As the first suspected cases of the novel coronavirus 2019-nCoV are investigated in Ivory Coast and Angola, and as the World Health Organization (WHO) declares a Public Health Emergency of International Concern, we have begun to worry about the outlook for people and health systems in low-income countries. At baseline, preparedness to respond to outbreaks is weak—of the 45 low-income countries that have undertaken a national preparedness assessment, none have been qualified as ready to respond, making them vulnerable to outbreaks.
But while most of the media coverage and response is focused on China and high-income countries, preventing or controlling spread in low- and middle-income countries (LMIC) is just as important, even if the case fatality rate stays low in higher-income settings. (The WHO-published data from China thus far suggests that around 3 percent of those contracting the virus die.)
Here’s why we must focus on low-income countries as well:
Poorer health and nutrition at outset, poor quality of healthcare: The 2009 H1N1 outbreak in Mexico illustrates how the consequences of outbreaks can be vastly different between wealthier and poorer countries and populations. In 2009, Mexico experienced much higher pandemic-related mortality rates than the United States, Europe, or Australia, a finding that has been linked to lower levels of baseline health and nutrition as well as poverty-related barriers to seeking timely care, but also to poorer infection control and inappropriate use of ventilators in the management of severe cases. While the 2019-nCoV guidance only recommends ventilation and other invasive procedures when cases are critical, about 17-20 percent of the cases do progress to severe disease in the China-reported data, so it is fair to anticipate that this may be a problem if spread happens unchecked in low-income countries.
Extreme resource constraints: Low- and middle-income country governments are highly constrained in their public spending on health, spending only about $267 per person each year (compare to China at $442 and the US at a whopping $10,000 per person). While external funders provide vital complementary support, the total per capita spend does not come near the baseline cost requirements for the provision of a full package of even routine healthcare. Adding a new set of cases requiring diagnosis, treatment, control and management to the usual competing needs and demands means a huge burden ahead for already taxed health systems.
Low influenza vaccination rates: Most low-income countries don’t include extensive use of the seasonal influenza vaccine in their basic immunization program, mainly for cost reasons. Indeed, coverage of flu vaccination is not part of WHO’s tracking of global immunization coverage. In addition, there are many more potential causes of symptoms that look like those of the novel virus. Taken together, this means there is no easy way for people or healthcare workers to distinguish the novel coronavirus from routine healthcare issues thus increasing the likelihood of missed cases and greater spread. Flu season will begin around May 2020 in Southern Hemisphere.
Vulnerable supply chains: Again, at outset, medicines procurement and supply chains in LMIC are weak outside of the “big three” diseases of HIV/AIDS, TB, and malaria (see our recent report), leading to limited visibility in orders and inventory, and frequent stockouts. In most countries, the private sector is more efficient at ordering and distributing medicines, but orders are made mostly with cash on hand, and assuring the quality of medicines is an ongoing challenge across the board, with some studies indicating that between 15-30 percent of medicines in LMIC are substandard or falsified. As we watch the price of N95 masks on Amazon skyrocket alongside warnings of counterfeits, it is easy to see how shortages and scarcity can occur, affecting the provision of routine care even without a significant outbreak.
There are still reasons to stay optimistic about the trajectory of this outbreak—lethality appears low, few children are affected, and the Chinese authorities with the World Health Organization are acting aggressively to limit spread. This time, there is an Africa Centres for Disease Control and Prevention that should enable Africa to have a clearer and more coordinated response(see their director, Dr. John Nkengasong on the China response here).
But while it is still too soon to assess the impact of the current outbreak, and to tell whether it reaches pandemic levels of spread—or more significant mortality—it is a good time to focus (again) on enhancing preparedness to identify and respond to outbreaks, or risk derailing the decades of investment that have yielded great returns for global health and development.
A sector-wide proposal: the Pandemic Preparedness Challenge Fund
As US global health and Congressional leaders have recommended as part of the CSIS Global Health Security Commission—based on a proposal from CGD and Resolve TSL authors—there is consensus that a Pandemic Preparedness Challenge Fund is needed to enable more direct support to low-income countries in filling the preparedness gaps identified in WHO’s Joint External Evaluation assessments. CGD colleagues and I have made the same recommendations to the European Union, We discussed these ideas at an event on the CSIS report in December here.
While more funding to WHO, the Africa CDC, and USG global health security accounts is also needed in the near-term, given the intense competing demands on low-income country government health budgets and the currently fragmented and scarce external funding for preparedness, there is a clear imperative to create dedicated funding and clear incentives for low-income governments’ own on-budget spend and effort to speed preparedness progress. The World Bank is probably the right home to assure that the funding is on-budget, additive, and synergistic, with overall health systems support and other global health priorities such as maternal and child health, and infectious disease control more broadly.
With colleagues from NTI, CSIS and elsewhere, I’ll be sharing our thinking on the form that the challenge fund should take and proposing that the G-7 make the Preparedness Fund a centerpiece of their meeting in June 2020.
Stay tuned, and in the meantime, your thoughts are welcome below.