Written by Leah Breen
Five months into the coronavirus crisis, the pandemic has permeated nearly all corners of the globe. Everywhere, Covid-19’s impact is exposing gaps in health systems’ capacity to ensure that people can access high-quality, affordable care. In low and middle-income countries (LMICs) with limited healthcare capacity, crowded living conditions, and inadequate access to sanitation resources, people are particularly vulnerable.
“If you think it is really terrifying to face the prospect of Covid-19 in an advanced industrialized country, if you’re worried about ventilators in New York City, if you’re concerned about the health system in Italy, just imagine what it’s like to face the prospect of a virus where there isn’t running water, where there isn’t a proper health system,” David Miliband, former British foreign secretary and president of the International Rescue Committee, said in an interview with the World Economic Forum.
Many LMICs are racing to respond to the pandemic: Senegal banned public gatherings, Indonesia is repurposing thousands of garment factories to produce PPE, and Peru implemented a strict lockdown. As countries attempt to turn the tide on Covid-19, it’s not enough to simply react to urgent needs. To get ahead of the pandemic’s next wave of disruption, defensive strategies are probably insufficient countries will most likely have to go on the offensive.
To help build a forward-facing strategy, health system experts at ThinkWell, a global development organization, weigh in on six ways that countries can act now to prepare for whatever comes next:
1. Copy and paste solutions won’t do the trick
Covid-19’s impact is starkly different not just across countries, but across communities. New York City, which has more Covid-19 cases than any other city in the world, has had to respond to the pandemic in a much different way than New York’s rural upstate counties, many of which remain largely unscathed. There is no such thing as a one-size-fits all response.
To factor regional differences into countries’ preparedness plans, Pierre-Marie Metangmo, MD, a ThinkWell senior policy advisor in Burkina Faso, recommends that countries conduct a baseline assessment for their health systems. This type of assessment gives policymakers and planners, “a clear sense of where their strengths and weaknesses lie across all health system levels and geographic regions.” With that data in hand, policymakers and planners have a better understanding of their country’s varying health needs and capabilities. And they can thereby target their investments to equitably build their capacity to respond to the pandemic’s ebbs and flows.
2. Pop stars can make good role models
With the world in unchartered waters, people are looking to others for how they should act in this new coronavirus era. Should they wear a facemask outside? Let their children play at the neighbor’s? Changing ingrained behavior is hard—and we know that information and knowledge doesn’t always lead to better habits. People don’t like being told what to do, but they do often respond when they observe others modeling behavior. Leaders in Hong Kong and Taiwan have set an example by wearing facemasks. Musicians in countries like Vietnam, Uganda, and Panama are creating viral songs and music videos to promote coronavirus prevention strategies in a way that aligns with local culture. Puerto Rican artist Bad Bunny’s Spanish lyrics for his song “At Home” include, “I wanted to see you/but that won’t be possible/I have to stay home.”
“Coronavirus response plans need to have a community dimension,” said Dr. Metangmo. “You need to communicate in the cultural context.” If countries have plans in place to equip local leaders and influencers with the tools to spark behavior change, through their own actions and modeling, a community will be in a better position to slow a pandemic.
Benter Owino, a ThinkWell senior technical advisor based in Kenya, recommends that governments harness mobile technology to deliver pandemic prevention and treatment messages. “Culturally appropriate communication in people’s local language, through popular mobile apps and platforms, can go a long way toward reaching people in a compelling way,” she says.
3. Trust: a health system’s secret weapon
West Africa and the Democratic Republic of Congo’s Ebola outbreaks have taught us that when people don’t trust their health care systems, pandemics thrive. In the Congo, a survey by Harvard Medical School found that 45 percent of respondents thought Ebola did not exist or was a political conspiracy.
While citizens’ trust in state institutions is critical to managing a pandemic, trust within the healthcare system is also paramount. “A crisis shows the broken pieces of a healthcare system,” says Dr. Metangmo. “When there’s little trust and poor communication between health leaders and personnel, you lose time addressing irrelevant issues instead of mobilizing people and resources to solve the crisis’ problems.”
Dr. Metangmo recommends that governments invest in strengthening collaboration and communication between community health workers, health facility managers, and all the way up to the ministry of health and executive office. That way, when a health crisis hits, the system has a united front of health experts who are prepared to fight together.
4. Start saving
During “normal” times, when a pandemic has ebbed, “financing for pandemic preparedness falls through the cracks,” says Angellah Nakyanzi, a private sector specialist at ThinkWell in Uganda. “That means we end up dealing with each health emergency as it comes. Health must be treated with the same priority as infrastructure development and national security.”
While many external financing mechanisms exist for responding to a pandemic, historically there have been fewer financing options for preventing a pandemic. The funding that does exist is fragmented, complicated to disburse, and doesn’t always align with existing domestic-health funding flows. “Uganda needs a deliberate mechanism for financing pandemic preparedness and response,” Angellah Nakyanzi argues. Supplementary budgets, passed during the heat of a crisis, are insufficient. Uganda and other countries might be better served if they maintain a continuous financing strategy for future epidemics and pandemics.
5. Remember not to let a pandemic’s shadow leave other health needs and workers in the dark
Pandemics tend to eclipse other healthcare needs. But chronic issues like diabetes or ER visits due to accidents don’t just disappear. “One of the most important things governments can do is determine how to keep essential services running during a pandemic,” says Dr. Metangmo. “You can’t lose sight of other health needs.” Dr. Metangmo suggests that LMICs plan for how clinics and hospitals can di
vide treatment wards for both pandemic patients and those battling other afflictions.
At the same time, it’s not always possible for organizations to continue providing all health services during a pandemic. Nonessential medical care and elective surgeries may need to be postponed. “You can’t do business as usual during a pandemic,” Dr. Metangmo says. Governments might prepare concrete plans for maintaining “must-have” care during a crisis while suspending “nice-to-have” services. They can also create strategies that enable health care workers to rapidly transition from providing nonessential care to urgent care. Without a flexible plan for health care workers to nimbly shift roles, skilled workers may find themselves needlessly out-of-work.
6. PPE can’t wear itself
“In Kenya, the rush to procure medical commodities for coronavirus overshadowed discussions around health worker needs,” Benter Owino shares. “When cases first appeared in Kenya, there were lots of political conversations about how to get more PPE and ventilators, but rarely did the government address the availability of health workers to fight on the frontlines.” If there’s no one to operate those ventilators, they’re obviously worthless.
With coronavirus infecting health workers at an alarming rate, there’s an even greater need for a robust force of trained medical personnel. India only has 0.8 physicians per 1,000 people (compared to 4.2 in Germany) and Ecuador has 12 nurses per 1,000 people (compared to 17.3 in Switzerland). There simply aren’t enough health personnel to adequately fight a pandemic in most low and middle-income countries. When this first tsunami of global Covid-19 cases has passed, countries would be wise to address their gaps in health worker capacity and build up their workforce, to prepare for the next wave, whenever it might come.
