Food systems encompass the whole range of actors and their interlinked value-adding activities along the food value chain. Food systems actors range from input suppliers and producers to aggregators, processors, distributors and consumers(1). The enabling policy environments and norms around food are also part of food systems(1). Several food systems frameworks have been developed that show the interrelatedness of the many components of food systems with nutrition and health outcomes(1). The concept of food systems is gaining momentum rapidly within global sustainable development debates. Almost all the UN Sustainable Development Goals (SDGs) are linked directly or indirectly to the food system concept(2). Food system frameworks and approaches are important for identifying and addressing system challenges related to food and enable the mapping of interactions and linkages with other sectors as a basis for designing coherent and consistent policies(Reference Rwamasirabo3). The three complex challenges that the global food system is expected to achieve are: (i) deliver to consumers sufficient, affordable, safe and nutritious and healthy food; (ii) avail livelihoods to all those in the food chain including farmers; and (iii) engage in environmentally sustainable practices(4).
An ideal food system is one that is sustainable, resilient, inclusive, climate-smart and delivers nutritious and healthier diets for all. A sustainable food system delivers food security and nutrition for all without compromising current and future generations’ economic, social and environmental bases(5), addresses inequity and helps to ensure that marginalised and vulnerable people enjoy the benefits and opportunities that food systems can bring(Reference Fan and Swinnen6). A resilient food system can withstand and recover from disruptions and shocks such as public health emergencies, local and global disruptions in food supplies and climatic and other weather-related shocks such as droughts, and flooding(Reference Dikoda7). African food systems are integrated into the global food systems and it is critical for them to deliver in all these areas and are resilient in meeting the needs of their population. Resilient African food systems should provide a sufficient supply of healthy diets that meet social and cultural preferences and are affordable and accessible food for all, including vulnerable groups and populations after exposure to shocks.
Food systems in Africa are however under pressure due to climate change, conflict, low productivity, rising population, changing diets with rapid urbanisation and external shocks among other factors(Reference Ulimwengu, Constas and Ubalijoro8) which have contributed to increasing malnutrition on the continent. The COVID-19 pandemic adversely affected the food system in Africa due to the containment measures countries implemented to curb its spread(Reference Madzorera, Ismail and Hemler9). Within the food system, COVID-19 affected health, livelihoods, food security and access to nutritious food in Africa. The COVID-19 pandemic also had profound impacts on various systems and sectors, including health, education, water and sanitation and social protection.
The current environment within which Africa’s food system is situated is not only affected by COVID-19 but it is being impinged upon by multiple global crises now referred to as the ‘Polycrisis’(10). These multiple, sustained and cascading crises including the effects of COVID-19, climate, economic crisis and protracted conflicts(10), many of which are ongoing on the African continent, as well as in other countries that were sources of food for import. The complex nature of these crises has affected all aspects of the food systems, negatively impacting access to healthy diets and aggravating the food security and nutrition situation(10). Most affected are the poorest and nutritionally vulnerable households who have been pushed deeper into severe poverty and malnutrition(Reference Torero, Ulimwengu, Constas and Ubalijoro11).
The COVID-19 pandemic has further eroded the global food systems and Africa’s already fragile food systems. Although COVID-19-related mortality and morbidity in Africa were relatively low in comparison to other regions(Reference Lawal12–Reference Nguimkeu and Tadadjeu14), the mitigation measures amplified a rather difficult situation through further disruptions in supply chains, food prices increase, income losses and unaffordability to healthy diets(Reference Ismail, Madzorera and Apraku15,Reference Mutua, Kang’ethe and Grace16) .
The objective of this paper is to review the impact of COVID-19 on Africa’s food systems and based on lessons learned, to propose practical recommendations to enhance resilience to future shocks while protecting Africa’s food systems to deliver healthy diets for all.
The state of food insecurity and malnutrition in Africa: Pre-COVID-19 situation
The Food and Agriculture Organization of the United Nations (FAO) defines food security as a situation when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food practices for an active and healthy life(17). Prior to the emergence of COVID-19, although Africa was making some progress in the reduction of food insecurity and malnutrition, it still carried a high burden, and undernourishment was already showing an increasing trend. The ability to consistently access sufficient, safe and nutritious food remained an illusion for millions of people across Africa. FAO’s Food Insecurity Experience Scale (FIES) data showed that 52.5% of Africans (678 million) were food insecure compared to the global prevalence of 26.4% in 2018(18) and severe food insecurity affected 21.5% of Africans compared to 9.2% globally. The high prevalence of food insecurity during this period was attributed to several factors including conflicts and extreme weather events(18). FAO analysis showed that conflict-affected regions of Sub-Saharan Africa (SSA) had 23.4 million more severe food insecure persons compared to countries not exposed to conflicts(18). Sub-Saharan countries classified as drought-resistant(19) had higher prevalence of severe food insecurity from 2012 to 2018 (17.4% to 21.8%) compared to countries in the region that did not experience drought(18).
Africa made some progress towards achieving the global nutrition targets for children under five years, between 2012 and 2018, with stunting decreasing from 32.6% to 30%, while wasting prevalence was 7.1% in 2018(20). Overweight and obesity were on average 4.9%(20). In 2018 more than one-third of all stunted children lived in Africa (20). About 58.8 million African children below the age of five years were stunted(20). However, the stunting prevalence decreased from 38% in 2000 to 30% in 2018, although due to population growth, the number of stunted increased from 50.3 million to 58.8 million children between 2000 and 2018. Africa carried a burden of wasted children under five years, estimated to be 14 million (7.1%) in 2018 of which 4.2 million (2.2%) were severely wasted(21). Clearly, before COVID-19, Africa was making little progress with its nutrition indicators.
Before COVID-19, several challenges were exacerbating the food insecurity situation(Reference Mohamed, Abdallah and Ahmadi22). Climate change is among the most pressing. Erratic rainfalls, prolonged droughts, flooding and rising temperatures have been impacting agricultural production(Reference Baptista, Farid and Fayad23); smallholder farmers, a majority of whom are women, constitute the backbone of Africa’s agriculture and are most affected. Frequent conflicts on the continent disrupt agricultural activities, destroying livelihoods and pushing households into food insecurity and poverty(Reference Muriuki, Hudson and Fuad24).
Impact of COVID-19 on Africa’s food systems
One of the critical areas severely impacted by COVID-19 in Africa is economic growth. COVID-19 resulted in a reversal of Africa’s economic growth as indicated by GDP(Reference Lakemann, Lay and Tafese25,Reference Anyanwu and Salami26) and a drop in employment, especially for the informal sector, with a corresponding decline in household income and subsequent increase in the levels of poverty and hunger(Reference Torero, Ulimwengu, Constas and Ubalijoro11). The 2024 Global Resilience Report(21) indicated that COVID-19 containment measures resulted in a loss in employment and income, particularly for urban poor working in the informal sector.
The impact of COVID-19 on the food systems was experienced through several avenues including reductions in economic activities in the countries due to lockdowns and restrictions on movement of people that affected the supply chain of agriculture and markets. The reduction in trade affected growth, especially for countries with less diverse export baskets(Reference Fofana and Sall27,Reference Fofana and Sall28) . Several other aspects of the food systems were impacted by COVID-19, with food factories and food services being affected by closures and other lockdown measures due to income losses. Lockdown measures also disrupted transport of food crops from rural to urban markets. Disruptions in the supply chains between 2020 and 2022 reduced food availability, and increased food prices and food insecurity. This impacted more women than men, with food insecurity affecting 27.8% of the women compared to 25.4% of the men(10).
The pandemic triggered income loss, particularly for those in the informal sector, affecting consumption patterns away from healthy diets that became unaffordable. The cost of a healthy diet has shown increasing trends in Africa since 2018, reaching a peak in 2020 (Fig. 1). Access to healthy diet also became increasingly unaffordable reaching $3.46 per person per day in 2020 (Figs. 1 and 2) and increasing thereafter(17).
Figure 1. Cost of a healthy diet in Africa ($ per person per day). Source of data: FAO, IFAD, UNICEF, WFP and WHO. 2022. The State of Food Security and Nutrition in the World 2022 (17).
Figure 2. Number of people in Africa unable to afford a healthy diet in 2020 (in million). Source of data: FAO, IFAD, UNICEF, WFP and WHO. 2022. The State of Food Security and Nutrition in the World 2022 (17).
About 79.9% of the population (1.03 billion people) in Africa could not afford a healthy diet in 2020(29). The regional distribution indicated that most of the people who could not afford a healthy diet in 2020 were in Eastern and Western Africa (Fig. 2).
Impact of COVID-19 on food security
COVID-19-induced income reductions and supply chain disruptions worsened the food insecurity situation in Africa. Moderate and severe food insecurity increased dramatically between 2019 and 2020 in six of the eight sub-Saharan African countries for which FIES data were available(29). COVID-19 impact on food insecurity was quite significant, rising from 52.3% in 2019 (pre-COVID-19) to 56% in 2020 to 59.9% in 2021(17).
Between 2016 and 2019, the prevalence of food insecurity was stabilising in Africa although the proportion remained the highest in the world. By 2019, the number of moderately or severely food-insecure people in the continent was 658 million. This increased to 750.9 million and further up to 794.7 million in 2020 and 2021 respectively (Figs. 3 and 4). The trend shows that significant proportion of people in Africa do not have access to adequate food and the magnitude increased notably since the onset of the pandemic. That is, 136.7 million people were added in the ranks of moderately or severely food insecure category in 2021 alone(17).
Figure 3. Prevalence of food insecure people (%).Source of data: FAO, IFAD, UNICEF, WFP and WHO. 2022. The State of Food Security and Nutrition in the World 2022 (17).
Figure 4. Number of food insecure people (millions). Source of data: FAO, IFAD, UNICEF, WFP and WHO. 2022. The State of Food Security and Nutrition in the World 2022 (17).
Impact of COVID-19 on nutrition
The Joint Child Malnutrition Estimates for 2023(21) indicated that globally child stunting has been declining steadily from 33% in 2000 to 22.3% in 2022. Within this period, the number of children affected by stunting globally decreased from 204.2 million in 2000 to 148.1 million in 2022(21). Africa showed a decline in under-five stunting prevalence from 34.4% in 2012 to 30.0% in 2022, although the number of stunted children increased (from 61.3 million in 2012 to 63.1 million in 2022)(21).
Globally 45 million children under five years were affected by wasting in 2022 of which 12.2 million (5.8%) were in Africa. Western Africa was most affected with the highest proportion of wasted children (6.7%)(21). The Global Resilience Report analysed data from 19 countries, of which 16 were from Africa, to determine the impact of the polycrisis. They found that acute malnutrition (wasting) in children increased by 20% between 2020 and 2022 in countries affected by humanitarian crises(10). Additionally, underweight women dramatically increased between 2020 and 2022 in twelve countries, of which 11 were African countries, while acute malnutrition in pregnant and lactating women and adolescent girls increased by 25% in 2022 (5.5 million in 2020 to 6.9 million in 2022) in most countries affected by the global food and nutrition crisis.
Impact of COVID-19 on diet quality
Changes in the price of food crops, as well as changes in income of households not only have implications on the consumption of food but also impact dietary quality and the amount of micronutrients consumed. There is evidence that the various measures implemented to curb the spread of COVID-19 led to changes in diet quality. A study in Kenya(Reference Chege, Onyango and Kabach30) examined the change in diets using data collected from urban dwellers during the lockdown. The findings showed that diet quality deteriorated in both low- and middle-income consumers. In addition, the reduction in the consumption of nutritious foods was significant among poor consumers in slum areas. Another study that sampled consumers from four states in Nigeria(Reference Balana, Ogunniyi and Oyeyemi31) found that consumption of fruits and vegetables (F&V), as well as animal source foods (ASF), substantially declined during the COVID-19 period. Finally, a study based on 1,797 urban and rural consumers sampled from Burkina Faso, Ethiopia and Nigeria,(Reference Madzorera, Ismail and Hemler9) concluded that price increases took place with the onset of the pandemic for various food items in the study countries. This led to a reduction in dietary intake including in F&V and ASF by at least 40% and a decrease in the dietary diversity score compared to the pre-COVID-19 period.
A systemic review of studies on diet quality related to the measures taken to curb the spread of the pandemic in SSA(Reference Picchioni, Goulao and Roberfroid32) reported (i) the presence of involuntary change of diets away from nutritious foods, (ii) reduction in consumption of dairy and eggs among children, and that (iii) a reduction in healthy diets was observed in women more than in men. Furthermore, the review showed that the pandemic had long-term negative implications on the consumption of foods that are diverse and healthy. It found that consumption had shifted from nutritious foods to staples even after the restrictions were lifted.
The increase in poverty prevalence and the deterioration in access to nutritious foods is also expected to negatively affect maternal and child undernutrition, particularly among the vulnerable groups. Osendarp et al.(Reference Osendarp, Akuoku and Black33) examined the consequences of the crisis on maternal and child nutrition for 118 lower-and middle-income countries around the world. The authors estimated that wasting, stunting and mortality in children under five years of age would increase in the study countries during 2020–2022. Several surveys conducted during the COVID-19 in some African countries showed compromised diet quality during the period(Reference Chege, Onyango and Kabach30,Reference Picchioni, Goulao and Roberfroid32,Reference Nicklett, Johnson and Troy34) .
Building resilient African food systems that deliver healthy diets
The importance of building resilience in the context of Africa’s food systems cannot be overemphasised. The shocks to food systems if not mitigated, could delay or limit economic progress, transformation, prosperity and self-reliance(35). Resilience refers to the ability to dampen the impact of and quickly recover from shocks and to adapt flexibly in response to stressors(Reference Cutter, Barnes and Berry36). Resilience has five distinctive capacities (prevent, anticipate, absorb, adapt and transform(Reference Mohamed, Abdallah and Ahmadi22). Building absorptive capacity is essential for dealing with unforeseen shocks and is complementary to risk management of shocks that can be anticipated(29). A resilient food system is characterised by two salient features(35): (i) a reduced likelihood that shocks to the food systems occur and (ii) measures are taken either ex-ante or ex-post to ensure that individuals, communities and regions recover quickly and resume normal performance after inevitable shocks occur.
To put Africa on a path to accelerated recovery from the impacts of COVID-19 and other future shocks, including climate change, and to achieve the SDGs(37) and the Malabo Declaration Commitments(38) productive, resilient and sustainable food systems will be critical at various stages of the food systems.
Increasing agricultural productivity
From a medium and long-term perspective, efforts must be made to notably increase the productivity of the agriculture sector in Africa. This will help to better cushion vulnerable groups from similar shocks in the future. With increased productivity, most smallholder farmers would be in a better position to produce more. More production has the potential to translate into increased income which could positively contribute to food security and decrease the vulnerability of households to shocks. Increasing agriculture productivity could be made possible through increased use of productive inputs, investment in agricultural research and development, as well as, addressing issues related to postharvest losses. Moreover, it is critical to make access to resources, technologies and advisory services inclusive of the marginal and vulnerable groups including women and the youth. This requires making productive enhancing solutions attractive to vulnerable groups through affordable loans and financing schemes.
Promoting the production and consumption of African traditional, indigenous foods (TIF)
TIFs present many benefits being nutrient-dense in comparison to so-called exotic crops, they are drought-resistant in the face of climate change conditions, and are an important source of livelihoods and income for vulnerable households and women, in addition to being more culturally acceptable(Reference Akinola, Pereira and Mabhaudhi39). Despite the potential of TIF to contribute to Africa’s food systems transformation, they are not given the needed support in resources, research, production, processing and consumption. Development of value chains for TIFs including agriculture extension support to encourage production is critical. A review of the contribution of TIF shows that they can play a significant role in the development of a more sustainable, resilient and healthy food systems in Africa(Reference Akinola, Pereira and Mabhaudhi39).
Promote farmer-managed seed control systems where a working seed system does not exist or is not accessible
For generations, African smallholder farmers have saved, improved, selected and managed their seeds due to the absence of a working seed production and distribution system. These farmer-managed seed systems have been responsible for 80-90% of seeds used in SSA(40). Based on farmers' indigenous knowledge, they are able to select seeds that are best suited for their environment and climate, a practice that enhances resilience of their farming systems. In situations where working seed production and distribution systems do not exist or are not accessible to small-scale farmers, efforts must be made to protect and promote traditional seed management systems, as a way to ensure resilience of food system and biodiversity(40).
Make interventions responsive to gender
Agrifood systems are a more important source of livelihood for women than men, yet women in agriculture wage employment earn less than men. Also, more women lost their jobs in agrifood systems in the first year of COVID-19 than men(41). Interventions should consider specific gender roles in agrifood systems and address women’s specific and multiple needs as guardians of household food security and requirements of food producers, farm managers, processors, traders, wage workers and entrepreneurs. Interventions should also integrate women and their organisations and informal networks to design and implement COVID-19 response and mitigation strategies. It is also important to identify the needs of the marginalised people and ensure their needs are considered and ensure policies that empower them and share benefits more equally.
Invest in social protection programmes
Based on the evidence available from the COVID-19 responses, governments in Africa used limited social protection instruments to deal with the pandemic(Reference Benammour, Davis and Knowles42). Social protection programmes such as direct food distribution and cash transfers, have been shown to have a positive effect on resilience(35,Reference Benammour, Davis and Knowles42) . These programmes enable households to take on risks, make investments, reallocate labour and even engage in markets. Social protection measures provide a more flexible, and relatively low-cost, mechanism to reach people operating in the informal sector, including the myriad of small-scale informal actors that constitute African food systems(Reference Benammour, Davis and Knowles42). Social protection can also help people, particularly those with few savings or resources, to cope with sustained income losses, and comply with lockdown measures without jeopardising their food security and welfare.
Address inequities within the food systems
The COVID-19 outbreak has taught important lessons in the sense that the inequalities that exist between the different groups and places make the impact of the pandemic different from one another. The evidence shows that the implementation of blanket lockdowns without considering existing inequalities has the potential to produce dire livelihood consequences. A study(Reference Teachout and Zipfel43) showed that the pandemic increased the population under extreme poverty by 9.1% and two-thirds of that was due to the lockdown measure. The same study also shows that savings of 30% of the population in Africa south of the Sahara are wiped out within eight weeks of blanket lockdown. Such lockdowns destroy the resilience capacity of communities, particularly vulnerable groups. The measures taken by governments to contain the spread of the COVID-19 virus disrupted the normal flow and price of agricultural produce in the continent in almost all places. This is because the movement restrictions affected the proper functioning of markets. Hence, governments need to refrain from blanket policy responses and apply targeted measures that are specific to local areas so that the economic cost become minimised.
Protect food environment to deliver healthy diets for all
While embarking on various programmes and interventions to enable the resilience of food systems, an aspect of food systems that must be protected is the food environment. The food environment has been defined as the ‘collective physical, economic, policy and sociocultural surroundings, opportunities and conditions that influence peoples food choices’(Reference Swinburn, Vandevijvere and Kraak44). Simply put, it is the space around the consumer from where food choices are made. Food environment is influenced by food availability, affordability, promotion, advertising and food quality and safety(1). Activities of the broader food systems impact the food environment, and the choices consumers make and ultimately their nutritional status.
A resilient food system must enable healthy diet to nourish people during periods of shock. At the peak of the COVID-19 pandemic, several studies reported associations between severe adverse COVID-19 outcomes and BMI (obesity) among adults(Reference Booth, Reed and Ponzo45,Reference Chu, Yang and Shi46) .
Small, medium and microenterprises (SMEs) have a significant influence on food environments. In sub-Saharan Africa, supply chains are heavily dominated by SMEs majority of whom are involved in processed food supply(Reference Reardon, Tschirley and Liverpool-Tasie47). SMEs fill an important gap in making food available during periods of shocks. Providing training to SMEs on nutritious foods and financial assistance would enable them to provide nutritious food to local communities.
Ultimately, it is the responsibility of governments to protect food environment to deliver healthy diets. Governments have various tools at their disposal – taxing of unhealthy foods, labelling regulations, marketing restrictions, prohibition of unhealthy food advertising to children. Indeed there is evidence of some governments making these intentional decisions of passing laws to protect food environment and reduce access to unhealthy foods(Reference Laar48).
Investing in data and information systems
Data and information are essential for food systems transformation as it empowers stakeholders, especially policy makers to assess progress and make informed decisions. For example, following the UN Food Systems Summit, the Food Systems Countdown Initiative was established to monitor the state of food system transformation up to 2030(49). As aptly described, ‘such monitoring can help align decision-makers around key priorities, incentivize action, hold stakeholders accountable, sustain commitment by demonstrating progress and enable course correction’(49).
Global call for Food systems transformation
The United Nations Food Systems Summit of September 2021 was a clarion call for the world to transform the way it produces and consumes food(50). The Summit brought together global leaders and food systems stakeholders to discuss the challenges of current food systems. It is rather coincidental that the UN Food Systems Summit of 2021 was held during the COVID-19 pandemic, presenting an unfortunate, but real-life pandemic situation to bring attention to the need to transform global food systems to make them fit for purpose(50). The summit identified five action areas to be achieved in the global food systems transformation effort: (i) ensure access to safe and nutritious food for all, (ii) shift to sustainable consumption, (iii) boost nature-positive production, (iv) advance equitable livelihoods and (v) build resilience to vulnerabilities, shocks and pandemics(50). Prior to the UN Food Systems Summit, many countries held national dialogues to identify challenges in their food systems and proposed pathways for transformation by 2030. Of the 111 countries that submitted food systems transformation pathways, 91% indicated that achieving healthy diets is a critical outcome for their food systems transformation, while 79% and 75% of countries cited climate/disaster resilience and resilient supply chains respectively as critical outcome(51). At the continental level, the Africa Union responded to the call and issued the ‘Africa Common Position on Food Systems’ (AU-NEPAD 2021)(52) which includes Africa’s commitment to ensuring access to safe and nutritious food for all (Box 1).
Box 1. Africa’s commitment to ensuring access to safe and nutritious food for all.
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Promote biofortification of staple foods and industrial fortification of complementary foods to deliver better diets for all.
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Facilitate the expansion of cash transfer programmes and use expanding cash transfer platforms to reach families with nutrition services and programmes that focus on producing nutritious foods.
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Promote and enforce food safety standards in both formal and non-formal food markets to protect consumers.
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Expand domesticated school feeding programmes to improve nutrition for school children and create markets for locally produced foods to increase farmer incomes.
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Adopt and implement coherent nutritious food policies and strategies that are evidence-based, along with enhanced institutional capacities and capabilities for accelerated transformation of sustainable food and nutrition systems.
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Identify, renew and implement longer-term actions across multiple systems–food, health, water and sanitation, education and social protection – in the food system to facilitate sustained access to affordable and nutritious foods, essential nutrition services and positive nutrition practices in all contexts; and to promote diversification, including in nutritious indigenous foods.
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Adopt policy and fiscal measures across government ministries to support food affordability (i.e. subsidies for healthy and sustainable foods, expansion of social protection programmes, taxation for unhealthy foods and procurement policies for healthy school meals).
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Implement long-term inclusive strategies that foster multifaceted investment in agriculture, agribusiness, and agro-industries; and ensure food safety, micronutrient content and sustained food quality and standards that enable micro and medium agri-SMEs to compete in domestic, regional and international value-added food markets.
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Promotion of national, regional and continental food information systems to share information on the availability of food and food prices at all levels, and how it could be accessed. Ensure adequate regional strategic emergency food reserves and storage facilities
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Incentivize national and trans-national trade corridors for food commodities and services and ensure dedicated attention to regional food markets and trade in all AfCFTA provisions and protocols.
Source: Africa Common Position on Food Systems | AUDA-NEPAD(52) https://www.nepad.org/publication/african-common-position-food-systems
Conclusion
Building resilient food systems in Africa that can withstand and recover from disruption and shocks is important for ensuring healthy diets for all. Shocks are inevitable, be they public health pandemics, climate-related or economic crises. Food systems everywhere must be always prepared to withstand these shocks. From this paper, our broad recommendations for building resilience in Africa’s food systems to deliver healthy diets include improving seed value chains, increasing the productivity of nutritious foods, promoting the production and consumption of Africa’s traditional and indigenous foods, promoting gender-sensitive food systems, investing in social protection programmes and creating a healthy food environment that would nourish the growing population without disadvantaging future generations. Africa is at the cross-roads of setting the Post-Malabo Agenda for the continent for another ten years. This is the time to set the bar high in its commitments that would really transform Africa’s agrifood systems to deliver healthy diets for all.
Acknowledgements
Anna Lartey would like to thank the Nutrition Society UK for the opportunity and invitation to give the opening keynote lecture at the 5th Federation of Africa Nutrition Societies Conference. The authors thank the Future for Health and Economic Resiliency in Africa (FHERA) Food Systems Working Group for their interest in the paper. FHERA Food Systems team: Fawzi, Wafaie, Isabel Madzorera, Anna Lartey, Sussy Munialo, Aboubacry Thiam, Ramadhani Abdallah Noor, Lindiwe Sibanda, Namukolo Covic, Amos Laar, Adelheid Onyango, Kaleab Baye, Laetitia Ouedraogo Nikiema.
Author contributions
AL and AT designed the article, AL, PG., OB. IM., WF drafted the paper. All co-authors reviewed the paper.
Financial support
The FHERA was partially supported by the Bill and Melinda Gates Foundation. The Bill and Melinda Gates Foundation had no role in the design, analysis or writing of this article.
Competing interests
The authors declare none.
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