the response to COVID-19 in the form of drawdowns of special drawing rights (SDR) allocations from the IMF. Zimbabwe received an SDR allocation equivalent to USD 958 million (3.7% of GDP in 2021) from the IMF in August 2021. From the perspective of the government of Zimbabwe, SDR allocations resemble a low-cost overdraft facility in foreign currency at the IMF, and these allocations have indeed in part been designed to provide countries facing borrowing constraints with additional liquidity to respond to the impact of COVID-19. This applies especially to Zimbabwe, where economic instability and the fact that the government is in arrears on most external debt severely limits how much, and for which purpose, it can borrow externally.
Zimbabwe has used part of its SDR allocation specifically in support of the COVID-19 response, funding the procurement of vaccines for USD 77 million (0.3% of GDP), and has allocated smaller amounts to developing health care infrastructure in areas which are economically behind (USD 35 million), procurement of health care supplies (USD 10 million) and social protection (USD 80 million). The significance of the SDR allocation is also visible in the aggregate fiscal data. More than one half of the government's borrowing in 2021 and of the budgeted deficit in 2022 is funded by drawing down some of the SDR allocation (Table 2).
Fifth, in terms of household-level impact of COVID-19, the rate of extreme poverty was already high before the COVID-19 pandemic hit. Nationally, the rate of extreme poverty was estimated at 23% in 2011, rising to 30% in 2017 and 38% in 2019. However, in 2020 the rate further increased to 49% or 7.9 million people, including 1.6 million children. The rural rate of extreme poverty was estimated to be significantly higher than the urban poverty rate: the rural rate increased from 51% in 2019 to 62% in 2020 compared to the urban rates at 10% and 16% respectively. Nearly 90% of the extreme poor live in rural areas. Alongside poverty, inequality increased as well: the Gini Index increased from 45 in 2017 to 50 in April-May 2019. The richest 10% of Zimbabweans consume 20 times more than the poorest 10% (World Bank, 2021).
The Zimbabwe Statistics Agency (with the World Bank and UNICEF) conducted several rounds of telephone surveys to ascertain the socio-economic impact of COVID-19 at the household level (UNICEF, World Bank, ZimStat & zimref [2021]) and for all data in the following unless indicated otherwise). The surveys were based on the Poverty, Income, Consumption and Expenditure Surveys (PICES) which were held in 2017 and 2019. The first round of the telephone survey (rapid PICES) was conducted between 6 and 24 July 2020, the second round between 24 August 2020 and 23 September 2020, and the third round between 15 December 2020 and 10 March 2021. These first three rounds showed the high impact of COVID-19 in the first phase of the pandemic. Three more rounds of the survey were conducted in 2021.
The increase in poverty since COVID-19 hit was driven by higher prices for food and necessities, income loss because of the economic contraction caused by the COVID-19 pandemic, on top of a drop in agricultural production because of the worst drought in a decade in 2019. A significant share of households reported reduced or no income since the onset of COVID-19, or the last round of the survey; however, the shares varied by source of income, from 87% of non-farm family businesses (in round 1) to 4% of pensioners (in round 3). By July 2020, half a million households had at least one member who had lost their job since the onset of the pandemic. Wage earners also experienced a loss of income. Generally, vulnerable populations who were dependent on assistance from family members abroad or in the country, by the government, or by NGOs, were hit hardest. The situation worsened between round 1 and round 3 of the survey, with more households reporting loss of income ( Figure 6). About 16% of urban households reported to have received public assistance, mostly in the form of COVID-19 cash transfers (10 %) and other cash transfers (4%) in round 3, while 24% of rural households received assistance, mostly as free food distribution (19%) and some in-kind and cash transfers.
The share of households able to buy basic food items (maize meal, cooking oil, chicken) was lowest during the first round of the rapid PICE Survey, improved slightly during the second, and significantly during the third. Generally, food items were more easily available in urban than in rural areas. The proportion of households facing severe food insecurity decreased between round 1 and round 3 of the survey, but the share of moderately or severely food-insecure households remained high at 71% of rural and 42% of urban households during round 3 (from 75% and 65% respectively during round 1). According to the Urban Livelihood Assessment conducted in 2020, food insecurity had increased by 12% compared to 2019. In 2021, the increased yield of the maize harvest alleviated some of the most urgent needs, but pockets of food insecurity remained. By September 2021, the rate of extreme poverty had decreased to 43% from 49% in 2020, mainly because of the resumption of economic activities in the rural areas which also decreased the need to buy additional food. Therefore, food insecurity fell to 39% in September 2021 from 72% the year before.
Relatedly, the share of households unable to access medical treatment remained high and stable between the first three rounds of the survey (between 82 and 84%), with more than three quarters of such households citing lack of money as the primary reason for not being able to access treatment. How the costs for the treatment of COVID-19 or precautionary measures affected households was not ascertained by the surveys.
Finally, regarding the impact on the health care sector, COVID-19 has affected this sector on the demand and supply side. It alters or suppresses health-seeking behaviour owing to the economic impacts and transport disruptions. It absorbs available resources (health care workers, facilities, supplies) and -if health care budgets are not adjusted one-to-one -crowds out other spending on health care. And it causes disruptions to health care services, through its impacts on health care workers and disruptions in supply chains.
Available data across 10 countries (but not including Zimbabwe) suggests widespread disruptions in health care services in 2020 (Arsenault et al., 2022). These disruptions often preceded the onset of COVID-19 and were not clearly associated with the severity of the epidemic, suggesting that disruptions associated with lockdowns and the economic consequences of COVID-19 (rather than disruptions in the health care sector caused by care for COVID-19 patients) have predominantly driven these effects. Disruptions were not uniform across health care services. The most severe declines occurred in immunisation, cancer screeningdown by more than two-thirds in Chile, Mexico and South Africa -and TB screening and detection, which "declined 28-66% in Ghana, Nepal and South Africa" (Arsenault et al., 2022). Smaller or shorter disruptions occurred for maternal and child health care services. Disruptions persisted throughout 2020 in about half of the countries and -according to preliminary data -into 2021. On HIV, the data support earlier findings -that the provision of antiretroviral therapy for people living with HIV has largely held up, while HIV testing declined (for only one country covered in this study) reaffirming cross-country findings, e.g. by the Global Fund.
In Zimbabwe, especially during the first phase of the pandemic, health care staff had to face high-risk conditions due to the lack of test kits and personal protective equipment like disposable suits, gloves, face shields and surgical masks, leading to a strike among health care personnel in June 2020. The lack of protective equipment might have exacerbated the risk for frontline health care workers, leading to a high share of infected staff which tightened scarce human resources for health care even more. By the end of June 2021, 4 444 health care staff had been infected with COVID-19 (Chingwere, 2021). 6 Fear of contracting the virus is common among health care workers and has compromised health care service delivery (MoHCC, 2020;Truscott, 2020). Reports about deaths among health care workers also likely deterred patients from seeking care (Murewanhema & Mutsigiri-Murewanhema, 2021).
Even when protective equipment is available, health care staff are subjected to community transmission. Therefore, infections among health care professionals mirror the epidemic development in the overall population. This can lead to high numbers of staff in quarantine during major outbreaks, e.g. at Mpilo Central Hospital in Bulawayo where 63 doctors and nurses were in isolation in July 2021, and overall, 390 health care workers had tested positive since the start of the pandemic (Kavenga et al., 2021;Rusakaniko et al., 2021). In September 2021, the government issued a mandate for all public employees to get vaccinated against COVID-19. According to a survey from WHO, 22% of health care facilities did not screen newly arriving patients for COVID-19 and a quarter of facilities did not have an isolation room for suspected cases. Existing screening points were sometimes found to be devoid of personnel and lacked protective equipment. Even before the pandemic, health care services in Zimbabwe were overstretched, and the COVID-19 pandemic reduced service readiness even further (WHO, Regional Office for Africa, 2021b). Apart from the lack of personal protective equipment, essential drugs for the management of COVID-19 as well as equipment like ventilators, piped oxygen and syringe pumps were in short supply. The number of intensive care beds was also limited (Makoni, 2020).
The pandemic caused disruptions in other areas as well. During the second wave of COVID-19, in January 2020, the two hospitals in Zimbabwe specialising in treating cancer patients had to close their cancer wards because the facility was overcrowded with COVID-19 patients, leaving thousands of cancer patients without any treatment option. Other anecdotal evidence points to serious disruptions in maternal and child health care, treatment for diabetes and hypertension and routine vaccinations. For example, the introduction of typhoid conjugate vaccines into the routine vaccination schedule was delayed because of the spread of COVID-19, but was rolled out a year later in 2021. There was also a shortage of blood products due to the disruption of supply chains.
Audits of data from two hospitals showed a decrease in facility-based deliveries (11 346 for 2019, and 8 489 for 2020) and an increase in maternal and perinatal mortality and in complications like breech deliveries and uterine ruptures in the period from March to May 2020 compared to the previous year. Extrapolated to the whole country, such increased risks would have led to about 340 excess maternal deaths, 2 650 neonatal deaths and 450 stillbirths (Bikwa et al., 2021). Similarly, antenatal care -obstetric scans, HIV testing and iron supplementation -declined in the first months of the pandemic . The government attempted to maintain essential maternal and child health care services by efforts to strengthen integrated outreach.
Like in many other countries, routine outpatient consultations and elective surgical procedures were stopped during the surges of COVID-19 cases. Before the pandemic, contagious diseases had been treated at infectious disease hospitals, but these facilities were not equipped for providing intensive care. The change of focus to COVID-19 raised worries about a failure of adequate treatment of other endemic illnesses, especially tuberculosis and typhoid, especially when infectious disease hospitals stopped admitting non-COVID-19 cases.
COVID-19 contributed to the ongoing general health care sector crisis. While not the only reason, the COVID-19 pandemic played a part in the country missing most of the targets for 2020 in the National Health Strategy 2016-2020. While presenting the 2021 budget, the minister of Finance and Economic Development, Mthuli Ncube, declared that the "COVID-19 pandemic has put a spotlight on the challenges in the healthcare system and infrastructure, from shortages of testing and medical supplies to access to health services for underserved populations" (Ministry of Finance and Economic Development, 2021, p. 148).
However, some measures against COVID-19 might have benefitted from the experience, and more importantly, from the infrastructure that was put in place in response to HIV and AIDS. For example, the transport of samples for testing for the SARS-CoV-2 virus utilised a transport system that was originally deployed for the transport of blood samples for viral load testing. There is also some hope that policies to ensure the continuation of essential health care services developed in response to the pandemic might extend beyond its duration, e.g. the dispensing of contraceptives for longer periods (Waiswa & Wanduru, 2021). Furthermore, the pandemic has led to a deepened collaboration between the government of Zimbabwe, the private sector and development partners in mobilising additional resources for the health care sector.

Impact of COVID-19 on PLHIV and consequences for HIV services
Data from South Africa show that COVID-19 is a risk factor for PLHIV, and vice versa, and suggest that high coverage and early initiation of treatment mitigate the impacts of COVID-19 for PLHIV. Survey data document difficulties in accessing health care services for PLHIV, and some HIV-related services were disrupted during lockdowns. Aggregate data on treatment access suggest that treatment retention has maintained, but that the rate of treatment initiation for PLHIV not yet receiving it may have declined. Below, in detail, we present an analysis of the COVID-19 impact on PLHIV and the implications of disruptions to HIV services.
First, in terms of the impact on PLHIV, so far there are no data available on COVID-19 disease progression among PLHIV in Zimbabwe. However, an analysis of health outcomes of COVID-19 patients admitted to hospital in South Africa, including many PLHIV, shows that HIV infection was a risk factor for mortality from COVID-19 (Jassat et al., 2022). Controlling for other factors like age or the presence of various non-communicable diseases, which increase the risk of adverse outcomes, the risk of progression to death for HIV-positive patients on ART was 30% higher than for HIV-negative patients, and for HIV-positive patients not on treatment, it was 45% higher than for patients receiving ART. The data from South Africa also underscore the importance of early treatment initiation and avoiding HIV disease progression. For HIV-positive patients with a CD4 count of over 200, mortality was not significantly different from HIV-negative patients, while mortality among patients with a weak immune system (CD4 count below 200) was more than two times higher than either HIV-negative patients or HIV-positive patients with a higher CD4 count. For Zimbabwe, the young age of the population and high treatment coverage thus likely mitigate the role of HIV as a risk factor of people who become infected with COVID-19, and also mitigate the effects of COVID-19 as a risk factor for PLHIV (Katsidzira et al., 2020).
Comprehensive survey data on the impacts of COVID-19 on PLHIV in Zimbabwe and access to care are unavailable. However, a web-based (SurveyMonkey, WhatsApp) rapid survey on the impact of the COVID-19 epidemic conducted by the National AIDS Council in collaboration with ZNNP+ and UNAIDS (UNICEF, World Bank, ZimStat & zimref. [2021]) offers a glimpse, even though the sample size (158 PLHIV, 18 years and older responded, about three quarters from areas self-identified as "urban") is rather small. Most respondents received their regular ART drugs as a supply for three months (76%), 18% for a shorter period (1% for a month, 3% less than a month), and only 6% for six months. More than half (54%) faced a potential stock-out of antiretroviral (ARV) medications within a month. Of those who tried to refill their ARV prescription, 9.4% were only able to get a partial refill and 9.4% were not able to get any refill. As the most important challenge to getting ARV treatment during the pandemic, the costs of the medicine were mentioned (23%), followed by the attitude of health care workers (18%), rumours of state violence in the streets (14%), illness within the family (8%), stock-outs (7%) and closure or restricted hours of the pharmacy (5%). Fear of contracting the virus or disruptions in transport only played a marginal role (1-2%).
Nevertheless, 31% of respondents were concerned about their own health. Other matters of concern were the health of family members (19%), having access to medication (18%), the fear of social isolation (14%) and stigma because of HIV (7%). Access to measures to avoid exposure to COVID-19 were rather limited (soap and hand sanitizer: 35%, clean water: 29%, tissues: 9%, masks: 4%, or space to isolate from potentially or actually infected people: 9%). Efforts for self-isolation and social distancing were hampered by the need to care for friends or family (40%), work (30%), and the need to get medicines or medical care (25%). ART refill was the most frequently listed immediate health need (20%), followed by mental health and stress (8%) and persistent headaches (5%).
The responses also showed that key health care services were not available to a significant fraction of PLHIV: 60% were not able to get oral contraceptives, 43% could not obtain condoms. More than half (55%) were not able to get psychosocial support, and almost a quarter (23%) and 15% were unable to get treatment for tuberculosis or opportunistic infections, respectively. As most important services to ensure adherence to ARV treatment, respondents mentioned safe access to HIV medications (27%), counselling for anxiety, depression, or other conditions (16%), a way to ensure privacy when taking drugs (13%), family counselling to provide information about HIV and AIDS to family members (9%) and peer support (9%).
A telephone-based survey in Manicaland suggested that sexual risk behaviour did not significantly change because of the pandemic. The share of respondents reporting at least one non-regular sexual partner in the last 12 months between February and mid-June 2021 (15.7% and 15.4% for men; 5.8% and 6.2% for women), as well as those reporting more than one partner in the last months (2.2% and 3.2% for men, and 0.8% and 1.1% for women), remained roughly at the level that was observed in 2018/2019. Condom use increased slightly to 86.5% compared to the pre-COVID-19 period (83.4%) (Manicaland Public Health Research, 2021).
Second, COVID-19 disrupted HIV services. As part of the COVID-19 case management directions, the MoHCC stressed that the delivery of essential health care services, including services to vulnerable populations such as PLHIV, should be "kept functional". Provisions should be made that PLHIV should not be put at additional risk by being forced to visit health care facilities during surges of COVID-19 cases. Despite partially adopting the dispensation of antiretrovirals for several months, there were reports of PLHIV defaulting on their medication due to the COVID-19 lockdown and of problems accessing a nutritious diet necessary for achieving viral suppression. Especially during the waves of COVID-19 infections, access to ARVs was erratic. The lack of knowledge about the new virus and its interaction with HIV added anxiety among PLHIV. UNAIDS launched a call centre for PLHIV to inform them about the relationship of HIV and COVID-19 and about ways to access drugs.
Voluntary medical male circumcision (VMMC) procedures were reported to have declined rapidly, from around 24 000 in February 2020 to only a few hundred in April the same year. Furthermore, the COVID-19 response (including a lockdown) contributed to sharp declines in the number of PLHIV receiving services for the period April to June 2020. The availability of self-test kits was reduced by 15%, and 49% fewer people with sexually transmitted infections were tested for syphilis (Global HIV Prevention Coalition, 2021). To compensate for the shortfall of access to HIV testing, new methods such as provider initiated testing and counselling, index contact testing, and HIV self-testing were implemented at the facility and community levels. Nevertheless, there was a significant decrease in the number of PLHIV receiving HIV testing between February and April 2020. In April 2020, only 18.2% of the previous year's figure received HIV testing (2 960, compared to 16 300 in April 2019). Consequently, the number of newly diagnosed HIV patients initiated on ARV treatment fell from 922 in April 2019 to 257 in April 2020, while the rate of initiation remained roughly stable (89% and 86% respectively). Similar trends were observed for viral load testing and screening for tuberculosis (MoHCC, 2020).
Early infant testing for HIV exposure also declined during the first weeks of the lockdown in March and April 2020. However, it is difficult to draw a conclusive picture and the situation may have fluctuated over time and for different geographic areas. In Manicaland, for example, the uptake of VMMC declined from 3.8% before the pandemic to 2.0% between February and June 2021, while the lack of access to the procedure for those who committed to undergo it rose from 10.5% to 18.7%. Early data also showed a rapid decline in new initiations of PrEP in April 2020 (from approximately 880 in March to about 200), but also an upward trend starting in May 2020. On the other hand, testing rates among PLHIV were reported high and not lower than before the pandemic, and surprisingly fewer respondents reported a lack of access to testing (5.2% compared to 8.2% in 2018/2019) (Manicaland Public Health Research, 2021). This survey also did not show evidence for a decline in adherence to ARV treatment compared to pre-COVID-19-levels, neither during the stricter lockdown between February and April 2021, nor in the more relaxed period of May and June 2021.
Available programme data on treatment access and modelled estimates of the state of the HIV epidemic corroborate the evidence of service disruptions. Reported loss-to-follow-up was nearly constant as the impacts of COVID-19 and the response to it unfolded at about 4.7% annually. However, while the available data are not entirely consistent, the transition to treatment appears to have slowed down. The annual number of people initiating treatment was at its lowest in 2020 (with 75 000) and 2021 (71 000) compared to 85 000 in 2019 and 159 000 in 2017 (Figure 7). Some decline in the number of people initiating treatment, though, would be expected as treatment coverage increased from 79% in 2017 to 93% in 2021, which meant that the pool of people not yet on treatment had also declined. On the other hand, the more people on treatment, the higher the loss to follow-up in absolute numbers. The number of people initiating treatment may thus overstate the net flow into treatment. If the loss to follow-up is netted out, the rate of transition to treatment in 2019-2021 comes out lower than in previous years, and attained its lowest point (at 11.5% annually) in 2020. Such a slowdown -equivalent to slower progression to treatment -would result in an increased number of AIDS deaths over the coming years. However, because of the high treatment coverage already attained and as PLHIV have tended to initiate treatment relatively early over the last years (estimated median CD4 count at treatment initiation of around 300), this effect is not visible in estimated health outcomes among PLHIV yet, and -based on current treatment data -will likely be small and spread out.

Conclusion and policy implications
This article shows that COVID-19 has had a clear and significant negative impact on the economy of Zimbabwe. Estimated GDP growth in 2020 (−4.1% in 2020, compared to an expansion of 2.7%, which was expected before that). This drop occurred in a volatile economic environment, compounding a severe contraction (largely from weatherrelated disruptions) in the previous year. More significantly, the impact of COVID-19 plays out during a yet incomplete recovery from a severe economic crisis which was about 10 times deeper and 10 times as sustained as the impact of COVID-19 so far, starting in 1998 and reaching its nadir in 2008. Real GDP per capita remained about one quarter below the level attained in 1998 in Zimbabwe as of 2019, while real GDP across SSA increased by 44% over the same period.
The difficult macro-economic environment by no means diminishes the implications of the adverse impacts of COVID-19. On the contrary, the economic stagnation has left many households vulnerable to the economic fallout from COVID-19, and the World Bank estimates that the number of extreme poor has increased to 49% of the population in 2020 (up from 38% estimated in 2019). And health care sector capacities remain weak -the burden of non-communicable diseases has been increasing (age-standardised and otherwise), vacancy rates for important categories of health care workers (like medical officers and specialist consultants) remain high and the rate of emigration is one of the highest globally.
This background shaped the government's fiscal response to COVID-19. It has not significantly increased borrowing. Access to external financing is limited as Zimbabwe has been in arrears on most of its external debt since 1999, and domestic borrowing -largely from the Reserve Bank of Zimbabwe -caused bouts of very high inflation in the recent past, so the government is reluctant to fund additional expenditure from this source and risks derailing its macro-economic stabilisation programme. Nevertheless, the government has spent about 1% of GDP annually on the response to COVID-19, of which about one third was financed by external grants.
Risk to the HIV response potentially arose from disruptions to funding and the repercussions of service disruptions for PLHIV. On financing, COVID-19 -and more recently, the war in Europe -have introduced significant new uncertainties in terms of the growth outlook for advanced economies, the longer term fiscal outlook for these economies where the response to COVID-19 was financed by large budget deficits (sometimes well over 10% of GDP) and the extent to which external support on COVID-19 and the fallout from the war in Europe shifts policy focus and fiscal space for external assistance away from HIV. These developments also have implications for the outlook on domestic financing, although the most important factor here is the successful continuation of macro-economic stabilisation. Direct evidence on disruptions of HIV-related services is scarce. Survey data among PLHIV document difficulties in accessing health care services during lockdowns. Additionally, PLHIV -just like the population overallwere affected by the negative economic consequences of COVID-19 and the increase in poverty attributed to it, which could have implications for service access and disease progression (through nutrition). However, aggregate data on treatment access suggest that retention has not declined, even though transition to treatment may have slowed down in 2019 (when an economic disruption preceding COVID-19 occurred) to 2021. The immediate health consequences of this slowdown are small because of the high level of treatment coverage already attained; a longer-lasting slowdown, however, could result in stagnation or a reversal of progress towards ending the AIDS pandemic as a public health threat.
The health care sector overall (like other public services) has been eroded by a history of economic crises, fiscal constraints and high rates of emigration. Consequently, the health care system struggled to cope with the early challenges posed by COVID-19 -e.g. testing for COVID-19 lagged behind regional peers. Meanwhile, access to selected and critical health care services appears to have been maintained. For example, treatment coverage for PLHIV remained high, and the pace of the vaccination roll-out for COVID-19 stood up well compared to regional peers. However, anecdotal evidence, consistent with similar data from other countries in the region, suggest that the utilisation of a range of health care and health care-related services was disrupted -including HIV testing and treatment initiation and TB screening and detection.
From the data available, it is often unclear to what extent disruptions observed across the health care sector were the result of supply-side constraints or changes in or constraints to health-seeking behaviour. One of the legacies of decades of economic crisis are high rates of poverty, leaving households vulnerable to further and deeper impoverishment through economic shocks which then contribute to increased barriers to accessing health care services. COVID-19 has certainly raised economic barriers in access to health care services, as evident from the steep increase in poverty observed in 2020. Fiscal policy (under severely constrained capacities) was unable to provide an effective buffer against this economic fall-out, although the government introduced some measures, such as cash transfers to households most in need.
On health care sector capacities, COVID-19 may have accelerated efforts to (re)build capacities. Health care sector capacities were clearly inadequate to cope with an additional health shock -mortality across disease categories exceeded the levels attained in the mid-1990s, and vacancy rates across the health sector remain high. Beyond the immediate needs posed by COVID-19, rebuilding an effective health care system thus remains an urgent priority. In this regard, measures taken by the governmentexempting the health care sector from the public-sector hiring freeze and increasing budget allocation to the health care sector -may have responded to imminent needs triggered by COVID-19, but could accelerate the health recovery if maintained over the coming years.
Finally, the COVID-19 pandemic has showcased the significant vulnerabilities of the national health care architecture and weaknesses in the resilience of the national health care system as well as the HIV response. As a corollary, it has also reinvigorated a debate about the right way to prioritise and use development finance. Given finite resources, financing prioritisation requires a careful rethink. Based on the findings in this article, we proffer some useful recommendations to this end.
Global health financing needs a full reset. We recommend strategic financing for HIV and COVID-19 pandemics as well as other ongoing and emerging pandemics in the framework of financing global common goods for health care. The world has entered an era of pandemics. COVID-19 will likely be a forerunner of future catastrophic pandemics, fuelled by global warming and biodiversity losses, unless significant new investments and reforms are urgently made to bolster capacities and resilient adaptative systems for pandemic preparedness and rapid response. Presenting a common international front is important to ensure the provision of global public goods and manage the world's resources equitably. Also, focusing on the common good to shape preparedness and response requires a move away from the dominant short-term thinking in planning and investment towards long-term thinking in building future-oriented policies and cooperation mechanisms. Thirty-eight per cent (38%) of positions in top management, 16% of doctors, 8% of nurses, 27% in pharmacy services, 46% in radiography, 12% in nutrition services, 18% in oral health care, 42% in laboratory and pathology, 53% in infrastructure, engineering and equipment maintenance, 35% in psychology, 35% in planning, monitoring, and evaluation, 37% in human resources, 8% in administration, 55% in procurement, 22% in records and information, 67% in reproductive health care, 41% in sexually transmitted diseases, HIV and AIDS and tuberculosis, and 20% in communicable disease control. 3 Because of high inflation and the steep depreciation which occurred through 2020, the estimate in US dollar terms is sensitive to assumptions on the timing of the spending. We apply the average exchange rate for the second half of 2020 as the package was only set up in mid-2020. 4 We do not consider additional taxes as a funding source, as so far the emphasis of the fiscal response has been on spending in response to COVID-19 and tax breaks to mitigate the economic consequences and support the response, rather than tax increases to support the additional spending. We subsume these tax breaks, together with spending allocations, under estimates of the direct costs of COVID-19, which need to be financed by other means (grants, borrowing). Looking ahead, the government is undertaking an ambitious economic and fiscal reform programme. Raising additional government revenues is integral to this agenda, irrespective of the impacts of COVID-19. 5 Our summary Table 2 records external grants separately from the fiscal accounts. In recent years, most external assistance was administrated outside the government's accounts, although it was used in accordance with objectives guided by and agreed with the government. The Health Development Fund was the most important example of this practice. The government (and estimates by the IMF which we use to complement the national data) therefore report fiscal summary data excluding grants. However, this distinction is not always made consistently, e.g. sometimes government estimates on the fiscal effort in response to COVID-19 include grant-financed expenditures. 6 As there is no reliable data on the prevalence of COVID-19 in the general population, it is impossible to say whether health care staff were at higher risk of contracting coronavirus. A scoping review found similar rates in health care workers as in the general population in seven African countries (Müller et al., 2021).