Making Kenya’s health care system fit for the future

By Joan Atim

Kenya has 8,250 confirmed Covid-19 cases and the figures show that the country may reach the 10,000 mark in a few weeks. Earlier, the government of Kenya seemed ahead of the curve and through an Executive Order issued on 28 February 2020, the President established the National Emergency and Response Committee (NERC) for Covid-19 chaired by the Cabinet Secretary (CS) for Health. The Ministry of Health also set up an Emergency Operations Centre comprising of four Rapid Response Teams (RRTs). Each team had five trained medical staff as well as designated telephone communication numbers for members of the public to report suspected cases, seek more information on the infection and ask questions. A treatment and isolation unit for managing Covid-19 positive cases was set up at the country’s largest teaching and referral hospital – Kenyatta National Hospital and over 1500 health workers have received training on managing Covid-19 patients. Further, monitoring the geographical spread and transmission intensity in different areas was started and intensified to curb community transmissions. There have also been infection prevention and control measures at all levels of the healthcare system even in counties within Kenya and the establishment of functional triage systems and isolation rooms, procurement of supplies based on the World Health Organization’s (WHO) Covid-19 Disease Commodity Package (DCP). Nationwide, there has been sensitization and public education through mainstream as well as social media; including advice on self-care for persons with mild symptoms.

Though the government enhanced public-private partnerships to increase the local capacity for production of PPE for the healthcare facilities, some loopholes were shown to exist especially regarding the management of the donations. Despite this, there has been increased local production and this has ensured a steady supply of PPEs to the healthcare facilities meeting the current demand. The Public Finance Management (Covid-19 Emergency Response Fund) Regulations, 2020 was also enacted and it established the Covid-19 Emergency Response Fund. It consists of monies appropriated by the National assembly, grants, donations, subscriptions, voluntary contributions from public officers and private persons and other gifts made. The fund shall be wound up when the President directs so after confirming that Covid-19 is no longer a threat to social-economic and political stability in Kenya. The fund should be utilized for the purposes given in an accountable and transparent manner. With all these measures in place, the virus has, however, proved to be stubborn and unrelenting, ravaging even the best healthcare systems in the world. This persistence led the WHO to declare it endemic on 13 th May 2020; as the world prepares to live with the virus.

In Kenya, data on the numbers reveal that the healthcare facilities are already overwhelmed. The government recently through the CS Health in his daily briefings announced that the hospitals and isolation centres are full and they were considering sending patients with mild symptoms to isolate at home. This is a recipe for disaster and the country should be prepared for worse. Take for instance places like Kibera and Kawangware (slum dwellings), maintaining physical distance is almost impossible. People live in tiny, overcrowded homes with few windows or other ventilation, thus, the usual health promotion messages just don’t apply. The ministry has also criticised the dangerous behaviour of issuing false contacts during targeted tracing and this is hurting the government efforts. There have also been challenges and gaps in coordination between the county and national levels of government in the procurement of critical equipment such as ventilators for respiratory support as well as recruitment of additional healthcare personnel. Patients have been witnessed escaping from these isolation centers; and this speaks to the status of the places. There is therefore, an urgent need for a better defined and coordinated mechanism to increase the capacity for intensive care, the supply of PPEs and recruitment of trained healthcare personnel in further anticipation of a high surge in the numbers of positive cases. The ministry could take advantage of its health workforce ranging from nurses, dentist, laboratory technicians, pharmacists, nutritionist, and virologists to public health officials and they could make use of this pool of workers to further intensify on the fight against the virus.

In summary, Kenya has taken most of the appropriate steps at implementing the WHO recommended Country Preparedness and Response measures for healthcare facilities. However, these require scaling-up. Kenya has also shown that it can deliver short term aid and try to develop innovative vaccines and treatments for infectious diseases, the real issue is the danger of a weak healthcare system. In the longer term, therefore, the government can focus on building better infrastructure; especially digital infrastructure (which means good electricity connectivity, internet fibres amongst others) and further leverage on digital technologies i.e., using mobile healthcare system, m-health systems in the wake of telemedicine. Kenya should also invest in training its next generation of medical experts especially on the right knowledge, skills and use of the available resources. This will add to the drugs, vaccines research and diagnostic tests. Further, research and innovation should be encouraged through funding. The government should be at the forefront in partnering with the private sector, civil society and donors. Public health schemes should be readily available and affordable. This calls for increased budget allocations and spending for the health sector and where possible exceed the recommended minimum of 15% of the total Government budget. As a result, the government should engage in reforming the financing mechanisms to improve flexibility, through programme based budgeting and modified regulations.

References
1. Institute for Health Metrics and Evaluation (IHME) (2014), Assessing Facility Capacity, Costs of Care, and Patient Perspectives. Available at http://publications.universalhealth2030.org/uploads/abce_kenya_full_report_2014.pdf
2. Kenyans warned against giving false contacts during targeted Covid19 testing. Available at https://www.standardmedia.co.ke/health/article/2001372826/kenyans-warned-against-giving- false-contacts-during-targeted-covid-19-testing
3. World Health Organisation, Investing in and building longer-term health emergency
preparedness during Covid-19 pandemic. Available at https://www.who.int/publications/i/item/investing-in-and-building-longer-term-health-
emergency-preparedness-during-the-covid-19-pandemic
4. Covid19, Ministry of Health Website. Accessible at https://www.health.go.ke/covid-19/
5. Kenya Health Workforce Report: The Status of Healthcare Professionals in Kenya, 2015. Available at https://taskforce.org/wp-
content/uploads/2019/09/KHWF_2017Report_Fullreport_042317-MR-comments.pdf

OPINION NO. 6 OF THE SCIENTIFIC COUNCIL ON COVID-19

20th APRIL 2020

GRADUAL EXIT FROM CONTAINMENT PREREQUISITES AND MEASURES


Members of the Scientific Council associated with this opinion:

Jean-François Delfraissy, President
Laetitia Atlani-Duault, Anthropologist
Daniel Benamouzig, Sociologist
Lila Bouadma, ICU

Jean-Laurent Casanova, Immunology/Pediatrics*
Simon Cauchemez, Modeller
Franck Chauvin, High Council of Public Health
Pierre Louis Druais, City Medicine
Arnaud Fontanet, Epidemiologist
Marie-Aleth Grard, Association
Aymeril Hoang, Digital Specialist
Bruno Lina, Virologist
Denis Malvy, Infectious Disease Specialist
Yazdan Yazdanpanah, Infectious Disease Specialist
French Public Health Correspondent: Jean-Claude Desenclos

The document is dated 20 April 2020. The opinion was finalised on 16 April 2020 and the technical data sheets and the international point on 20 April 2020. This opinion was sent to the national authorities on 20 April 2020 at 20H. Like the other opinions of the Scientific Council, this opinion is intended to be made public.The purpose of this Notice is to indicate the minimum conditions necessary to prepare consistently and effectively for the phase-out and controlled release of containment. This notice is organized in 2 parts:
(i) Minimum containment exit requirements, and (ii) containment exit scenarios. It is completed by a set of annexes.Jean-Laurent Casanova disagreed on the nature of the recommended masks for caregivers and the nature of the recommendations for digital tracing. His opinion is mentioned at the bottom of these points.

*Jean-Laurent Casanova disagreed on the nature of the recommended masks for caregivers and the nature of the recommendations for digital tracing. His opinion is mentioned at the bottom of these points.

INTRODUCTION

This notice shall cover the two months following release from confinement.

Progressive and controlled relief does not mean lifting control measures

The Scientific Council would first like to clarify that preparing the conditions for the gradual release from containment does not mean announcing that the control measures against COVID-19 must be lifted. These measures must remain strong because too sudden a relaxation of control measures could result in a rapid increase in the number of cases and a return of serious cases in hospitalization and resuscitation.Thanks to containment, the transmission rate of SARS-Cov-2 in the French population has been reduced by at least 70%. This extremely large reduction in transmission has allowed the expansion dynamics of SARS-Cov-2 to be broken. It must be maintained over time in order to be able to largely reduce the number of resuscitation admissions for COVID-19 and more generally, the number of cases of COVID-19 in the national territory.At the time of release from containment, if all control measures are lifted at once, a second epidemic wave of COVID-19 is expected. Indeed, for a virus as transmissible as SARS-Cov-2, it is estimated that at least 70% of the population should be immunized to avoid an epidemic recurrence. Even if significant uncertainties persist on the current level of immunity in the French population, in any case, this level is much less than 70%, as it is between 5% and 20% depending on the more or less affected regions, with all the necessary caution.

The society’s adherence to strict containment measures that are difficult to tolerate in the long term

Considering the conditions for phasing out of containment must take into account not only the economic burden of containment, which is considerable but also the weight that containment places on society as a whole. For example, difficulties in monitoring other pathologies making it more difficult to manage in the epidemic context, or the increase of psychic disorders, sleep disorders, forms of violence as well as the consumption of drugs and alcohol, etc. Confinement weighs heavily on the general condition of the population and causes suffering for many of our fellow citizens, as has been pointed out
in previous opinions.

Objectives for a gradual and controlled release from containment

Release from containment should be seen as a continuation of the epidemic control strategy that was previously adopted, not as a break or a new strategy.
In the current state of knowledge, two main objectives must be pursued:

•Control of the epidemic: the virus will continue to circulate with different levels depending on the region. It is imperative to limit the appearance of new infections.
•Limiting the number of serious cases and deaths: The detected cases must have optimal management to avoid aggravation and death. It must also be ensured that the measures put in place are not accompanied by an increase in deaths due to causes other than COVID-19 due to a lack of prevention or management.In addition to these objectives, social and economic objectives must be integrated into strategic thinking.

Prerequisites and measures to be put in place before any progressive and controlled release from containment

In order to achieve these objectives and to gradually and partially relieve the constraints of containment while maintaining a low level of SARS-Cov-2 transmission, a series of prerequisites and measures to be implemented is proposed in this notice. It must be made possible to identify suspect cases on national territory as quickly and as comprehensively as possible to test them and isolate them if they are positive. Case contacts must also be identified, tested and, in turn, isolated.At the outset, the Scientific Council wishes to highlight the many challenges associated with the implementation of such measures. They must be backed up by extremely important technological, logistical and human resources, enabling them to cover the entire national territory efficiently and quickly. Digital tools also have an important role to play in enhancing effectiveness.

Given the characteristics of SARS-Cov-2, these measures will have to be complemented by other strong control measures, including the maintenance of significant barriers and social distancing measures and the protection of the most vulnerable populations. These measures may be strengthened or relaxed depending on the evolution of the epidemic.At this stage, given the many uncertainties, the great transmissibility of the virus, the unknown proportion of asymptomatic forms, the logistical and technological challenges, and the heterogeneity of the population’s adherence, the resurgence of the epidemic after containment remains possible. In such a case, a new containment cannot be excluded. Everything must be implemented to avoid such a scenario.Data available to date indicate that containment since March 17 has reduced virus transmission by 84%, with an estimated reproduction of 0.5 during containment, up from 3.3 before containment initiation. This resulted in a significant decrease in the number of ICU admissions from approximately 700 cases per day at the end of March to 220 cases per day on April 14. If this trend continues, it is expected to observe 10-50 ICU admissions per day on May 11. Given the length of stay observed, the number of beds occupied in the ICU could then be of the order of 1400-1900. This could be 1000-3000 people newly infected with SARS-Cov-2 per day on May 11. These assessments are likely to change significantly, particularly if there is a relaxation, even partial, of the application of containment (Salje et al, 2020). The proportion of asymptomatic carriers is still poorly known, estimated at around 20% or more, with all the prudence that this figure imposes (see Sheet 1).

MINIMUM REQUIREMENTS FOR RELEASE FROM CONTAINMENT

In this context, the Scientific Council wishes to emphasize that an exit strategy must ensure six distinct minimum prerequisites:
Prerequisite 1. Implementation of governance in charge of containment exit
• A unified and coherent national governance, including cases of regional variations.
• Impartial consideration of ethical issues, including digital tools, which should not stop the fight against the epidemic.
• Governance coordinated with other European strategies and taking into account the stakes of national or European sovereignty, in particular concerning the deployment of digital tools.
• Governance that is supported by the population.Phasing out containment requires consistent national governance. It aims to avoid or control the occurrence of new epidemics. In view of the strong territorial interdependencies, a clear national system must make it possible to implement a coherent strategy at the national level, including in the event of possible regional variations. In addition, a link with the measures taken in other countries, particularly in Europe, is also essential. Finally, the lifting of containment must be welcomed by our fellow citizens, who are called upon to take an active part in it. The governance chosen should ensure an impartial observance of ethical principles and involve the participation of citizens. The Scientific Council appreciates the establishment of the team with the Prime Minister which is responsible for preparing and conducting the release from containment.

Prerequisite 2. Hospitals and reconstituted health services
• Relieving resuscitation and hospitalization services, ensuring nursing teams are rested, stock of equipment, treatments and reconstituting protective equipment
• Intermediary facilities for the management of dependent elderly patients
• Urban medicine repositioned on the front line, with integrated digital patient tracking tools COVID-19 consolidated
The short-term objective of the confinement was to reduce the burden on French ICU services, by decreasing the arrival in ICU of patients with serious and critical symptoms. The exit from confinement can therefore only be done when the indicators of monitoring the hospital load in the resuscitation of hospitals located in epidemic areas show a return to an acceptable routine functioning. It will be necessary to ensure that hospital and non-hospital care teams have been provided with a sufficient recovery period to overcome the considerable effort made in the past few weeks.

Prerequisite 3. Ability to quickly identify cases, their contacts, and isolate patients and all contagious healthy carriers (see Sheet 4)

•Diagnostic capacity of new cases based on reliable and accessible RT-PCR tests throughout the territory, following a medical prescription.
•An effective system based on urban medicine, digital platforms, and mobile teams to identify suspected cases and direct them to test structures.
• Dedicated locations for the rapid diagnosis of suspected cases, with rapid transmission of test results to individuals, their doctors and surveillance systems for the follow-up of the epidemic.
• Telephone platforms complemented by mobile teams for the management of diagnosed cases and their contacts.
• Mobile teams and digital tools for efficient contact tracing.
• Accommodation facilities for people suffering from benign forms of the disease.
The availability of these tools is essential to consider a containment exit.
A rendering of the individual results of RT-PCR or serology should be implemented with real-time data transfer to epidemiological surveillance systems. These are essentially RT-PCR COVID tests that allow the diagnosis of infected people. The place of serology (search for anti-COVID antibodies) will probably have a more targeted role than hoped at the level of individual management.

Prerequisite 4. An epidemiological surveillance system capable of detecting new cases and a resumption of the epidemic (see Sheet 5)
• National coverage of surveillance of new cases, hospitalizations, and ICU admissions
allowing the production of regional, departmental and even territorial indicators (large
agglomerations).
• Monitoring of COVID-19 mortality and other causes.
• Serological surveys allowing the monitoring of the acquisition of immunity in the population (serological test looking for anti-COVID antibodies).
The system of collecting the most sensitive indicators, such as the number of new cases on the national territory and the number of new hospital admissions, must be consolidated in order to ensure extremely strict control of the epidemic. Surveillance must make it possible to identify places at risk of transmission or even epidemic.
Finally, it is urgent to build a database in a first-time hospital, allowing to have, in real-time, characteristics of patients hospitalized for COVID-19. This database, which is linked to the SNDS, will be used to describe patient trajectories and to identify risk factors for serious cases, as well as to assess the possible poor management of other pathologies.
Prerequisite 5. Epidemiological criteria
Containment removal must be managed by monitoring epidemiological parameters to assess the performance of the new case identification system, the epidemic risk and the health risk. For containment removal to be carried out in good conditions, it is necessary that:the daily number of hospitalizations and admissions to resuscitation for COVID-19 must be low;
• The daily number of hospitalizations and admissions to resuscitation for COVID-19 must be low;
• The number of breeding on the territory must be less than 1 (R<1);the number of occupied and available resuscitation beds allows for the management of COVID-19 cases, especially if there is an epidemic recurrence, as well as for other serious pathologies.
The first set of indicators makes it possible to measure the level of circulation of the SARS-Cov-2 virus in France. If there are too many people infected with SARS-Cov-2 on the national territory, the capacities may be insufficient to quickly identify, test and isolate these people and investigate their contacts. The exact level of circulation for successful containment removal will depend on the ability to quickly identify cases, their contacts, and isolation at the time of containment removal. For example, while we wait for 10-50 COVID-19 admissions in resuscitation per day, there could be 1000-3000 people infected with SARS-Cov-2 per day on the national territory. When containment is lifted, the government must ensure that it has the means to detect the significant proportion of people infected with SARS-Cov-2, in a context where other respiratory viruses can circulate. One criterion could be that the number of confirmed cases per day is relatively close to the number of infections expected per day. The latter number can be estimated based on mathematical modelling. The second indicator, the number of breeding on the territory, makes it possible to understand the impact of control measures on the epidemic dynamics and to anticipate a resumption of the epidemic. The latest indicators, the number of occupied and available ICU beds, are essential to ensure that ICU resources are sufficient to manage COVID-19 cases but also other serious conditions.
Prerequisite 6. Availability of physical protection gear stock for the entire population

¹FFP2 and/or surgical masks be made available and accessible to caregivers and people at risk of contamination depending on the context(WHO, 2020; recommendations from different learned societies and/or health agencies)

•Hydro-alcoholic gels.
• alternative masks of industrial or artisanal anti-projection production available for the whole population and distributed in priority to people in regular contact with the public.
• education on the use of masks to the general population.
All these elements constitute this prerequisite for the containment exit. It should be noted that we do not currently have solid data on the effectiveness of alternative masks; the results of the effectiveness of alternative masks evaluated by health agencies will be available soon. Stockpiles of equipment, specific resuscitation treatments, and protective equipment (masks, etc.) will need to be adequately replenished, both for the target individuals (hospital and non-hospital care staff, people with increased exposure to the virus as a result of their work), then for the general population, according to their needs. The whole population must wear a mask in spaces welcoming the public (closed spaces, especially in transport, shops, etc.). This reduces the transmission of droplets and possibly aerosols. In the most affected areas, beds, 2 trained staff and dedicated equipment, including respirators, must be available in sufficient numbers. For the general population, the reinforcement of barrier measures is dependent on the availability of hydro-alcoholic solutions in public places and handwashing points in places that do not. The availability of masks is an additional measure compared to the barrier measures that remain the key element.

SCENARIOS FOR CONTAINMENT EXIT (THE FIRST TWO MONTHS)

The government will have to ensure that all the prerequisites as detailed above are operational at the time of release from containment. In terms of timing, it seems difficult to envisage, in the current state of knowledge that these prerequisites can be fulfilled before, at best, May 2020. Available epidemiological data suggest that containment since 17 March has reduced virus transmission by 84%. This resulted in a significant decrease in the number of emergency room admissions for suspected COVID-19, the number of COVID-19 hospitalizations, and finally the number of COVID-19 resuscitation admissions. The saturation of the resuscitation beds by COVID-19 patients will nevertheless continue for a few weeks, as patients with severe forms of inflammatory pneumonia require prolonged ventilation.
Three scenarios are possible:
i. Strict containment continued until the number of new cases is extinguished;
ii. The total exit from containment to acquire collective immunity but with an unacceptable risk of extremely high mortality;
iii. The continuation of the strategy with a gradual, cautious and monitored removal of containment and adaptation of measures according to epidemiological results.
Only the latter scenario was chosen by the Scientific Council and it is presented below.
This scenario is proposed for the two months following release from containment. The Scientific Council considers that it is impossible at this stage to estimate the evolution of the epidemic beyond this period. Only strict and regular monitoring of the spread of the epidemic will make it possible to adapt the proposed measures. The Scientific Council assumes that for this period there will be no curative or preventive treatment or vaccine.
The Scientific Council proposes the first draft of a containment exit scenario, based on the current state of knowledge. This scenario shows the big trade-offs that must be made for a successful exit from containment.This scenario will evolve in the coming weeks as
i) the operational aspects of its implementation will be implemented and the performance of the new control systems will be evaluated,
ii) the exact level of immunity in the population will be better known,
iii) new studies will refine our understanding of the impact of the various control measures,
iv) the adherence of the French population to the control strategy will be known.Moreover, in the coming months, the control strategy will have to remain very flexible and adapt rapidly to the evolution of the epidemic and the latest advances in research. The impact of the various control measures will have to be assessed in order to gradually optimize the control strategy.
The Scientific Council proposes a containment exit strategy based on:
1. Identification of the broadest possible cases allowing for early diagnosis and the implementation of isolation measures;
2. Identification of contacts of diagnosed cases to allow for systematic detection of the presence of the virus, and isolation in case of positivity, including for asymptomatic persons;
3. Systematic measures to reduce the risk of transmission in the general population applied for several months depending on the kinetics of the epidemic, the wearing of a mask in public places and the maintenance of the rules of hygiene and social distancing;
4. Specific measures to control the epidemic by sub-populations taking into account the age and social situation;
5. Regular interval surveys to estimate immunization in the population. These measurements can be located if a cluster is detected.
The Scientific Council recommends that the exit from containment be carried out throughout the national territory. An exit of containment by regions does not appear realistic as an instrument of control of the epidemic because it would imply a very fine sanitary and epidemiological monitoring at the regional level. This does not exclude regional or even departmental variations, depending on the level of circulation of the virus. It should be noted that the restart of the epidemic will require a strengthening of measures to control the epidemic or a new territorial or national containment. In this sense, particular attention should be paid to regions with high population density and/or high viral circulation.
1. Case and Contact Identification and Isolation: Test and Isolation Strategy (see Sheet 3 and Sheet 4)
This is essential to maintain control of the outbreak during the containment period. Its strict application is essential.
This measure is based on:
•Voluntary reporting by any person presenting a suspicion of cases to the health authorities (call from the general practitioner, digital diagnostic aid system, telephone platforms, etc.).
•Referral of any potentially infected person to an RT-PCR COVID diagnostic location or a rapid diagnostic point when available on medical prescription.
•The fastest possible alert for people diagnosed positive by phone or SMS.
•Isolation of suspect cases at home until results are available
•The immediate isolation of confirmed cases under conditions adapted to the environment of the person concerned, which can range from hotel-type places to strict confinement in the habitual residence.
The process for monitoring and isolating contacts must be based on: •The earliest possible identification of contacts of detected cases.
•The combination of two complementary approaches: intensive investigation around all new cases and mobilization of digital tools under development.
•A diagnosis of the presence of the virus by RT-PCR COVID. Rapid tests that have been validated would probably only be available in a second time.
•If the contacts prove to be positive, then they are cases and the above process is again engaged for their contacts.
•If the close contacts (cf. the definition of cases and contacts given by Public Health France) are negative, about 14 days quarantine at home must be respected.

a) Principles of Implementation
The application of such a device has made it possible to control epidemics such as SARS, MERS-COV and Ebola. For SARS-Cov-2, which has particularly high transmissibility and can be done in the absence of symptoms or before the onset of symptoms, such a device is theoretically likely to significantly reduce transmission of the virus only if it is able to affect a high proportion of cases and their contact (Hellewell J. et al., 2020). To date, it has shown its effectiveness on the ground in Korea and Norway at the cost of a very strong mobilization, not only digital but also human and societal. The high level of coverage, responsiveness and buy-in of the people concerned means mobilising a transparent organisation with proactive communication, technological resources, logistical, and humane, which is particularly important at all stages of the process. Perfect integration between the steps of the process will be a key element, in particular with the production of the results of the COVID RT-PCR tests and the availability of the contact details of the people tested positive. The digital tool can be decisive to strengthen the overall effectiveness of the system, by complementing the actions carried out elsewhere in the field. In practice, this involves implementing a professional public health service to detect, monitor, isolate cases and their contacts. This service will have to be created on the basis of a clear expression of objectives and needs and meet a specification whose principles are indicated above.This service would be based on:
•Regional and/or territorial professionalized platforms linked to the results of the tests and with the information to call the listed cases and their contacts and to propose for each of the identified persons an effective and adapted isolation solution. The issues of protection of the identity of individuals and confidentiality of data concerning them must be controlled with the highest level of security as for any activity of a medical nature.
•Mobile contact tracing and isolation teams, in particular to target isolated or precarious
populations or in case of outbreaks of transmission (clusters). These teams are complementary to the aforementioned platforms and would be coordinated directly with them.
•Digital tools under development (see below). The two approaches (digital tools, platforms and mobile teams) are complementary and potentially affect different audiences. The combination of the two approaches should make it possible to reach all residents on the national territory even those who do not have a smartphone.
These infrastructures and teams will have to be put in place, coordinated and animated at the different regional and territorial levels closest to the population. They will mobilise the public health resources of the state, local authorities and municipalities. They may be formed by the mobilization of doctors, paramedics, volunteers and personnel to be recruited. Operational training providing the data confidentiality requirements must be formalised and provided to each of the components of this service
in terms of contact tracing, risk assessment based on reference systems, conduct delivery to be maintained in terms of isolation and orientation towards diagnostic and clinical care of proximity (general medicine, etc.).
This service must be known and understood by the population as a whole, especially by those who are least socially privileged. There will be a need for transparent and appropriate communication, particularly in the area of literacy. It will have to use multiple complementary approaches including the active involvement, as early as possible, of the entire medical community, in particular of the urban medicine.
b) A specific place for digital tools (see Sheet 6)² 
At the same time, digital tools provide the public with simple ways to determine whether one is a probable case, in this case being oriented towards test sites, quickly obtaining the result of one’s test, being followed medically if one is positive, learn if you have been in contact with a case and more generally assess the risk of infection to which you have been exposed. Digital tools also have a key role to play in supporting logistics, including testing, rendering test results, managing hospital resources
The Scientific Council sees digital tools as a very useful part of the epidemic control strategy. In support of the other recommendations, given the significant risk of a second epidemic wave and new containment, the Scientific Council considers that the digital tools to improve the effectiveness of health control should be deployed in France, in consultation with the European institutions and European countries if possible. These tools must be part of a comprehensive health control strategy, of which they are only one element. It will be necessary for people using these digital tools to be able to contact a telephone platform (see above) whose function will be to respond in a personalized way on the conduct of isolation and to accompany and support them in this perspective.
These tools are not technologically neutral, especially since they use a variety of instruments (mobile applications, platforms, algorithms, software, extremely varied datasets) that can give rise to a wide variety of organizational uses, clinics or public health. They can raise acute legal and ethical issues that need to be addressed to strengthen public and health staff buy-in for their use. In this regard, the Council insists on the importance of working on devices that are also designed to benefit the millions of
our remote citizens. Health effectiveness is achieved through adherence, inclusion and transparency. In view of their sensitive nature, the Council considers that these tools should be put into service and managed by public health authorities and that their deployment should be limited to the period of the state of health emergency and be framed by clear governance, open and transparent to encourage our fellow citizens to support their public health goals.
2. The general rules of containment lifting: maintaining social distancing and reinforcing barrier gestures
Only compliance with rules strictly limiting the circulation of the virus makes it possible to consider lifting the containment.
a) Strict compliance with barrier measures
This respect is essential in controlling the epidemic. This will include maintaining the social distancing rules developed and implemented in recent weeks (maintain a physical distance of at least one metre on each side, do not shake hands, do not kiss, do not hug, telework, school closures, the prohibition of gatherings, closures of gathering places, closure of certain types of trade…).
The principle is the respect of the minimum distances (at least 1 meter on each side) to avoid respiratory and manual contamination by droplets. This principle must be respected in all public places, businesses and public transport. Hydro-alcoholic gels and masks for the use of health care personnel, people exposed to the virus, and more generally of the population will have to be available without risk of supply disruption. In particular, it is necessary to provide a sufficient number of physical protection material accessible to the whole population.
Places receiving the public must offer protective equipment for customers or residents: protective masks and hydro-alcoholic solution. Failure to comply with these rules must lead to administrative closure of these premises.
The wearing of an individual mask in places receiving the public must be systematic during the post-confinement period. Only a continuation of the low-level epidemic monitoring indicators for several weeks could lift this measure. The Scientific Council wishes to emphasize the feeling of security wrongly given by wearing a mask. It is effective when coupled with strict respect for the confinement measures and social distancing and the respect of the instructions of use.
(b) Places that are in confined spaces
It is suitable for each to strictly respect the physical distance rule of one meter on both sides in all places outside his home, including in closed or confined places if he is close to persons outside his intra-family home. Confined places correspond in particular to workplaces and all establishments receiving the public. In the absence of compliance with these rules, the risk of transmission of the virus between people remains very high.The Scientific Council considers that strict compliance with all rules is mandatory (social distancing, mask, gel, etc.) for a careful and progressive opening of businesses. With regard to the places remaining open, the control of the measures implemented by their operators and their effective respect (display of information on barrier gestures and physical distance rule of one meter on each side and another maximum density rule of people in these different places, etc.) is the responsibility of the authorities who must consider conditions for their application.The Scientific Council calls the attention of the authorities to the particular issue of public transport. Failure to comply with distance rules a metre on both sides whether or not users wear a mask of protection (is an important vector of virus transmission, both in terms of speed than volume) which could lead to the uncontrollable recovery of the epidemic.
c) Continued closure of public assembly sites
The Scientific Council considers it necessary to keep closed or banned all places and events that have as their object or consequence to bring the public together in numbers, whether they are in closed rooms or outdoor spaces.
3. General Travel Rules
The movement of individuals is a potential source of circulation of the virus and therefore of reappearance in areas with high circulation. This opinion concerns, as a reminder, the strategy for the two months following the release of the containment.
a) Urban and peri-urban transport
It is proposed to allow urban and peri-urban travel as long as the above-mentioned barrier measures and social distancing rules are respected. If the resumption of work is contained by telework-type measures (see below), maintaining the usual transport rates will limit the concentrations of passengers in confined spaces at high risk of viral transmission.
b) Inter-regional transport
It is proposed to allow interregional travel by public transport once again, as long as the barrier measures and social distancing rules are respected (cf. supra.). The occurrence of a regional epidemic outbreak can lead to a resumption of local containment rules and the suspension of inter-regional transport.
c) Transport between the metropolitan area and the ultra-marine territories and departments
The Scientific Council delivered a specific opinion on these territories and departments. It stresses the need to protect these territories and departments by applying strict rules of fourteen and diagnostic at the arrival of travellers.
d) International transport until summer 2020
The aim is to reduce the risk of reintroduction of the virus on national territory.
These movements are strongly discouraged during the months following the release period. Travelers are exposed to a risk of quarantine upon arrival in the destination country, a risk of contamination during the stay and the application of quarantine measures upon return to France. This policy should particularly target people coming from areas (EU or non-EU) with a high circulation of SARS-Cov-2, as well as from areas or countries (EU or non-EU) according to the degree of strict health control at their borders. Several intensities of controls can be considered, up to the systematic quarantine of people from areas with a high circulation of SARS-Cov-2 and/or without strict health control of their bordersConcerning mobility in the euro area, measures to diagnose and isolate people from outside the euro area. The European Union must first be harmonised on a sufficiently high standard to allow sufficient control of the epidemic within the intra-European area before it can be envisaged to allow movement without health checks at the entry of the national territory.
Travel abroad will in all circumstances have to respect the rules regarding travel abroad during the period of COVID-19 stipulated by the Ministry of Foreign Affairs.
Upon return, persons arriving on French territory must be subject to:
•A COVID RT-PCR diagnosis;
•Strict isolation if the diagnostic test is positive;
•Voluntary isolation at home if the diagnostic test is negative.
4. Rules applicable to specific populations at risk of serious forms and/or risk of transmission (see Form 2)
The different populations involved present different risks that make it possible to propose differentiated provisions:
a) People over 65 and/or with chronic conditions
Some of our fellow citizens are at higher risk of serious illness and death due to age or health (chronic at-risk conditions such as high blood pressure, diabetes, coronary heart disease or cancer being treated, etc.). 82% of deaths were observed in hospital in patients over 70 years of age. The population at risk of severe forms requiring hospitalization or ICU care is for people over 65 years of age, 800,000 of whom live in accommodation facilities for dependent elderly people. People with long-term illnesses and 160,000 people with disabilities living in community housing facilities. In total, this population is estimated at nearly 18 million people.
In the exit phase of containment, many people carry the virus and are therefore potentially contaminating, even when they show no clinical signs. These individuals are at a very high individual risk of developing serious symptoms. They need to be informed. However, this population does not have a higher risk of transmission of SARS-Cov-2 to other citizens. The Scientific Council advises these people to respect a strict and voluntary containment, which protects them from contamination risks. Unlike mandatory confinement, voluntary confinement is not intended to curb the epidemic; it allows people to protect themselves on the basis of an informed personal choice. This choice must be available to those at risk who are working.
The situation of persons residing in collective accommodation facilities must also be carefully considered because the risks are not only individual but also linked to the organisation of the establishments. In collective hosting structures, the diagnostic strategy of cases and contacts must be strictly applied. Upon diagnosis of a contaminated person, he/she must be isolated in an ad hoc structure until recovery. In this case, all persons in the structure must be diagnosed by an RT-PCR test, including caregivers and
administrative staff.For older people residing in facilities with dependent elderly people (EHPAD), the risk of transmission is significantly higher for both residents and caregivers. In view of this factor and the risk of serious forms, it is necessary to continue to confine the residents, although they must urgently find means of social liaison between the residents and their families (visual visit, RT-PCR COVID diagnostic tests before a physical visit, etc.). Strict adherence to barrier measures must be maintained to minimize the risk of virus intrusion into still healthy institutions. A minimum number of visits is likely to reduce the suffering of residents and to avoid very harmful or even fatal &quot;slips&quot;, at least in regions where this is possible.
b) Populations under 25 years of age
In the current state of epidemic knowledge, the risk of serious symptoms is low in this population. The risk of individual contagiousness in young children is uncertain but appears to be low. On the other hand, the risk of transmission is high in places where schools and universities form a large group, with measures that are particularly difficult to implement among the youngest.
As a result, the Scientific Council proposes to keep nurseries, schools, colleges, high schools and universities closed until September. Societal issues also exist, particularly for children who, as a lack of school can lead to situations of abuse.
The Scientific Council takes note of the political decision taking into account the health issues but also societal and economic, of the progressive and prudent reopening of nurseries, schools, colleges and high schools. For nurseries, schools, colleges and high schools alternative solutions allowing reception and learning while respecting the measures barriers and distance can be considered. In this case:1) These establishments must imperatively put in place the necessary conditions for their reopening: compliance of sanitary facilities in schools, provision of hydro-alcoholic solutions, the arrangement of rooms allowing the respect of interindividual distances etc., and 2) the measures barriers will have to be pursued in a reasonable and individualized way at the home of the children to avoid the risk of contagion in the context of the family home.
In addition, the Council calls for special vigilance to maintain the continuity of all child welfare services. This continuity must be accompanied by a clear reference of the persons and services or structures that can be reached. This listing will be communicated to all children, families and professionals concerned. It will be accessible online.
The Scientific Council proposes that epidemiological and virological pilot surveys (RT-PCR and serology) be carried out urgently and iteratively on this population. A more precise note on the procedures for reopening schools and colleges is being prepared.
c) Persons aged 25 to 65 years with no chronic diseases
This is a normal working population. These people have a limited risk of serious form but sufficient to succeed in case of massive contamination like the one known before the confinement period in some regions (Grand Est, Ile de France), a new saturation of hospital services and consequent mortality. It is, therefore, possible to consider lifting the containment subject to the general rules outlined above.For administrations, it is proposed to maintain Business Continuity Plans allowing for teleworking for a significant proportion of staff.
For companies, it is proposed to maintain teleworking where possible, on all or more than half of the working time. For shops, craftsmen, etc., it is proposed to resume an activity scrupulously respecting the rules of social distancing and the use of masks in shops, workshops etc. which must be organized accordingly.
The aim is to gradually resume a face-to-face activity involving, if possible, only half of the workers.
d) Precarious or homeless persons
The Council has already stressed the fragility of these people in epidemic situations. In addition to the consequences of their personal health, their living conditions reinforce their vulnerability to contamination and thus to the recovery of epidemic outbreaks. It is necessary to protect the populations most at risk of the epidemic due to their habitat situation with targeted efforts (e.g.: in situations of great insecurity, prisons, people in institutions).
e) People who developed COVID-19
In the absence of scientific certainty at this stage on the acquisition of protective immunity in people who have developed COVID-19, it is proposed that the general measures be applied including to those immunized people.

5. Regular interval surveys to estimate immunization in the population including children
It is essential to have an estimate of the proportion of the population that has acquired immunity to the consequences of the first epidemic phase according to the regions. Serological tests are currently being validated, for some already existing and likely to be deployed on a large scale within a few weeks.
Knowledge of the level of immunity of individuals and the population is essential to follow a strategy of phasing out containment. These tests are a tool for epidemiologists and have a reduced utility for individual management.
6. The implementation of targeted communication for different target audiences
All the measures proposed above must be accompanied by appropriate and renewed communication in order to strengthen the support of our fellow citizens. This communication should be based on repeated assessments of the public’s knowledge, perceptions, attitudes and practices, and use available communication and public health knowledge. It must be stable and in the long term, corresponding to the prospects of returning to normal, even if it is to be shortened later, rather than the reverse, each extension representing a significant cost in an emotionally sensitive context. It must make use, in a differentiated manner according to the target groups, of the available knowledge on communication and public health.

CONCLUSIONS

The Scientific Council identified six prerequisites for mobilizing sufficient resources to implement a strategy to exit containment. These epidemiological and operational requirements must be met before a release of containment can be authorized. Otherwise, significant risks would be taken. Other parameters such as the incidence of diseases other than COVID-19, but also the economic and social impact of the health crisis, must be taken into account in this period.
The Scientific Council proposes a scenario of phase-out of containment for the next two months based on the application of measures whose intensity can be modulated over time according to the monitoring indicators. All these six measures must be implemented and followed up so that such a strategy is not only coherent but also effective. Specific data sheets on tools, instruments and measures are proposed in the Annex. The implementation of these measures and the longer-term perspective will be reviewed in future notices.
The risk of release from containment is that of a second epidemic wave, particularly if, as is likely, collective immunity remains low. If the early epidemiological indicators based on extensive diagnostic testing (RT-PCR) showed a resumption of the epidemic, it would be necessary to apply stricter social distancing measures up to a new containment. It could be partial or generalized. It could be regional or implemented in a specific territory. This scenario must be avoided, both from a health and economic point of view.
In the current state of knowledge, the only possible strategy is a gradual exit from the containment taking into account the risks of the different populations to adapt the protective measures.

3 key points

1. The Scientific Council stresses the importance of implementing the necessary actions to ensure that the 6 prerequisites are met, and the 6 key measures of the recommended scenario are operational before considering an exit from containment.
2. The Scientific Council highlights measures such as case screening, the possibility of screening for hospital and non-hospital caregivers, expanded screening in EHPAD-type containment sites, etc. can and should be implemented now, without waiting until mid-May. This will allow for a gradual increase in load and facilitate steering.
3. The Commission considers it essential that civil society is involved in this process and its implementation, with the creation of a Community Liaison Committee.                                                                                                     “Trust to maintain trust”

SHEET 1

INSTRUMENTS AND STRATEGIES FOR THE CONTROL OF EPIDEMICS/COVID-19

I. THE INSTRUMENTS
3 instruments contribute to the non-targeted limitation of the number of new cases:
1. Social distancing. The strategies of individual distancing (restriction of inter-individual contacts) or collective (restriction of social life, more or less strict forms of containment) make it possible to fight effectively against the transmission of the virus. It is possible to scale the intensity of these social distancing measures.
2. Material protection. These include public health measures, barrier gestures, the use of hydro-alcoholic solutions, or the deployment of protective equipment, including masks of various types.
3. Immunization. Immunization can be acquired naturally through direct contact with the virus or through vaccination. There are currently no vaccines available for COVID-19. Serological tests are used to detect immunization acquired after exposure to the virus. These tests can be used on a large scale after the qualification of the solutions under development.
4 instruments allow a targeted limitation of new cases by identifying cases and their contacts:
1. Virological tests for diagnosis of acute forms, making it possible to make the diagnosis of people carrying the virus and therefore contagious (existing PCR tests and possibly rapid antigenic tests to come)
2. Contact survey technologies. These investigations are an important part of controlling an outbreak when it is either at its beginning or at its end to identify and control residual cases.
3. Digital technologies for probable case diagnosis and contact identification. Digital tools downloadable on smartphones offer diagnostic help to relieve congestion in call numbers like the 15. Other tools allow the identification and alert of contacts of a confirmed case.
4. Isolation of contacts or COVID+ patients. The use of the solutions described above is of interest only if a proactive policy of containment of cases and contacts is applied, the only one capable of allowing control of the epidemic.
2 instruments to limit the impact in terms of mortality:
1. Hospital-based care and resuscitation capabilities directly impact the number of deaths. In addition to this hospital capacity, extra-hospital courses using ancillary units (COVID-Anciens SSR) are being set up in certain regions.
2. Drugs. There is currently no effective drug for COVID-19. Once available, a more or less active drug may play a decisive role in limiting the impact of the epidemic (i) by avoiding the evolution of benign cases to serious forms requiring hospitalization and (ii) by rapidly decreasing the viral load, certain anti-viral treatments that also reduce the contagiousness of cases.
II. STRATEGIES
Different strategies can be adapted to control an epidemic. These strategies are not exclusive and are adapted according to the evolution of this epidemic assessed by its transmissibility, the number of new cases and its geographical distribution.The ultimate goal of these strategies is to completely suppress circulation and lead to the absence of new cases.
The natural evolution of the epidemic
A strategy to control an epidemic must be compared with the evolution that would be observed in the absence of intervention. For COVID-19, the natural evolution of the disease implies a spread of the epidemic until the development of a collective immunity preventing the spread of the virus in the population. Given what we know about COVID-19, only immunity of at least 60% of the population would allow protection that could stop the epidemic (cf. previous opinions of the Scientific Council).
To date, no country has maintained a strategy based solely on the development of collective immunity when the number of hospitalized and deceased has increased substantially. The rate of spread of the disease and its lethality rate close to 1% prevents this option from being considered. Faced with this natural evolution of the disease, two approaches were proposed: the Chinese strategy in Wuhan and the strategy implemented in Korea.
The strategy of extinction of the epidemic
This strategy consists in stopping the spread of the virus until no more transmission of benign cases or complicated hospital cases. The objective is to flatten the appearance curve of new cases. The protection of the population is not achieved by the development of collective immunity but by the suppression of circulation in the population. This risk suppression involves drastic measures to prevent the virus from circulating outside a nearby family environment. This strategy is therefore based on strict containment (without exit for any reason), important control measures and systematic detection and
management of cases.
To be effective, this strategy presupposes that the measures are maintained for a long enough period of time to virtually stop the circulation of the virus. Wuhan’s Chinese experience shows that 10 weeks of confinement seems necessary to achieve this goal (Fineberg, 2020) and to find that the virus is not circulating. Finally, when the measures are lifted, it is necessary to maintain a very strict device preventing any new circulation of the virus.
Often used at the beginning of the epidemic, this strategy involves implementing very important means of control by reducing individual freedoms (freedom to come and go in particular) and by very strongly restricting the activity of a region or a country.

The epidemic risk control strategy
This strategy aims to slow the progression of the virus, without the objective of stopping it completely. It is based on the activation of the different measures (cf. supra) according to the speed of circulation of the virus. This reduces the pressure on the health system and allows research teams to develop preventive (vaccines or drugs), therapeutic (drugs) or diagnostic solutions (tests, digital solutions, etc.).
This strategy implies accepting, in the current state of knowledge, that a number of serious forms of death occur as a result of the low-noise progression of the epidemic. The intensity of control exerted on the circulation of the virus will condition the observed results.
In summary, only China in the Hubei region and specifically in Wuhan has chosen a strategy of extinction of the epidemic from the outset. This strategy was based on a very strict, controlled and prolonged containment until the disappearance of the virus transmission measured by the disappearance of new cases, that is 10 weeks before a gradual lifting.
Many other countries have implemented a strategy to control the epidemic with the eventual goal of extinction. Several countries, such as Korea, Singapore, Hong Kong and Taiwan, have so far managed to contain the COVID-19 epidemic without resorting to containment. These countries rely on the combination of strong control measures accompanied by a significant deployment of technological and human resources. New digital tools strengthen epidemic control performance. These examples suggest that an epidemic control objective can be achieved with very restrictive measures but without general containment of the population.

SHEET 2

THE DIFFERENT POPULATIONS CONCERNED IN FRANCE

Epidemic control tools can be targeted differently depending on the risk of developing serious forms of the disease.
Populations at high risk of serious forms and death
Age appears to be a risk factor for severe forms of COVID-19 with lethality rates for clinical forms of infection close to 15% in people over the age of 80, compared to 3/1000 (0.3%) in people under the age of 60 (Verity et al, 2020).
The presence of comorbidities is another risk factor for severe forms. The main comorbidities are high blood pressure, diabetes, coronary heart disease, and overweight. It should be noted that there is no French data to establish risk scores at this stage.
Age
In France, 82% of patients who died in hospital were 70 years of age. Moreover, only 10% of the people who died in France were under 70 and 4% under 60. The proportion of patients admitted to resuscitation was as follows: 1% in the under 15 years: 1%, 15-44 years: 8%, 45-64 years: 29%, 65-74 years: 36%, and over 75 years: 26%. The average age of people admitted to ICU was 65. Age is therefore a major risk factor for death and serious forms, many of which are not managed in ICU in people over the age of 70.
Comorbidities
Among 1099 infected patients documented in the Chinese study, the frequency of comorbidities was 39% in severe forms. An unfavourable trend (defined by a composite criterion: admission to resuscitation/ assisted ventilation/ death) was noted in 58.2% of cases in the presence of comorbidity, compared to 21.5% in the absence of comorbidity. The main comorbidities are high blood pressure, diabetes and coronary heart disease.
In the absence of reliable data in France, it can be noted that 5 million people under the age of 65 are carriers of long-term conditions. Add all people treated for high blood pressure who do not fall under ALD 30, especially for medium and severe forms.
In France, for example, 18 million people are at higher risk of serious forms or death. Of these, 14 million people are over the age of 65. In addition, 700,000 seniors live in accommodation facilities for dependent elderly people.

Active and low risk or moderate risk population
People aged 20 to 65 (43 million people) without comorbidities have a low or moderate risk of serious forms of death. Moreover, they have no particular risk of contamination and carry out an activity that can be completely or partially dematerialised.
Some of this population is not or is only very little affected by the current containment. This is the case for hospital and city caregivers and auxiliary workers, especially in public places that are exposed to high viral load environments and therefore to a high contagious risk.
Others work in strategic areas that cannot be dematerialised.

School and University Youth
This population (15 million people) is at little risk of serious forms but is exposed to a high risk of contamination and can be a vector of contamination to older people. Schools and universities are places at significant risk of contamination.
The immunised populations
In the absence of a vaccine, only contact with the virus can lead to immunisation that can protect individuals. Based on the surveys carried out in late March and early April 2020 in the regions most affected by the epidemic, it can be estimated that the proportion of subjects carrying antibodies is less than 15% in these regions. Therefore, we can think that the collective immunity, which should be of the order of 60% of the population to be effective, will not contribute or little to the control of the epidemic when leaving confinement.
Principles for a successful exit from containment for people at risk of severe forms
It is important to recall the severity of COVID19 for people at risk as previously defined. Exit from containment must therefore be considered according to the following principles:
-If the first phase of containment was to reduce the circulation of the virus by decreasing the inter-personal relations, the exit from containment raises the question of the protection of the people most at risk.
– The protection of fragile people at risk of serious forms requires the reduction of the risk of contamination, in particular by carriers of the virus presenting no symptoms.
– This protection can only be a voluntary attitude on the part of the people concerned.
– Collective housing conditions that may promote the risk of contamination of people at risk of serious forms may require maintaining significant barrier measures.

Proposals for containment exit conditions
The Scientific Council wishes to reiterate that the following proposals are valid for the two months following the release from containment. At the end, they will have to be reconsidered according to the circulation of the virus.
Persons in employment with risk factorsThe Scientific Council recommends that an individual risk assessment be carried out by the treating physician before 11 May for people with ALD, receiving long-term treatment, over 65 years of age or who consider themselves at risk. This assessment should take into account the pathology and treatment received, the work situation and the geographical situation (active or not circulation of the virus).
The Scientific Council considers that, in the current state of knowledge, teleworking must be promoted for this category of persons but that it is possible, depending on the individual risk assessment, to consider either a work stoppage or a face-to-face work, the occupational doctor must then ensure that the barrier measures are strictly observed at the workplace.
Persons over 65 years of age or who have risk factors but do not work
The Scientific Council recommends that, in the state of knowledge, these people avoid the risk of contamination, in particular by asymptomatic carriers, by adopting a ‘containment’ voluntary during the weeks following release from confinement and close contact with children potentially presenting a particular risk due to the frequency of asymptomatic forms. This voluntary confinement therefore consists in limiting to the maximum the risk of contagion in places with high frequentation.
People at risk of serious forms in collective accommodation
The Scientific Council considers that in the state of knowledge these establishments must avoid the risk of contamination of residents by detecting positive people as quickly as possible by extensive practice of diagnostic tests by RT-PCR according to the rapid investigation methods proposed upon release of containment, and by immediate isolation of cases of COVID-19 confirmed by these tests.
Persons residing in care facilities for dependent elderly persons (EHPAD)
The Scientific Council considers that, in the state of knowledge, these establishments must maintain containment measures to protect the residents of these establishments from contamination. However, the Scientific Council considers that prolonged confinement in these establishments can be a source of long-term deleterious effects (social isolation which can lead to sliding syndromes in the elderly and a mobi-mortality unrelated to COVID-19). From 11 May, the resumption of visits should be considered. The arrangements for the organization of visits must be done on a case-by- case basis and in conjunction with the supervisory authorities (ARS and departmental councils) and under sanitary conditions that allow strict respect for social distancing and barrier measures.
The extensive practice of diagnostic tests by RT-PCR at the first signs suggestive of COVID19 impairment in both a staff member and one of the residents must allow for any significant risk of contamination.

SHEET 3

SEROLOGICAL TESTS: LIMITS AND USEFULNESS

At the beginning of a pandemic, the entire population is “immunologically naive” to the pandemic virus. This means that no one has protective antibodies, which allows the virus to spread massively throughout the population. The detection by serological testing of specific antibodies to the circulating virus makes it possible to confirm retrospectively the diagnosis of infection in an individual, Igg antibodies are detectable 15 days after infection in the vast majority of patients with severe forms of COVID-19. For those who have made benign, even asymptomatic forms of the disease, the detection of antibodies may be later and requires more sensitive tests.
The current data available does not yet allow to know the duration of protection conferred by antibodies developed by people infected with SARS-Cov-2. Experience from other seasonal coronaviruses (OC43, 228E, NL63 and HKU1) suggests that infected individuals will benefit from short-term protective immunity (at least a few months). The measurement of antibody titers and the analysis of their neutralizing capacities, will allow to better estimate the duration of protection. The exact protective value of these antibodies is not yet known.
The ability of a serological test to detect antibodies in an individual carrying antibodies is called test sensitivity. The ability of a serological test to declare an antibody-free individual when it does not have one is the specificity of the test. The tests now available and intended to be widely used are field unit tests and automated laboratory tests of the ELISA type. The sensitivity and specificity of field unit tests will likely be lower than that of ELISA tests, making them less accurate and informative.
Two uses of serological tests are possible: individual and collective. The individual tests will allow a subject to know if he has been infected with the new coronavirus. Group tests will be carried out in the context of population epidemiological investigations to determine the degree of collective immunity acquired by a given population.
For the individual use of the tests, one of the main limitations today to their practice is the lack of sensitivity and specificity of the tests, estimated overall at 90% and 95%, respectively. This means that one in 10 antibody carriers can be falsely declared negative by the test. And that one in 20 non antibody carriers can be falsely declared positive by the test. In a context of low prevalence of carrying antibodies in population at the end of the first epidemic wave (estimated around 5% for France), 5% of false positives from the test mean that only half of people with a positive HIV test will actually carry antibodies. Finally, in the absence of reliable data on the protective or non-protective nature of antibodies, the recommendation given to people with a positive HIV test result will be to continue to practice barrier gestures and social distancing measures. For all these reasons, the interest of antibody screening for individuals is limited and will be reserved for specific situations (e.g., health care personnel, especially those working in accommodation facilities for dependent elderly people).
In this context, serological tests will be used primarily not for the determination of an individual status, but rather for epidemiological investigations in order to determine the level of collective immunity reached in populations more or less exposed during the first epidemic wave. These surveys will need to be conducted regionally and nationally, and will be repeated regularly to monitor the evolution of immunity in populations. This information is essential to accurately assess the risk of re-circulation of the virus from containment release, and therefore the risk of a second outbreak. The collective immunity necessary to protect the population from a restart of the epidemic is estimated at 60%.The collective immunity acquired during the first epidemic wave in the most affected regions is estimated at around 10%. When the containment is released in mid-May 2020, serological tests can be performed on a large scale using ELISA or similar techniques (possible flow of more than 100 000 tests per day). The usefulness of TROD at the individual level is relative, but there will likely be strong demand. It should be recalled that these tests can be performed on medical prescription only.
Thus, the priority of the coming weeks will focus instead on the wide-scale availability of diagnostic tests RT-PCR, carried out on medical prescription, the main tool of diagnosis of infection in front of a symptomatic patient and control of the epidemic. The realisation of large quantities of this test will make it possible to accompany the lifting of the containment and to minimize the risks of recovery of the epidemic. Serological tests should be performed in addition to RT-PCR tests. They will make it possible to carry out targeted surveys (using the most efficient TROD), and especially repeated sero-epidemiological surveys (using ELISA tests) to determine the level of population immunity, a major and complementary element of RT-PCR for the determination of the risk of resumption of the epidemic.

SHEET 4

IDENTIFICATION, ISOLATION OF CASES AND FOLLOW-UP OF CONTACTS

In order to be able to gradually and partially release the constraints of containment while maintaining a low level of transmission of SARS-Cov-2, an extremely ambitious program of control of the epidemic must be developed. This programme should make it possible to identify the likely cases on the national territory as quickly and as comprehensively as possible in order to test them and isolate them if they are positive. Case contacts should also be identified, tested and isolated if necessary. Such a strategy, advocated by the WHO, draws on the experience of countries such as Korea, Taiwan, Singapore, or regions such as Hong Kong, which have so far managed to control the COVID-19 epidemic.
The Scientific Council would like to begin by highlighting the many challenges associated with the implementation of such a program. Indeed, a strategy based on identification, case isolation and contact tracking can be very effective in fighting viruses such as SARS where the majority of infected people have severe symptoms and are therefore easily identifiable. For a virus such as SARS-Cov-2, the effectiveness of the device is reduced because many cases with little symptoms may not be identified. In addition, isolated cases may have transmitted the virus before becoming symptomatic. Despite this reduced effectiveness, it is clear that the use of this strategy has produced very interesting results in several countries. In order for such a strategy to produce similar results in France, the system put in place must be extremely effective. It must be based on extremely important technological, logistical and human resources, enabling it to cover the entire national territory efficiently and quickly. Digital tools have an important role to play in enhancing its effectiveness. Ultimately, the level of containment release will depend on the effectiveness of this new device.In order for this strategy to be used, the following elements must be brought together:
Detection and referral of suspect cases
The Professional Public Health Service, which relies on regional professionalised platforms, mobile teams and digital tools (see Main Notice), must make it possible to detect suspicious cases as quickly as possible. In case of suspicion of SARS-Cov-2 infection, the person is referred to a test facility near his home for testing.
A network of infrastructures to test cases
Suspect cases should be easily tested and receive their results quickly. This requires a large network of infrastructures on the national territory, as well as a very efficient logistics organization. France can draw inspiration from the Korean model where patients can be tested in hundreds of clinics and in dedicated drive-in screening stations, very well organized throughout the country.
It is essential to have adequate “digital tools” so that patients can receive their results as soon as they are generated, for example by SMS. These results should be able to be used to inform other parts of the response, for example by initiating epidemiological investigations to find the contacts of cases. It is therefore necessary to ensure good interoperability between digital systems supporting the different
aspects of the response.
Case Isolation Measures
To reduce the risk of community transmission, suspected cases should be isolated at home until the test result is known or for a period of two weeks after the onset of symptoms. Positive cases should be isolated for a period of two weeks after the onset of symptoms. For cases with mild symptoms, two approaches can be considered: the person isolates himself in the family home; or he is quarantined in a dedicated structure.
Isolation within the family home increases the risk of intra-family transmission. This risk varies from one household to another depending on the characteristics of the household (housing size, number of people, presence of vulnerable people). This risk can be more easily controlled in some family settings, and more difficult in others.
The reception of the case in a dedicated structure limits the intra-family transmission but raises other important problems both in maintaining the relational links (between adults, children, etc.) and in terms, once isolated, of protection of the rights of the infected people. The effectiveness of such a measure of isolation in structures dedicated to infected persons may also be limited when isolation is delayed and intra-family transmissions may already have taken place.
When a positive case is detected, all members of the focus are tested to assess the extent of intra-focus transmissions. A risk assessment of intra-family transmission is then conducted by a physician or a member of the local COVID-19 team to determine with the family the most appropriate isolation strategy given the family context. Isolation in a dedicated structure should be preferred where possible.
If isolation within the household is decided, the other members of the household must also isolate themselves. The duration of this isolation should be extended if other cases are detected in the household.
Epidemiological investigations around cases
Given the possibility of transmission through asymptomatic or pre-symptomatic cases, it is essential to have particularly effective tools to quickly identify case contacts. Two complementary approaches must be considered:
Epidemiological surveys: Investigative work is traditionally carried out by teams of
epidemiologists who interview the identified cases to establish their contact list. The latter shall be informed individually of their status. The procedure can be lengthy, laborious and imperfect (a case does not necessarily declare all its contacts). Due to these delays, the contacts identified have already been able to transmit the virus themselves. Given the significant resources mobilized by this type of investigation, a large scale transition seems impossible in this form if it were to be based solely on the ARS teams. The creation of local control teams COVID-19, spread across the territory, is an important tool to contribute to this effort (see main notice).

Digital tool: The digital tool can be extremely valuable in enhancing the effectiveness of this device. Asian countries that have contained the COVID-19 epidemic to date have used strategies that combine field investigations involving large teams using digital tools. These approaches may have been criticized when they did not comply with the rules on the protection of personal data, in terms of consent or anonymity in particular. However, we note the emergence of an alternative European model, which ensures respect for the
protection of personal data. For example, a pan-European consortium is currently working on a tool that complies with the General Data Protection Regulation (GDPR). This tool is developed in partnership by several public research centres in conjunction with German cyber security and data protection agencies. An App is installed on mobile phones based on volunteering. It encrypts contacts between users, based on criteria such as distance between phones and contact duration. If a person is diagnosed positive, the contact list is extracted from the phone and decrypted. Contacts are invited to be tested and isolated if necessary (see above). Each contact does not know who was found positive among their own contacts. It could be a close acquaintance or a crossed stranger in a public place. This approach makes it possible to obtain for each case a list of contacts who have consented to use the application. This information can be obtained instantaneously and for all cases detected on a given day, which is impossible to envisage with more traditional approaches.
Several European countries have announced that they want to use this type of tool. A pan-European solution would allow cross-border transmission cases to be taken into account. Modelling work suggests that this type of approach can significantly enhance the effectiveness of epidemic health control. To avoid duplication of effort, it is essential that these two complementary contact tracking systems (mobile teams and digital tools) be as integrated as possible.
Follow-up of contacts
Once identified, case contacts are immediately notified of their status. They are encouraged to be tested by RT-PCR ideally five days after the date of contact to maximize the chance that the test will be positive if the person was infected during contact. A serological test can also be performed concurrently to determine if they have been previously infected. Contacts should isolate themselves at home until they are confirmed not to be infected with Sars-Cov-2, for a maximum of 15 days. If they are tested positive, they are considered cases. If they develop symptoms within 15 days of contact, they are also considered cases, even in the absence of diagnostic testing.

SHEET 5

AN OPERATIONAL EPIDEMIOLOGICAL SURVEILLANCE SYSTEM

Exit from containment shall be based on an operational, reactive and reliable epidemiological surveillance system that:
1. Identification of new cases and their contacts for immediate management
2. Measuring severe morbidity related to COVID-19 through hospitalisations and ICU admissions
3. The detection of a recovery of the epidemic, local or general, with in particular the estimation of the effective R.
4. Estimation of the impact on mortality related or not to COVID-19
5. The estimation of the acquisition of collective immunity against SARS-Cov-2 and its tracking in time and space

1. Identification of new cases and their contacts for immediate management
Identification of new cases in community for immediate care
Diagnoses of infection must be communicated in real time to the ARS and France Public Health whose role is to update the available data on new cases, to estimate the temporo-spatial dynamics at a fine territorial level (e.g. department) and the identification of clusters that may require special support.
Case identification and home control in social and medico-social institutions
These include accommodation facilities for dependent elderly people, medical and social facilities, accommodation for disabled people, other facilities for children, Institutes for hearing and visual impairment), other institutions for adults (home of life, shelter), social assistance for children (departmental centres of children, children’s homes) and other institutions. A reporting system has been set up in the accommodation facilities for dependent elderly people and medical and social facilities, and is being extended to other institutions. The priority objective is to identify the outbreaks early and in a very reactive way by the ARS to intervene, implement the control measures. It should also be used to assess the number of people affected (residents and staff
affected) and deaths in these establishments by region and at national level.
Surveillance of COVID-19 among Infected Health Care Professionals
Health professionals are particularly exposed to SARS-Cov-2 and it is important that the
surveillance system be able to account for the impact of CODIV-19 in this population at national and regional level. France Public Health is currently implementing a surveillance system in this field involving field actors and ARS.
2. Measuring severe morbidity related to COVID-19 through hospitalisations and ICU admissions
The measure of severe morbidity will be based on the number of patients hospitalized for COVID-19 (SI-VIC data) and the number of patients admitted to resuscitation (data from a network of 194 sentinel resuscitation services).
3. The detection of a recovery of the epidemic, local or general and the prediction of the evolution of the epidemic
The monitoring of the epidemic will also rely on a set of surveillance networks already in place such as the network of general practitioners Sentinels, the number of medical acts for suspicion of COVID-19 in the associations SOS doctors, and the number of emergency room visits for suspected COVID-19 (OSCUR data).
Monitoring of diagnostic activity will be essential. The current increase in RT-PCR virological diagnostic capacity will achieve this objective. The return in real time of the results of all diagnostic sources (public and private) including age, sex, place of diagnosis and residence (municipality of residence) to France Public Health is essential to be able to produce indicators (proxy) the incidence at territorial, regional and national level for short time units (week or less). This comprehensive report will allow us to closely monitor the dynamics and detect early transmission repeats and grouped cases (clusters).
New surveillance systems based on internet sites or smartphone triage applications, as well as callbots installed upstream of the emergency numbers on the 15th, will complement the surveillance systems already in place at France Public Health, which are both centralised and regionalised.All these data (case detection, monitoring of severe morbidity, and population-based surveillance systems) allow to feed mathematical models, one of whose objectives is to anticipate the trajectory of the epidemic in the coming weeks, including the daily number of hospitalizations or ICU admissions, the number of beds occupied by COVID-19 patients in conventional hospitalisation or ICU. These models also measure the effective reproduction number R (average number of people infected with a case) at national and regional level. This number must remain below 1 for the epidemic to remain under control.
4. Monitoring of mortality related or not to COVID-19
The number of deaths related to COVID-19 is available daily in hospitals (SI-VIC data) and EHPAD, EMS and other social institutions (see above). The electronic certification of deaths allows a daily count of certified deaths with mentions of causes of death suggestive of COVID-19 infection (pneumopathy, respiratory failure, ARDS, COVID-19). This system, which covered only 20% of national mortality, with a high heterogeneity according to the regions before the epidemic of COVID-19, is in the phase of rapid rise in load requiring, in particular, for city medicine, increase the connection of municipalities to the Exchange and Trust Platform (PEC), allowing doctors to use a mobile application to report death.
The all-cause mortality is estimated on a sample of 3000 communes allowing a surveillance of 77% of the national mortality with a delay of two weeks. This tool allows France Public Health to identify excess mortality at the departmental, regional and national level and according to age by comparison with historical data over several years. These data can also be compared at European level via the Euromomo website.
5. Estimation of the acquisition of collective immunity against SARS-Cov-2
The availability of serological tests for the detection of anti-SARS-Cov-2 antibodies should allow the carrying out of epidemiological investigations to estimate population immunity to the consequences of the first epidemic wave. Studies should focus on the areas most affected by the epidemic to determine whether the immunity acquired in these populations can contribute to the control of the epidemic. The first available results suggest that this will not be the case (around 10%). Other surveys will need to be among the most exposed (caregivers) and most at risk (dependent elderly population).Population surveys based on existing large cohorts (e.g., Constancy) or representative samples of the general population are being prepared. Finally, the system will be supplemented by a system of regular collection in blood banks to follow the major evolutionary trends of the epidemic throughout the national territory.
The completion of these surveys will depend on the validity of the tests used (being confirmed) and their availability. It will also be important to have an estimate of whether or not the antibodies detected are protective.

SHEET 6

ETHICAL AND STRATEGIC IMPLICATIONS OF DIGITAL OPTIONS

The exit from containment involves epidemiological, biological and digital technologies. These uses are based on well-established methods in public health, particularly in an infectious context. The use of digital technologies can significantly increase the effectiveness of these measures, which must be implemented in the epidemic context (Ferretti et al., 2020). They may comply with the principles of personal data protection, but may also be more derogatory in case of obligation. If voluntary uses are preferred, mandatory options cannot be ruled out. They raise a number of ethical issues (Heard, 2020). These uses are also part of a broader digital ecology that needs to take into account strategic and sometimes normative issues.
It is not for the Scientific Council to decide on the normative choices at stake or on the technological options chosen. It would, however, like to stress their importance, particularly with a view to promoting broad acceptance, which is essential to the effectiveness of the solutions implemented.
1. Digital strategies, ethics and public health principles
From the point of view of the Scientific Council, the debate is not to choose between the use and non-use of personalised epidemiological surveillance, traditionally implemented in an epidemic context, but to make the best possible choices, including technological ones. Various bodies have examined the ethical and civil liberties implications of such strategies. They make strong arguments in their favour when saving lives (WHO, 2017). The European Data Protection Committee recently stressed the importance of compliance with the General Data Protection Regulation (EDPB, 2020). The National Digital Steering Committee, attached to the CCNE, has issued ethical recommendations (CCNE-CNPEN, 2020).
In general, health measures to protect the population are a duty of a State. If the principles of consent and anonymity can be lifted in an epidemic situation, this derogatory situation must be limited and proportionate to the expected effects, which can be considerable here. While being technically able to dispense with consent, digital tools also make it possible to collect it through voluntary uses. In the absence of consent, a high degree of transparency must be accompanied by intelligible information, including for people far away from digital.
In the epidemic context, public expectations of technological options are evolving. They are also socially differentiated according to age, relationship to digital, trust in public authorities or socio- educational profile. Possible uses of derogations present real risks, which must not be obscured.
A waiver of anonymity does not imply a waiver of confidentiality. The collection of anonymous information, which can be encrypted, does not imply their open retrieval. These data must not give rise to any uses other than public health related to the resolution of the health crisis, whether these uses are judicial, media, sensationalist («horror stories») or commercial, including in the field of health. These abuses can be detrimental to people as well as to the fight against the epidemic.
The deployment of digital options raises important questions in terms of social justice for our citizens who are far from digital because of their condition, age or geographic location. The deployment of digital solutions cannot dispense with considering the entire population, which is also entitled to the benefits of the intervention. Options adapted to different situations must be proposed using appropriate human, material or digital means.
These elements lead the Scientific Council to formulate some principles that meet the public health objectives of these tools. The technological options envisaged must be informed not only by science and technology, but also by legal, ethical and democratic considerations. The competent public authorities may be asked to make a decision (CNIL, CCNE, CNTR, ARCEP, Agence des données de santé, etc.). The adherence of our fellow citizens to the chosen options, especially digital ones, can be favoured by participatory approaches and by the choice of operators presenting guarantees in terms of ethics and sovereignty.
-General principles and good governance
– A transparent intervention preceded by a period of debate.
-Clear governance and democratic control.
-An impartial ethical monitoring system.
-An intervention respecting privacy and limiting intrusions to the strict necessary.
– An intervention intelligible to the public, including technically (open source code, auditability of algorithms, etc.).
-Respect of ethical principles regarding health and personal data.
-High level of guarantees of security, transparency, reversibility and continuity, in particular through shared solutions serving the public interest (principle of “common”).
-Continuous monitoring of health, social, psychological, legal or economic risks to allow for error reporting and rectification.
-Possible questioning in appropriate legal forms.
-Time limit and explicit exit strategy (erasure of data, absence of tacit extension, etc.).
-An exit strategy that applies to both the public authorities and the companies concerned.
-Evaluation of the intervention
-Public health objectives strictly linked to the fight against the epidemic
-Objective of greater effectiveness in relation to expected public health effects.
-Communication concise and understandable by all results.-Focus on vulnerable or stigmatized groups to ensure that they have equal, unbiased access to intervention.
-Limitation of statements to essential information, without unjustified personal or clinical details.
-Protection against fraudulent or malicious uses (hacking, scams, stolen property, etc.).
-Accessibility for audit and evaluation purposes.

2. Sovereignty and effects on the health care system
On another scale, the deployment of digital solutions can affect the health care system over time, which can be impacted by innovative digital solutions. Without evoking scenarios – however plausible – of a “Uberisation” of the health system, a digital strategy can lead to a significant technological rupture. While the use of digital health has long been the subject of innovations in France, including in the context of derogations (Article 51 of the Law on the Financing of Social Security), the solutions adopted during the epidemic can cause an unprecedented acceleration.
French Tech offers promising hopes and is mobilizing to develop new solutions in an epidemic context. Some solutions are developed in conjunction with public authorities (teleconsultation, logistics, applications, etc.). These options can be part of a not only sovereign but also European framework, by devising European options available in the French context, or by pooling European-wide options designed in a sovereign framework. Whatever the level of intervention, cooperative work between research and industry, between public and private actors and by associating citizen initiatives, can be mobilized. The Epidemic Research Support Committee can help identify useful technological options.
A digital strategy mobilizes a broader technological complex, both biological and digital,
combining public and private capacities, partly international, in a not only cooperative context (European logic, statement by G7 heads of state and government, for example) but also competitive and sometimes protectionist. These links between health, industrial and geopolitical logic are also evolutionary. They require vigilance devoid of naivety on their possible medium-term effects. Beyond the immediate issues, of particular importance, there are issues whose systemic consequences may prove even more important. These issues need to be clarified as soon as possible. The urgency of immediate health objectives can pave the way for an in-depth redefinition of health system regulations, affecting all stakeholders.National regulation can be followed by more international logic likely to escape the logic of sovereignty; a public dominant guarantor of a high degree of solidarity, can be associated with commercial purposes associated with digital in unprecedented proportions; with a professional and institutional organisation, can succeed industrial logic reshaping care activities. Even if these new logic are not absent from the French health system, they can accelerate and change the characteristics of the French health system and the respective positions of the health actors, whether they are professionals, patients or public and social organizations. Particular attention must be paid to the speed of change. The epidemic environment creates a strong demand for digital health services, anchored in pressing and urgent needs. The incentives for these developments are very strong for certain actors, who can legitimately see, beyond commitments motivated by the common good, structural economic opportunities in the medium term.
The usual regulatory elements for this type of evolution, whether professional, institutional or legal, are weakened by the epidemic context. Health workers, who are overwhelmed by their professional duties, can value industrial logic because of its immediate effectiveness, while their consequences can prove problematic. Thanks to technological irreversibility, these developments, if not regulated, can produce important systemic effects. Several scenarios can be outlined. They all describe a logic of rapid innovation, which appears indispensable, but whose effects are differentiated. These scenarios do not exhaust all the possibilities. They can be specified according
to the observed effects.
– Strong innovation scenario without systematic change: accelerated technical innovations without systemic change; effects remain limited to the time of the epidemic, and then serve as support for incremental extensions and innovation logics in a health system that maintains its overall equilibrium.
– Scenario of strong innovation with systemic change: accelerated innovations with long-term effects on the organization of care and the health system, producing a systemic change in which new industrial operators acquire a structuring capacity at the expense of professional and institutional actors, with difficulties of public regulation due to strong international logic, the irreversibility of technological options, the high speed of sustained deployment of innovations, the active political work of the sectors concerned; the delay of regulatory institutions compared to the stakes in a context of structuring not only national but also global.- Strong and regulated innovation scenario: accelerated innovation in the time of the epidemic, mobilizing technological options compatible with the logic and information systems of the French health system, combined with public regulation work, ranging from the regulation of technological options to the supervision of market players, until their integration into the public sphere for reasons relating to the sovereignty or solidarity of the French health system.

INTERNATIONAL POINT

EXPERIENCES OF OTHER COUNTRIES ON EXIT FROM CONTAINMENT AS OF 18 APRIL 2020

The objective of this point is to study the exit strategies established by the other European countries, similar to France in institutional, economic, legal and technological terms. However, it is necessary to recall that these comparisons of European strategy are limited since the national situations are extremely heterogeneous from the epidemiological point of view. Thus, exit strategies from containment cannot be transposed into the same modalities in France. In addition, these operational strategies are evolving rapidly.
Two specific points are addressed: the reopening of schools and the specific procedures for deconfinement of people at risk.
1. The reopening of schools
As of 19 April 2020, UNESCO, in charge of the global monitoring of national school closure decisions related to COVID-19, has identified 191 state closure decisions. In Europe, all schools are closed at national level, with some exceptions:
– Belarus, which has put no containment measures in place since the beginning of the COVID-19 pandemic;
– Russia, which leaves these decisions to local authorities;
– Sweden, which maintained the classes for those under 15 years;
– Iceland, where nurseries and primary schools remained open under conditions of compliance with health measures;
– Denmark, which after a national decision to close all schools and nurseries on 14 March, decided to open these establishments on 15 April under certain conditions.
-Procedures for opening schools in Denmark
On Wednesday 15 April 2020, Denmark was the first European country to set up a lockdown to open schools. The implementation of this gradual reopening took place in two stages: the choice of the levels to be opened and the variation of the different sanitary conditions to be respected for the levels chosen.

The Danish Prime Minister, Mette Frederiksen, first explained that only certain levels would be affected by the reopening of April 15, in order to allow the economic protection of the country: nurseries, kindergartens, primary schools, first and final. Colleges and high schools will not open until May 11, with the exception of the two exam levels already mentioned.
After these choices, a very precise specification was drawn up by the Danish Minister for Children and Education, establishing the list of conditions to be met to ensure the health safety of pupils and staff:
– hand washing every two hours, for students and teachers;
– a distance of two meters in the classrooms;
– indoor games limited to groups of 2 children and groups of 5 children for the outside
– schools must be cleaned twice a day;
– parents are advised not to put their child in school at the slightest suspicion of contamination.
However, as of 15 April 2020, only half of the Danish municipalities have managed to implement and comply with these specifications. An additional period has been granted to the institutions of these communes, which must be able to welcome their students on 20 April 2020.
Norway and the Czech Republic have developed a reopening strategy similar to that of Denmark. Norway, which set up a flexible confinement on 12 March, announced a gradual reopening of nurseries on Monday 20 April 2020, followed by schools, colleges and high schools scheduled for 27 April. The Czech Republic has chosen a gradual deconfinement from 20 April 2020, with the opening of open-air markets, the authorization of wedding ceremonies under conditions, the opening of shops of artisans. In this context, a reopening of schools is planned for April 20, with a priority to welcome examination classes.
Other European countries: reopening plans for May or September 2020
Other countries are planning to reopen schools such as Austria, Germany, Luxembourg and Belgium.
The reopening plans will have to be produced in the coming weeks, with the objective of a reduced reception of students in May, beginning with the first and final classes in Germany for example.
Some countries, including Italy, have already announced that schools will remain closed until September 2020. The Portuguese Government said the same on 9 April, leaving the question of the examination classes in abeyance. The United Kingdom is currently uncertain as to the usefulness of a reopening since the GCSE (equivalent of the college patent) and the A level (equivalent of the baccalaureate) have been cancelled and universities are organizing independently, most have already implemented remote exam modalities.
2. Populations at risk: international, European and British examples
At the international level, on 2 April 2020, the Regional Director of the World Health Organization (WHO) for Europe expressed the need to adjust exit measures according to risk factors, particularly for the elderly: Many European authorities are now urging older people to stay at home for a long period of self-isolation (otherwise known as “shields”), especially those who are immunocompromised or suffering from chronic diseases. For them, we need to secure updated care plans, identify pathways to services, monitor their compliance with prescribed medications, supplies and equipment; transportation and support for self-management, access to rehabilitation and palliative care, if necessary. Overall, making sure we stay connected is critical.”
At the European level, the President of the European Commission, Ursula von der Leyen, also announced that the elderly could remain isolated until the end of 2020, in order to protect themselves from COVID-19, admitting that the isolation measures were «difficult», while stating that this was a “life and death” issue for this population.
As a national example, concerning the maintenance of restrictions for people at risk at the exit of confinement, the United Kingdom has very quickly positioned itself, and this, by announcing from the beginning of the containment measures that it would apply for a longer period of time for people who are called “extremely at risk”.
On March 22, the British government announced the first three weeks of confinement for the entire population, the people considered &quot;extremely at risk&quot; (transplant recipients, immunosuppressed individuals, severe asthma patients, cancer patients, etc.) and registered in the National Health Service (NHS) files, or 1.5 million people, have been advised by telephone and letter that they should adhere to a strict (no release) containment of at least 12 weeks. The British government has set up a delivery service to provide them with food and medicine. There was also a telephone follow-up: the “UK Government National Shielding Service” is responsible for contacting people who are “extremely at risk” in order to gather information on their daily difficulties, information transferred to the local authorities responsible for arranging assistance for these persons.
A second group of people ‘at risk’; was identified by the UK national authorities: this second specific population is subject to the same duration of confinement as the general population but must take &quot;additional precautions&quot;, recommended by the NHS. This population includes 19 million Brits (people over 70, pregnant women, people with heart disease, etc.).
For the general population, confinement was extended by three weeks from April 20 with a government announcement on April 16, 2020. As a result, at-risk individuals should be confined twice as long as the general population, based on government decisions and NHS recommendations

¹Jean-Laurent Casanova’s position: FFP2 (or N-95) masks must be available and accessible to all healthcare professionals in contact with infected or potentially infected patients, and therefore contagious. These caregivers are at high risk of contamination. For the general population, surgical masks or equivalent are sufficient.

²*Jean-Laurent Casanova’s minority position: he proposes that the contacts of all diagnosed cases be traced via their smartphone. To do so, the smartphone and Bluetooth should be turned on at all times when each person is travelling in the public space. It proposes that the government make this recommendation mandatory for all smartphone owners, subject to possible exemptions.

Covid-19 and Social Protection: A case of Kenya

Written by Damaris Muhika

The current Covid-19 situation has demonstrated the importance of increasing investments towards universal social protection. Social protection systems, both contributory and tax-financed benefits such as social assistance, have played an important role during the current crisis by facilitating access to
affordable health services and guaranteeing income security to workers and other vulnerable groups. Past responses to disasters and the current Covid-19 interventions in Africa have exposed critical gaps in the existing social protection systems and the need to accelerate implementation of minimum standards as prescribed by the ILO Convention 102 and Recommendation 202. The Disruption caused by Covid-19 in Kenya has resulted in social-economic deterioration which is manifested in form of food insecurity, anxiety, gender-based violence and general destitution.

The constitution of Kenya which was inaugurated in 2010 declared social protection as a fundamental right in line with the 2030 Agenda for sustainable development. Indeed Article 43 states that the ‘State shall provide appropriate social security to persons, who are unable to support themselves and their
dependents’. Kenya’s social protection system consists of three pillars namely; social security, social health insurance and social assistance.

Social security is in form of contributory programmes through NSSF (mandatory), Civil Service Pension Scheme (for teachers and disciplined forces) and occupational schemes sponsored by individual employers. With a working population of 18.1 million in both formal and informal employment, only 6.9
million workers are contributing for retirement in 1300 pension schemes, including 3.9 million in NSSF. This implies that only 28% of workers and mainly from the formal economy are assured of a pension.

Social health insurance on the other hand is mainly administered through NHIF (mandatory) complemented by Private Health Schemes and Community Based Health Financing Schemes. Only about 20% of Kenya’s population is covered by some form of health insurance with NHIF being the principal health insurance scheme for Kenyans. Currently, NHIF has seven million members (50 percent from the informal economy) hence a coverage of about 25 million beneficiaries.

Although the NSSF Act and NHIF Act provides for inclusion of the informal economy workers through voluntary contributions, enrolment has been slow leaving the target exposed to shocks such as Covid-19. The major challenge facing informal economy workers’ contribution into both social security and
health insurance is low due to irregular incomes.

The Social Assistance component which is administered through the Social Protection Secretariat facilitates cash transfer of KES. 2000 per month to four target groups; older persons of 65+ living in poverty and a universal pension coverage for 70+, orphans and vulnerable Children, persons with severe disabilities and a hunger safety net for vulnerable persons in four Arid Counties of Turkana, Mandera, Wajir and Marsabit. However, cash transfer program coverage is very minimal in the context of Kenya’s high dependency rate (81%) owing to a large number of unemployed youth and a significant size of the elderly who retire without any pension.

In addition, selected counties have evidenced that devolved units have the capacity to initiate complementary social protection programs. For instance, Makueni County has improved community livelihood by supporting value addition to locally produced fruits while Kakamega has successfully rolled
out the ‘Oparanya care’ programme to support expectant mothers and infants for medical service and nutrition. To counter the impact of Covid-19, the counties have to established measures such as acquisition of critical health equipment, employment of more healthcare workers and distribution of
relief aid to affected households.

For Kenya to mitigate vulnerability caused by shocks such as Covid-19, there is need to introduce measures to cushion the working age population from income loss. An immediate priority is the establishment of an unemployment relief fund targeting workers who have been laid off or are on unpaid leave. Trade unions and informal economy associations have existing structures to identify beneficiaries, who would receive cash transfers from the Kenya Covid-19 Emergency Response Fund that is mobilizing finances from development partners and private sector. In the long-term, a contributory unemployment insurance fund is required to support income replacement for workers,
who lose jobs to redundancy and any other cause like a pandemic. However, such drastic interventions call for inclusion of trade unions and employers into the policy dialogue for buy-in and enhanced implementation.

Secondly, there is need for a horizontal expansion of social protection programmes to increase coverage to excluded groups especially the informal economy workers. For instance, contributory social protection schemes such as NSSF and NHIF need to adopt the use of innovative delivery models such as Mpesa to penetrate the hard to reach groups especially the informal economy workers. In the long-term, targeted cash transfer programmes to the elderly, vulnerable children and persons with disabilities ought to be graduated into tax-financed universal coverage schemes.

The current Covid -19 interventions, which include weekly stipends to the urban poor, require proper coordination by incorporating all key actors and strengthening existing labour management information system including the single registry to ease identification of vulnerable populations, eradicate double
dipping and duplication while reducing the administration costs too.

Covid-19 und Sozialstaat: Der Fall Kenia

Geschrieben von: Damaris Muhika

Die aktuelle Covid-19-Situation hat gezeigt, wie wichtig es ist, die Investitionen in die universelle soziale Absicherung zu erhöhen. Die Sozialschutzsysteme, sowohl beitrags- als auch steuerfinanzierte Leistungen wie die Sozialhilfe, haben während der aktuellen Krise eine wichtige Rolle gespielt, indem sie den Zugang zu erschwinglichen Gesundheitsdiensten erleichtern und Arbeitnehmern und anderen gefährdeten Gruppen Einkommenssicherheit garantieren. Frühere Reaktionen auf Katastrophen und die aktuellen Covid-19-Interventionen in Afrika haben kritische Lücken in den bestehenden Sozialschutzsystemen und die Notwendigkeit aufgezeigt, die Umsetzung
von Mindeststandards, wie sie im ILO-Übereinkommen 102 und in der Empfehlung 202 vorgeschrieben sind, zu beschleunigen. Die durch Covid-19 verursachten sozialen Verwerfungen in Kenia haben zu einer sozioökonomischen Verschlechterung geführt, die sich in Form von Ernährungsunsicherheit, Angst, geschlechtsspezifischer Gewalt und allgemeiner Not manifestiert.

In der 2010 verabschiedeten Verfassung Kenias wurde der soziale Schutz zu einem Grundrecht erklärt, das mit der Agenda für nachhaltige Entwicklung bis 2030 im Einklang steht. In der Tat heißt es in Artikel 43: “Der Staat sorgt für angemessene soziale Sicherheit für Personen, die nicht in der Lage sind, für ihren eigenen Lebensunterhalt und den ihrer Angehörigen aufzukommen”. Das
kenianische Sozialschutzsystem besteht aus drei Säulen: soziale Sicherheit, Krankenversicherung und Sozialhilfe.

Die soziale Sicherheit erfolgt in Form von beitragspflichtigen Programmen durch das NSSF (obligatorisch), das Rentensystem für den öffentlichen Dienst (für Lehrer und öffentlich Angestellte) und durch betriebliche Vorsorgesysteme, die von einzelnen Arbeitgebern finanziert werden. Bei
einer Erwerbsbevölkerung von 18,1 Millionen Menschen, die sowohl formell als auch informell beschäftigt sind, leisten nur 6.9 Millionen Arbeitnehmer Beiträge für das Rentensystemen, darunter 3.9 Millionen im NSSF. Dies bedeutet, dass nur 28% der Arbeitnehmer und hauptsächlich aus der
formellen Wirtschaft in die Rentenkasse einzahlen.

Die Krankenversicherung hingegen wird hauptsächlich über den NHIF verwaltet, der durch private Gesundheitssysteme und gemeindebasierte Gesundheitsfinanzierungssysteme ergänzt wird. Nur etwa 20% der kenianischen Bevölkerung sind in irgendeiner Form krankenversichert, wobei der NHIF das wichtigste Krankenversicherungssystem für Kenianer ist. Gegenwärtig hat der NHIF sieben Millionen Mitglieder (50 Prozent aus der informellen Wirtschaft), was einer Abdeckung von etwa 25 Millionen Versichertern entspricht.

Obwohl das NSSF-Gesetz und das NHIF-Gesetz die Einbeziehung der Beschäftigten in der informellen Wirtschaft durch freiwillige Beiträge vorsehen, hat sich die Einschreibung nur langsam vollzogen, so dass die Zielgruppe Schocks wie Covid-19 ausgesetzt ist. Die größte Herausforderung für die Beiträge der Beschäftigten der informellen Wirtschaft sowohl zur Sozialversicherung als auch zur Krankenversicherung liegt in den unregelmäßigen Einkommenszahlungen.

Die Sozialhilfekomponente, die über das Sekretariat für Sozialschutz verwaltet wird, erleichtert den Geldtransfer von KES. 2000 pro Monat an vier Zielgruppen: ältere Menschen über 65 Jahre, die in Armut leben, eine universelle Rentenversicherung für Menschen über 70 Jahre, Waisen und
gefährdete Kinder, Menschen mit schweren Behinderungen und ein Sicherheitsnetz gegen Hunger für gefährdete Personen in den vier Trockengebieten Turkana, Mandera, Wajir und Marsabit. Angesichts der hohen Rate der Beschäftigten im informellen Sektor (81%), die auf die große Zahl
arbeitsloser Jugendlicher und eine beträchtliche Zahl älterer Menschen zurückzuführen ist, die ohne Rente in den Ruhestand gehen, ist die Abdeckung durch das Geldtransferprogramm jedoch sehr
gering.

Jedoch konnten ausgewählte Bezirke nachgewiesen, dass die dezentralen Einheiten in der Lage sind, ergänzende Sozialschutzprogramme zu initiieren. So hat beispielsweise der Bezirk Makueni die Lebensgrundlagen der Gemeinden verbessert, indem er die Wertschöpfung bei lokal produzierten Früchten unterstützt hat, während Kakamega das “Oparanya care”-Programm zur Unterstützung werdender Mütter und Kleinkinder in Bezug auf medizinische Versorgung und Ernährung erfolgreich eingeführt hat. Um den Auswirkungen von Covid-19 entgegenzuwirken, müssen die Bezirke Maßnahmen wie den Erwerb kritischer Gesundheitsausrüstung, die Beschäftigung von mehr medizinischem Personal und die Verteilung von Hilfsgütern an die betroffenen Haushalte einführen.

Damit Kenia die durch Covid-19 verursachten Schocks abmildern kann, müssen Maßnahmen ergriffen werden, um die Bevölkerung im erwerbsfähigen Alter vor Einkommensverlusten zu schützen. Eine unmittelbare Priorität ist die Einrichtung eines Hilfsfonds für Arbeitslose, die entlassen wurden oder unbezahlten Urlaub nehmen. Gewerkschaften und Vereinigungen der
informellen Wirtschaft verfügen zudem über bestehende Strukturen zur Ermittlung der Begünstigten, die Geldtransfers aus dem kenianischen Covid-19-Nothilfefonds erhalten würden, der Finanzmittel von Entwicklungspartnern und dem privaten Sektor mobilisiert. Langfristig und damit auch nach Covid-19 ist ein beitragspflichtiger Arbeitslosenversicherungsfonds erforderlich, um den
Einkommensersatz für Arbeitnehmer zu unterstützen, die aufgrund von Entlassungen oder anderen Ursachen wie einer Pandemie ihren Arbeitsplatz verlieren. Solche drastischen Interventionen erfordern jedoch die Einbeziehung von Gewerkschaften und Arbeitgebern in den politischen Dialog, um Einfluss auf die Sozialpolitik umzusetzen und Reformen anzustoßen.

Zweitens ist eine horizontale Ausweitung der Sozialschutzprogramme erforderlich, um die Abdeckung ausgegrenzter Gruppen, insbesondere der Beschäftigten der informellen Wirtschaft, zuerhöhen. So müssen z.B. beitragspflichtige Sozialschutzsysteme wie NSSF und NHIF den Einsatz
innovativer Bereitstellungsmodelle wie Mpesa übernehmen, um die schwer zugänglichen Gruppen, insbesondere die Beschäftigten der informellen Wirtschaft, zu erreichen. Langfristig sollten gezielte Geldtransferprogramme für ältere Menschen, gefährdete Kinder und Menschen mit Behinderungen mit Hilfe von universell steuerfinanzierten Umschichtungsmodellen finanziert werden.

Die derzeitigen Covid-19-Interventionen, wie die augenblicklichen wöchentlichen Cash-Transfers für die arme städtische Bevölkerung, erfordern eine angemessene Koordinierung durch die Einbeziehung aller wichtigen Akteure und die Stärkung des bestehenden Informationssystems für das Arbeitsmanagement, einschließlich des einheitlichen Registers, um die Identifizierung gefährdeter Bevölkerungsgruppen zu erleichtern, Doppelarbeit und Doppelarbeit zu vermeiden und gleichzeitig auch die Verwaltungskosten zu senken.

LEGISLATIVE RESPONSE TO COVID-19: THE CASE OF UGANDA

By Hellen Mwongeli

On March 11, 2020, the World Health Organization (WHO) declared the novel corona virus (COVID – 19) outbreak a pandemic due to its spread to over 184 countries. This pandemic has affected people globally, forcing states to take action to combat it. To this end, governments have put in place a number of measures, which often require the force of law. This article analyses legislation regarding COVID-19 in Uganda.

Uganda is a landlocked country in East Africa with population of around 45 million.[1] The country reported its first confirmed case of COVID-19 on 22nd March 2020.[2] The number of confirmed cases as at 15th May is 160, with 63 recoveries and no deaths.[3] Discussed below are directives and pieces of legislation enacted to combat the pandemic.

PRESIDENTIAL DIRECTIVES

  1. Ban on Public Gatherings

The President banned gatherings of more than 5 people, including weddings; church, burials and Jumat services. He also ordered a closure of schools including universities. Banks, hospitals, supermarkets and markets were exempt from this ban, but the President directed them to adhere to hygiene measures; provide hand sanitizers to their employees and patrons. Public gatherings have been shown to be responsible for the spike in new infections of COVID-19. An example is South Korea, whose Patient 31 attended a church service and infected many people, resulting in a great increase in infections in the country. Therefore, Uganda is learning from the occurrences in other countries and is acting accordingly to flatten the curve.  

Travel Restrictions

On 26th March, the President banned public transport for 14 days and subsequently banned the travel of all private vehicles to prevent the crowding that he stated takes place in vehicles. Motorcycle (bodaboda) operators were only allowed to operate until 2pm. In cases of unavoidable health emergencies, people could seek a permit from the Resident District Commissioner (RDC) to travel using private means. However, this did not accommodate people who have no access to private means of travel but may also suffer health emergencies. Further, some of the RDC offices are reported as being closed when people go to seek permits.[4] The President then directed that visibly pregnant women would be allowed to travel without permits. This is a move in the right direction to reduce child and mother mortality rates for lack of access to life saving treatment. The President has stated that the current restrictions in place are under review with the intention of easing them.  

Closure of Non-Essential Services

The President ordered a shutdown of government services, except for the army, police, health services and essential services. Shopping malls and arcades, which sell non-food items would be closed for 14 days. Supermarkets could therefore operate, but with a limited number of customers at a time, and their trolleys would also have to be disinfected. In the open air markets that sell food, an area of four squared metres would have to be observed as space between vendors, who would have to spend 14 days in the market.

Lockdown and Food Relief

On 30th March, the President announced a 14 day lockdown, which has been extended twice by the time of writing. This is to prevent the spread of the virus. The government provided relief food to the urban poor since they cannot work at this time. Unfortunately, the food has not been enough and the government has been urged to facilitate access to food donations from well-wishers at this difficult time instead of banning them altogether. [5]

REGULATIONS PASSED UNDER THE PUBLIC HEALTH ACT OF 1935

The Public Health Act empowers the Minister of Health of Uganda to declare – by statutory order – a notifiable disease[6] and to make regulations. The regulations are all subsidiary legislation formulated by the Minister, Dr. Jane Ruth Aceng, passed by Parliament and assented to by the President. These powers allow the country to take decisive and quick action to control the spread of a notifiable disease.

The Public Health (Notification of COVID–19) Order, 2020

On 17th March, 2020, vide this order, the Minister declared COVID–19 a notifiable disease. With this Order, the Minster is empowered to make rules as to the duties of certain persons once a notifiable disease has been declared,[7] and activates certain sections of the Act. This Order is important because it activated the machinery of the Public Health Act to deal with COVID-19. It also shows that the government is taking the pandemic seriously.

The Public Health (Control of COVID-19) Rules, 2020,

The Rules were promulgated and commenced on 24th March, 2020. They provide for the protocol to be followed once a person is suspected of having the virus, empowers medical officers to order people to self-isolate and also gives them the power to disinfect premises. The rules provide for the disposal of bodies of those who succumb to COVID-19 as per the directions of the medical officers, similar to the Presidential directive on the disposal of bodies. There is a loophole in that the rights of the families of the deceased to be involved in burying their loved ones are not recognized.

The Public Health (Prevention of COVID-19) (Requirements and Conditions of Entry into Uganda) Order, 2020

The Order obliges medical officers, who are predefined, to test any person arriving in the country for COVID-19 and hold them in isolation or quarantine as the situation requires. Prevention is core, with particular focus on curbing the spread of the disease; especially from those travelling from high risk countries to Uganda.

The Public Health (Prohibition of Entry into Uganda) Order, 2020

These rules effectively legislate the closure of the borders of Uganda, save for entry by United Nations organizations personnel and cargo from such organizations. This is a more effective approach to limiting the possibility of the spread of COVID-19 from persons travelling to Uganda from other countries compared to the approach in the above order. The exemption for UN organizations personnel and cargo indicates that the country welcomes assistance in fighting COVID-19. Given that these persons are coming into the country, the previous order on their testing and possible isolation or quarantine still applies. Therefore, the two orders are not inconsistent with each other.

Uganda’s COVID-19 infections are relatively low and no COVID-related deaths have been recorded in the country. This indicates that some of the country’s efforts such as the lock-down have been of great help in preventing the spread of the disease. The Presidential directives and legislation have been key to these efforts. However, the deaths and suffering caused by the inability to access emergency medical treatment at this time reflect poorly on Uganda.

CONCLUSION

In order to ensure the C0vid-19 infections don’t rise and citizens don’t suffer or die from the aforementioned issues; the government should ensure that the people in need get adequate and nutritious food at this time, that their rights are not violated, and that they receive emergency medical treatment when they need it.


[1] ‘Uganda Population (2020) – Worldometer’ (Worldometers.info, 2020) <https://www.worldometers.info/world-population/uganda-population/&gt; accessed 8 April 2020.

[2] Daily Monitor, ‘Coronavirus Cases in Uganda rise to 63’ (Daily Nation, 2020) <https://www.nation.co.ke/news/africa/Coronavirus-cases-in-Uganda-rise-to-63/1066-5531900-5xbgu1/index.html&gt; accessed 23 April 2020.

[3] ‘Coronavirus – COVID-19’ (News.google.com, 2020) <https://news.google.com/covid19/map?hl=en-KE&gl=KE&ceid=KE:en&gt; accessed 15 May 2020.

[4] Sally Hayden, ‘Children, Women Casualties of Uganda’s Coronavirus Transport Ban’ (Aljazeera.com, 2020) <https://www.aljazeera.com/indepth/features/children-women-casualties-uganda-coronavirus-transport-ban-200421093822669.html&gt; accessed 25 April 2020.

[5] Leonard Mukooli, ‘Did Government Get It Wrong On Covid-19 Relief Food?’ (Daily Monitor, 2020) <https://www.monitor.co.ug/News/National/Did-government-get-it-wrong-Covid-19-relief-food-/688334-5531312-axnu9fz/index.html&gt; accessed 25 April 2020.

[6] Public Health Act, 1935, Chapter 281 Laws of Uganda.

[7] Public Health (Notification of COVID–19) Order, 2020

DER INFORMELLE SEKTOR IN KENIA DARF WÄHREND DER COVID-19-PANDEMIE NICHT IM STICH GELASSEN WERDEN

Geschrieben von Joan Atim

Wir leben in beispiellosen Zeiten, in denen die COVID-19-Pandemie weiterhin weltweit hohe und steigende gesundheitliche und soziale Kosten für die Menschen verursacht. Durch den Schutz von Menschenleben und der Überlastung der Gesundheitssysteme hatte die Gesundheitskrise bereits sehr schwerwiegende Auswirkungen auf die Wirtschaftstätigkeit, da die Ansteckung eine Isolierung und weitestgehenden Lock-Down der Wirtschaftstätigkeit erforderlich machte, um die Ausbreitung des Virus zu verlangsamen. Infolgedessen geht der IWF davon aus, dass die Weltwirtschaft im Jahr 2020 voraussichtlich um 3% schrumpfen wird, viel schlimmer als während der Finanzkrise 2008-2009. Unter Verwendung eines Basisszenarios geht man davon aus, dass die Pandemie in der zweiten Hälfte des Jahres 2020 abklingt und die Eindämmungseffekte durch politische Unterstützung allmählich rückgängig gemacht werden können. Aufgrund der Neuinfektionsraten in Kenia zwischen dem 3. und 6. Mai 2020 erscheint dies jedoch unwahrscheinlich.

Die Regierung hat zwar Maßnahmen ergriffen, doch beschränken sich diese Maßnahmen auf den formellen Sektor, sodass der informelle Sektor vergessen wird, in dem ein großer Prozentsatz der arbeitenden Bevölkerung in Kenia beschäftigt ist: 83,6% der Gesamtbeschäftigung und 762,1 Tausend neue Arbeitsplätze im Jahr 2018, so das kenianische Statistikamt. Dr. Jacob Omolo (Wirtschaftswissenschaftler an der Kenyatta University) bezeichnet den Sektor als Waisenkind der Politik und stellt fest, dass die Arbeitnehmer im informellen Sektor am stärksten von den Lock-Down Maßnahmen betroffen sind. Es ist jedoch wichtig, die recht dynamischen Aktivitäten des informellen Sektors genau zu beobachten. Dahinter verbergen sich soziale Beziehungen und Verbände, die von Menschen gebildet werden, die größtenteils selbst als Händler, Hersteller und Kleinbauern tätig sind. Ihre Interaktionen sind vertrauensbasierte, persönliche Beziehungen und Transaktionen in gegenseitiger Abhängigkeit. Diese sozialen Beziehungen und Vereinigungen erfüllen vielfältige Aufgaben und Funktionen, wie das Ansprechen grundlegender Anliegen, die Regulierung des Verhaltens der Mitglieder, die Koordinierung von Märkten, Produktion, Konsum, Verteilung, Schutz und Transformation. Jüngste Maßnahmen des ostafrikanischen Regionalblocks haben dies jedoch beeinträchtigt, wie Dr. Omolo argumentiert: “Die Schließung der Grenzen, insbesondere durch Kenias Handelspartner in der ostafrikanischen Gemeinschaft und die Reisebeschränkungen innerhalb des Landes haben zu Unterbrechungen in den Versorgungsketten des Sektors geführt, indem sie die Produktion, die Vermarktung und den Vertrieb von Gütern und Dienstleistungen eingeschränkt haben und als Konsequenz haben Arbeiter und Betreiber des informellen Sektors Beschäftigung und Einkommen verloren”.

Darüber hinaus ist es möglich, dass die Senkung der Umsatzsteuer (die jetzt jeden Monat nur noch zu einem Satz von 1% der früheren 3% zu entrichten ist) sowie der präsumptiven Steuer (eine Vorauszahlung der Steuer, die von einer Person, die eine Geschäftsgenehmigung oder Handelslizenz bei der Bezirksregierung erwirbt oder erneuert, die in Höhe von 15% der Gebühr für die Geschäftsgenehmigung oder Lizenz gezahlt wird) dem Sektor nicht zu Gute kommt. Die Steuersenkungen sind für kleine Unternehmen bestimmt, deren Bruttoumsatz die Obergrenze von 5 Millionen KES nicht übersteigt oder voraussichtlich nicht übersteigen wird. Die kenianische Steuerbehörde (Kenya Revenue Authority – KRA) gibt an, dass alle Kenianer nun ihren gerechten Anteil an den Steuersenkungen erhalten werden. Dies ist möglicherweise nicht der Fall, da die präsumtive Steuer im Jahr 2019 eingeführt wurde, um die Umsatzsteuer abzuschaffen, nachdem die KRA zugegeben hatte, dass sie nicht funktionierte, aber beide Steuern sind jetzt im Steuergesetz für 2020 enthalten, dem der Präsident soeben zugestimmt hat. Es wird argumentiert, dass mit der Einführung der präsumtiven Steuer, der Umsatzsteuer und der steuerlichen Bildung die KRA zuversichtlich ist, dass sich die Besteuerungslandschaft des informellen Sektors endgültig verändern wird. Diese Veränderungen erfassen jedoch in keiner Weise den informellen Sektor, da die Umsatzsteuer die kleinen Unternehmen völlig ignorieren würde, da keine Klahrheit über den Status von Unternehmen mit einem Umsatz unterhalb der vorgeschriebenen Grenze besteht; (unter die die meisten Unternehmen im informellen Sektor zu fallen scheinen). Was die vom Präsidenten in seiner Rede vom 25. März 2020 angekündigten Steuersenkungen anbelangt, so gehen die spezifischen fiskalischen Interventionen, die darauf abzielen, die Kaufkraft von Einzelpersonen und die Cashflows für Unternehmen zu erhöhen, und die Steuergesetze in ihrer geänderten Fassung laut KPMG über die COVID-19-Interventionen hinaus, da drastische Änderungen des Systems der Steueranreize und -Befreiungen die Steuersenkungen lediglich verwässern. Professor Attiya Waris (Direktor für Forschung und Unternehmen an der Universität Nairobi) hingegen präsentiert sehr interessante Daten und zeigt den Prozentsatz der registrierten Steuerzahler in einigen afrikanischen Ländern einschließlich Kenia anhand der Anzahl der registrierten Wähler, d.h. nur 39% der 19,6 Millionen registrierten Wähler sind registrierte Steuerzahler (Einzelpersonen und Unternehmen – keine Datenaggregation). Der Grund dafür ist, dass es eine hohe Arbeitslosigkeit und eine höhere Wahrscheinlichkeit zu geben scheint, dass viele der nicht registrierten Steuerzahler im informellen Sektor tätig sind, andere sind Studenten oder Gefangene.

Trotz des oben Gesagten hat sich der informelle Sektor aufgrund der Realität, die er erfasst, für viele politische Entscheidungsträger_innen, Aktivist_innen und Forscher_innen weiterhin als nützliches Konzept erwiesen. Wir müssen realisieren, dass die Regierung im Kampf gegen COVID-19 bis heute nicht nur Gelder von internationalen Finanzinstitutionen, sondern auch Spenden und Geschenke erhalten hat. Es gab Budgetzuweisungen; einschließlich der Nachtragshaushalte wurden jedoch keine Mittel für den informellen Sektor bereitgestellt, und der Sektor wurde der Gnade der Philanthropen überlassen. Die Regierung hat jedoch den Auftrag, sich durch ihre Gesetze und ihre Politik um alle Menschen und ihre Probleme zu kümmern. Aus meiner Sicht kann die Regierung Folgendes tun, um den informellen Sektor in diesen schweren Zeiten zu unterstützen:

Die kenianische Regierung kann umfangreiche steuerliche und monetäre Maßnahmen durchführen, um Haushalte und Unternehmen im informellen Sektor zu unterstützen, die durch mangelnde Budgetzuweisungen betroffen sind. Insbesondere im Bereich der Sozialsysteme, d.h. Gesundheits- und Mutterschutzsysteme, Sozialversicherung, Sozialhilfesysteme und steuerfinanzierte Leistungen vor allem für die Armen, die wenig oder keine Leistungen aus anderen Formen des Sozialsystems erhalten. Die öffentliche Finanzierung des informellen Sektors ist von herausragender Bedeutung, da die überwältigende Mehrheit der Geschäfte im informellen Sektor sich aus eigenen Mitteln finanziert. Die Menschen erhalten hauptsächlich Geld von Freunden und Verwandten, Kredite und Vorschüsse von Lieferanten und Kunden, die in der Regel nicht nachhaltig sind. Sie sollten ermutigt werden, die Vorteile des Immobiliarvermögenssicherheitsgesetzes (Immovable Property Security Rights Act) zu nutzen.

Die kenianische Regierung sollte darüber hinaus auf die sozialen Institutionen und Gruppen innerhalb des informellen Sektors zugehen und dabei helfen, all jene zu registrieren, deren Geschäfte beeinträchtigt sind, damit sie in die Hilfspakete der Regierung aufgenommen werden. Diejenigen, deren Beschäftigungsverhältnisse gefährdet sind, sollten ermutigt werden, sich bei staatlichen Institutionen registrieren zu lassen, damit sie von den Konjunkturpaketen profitieren können. So sollte das Corona-“Sicherheitspaket” beispielsweise mit Direktzahlungen die genannten Gruppen erreichen, bis die Pandemie endet und die Geschäfte wieder geöffnet werden können. Geldtransfers sind eine gute Initiative und die Regierung muss sie vorrangig für gefährdete Gruppen (unter die der informelle Sektor fällt) einsetzen. Dieselbe Plattform kann genutzt werden, um die gefährdeten Gruppen weiter für das Gesetz über die Sicherheit von Immobilieneigentumsrechten und für die Verwendung von Wertpapieren zu sensibilisieren, was kleine Unternehmen begünstigt.

Die kenianische Regierung sollte zudem für die Zeit nach der Krise Konjunkturpakete für den informellen Sektor schnüren: Dieses sollte Bargeldtransfers, Vermögenstransfers und Unternehmenscoaching beeinhalten.

Letztendlich sollte die kenianische Regierung langfristig in Infrastruktur und den Aufbau moderner Märkte mit angemessener Raumgröße, Lagerung und Ausstellung für Händler, Handwerker und Bauern investieren. Außerdem ist der Ausbau der digitalen Infrastruktur und eine konstante Stromversorgung in ländlichen Gebieten essentiell. Die dadurch nutzbaren digitalen Plattformen sind ein progressiver Weg zur Formalisierung des informellen Sektors. Menschen werden zu Steuerzahlern und die Steuerbasis wird sich erhöhen.

CUSHIONING THE INFORMAL SECTOR DURING THE COVID-19 PANDEMIC IN KENYA

By Joan Atim

We live in unprecedented times as the COVID-19 pandemic continues to inflict high and rising human costs worldwide. By protecting lives and allowing healthcare systems to cope, the health crisis has already had and is having a very severe impact on economic activity since contagion has required isolation, lock-downs and widespread closures to slow the spread of the virus. As a result, the IMF projects that the global economy is projected to contract sharply by 3% in 2020 much worse than during the 2008-2009 financial crisis and using a baseline scenario, the assumption is that the pandemic fades in the second half of 2020 and containment effects can be gradually unwound helped by policy support. Nevertheless, this seems rather unlikely due to the new infection rates in Kenya in recent weeks.

Measures have indeed been put in place by the government, however, these measures are restricted to the formal sector hence forgetting the informal sector that houses and employs a big percentage of the working population in Kenya; 83.6% of the total employment and 762.1 thousand new jobs in 2018
according to the Kenya National Bureau of Statistics. Dr. Jacob Omolo (economist at Kenyatta University) calls the sector a policy orphan and states that workers in the informal sector are most affected by these measures. It’s key to note the operations of the informal sector; which are quite dynamic. Underneath lie social relations and associations formed by people largely involved as traders, manufacturers, and small-scale farmers in their own right. Their interactions are trust-based, face-to-face relations, and transactions of inter-dependence. These social relations and associations fulfill multiple tasks and functions like addressing fundamental concerns, regulating members’ behavior, coordinating markets, production, consumption, distribution, protection, and transformation.

Moreover, recent measures by the regional block have affected this as Dr. Omolo argues, “the closure of borders particularly by Kenya’s trading partners in the East African Community, in-country travel restrictions have caused disruptions in the sector’s supply chains by constraining production, marketing, and distribution of goods and services and as such informal sector workers and operators have lost employment, income, and consumption.” In addition, the introduction of a reduction in turnover tax (now payable every month at a rate of 1% from the previous 3%) and presumptive tax (an advance tax paid by a person acquiring or renewing a business permit or trade license at the county government at a rate of 15% of the business permit fee or license) may not benefit the sector. The taxes are for small businesses whose gross sales does not exceed or is not expected to exceed KES 50 million from the upper limit of 5 million.

However, in no way do these changes capture the informal sector as the reduction in turnover tax would completely ignore the small businesses since there is no clarity on the status of businesses with turnover below the prescribed limit; (which most businesses in the informal sector seem to fall under). As for taxing reductions as announced by the president in his speech of the 25th of March 2020; the specific fiscal interventions aimed at increasing the spending power of individuals and cash flows for businesses and the Tax Laws as amended is according to KPMG beyond the COVID-19 interventions since drastic changes to the tax incentives and exemptions regime simply water down the tax reductions. Professor Attiya Waris (Director of Research and Enterprise at the University of Nairobi) on the other hand presents very interesting data and shows the percentage of registered taxpayers in a few African countries including Kenya by using the number of registered voters i.e., just 39% of 19.6 million registered voters are registered taxpayers (individuals and corporations-no data aggregation). The reason is that; there seems to be high unemployment and a higher probability that many of the
unregistered taxpayers are in the informal sector

Despite the above, the informal sector has continued to prove a useful concept for many policymakers, activists, and researchers because of the reality it captures. We acknowledge that the government has to date not only received funding from international financial institutions, but received donations and
gifts in the fight against COVID-19. There have been budget allocations; including supplementary budgets, however, allocations have not been made to the informal sector and the sector has been left at the mercy of philanthropists. The government has the mandate to take care of all its people and their
innovations through its laws and policies.

From my point of view, the government can do the following to cushion the informal sector during these hard times:
Implement substantial targeted fiscal, and monetary measures to support households and businesses in the informal sector. In particular, social protection schemes i.e. healthcare and maternity protection schemes, social insurance, social assistance schemes; and tax-financed benefits mainly for the poor, who receive little or no benefits from other forms of social protection.

Financing the informal sector should be an option explored with proper policies and regulations, because the overwhelming majority of informal sector business is self-fund. People mostly get money from friends and relatives, credit, and advances from suppliers and customers which tend not to be sustainable. They should also be encouraged to take advantage of the Immovable Property Security Rights Act while the government gives directives to financial institutes to lessen their financing requirements.


The Kenyan Government should further reach out to the social institutions and groups within the informal sector to help register all those whose businesses have been disrupted so that they are included in government relief packages. Those whose employments have been disrupted should be encouraged to register with their institutions and groups so that they can benefit from stimulus packages. Thus, the coronavirus “safety net” with direct payments should reach everybody until the pandemic ends and businesses reopen. Cash transfers are a good initiative and the government must prioritize it to vulnerable groups (under which the informal sector falls under). Moreover, the Kenyan Government should undertake post-crisis economic inclusive packages with the aim to introduce sustainable effects on the sector, i.e., improve cash transfers, asset transfers and business coaching in the long run.


The Kenyan Government should invest in long-term infrastructure and build modern market places with adequate room size, and storage that will accommodate traders, artisans, and peasants. Finally, the Kenyan government should invest in better digital infrastructures i.e., the installation of fibre optics
even in rural areas, and constant power supply as digital platforms offer a progressive road to formalization. The more people use them, the more they become formalized tax payers.

Interview with the Director General of Taxes, MOPA Modeste FATOING

Cameroon Tribune, 8th of May 2020 edition

Comments collected by Jocelyne Ndouyou-Mouliom and Aicha Nsangou

1. Mr Director-General, the Head of State has just released 19 measures to ease the restrictions imposed in the fight against Covid-19. About 10 of them are tax-related. Your administration was probably involved in the development of these measures, what are the prerequisites that led to their validation?

Tax measures are indeed prominently included in the support mechanism for businesses and households, decided by the President of the Republic, His Excellency Paul BIYA, and made public by the Prime Minister, Head of Government. These tax measures are the culmination of a process that involved the authorities, as part of a participatory approach, assessing the impact of the crisis on businesses, and then identifying possible solutions, to examine them, to evaluate them and finally to make choices. Since the outbreak of the crisis, under the leadership of the Minister of Finance, the tax administration has engaged consultations with the entire private sector through socio-professional groups (GICAM, ECAM, MECAM, CCIMA, APECCAM, Filière Bois, ASAC, CAFCAM, AMCHAM, SYNDUSTRICAM, Hôtellerie, Cimenterie, Association des Bayam Selam, Plateforme des Syndicats des Transporteurs, etc.). As a sign of the times, most of these consultations took place via videoconferencing for obvious reasons. The main aim was to gather from the main players in the economy, their assessment of the crisis, its impact on their
activities, and their proposals for support measures expected from the authorities
In addition to this dialogue with the private sector, the tax administration has, thanks to the videoconferencing system, actively participated in numerous initiatives to exchange and mutualize best tax practices in response to Covid launched by international partners such as the OECD, the IMF, the African Tax Administration Forum (ATAF) and the Tax Administration Leaders’ Circle of Reflection and Exchange(CREDAF).At the end of all these consultations, the first observations made showed that the Cameroonian companies were affected, to varying degrees, by the crisis due in particular to the slowdown in economic activity at the international and national level, and the implementation of the first round of response measures. The consultations made it possible in this respect to identify the sectors most affected by the crisis, in particular the hotel industry, transport, companies whose activities are outward-looking; but also those which are less or very little. All the proposals identified were then examined and submitted to the authorities according to the various scenarios of the crisis.

2. To decipher in a specific way these measures, how to understand the one that concerns the suspension under the 2nd quarter 2020 of general accounting audits, except in case of suspicious tax behavior. What does that mean?
In a tax reporting system such as ours, it is the taxpayer who freely reports the activities he or she has carried out over a period of time and the amount of tax payable. In order to prevent this freedom from giving rise to abuse, tax checks are regularly carried out and often result in corrections of the declarations previously subscribed; this makes it possible to restore the equality of all before the tax.
In view of the impact of the crisis on the treasury of companies, the authorities wanted to exempt them from accounting checks which, by their nature, are likely to give rise to immediate payments of additional taxes. Since these accounting checks are on-the-spot checks within the undertakings, the requirement to comply with the rules on distance-sharing has also reinforced the authorities in taking this measure.
It should be noted, however, that this suspension does not apply in the case of suspicious tax behavior; that is, where a company bears a strong suspicion of fraud or of undermining its declarations. This safeguard makes it possible to limit the abuses and windfall effects that would not only deprive the State of resources but would also promote distortions between citizens’ taxpayers and those who are not.

3.This refers to the extension of the deadline for filing statistical and tax returns without penalties for the payment of the corresponding balance. What was the originally planned date and what will be done in case the payment has already been made?
The deadline for submitting statistical and tax returns (FSD) is 15 March of each year. Taking into account the difficulties that the companies may have encountered in subscribing to this declaration within this period, in the context of the current health crisis, the authorities granted them an extension of time to comply with this tax obligation without incurring penalties. Certainly, to date, some companies had already been subject to late filing penalties for their DSF. However, with the penalty relief that has just been granted, those companies to which penalties have been applied will be cancelled outright, and for those who have already paid them, they will receive a competitive tax credit, which can be carried forward to future payments. I would point out that it is this approach that will apply to all those who had already paid taxes in the second
quarter and who have been the subject of tax relief measures by the authorities.

4. Mr Director General, the President of the Republic has decided to support businesses through the allocation of a special envelope of FCFA 25 billion, for the clearance of VAT credits pending reimbursement. Is that enough to clear the state’s debt?
I think it is important to point out at the outset that the authorities have worked hard to improve our system of refunding VAT credits in recent years. In this respect, we can mention the escrow account mechanism set up which makes it possible to automatically allocate each month 6 billion FCFA to operations to refund VAT credits; the processing of applications following a risk-based
approach, making possible the spontaneous repayment without prior checking to the companies presenting no risk, the checks being done a posteriori; and, above all, the dematerialisation of the entire procedure for claiming VAT credits already implemented at the level of the Large Enterprises Directorate. The only difficulty that remained until then was the one related to the stock of credit
accumulated before the reforms I have just mentioned; stock valued to date at about 25 billion. Hence the allocation of this special envelope of equal amount that will make it possible to eliminate this stock pending reimbursement. I should also point out, so that it is clear enough, that this special envelope is in addition to the initial provision of 72 billion in the state budget for the financial year 2020.

5. Several tax payment exemptions are announced: property tax, tourist tax in the hotel and restaurant sector for the remainder of the 2020 financial year, starting in March; exemption from the duty-free tax and parking tax for taxis and motorcycles, axle tax for the second quarter. What were the revenue forecasts for these different revenue items?
Let me clarify that with respect to the property tax, this is not an exemption, but rather a deferral to September 30 of the due date of this tax normally set at June 30. This measure is aimed at households that are the main contributors.
As for the axle tax, the discharge tax and other municipal taxes, this is effectively an exemption limited to the second quarter. In addition, the Head of State had already long before the publication of the measures of 30 April 2020, declared the exemption of VAT and customs duties on materials and equipment directly intended for the fight against Covid 19. It should be noted that measures to suspend tax controls and enforce collection also have a cost. Overall, for the time being, all the tax support measures decided by the authorities are estimated at FCFA 114 billion, that is to say, 92 billion in internal revenue and 22 billion in customs revenue. This tax cost, as you can guess, is only a portion of the overall cost incurred by the authorities in the response to the severe Covid 19 pandemic.

6. The exemption, for the second quarter, from the duty-free tax and community taxes (market duty, etc.) for the benefit of small food retailers (bayam-sellam) is also approved. Have decentralised local authorities already been made aware?
As you have well perceived, these measures directly concern decentralised local and regional authorities which are the beneficiaries of the proceeds of these levies. With a view to the effective application of these measures on the ground, consultations are held with all the actors involved for their harmonious implementation. In any case, the Prime Minister, Head of Government, personally ensures that all measures of support to taxpayers decided by the Head of State are scrupulously respected. We work in this direction under the supervision of the Minister of Finance and his counterpart in charge of
decentralized local authorities.

7. Are compensations planned for these decentralised local authorities?
In the context of the necessary future budgetary adjustments to take into account the impact of Covid 19 on the public finances of the State and the decentralised local and regional authorities, the authorities will, as usual, make the necessary arbitrations so that the decentralised local and regional authorities can absorb this external shock.

8. Are new measures possible, particularly for better support for small and medium-sized enterprises?
It seems to me important to emphasize at the outset that when reading the 9 measures decided by the Head of State, no category of enterprise was forgotten: large, medium, and small enterprises, and even micro-enterprises are not left out. It should be noted that none of the measures taken excludes SMEs. Whether it is a question of refunding VAT credits which, moreover, concern medium-sized enterprises more in the light of the credits they accumulate as a result of the withholding mechanism; whether it is a question of suspension of tax controls or forced recovery. All these measures benefit SMEs in the first place.
In addition, some of the measures taken specifically target this category of enterprise. This is the case, in particular, of the suspension of taxes applicable to the transport, hotel and food retailers sector; that is to say, all the attention that is given to SMEs which, in a crisis situation, are generally the most affected. Now it is essential to point out that, in general, our tax system is not based on a lump sum and mandatory payments. It is designed so that you only pay when you do an activity, a turnover. Since the tax is based on real and not flat rates, companies which, as a result of the crisis, are temporarily out of business or have low turnover will have nothing or little to pay.

9. Are these tax measures sufficient to enable companies to cope with the consequences of Covid?
In the current state of the crisis, they seem to be largely up to the task. In fact, as I said earlier, we are in discussions with other tax administrations and technical partners that are dealing with the issue of taxation in this crisis. In this regard, I must say that almost all States adopt this approach of fiscal prudence. The facilities granted in most cases are administrative in nature
(suspension of tax controls and compulsory recovery, etc.).
Cameroonian companies are therefore not at all disadvantaged in this regard. Better yet, they have other exceptional advantages. Look, companies affected by the crisis can also benefit from the special transaction measure on tax arrears dedicated by the Finance Act 2020 promulgated by the Head of State. This is an important measure to support businesses by allowing them to benefit from substantial reductions in their tax arrears. These reductions go up to 75%. The State has thus decided to virtually erase all the tax debts of the companies registered until 31 December 2018. This is unprecedented. However, it is time-limited. I would, therefore, like to invite companies that have tax debts to seize this opportunity to clear them up and thus clean up their balance sheet; this would allow them to more easily access financing as part of the relaunch of their activities after the crisis. The approach is quite simple: it is enough to send a request to the Director General of Taxes and a letter of reply indicating the rates of abatement already fixed by the law is notified to the taxpayer.

10.How does the tax administration itself adjust to always be able to do its job and make it easier for taxpayers?
The many reforms carried out in recent years in the tax administration, which for the most part had as a common denominator ICT, have so far enabled our services to cope with crisis situations. The same is true of the current health crisis. In addition to the teledeclaration and the telepayment already operational for several procedures for several years, we have worked to
launch new online services accessible to taxpayers remotely from their offices or homes without making any physical trips. These include tax registration, tax litigation and the repayment of VAT credits, all of which are now digitalized.

11. All these tax exemption measures will cause a significant loss of revenue in the state coffers. How do you plan to redeploy to replenish the funds differently?
The crisis necessarily has an impact on the mobilization of revenues insofar as they are dependent on economic activity. This impact, therefore, goes well beyond the cost of support measures to include the revenue losses associated with the decline in activity. As you know, the tax revenues to be raised in a given year are projected on the basis of assumptions. For the 2020 financial year, they were set based on a real GDP growth rate of 4% and a GDP deflator of 1.4%, or a nominal GDP growth rate of 5.4%. We also expected a barrel price of oil of more than 50 dollars. In view of these macroeconomic parameters, an objective of
2.103 billion has been set for the General Directorate for Taxation, which, as you know, is the first item of revenue mobilization for the state budget.
After the first quarter during which the DGI has mobilised beyond the objectives assigned to it, with 537 billion mobilized against 463 billion for the same period in 2019, a progression of FCFA 74 billion in absolute value and 16% in relative value, The Covid-19 health crisis is upsetting all these assumptions: the growth rate is expected to fall significantly and the barrel of oil is currently, as you know, below 30 dollars. The revenue forecasts should therefore be
adjusted in due course. However, it should be noted, as I said earlier, that the reforms to modernise the tax administration, carried out with the constant support of the authorities in recent years, have enabled our collection system to demonstrate a strong capacity for resilience in times of crisis. We, therefore, rely on the fundamentals of this resilience, namely the mechanism of securing our revenues and modernizing recovery, to preserve most of the State’s resources.

UNDERSTANDING THE EFFECTS OF THE COVID-19 PANDEMIC ON FOOD SECURITY

Compiled by Clara Kitungulu

This article is based on a Committee on Fiscal Studies webinar and tax talk 35 that aimed to spark conversations about whether Kenya will be able to sustain its population with the current lock-down measures put in place as a result of the pandemic.

Food security is the availability of adequate, nourishing, balanced, and safe food at all times. It also entails that food is available, accessible, and affordable. According to the Food and Agriculture Organization, there is enough food to sustain Kenyans during this pandemic, and the major problem is its accessibility and safety. Before the pandemic reached Africa, food insecurity was already a reality, with areas such as East Africa where there was a problem of locust infestation. The locusts were moving in large swarms causing havoc to many farms by destroying crops, and it is important to note that even with the pandemic going on, they are continuing to breed and are in the second stage of inversion thus they will exacerbate the food security issue.

Vulnerable groups e.g. refugees, arid and semi-arid areas who rely mostly on international assistance will be disproportionately affected since borders have been closed. People living below the poverty line and children who were benefiting from school feeding programs will also be disadvantaged due to the containment measures which restrict charity and donations and the closure of schools. The sick also need more care since they are already in a disadvantaged situation of having low immunity and being unable to go out and access food.
Low-income households are also greatly disadvantaged since they cannot stock their homes with food in bulk, to buy ultra-processed foods with long shelf-lives, or the means to appropriately store food. Such households work in the informal sector and thus the work-from-home measure is not practical for them. An increase in the cost of production and transportation will cause an increase in food prices, which affects food affordability.

With containment measures in place, it has become difficult to transport food between counties leave alone imports and exports. If this continues, there will be an issue of two extremes, where some regions have excess food that is going bad hence being wasted, while other regions will lack food and there will be starvation. In addition to that, companies want to continue making profits causing food prices to rise and thus making food inaccessible to the vulnerable.

Urban areas are likely to be more affected. In rural areas, there is an advantage in that since there are farms, so most families will be able to sustain themselves with the subsistence food from individual farms. Towns and cities are the main consumers of food, yet they produce the least and pollute the most since the land is mainly used for infrastructural development. However, with new cleaner industrial production, reliance on rural areas should be less in the future, with the government encouraging urban farming. There is also a need for better urban planning to stop the city from encroaching to agricultural areas.

Storage is a major factor since there is a clear disruption in the food supply chain. There will be an issue of post-harvest losses, with perishables such as fruits and vegetables rotting, grains will be damaged by insects and toxins due to poor storage, and meat products such as fish, beef, etc. will spoil as there is no capacity to keep them fresh for long periods.

Small scale farmers are the most disadvantaged as they are likely not to have documentation which allows them to operate as essential service providers, therefore produce ends up spoiling as they cannot transport it and have no reliable storage facilities. It is important to note that small scale farmers are crucial in ensuring the country can be sustained food-wise. In addition, large scale farmers are also disadvantaged, but to a lesser degree as it is easier for them to get support from the government. The Strategic Food Reserve Fund and the National Cereals and Produce Board’s main role and focus has been seeds and legumes but this is not enough as regards food security and should aim to include fruits and vegetables, and the funds allocated should be used to bring small scale suppliers into the loop as it has in the past only been accessible to large scale food suppliers.

The Tax Amendment Bill 2020 contains three issues that directly affect food security, which should be reconsidered and eliminated since they do not benefit the common citizen in any way and instead puts them under even more pressure economically. They include; Firstly, the proposal to introduce a tax to fertilizer (which was previously tax-exempt) and the result of this will be increased cost of production which will disadvantage food security regarding affordability. Secondly, is the increase of tax on fuels yet most agricultural products are processed this way, furthermore, this will be a challenge since it will push the vulnerable low-income households to use unsafe fuels such as charcoal. Lastly, the classification of bread to introduce a tax to non-basic bread i.e. containing anything other than wheat will lead to problems in terms of immunity since people should be trying to improve the nutritional content of food eaten yet they will not be able to afford such.

Some solutions suggested include;
Government to regularly supply food to low-income households during the pandemic, as is being done in Mombasa County

The government should work with major retailers to ensure that food is still available in the markets and other retail points so that people can access it and are able to purchase

Provision of preferential tax relief when it comes to food products and the food market thus ensuring that prices do not increase

Food safety agencies to be added to the supply chain to ensure inspection of the quality of food and ensuring that proper storage measures are taken, vehicles used to transport food should also be inspected to ensure that they are clean and fumigated before food is put in them

The government should invest in infrastructure such as solar-driven dryers to ensure excess food is properly preserved and support offered to farmers in terms of storage facilities to ensure food safety and non-wastage

Mobilizing different the national and county governments to work together in ensuring the whole county has access to food.

Financing Refugees during a pandemic: How has COVID-19 affected funding of refugee programs?

BY Cynthia Njeru

“Stay home,” they said. But what if home is the mouth of a shark? As the world addresses the COVID-19 pandemic and we stay indoors to ‘flatten the curve,’ I think of one of the most vulnerable groups in the world, refugees. For many of us, COVID-19 is an adversity that we want to end as fast as it came so that we can return to our ‘normal’ lives. To persons forced to flee their homes however, this is yet another hurdle that they have to navigate on their quest for safety.

Refugee:  a person who is outside his or her country of nationality or habitual residence and has a well-founded fear of being persecuted because of his or her race, religion, nationality, membership of a particular social group or political opinion; and is unable or unwilling to avail him or herself to the protection of that country, or to return there, for fear of persecution.[1]

In this blog we discuss two main concerns for refugee programs and refugees during this time which are: access to funding by organizations working with refugees to respond to COVID-19 related needs of refugees and access of asylum by persons in need of international protection in light of border closures. It is the view of the blogger that states, should continue to implement the principle of burden sharing so that international organizations working with refugees in the global south are able to respond to the immediate needs of refugees during this period.

States are responsible for the protection of the fundamental human rights of their citizens, among them, the responsibility to ensure that their citizens access healthy working and environmental conditions. During this period, states have taken stringent measures to manage risks to public health, including risks that could arise in connection with non-nationals arriving at their borders. These measures include screening travelers on arrival and closure of international borders. While these they may be effective in containing the infectious disease and preventing its spread, it poses a threat to persons who are in need of international protection. While the world is worried about the spread of the virus, there are parts of the world where active conflict is still on-going and persons need to flee their homes to seek safety in other countries. The closure of international borders by states will be a hindrance for such people as they seek safety.

The United Nations High Commissioner for Refugees, UNHCR, through their press release here, has encouraged states to implement reasonable and non-discriminatory public health measures that continue to allow access to international protection. They have also reiterated the principle of nonrefoulement and encouraged states to ensure that asylum seekers have access to information on Covid-19 in a language that they understand.[2]

Principle of non-refoulement: “No Contracting State shall expel or return (“refouler”) a refugee in any manner whatsoever to the frontiers of territories where his [or her] life or freedom would be threatened on account of his [or her] race, religion, nationality, membership of a particular social group or political opinion.”[3]

With the closure to passenger traffic on most international borders it is worrying that many refugees may not be able to flee to safety and those who do, may result to desperate measures to cross international borders. For instance, the Kenya-Uganda Busia border was closed for a period of one month on March 22, 2020.[4] Although illegally, many refugees from Rwanda, Burundi, Uganda and the Democratic Republic of Congo cross the border into Kenya through the Busia border. With the closure of this border, refugees seeking to access asylum in Kenya through this border may result to

UNHCR and other Non-governmental organizations working with refugees rely on funding from governments, the UN and pooled funding mechanisms from intergovernmental institutions and the private sector. Most of these budgets run from January to December while they raise funds for emergencies as they occur[5]. In 2019 for instance, the top three donors to UNHCR were the United States of America, the European Union and Germany. Considering that the U.S. and European countries have registered significant cases of COVID-19, their funding to organizations such as UNHCR is likely to be affected. To bridge a likely funding gap, UNHCR has taken to fundraising from private donors through their website.

UNHCR has appealed for a budget of $255 million in addition to its 2020 global budget of $8.6 billion to increase their preparedness for COVID-19 for the 71 million displaced people in the world.[6] Most of this funding is geared towards up scaling its health and water, sanitation and hygiene (WASH) preparedness and response interventions, providing support to vulnerable displaced families experiencing economic shock, and ensuring protection and assistance for those most affected. While UNHCR has not published what percentage of the requested funding for the COVID-19 pandemic response has been received, the agency has continued to receive funding throughout the period of the pandemic with their most recent funding of $2,988,345 received from Sweden on 08 April 2020[7]. It is important to note that in 2018, UNHCR had a budget of $8.2 billion and only received funding of $4.184 billion[8]. Limited funding led UNHCR to minimize their activities causing a major gap in fulfilling their mandate, to protect refugees. For the Burundian situation for instance, UNHCR could not construct adequate shelters in refugee camps hosting refugees of Burundian origin in neighboring countries. Health Centers in these camps struggled to cope with the number of patients, classrooms were overcrowded, and capacity to assist unaccompanied children and survivors of sexual violence was extremely limited[9].

Refugees often face unique challenges and the pandemic is likely to affect them differently as compared to other people. Some of the unique protection concerns faced by refugees are discussed below.

Most refugees lack quality education and professional skills and due to poor living conditions in refugee camps, most refugees migrate to urban centers where they engage in menial work such as construction work and washing clothes to provide for their often large families. The COVID-19 pandemic has forced countries to impose a curfew and lockdowns causing a disruption for most informal employees, among them refugees. Most of these refugees live in urban slums where they are at a heightened risk of contracting the illness due population density in these areas. Without jobs, the refugees are left to rely on local charities for survival, many of which are now closed due to the pandemic and government-ordered lockdowns[10]. Some questions that can help to inform future research on this issue include: are refugees who depend on informal employment in urban centers across the world coping during this pandemic? Have some refugees opted to relocate to camp locations where, though the living standards are poor, they can receive food rations or cash assistance?

Host governments, with the help of UNHCR, are responsible for the process of Refugee Status Determination (RSD). This is the legal or administrative process by which governments or UNHCR determine whether a person seeking international protection is considered a refugee under international, regional or national law[11]. Taking Kenya as an example, the continuous inflow of refugees into the country and the lack of adequate funding for UNHCR and the government, has led to an increased backlog in the number of asylum seekers in need of refugee status determination[12]. Currently most offices are closed indefinitely, cancelling all scheduled interviews and counselling sessions. This will lead to increasing the backlog and many more asylum seekers have to wait longer for their status determination. To cover the gap, UNHCR and host governments may need more funding to increase their capacity to meet their target interviews for the year.

The restriction on movement of people from one country to another as a measure to prevent the spread of COVID-19 has also had a direct impact to some functions of UNHCR such as resettlement. Resettlement involves the identification and transfer of refugees from a State in which they have sought protection to a third State that has agreed to admit them with permanent residence status[13]. Refugees who were scheduled to depart for resettlement cannot depart because of the travel ban imposed by many countries. This means that UNHCR and their partners have to continue offering assistance especially in terms of rations and cash assistance to refugee families whom they had projected that would no longer be in need of this assistance.

Currently, there is not conclusive information on how the pandemic has affected the funding of refugee programs and this will be an interesting topic to follow. Noting that only 45% of UNHCR’s budget was funded in 2018, it is important to check the trend of funding in 2020 and for as long as the pandemic lasts. Future research on this topic should investigate whether most donor countries will withdraw their funding to fix their health sectors.


[1] UN High Commissioner for Refugees (UNHCR), The 1951 Convention Relating to the Status of Refugees and its 1967 Protocol, September 2011, available at: https://www.refworld.org/docid/4ec4a7f02.html

[2] UN High Commissioner for Refugees (UNHCR), Key Legal Considerations on access to territory for persons in need of international protection in the context of the COVID-19 response, 16 March 2020, available at: https://www.refworld.org/docid/5e7132834.html

[3] Non-refoulement and the scope of its application. Available at: https://www.unhcr.org/4d9486929.pdf

[4] State closes Busia, Malaba borders over Corona fears. Available at: https://www.standardmedia.co.ke/article/2001365249/borders-closed-for-a-month

[5] https://www.unhcr.org/donors.html

[6] http://reporting.unhcr.org/

[7] http://reporting.unhcr.org/

[8] UNHCR 2018 Global Report. Available at: http://reporting.unhcr.org/sites/default/files/gr2018/pdf/GR2018_English_Full_lowres.pdf Page. 5

[9] UNHCR 2018 Global Report. Available at: http://reporting.unhcr.org/sites/default/files/gr2018/pdf/GR2018_English_Full_lowres.pdf Page. 41

[10] COVID-19 responses in Africa must include migrants and refugees. Available at: https://reliefweb.int/report/world/covid-19-responses-africa-must-include-migrants-and-refugees

[11] UN High Commissioner for Refugees (UNHCR), Handbook and Guidelines on Procedures and Criteria for Determining Refugee Status under the 1951 Convention and the 1967 Protocol Relating to the Status of Refugees, December 2011, HCR/1P/4/ENG/REV. 3, available at: https://www.refworld.org/docid/4f33c8d92.html

[12] https://www.unhcr.org/ke/refugee-status-determination

[13] https://www.unhcr.org/ke/resettlement