Developing Countries’ Weak Health Systems
Health systems in most developing countries are unevenly inadequate, even in normal times. Despite several pandemics in recent years, most countries have remained poorly prepared, even for the specific challenges posed by COVID-19. Even many health systems in Europe and North America have faced major shortages of doctors, respirators/ventilators, basic infection prevention (BIP) gear, PPE and testing kits.Footnote 19
A recent survey of the availability of four BIP and four PPE items in seven poor countries (Afghanistan, Bangladesh, Democratic Republic of Congo [DRC], Haiti, Nepal, Senegal and Tanzania) found less than a third of clinics and health centres in Bangladesh, the DRC, Nepal and Tanzania had any face masks (Gage and Bauhoff 2020). In all seven countries, clinics and health centres, often the first point of public contact with the health system, had, on average, just 2.3 (of four) BIP items and two (of four) PPE items. Most countries also scored poorly on health workers’ preparedness with reference to the 2005 IHR to prevent disease spread.
While the US has about 33 intensive care unit (ICU) beds per 100,000 population, the ratio is around 2 per 100,000 in India, Pakistan and Bangladesh in South Asia. In sub-Saharan Africa, the situation is even more dire: Zambia has 0.6 ICU beds per 100,000, Gambia 0.4, and Uganda 0.1 (Malley and Malley 2020). In 43 of Africa’s 55 countries, total ICU beds number less than 5000, or about 5 beds per million, compared with about 4000 per million in Europe. There are also serious respirator shortages in Africa, with 41 African countries together having fewer than 2000 as of mid-April, and ten with none at all, while the US had 170,000 respirators in mid-March (Maclean and Marks 2020). The average low-income country has 0.2 physicians and 1.0 nurses per thousand people, compared to 3.0 and 8.8 respectively in high-income countries (Gage and Bauhoff 2020).
Global markets for crucial WHO designated COVID-19 products are highly concentrated (Espitia et al. 2020). The EU, US, China, Japan and Korea—account for 80% of total imports. The import shares of products needed for case management and diagnostics are even higher, close to 90%. Import shares for PPE and hygiene products are somewhat lower, around 50–60%, requiring countries to compete on the basis of their respective means, regardless of need.
Developing countries are also extremely vulnerable to changes in exporter policies, such as export restrictions on COVID-19 tests, treatments and PPE. Besides affecting availability, export restrictions—supposedly due to domestic shortages—have pushed up world prices. Espitia et al. (2020) estimate that current export restrictions could initially increase prices of medical masks by 20.5%, Venturi masks by 9.1%, and protective equipment, such as aprons and gloves by 1% and 2% respectively. If exporting countries tighten export restrictions in response to domestic price rises, prices of such COVID-19 relevant goods could rise by 23% on average; most affected would be PPE, such as aprons (52% increase) as well as goggles and masks (40% increase) (Espitia et al. 2020).
Therefore, as high-income countries scramble to secure crucial supplies such as face masks, low-income countries face much tougher choices. Their budgets are far more limited, and they typically lack local producers for most PPE, relying on donors and multilateral organizations for procurement in the face of unreliable supply chains.
The COVID-19 threat to frontline health workers in low-income countries has been largely ignored. Only a small fraction of needed PPE has gone to them. The WHO has dispatched 0.5 million PPE sets, while UNICEF has dispatched 100,000 N95 masks, 4.3 million gloves and other PPE. Billionaire philanthropist Jack Ma has donated 100,000 masks and 1000 protective suits each to every African country and 1.8 million masks to 10 Asian countries (Gage and Bauhoff 2020).
In recent decades, developed economies, through the IMF and World Bank, have used aid conditionalities to demand fiscal cuts and neoliberal health reforms, e.g., by imposing user fees in developing countries (Lister and Labonté 2009). Instead of improving efficiency, quality and coverage, these reforms have had deleterious implications for public health, besides exacerbating inequalities in access to health care (Stubbs and Kentikelenis 2017; Forstera et al. 2019; Sobhani 2019).Their structural adjustment programmes in developing countries, particularly in Africa, have resulted in underinvestment in health care systems, causing them to be poorly prepared to respond to the Ebola epidemic (Nkwanga 2015). Besides IMF and World Bank programmes, such underinvestment was also due to compromised fiscal capacities and regressive fiscal priorities (Sanders et al. 2015; Scott et al. 2016).
Developing Country Responses
With no known effective treatment for the infection, as the deadly nature of the virus became clear, many countries, even the world’s most ‘advanced’ and richest, have adopted draconian measures, such as total or nationwide ‘stay in shelter’ lockdowns, often in panic and ignorant of other options. Accustomed to adopting supposed ‘best practices’ prescribed by the rich and powerful, all too many developing country governments are implementing such measures without sufficiently taking into account country-specific circumstances and other challenges. Besides the obvious differences between developed and developing countries, especially in terms of resources, demography, governance and other institutional capacities, there are significant differences among the developing countries themselves.
In most slums and villages, many people often live together in one or two rooms, sharing common facilities. Safe physical distancing is virtually impossible in such circumstances. Even basic hygiene and other prescribed sanitary measures are not easy when even clean running water is scarce.Footnote 20
Most of the population in many developing countries is in the informal sector, earning meagre, typically daily incomes, and with paltry savings. All too many developing countries do not have enough fiscal space to provide sufficient relief for vulnerable populations and small businesses for very long. Hence, extending strict lockdown measures and causing an economy to be locked down for too long may erode public support, even if high at the outset. But as it is often too late to rely solely on early preventive and precautionary measures, authorities typically see no choice but to implement strict and effective contagion containment at the expense of disrupting livelihoods. This dilemma is often misrepresented as choosing between life and the economy.
Transmission patterns are determined by many factors, some social, local and intimate. International and even national public health decision makers are often oblivious to some such factors, which community members know all too well. Therefore, joint learning, involving both experts and affected communities, can be vital for effective responses.
Selected Country Experiences
Brazil and Peru are two of the worst hit countries in Latin America, but for different reasons. While the failure in Brazil has been due to complacency, denial and lack of national/social solidarity, the Peruvian setback has been due to poor design of relief measures. Despite life-threatening risks, Brazil’s President Bolsonaro chose to emulate US President Trump, infamously comparing the COVID-19 threat to a ‘little flu’ or ‘cold’, even dismissing it as a media-hyped ‘fantasy (Borges 2020). He also dismissed preventive measures as ‘hysterical’ and repeatedly demanded that state governors withdraw their physical distancing and stay-in-shelter lockdown orders. Displeased by his public remarks on the need for lockdowns and physical distancing, Bolsonaro fired his health minister, causing outrage across Brazil. Locked-down citizens of Brazil protested, even charging ‘Bolsonaro Murder’ (Quinn 2020). Instead of an ‘all of government’ approach, Bolsonaro also started disputes with Brazil’s Congress and Supreme Court (Oliveira 2020; Santos 2020; BBC News 2020).
Peru, on the other hand, acted early and as decisively as Argentina, but met with different outcomes. Peru imposed lockdowns, closed schools and borders, cancelled international flights, and introduced relief measures. But its response was flawed as the government had not sufficiently considered the country’s socio-economic conditions. For example, most poor Peruvians living in slums do not have bank accounts, and had to stand long hours queuing for cash relief grants. Ironically, this became a major cause of contagion (Ghitis 2020). The government’s relief and preventive public health measures did not address the needs of the most vulnerable sectors of society, including the poor, self-employed, informally employed, Indigenous communities and indebted middle-income households. Rather, the government targeted its subsidies at large companies, who were presumed to be the major employers. Its safety-net programmes were based on census and municipality records, suffering serious data deficiencies. Hence, government measures barely reached those in greatest need (Martínez 2020). More than 21% of Peru’s population live in extreme poverty, with around 70% in the informal sector depending on daily work for their livelihoods. While poor people, especially in cities, find it almost impossible to comply with lockdown restrictions as they struggled to survive, officials and much of the media portrayed them as ‘irresponsible’. Trust and community support for government measures were undermined with the revelation of corruption scandals in the procurement of sanitary, protective, testing, medical and other supplies (Martínez 2020).
Other resource constrained developing countries, like Vietnam and Argentina, and India’s Kerala state have tackled the pandemic far more effectively, at low cost and with impressive results. Some key features of their policy responses are highlighted below:
The Kerala state government invited religious leaders, local bodies and civil society organisations (CSOs) to participate in policy design and implementation. It refused to use the term ‘social distancing’, which has caste and class connotations, and instead emphasized ‘physical distancing’ as part of a more socially inclusive approach to more people-centric development practices based on social solidarity. It carefully crafted political messages, such as ‘Break the Chain’, with larger political connotations, e.g., breaking the chains of oppression and popular emancipation.
Social Mobilization and Solidarity
Instead of using the pandemic for political advantage against Argentina’s long history of fiercely divisive politics, President Alberto Fernandez invited and stood together with leaders from across the political spectrum when he announced lockdown measures on 19 March in a rare display of national political consensus (Gillespie and Do Rosario 2020). Social, religious and business groups partnered to deliver food cartons to more than two million people in Buenos Aires and the surrounding areas (Alcoba 2020). The Argentine national government has worked closely with opposition party state governors, as well as private and union-linked health providers to secure private cooperation without nationalization (WHO 2020c). Fernandez organized another display of national unity to announce that Argentina would not pay external creditors while dealing with the pandemic, demanding favourable debt-restructuring terms, a bold approach which appears to be working.
The Kerala state government mobilized more than 300,000 volunteers to help implement various infection control measures. It successfully mobilized CSOs to support its ‘Break the Chain’ awareness campaign, and got numerous micro-enterprises to produce hand sanitizers and face masks, while distributing interest-free loans worth 200 billion rupees to needy families (Krishna 2020). In Vietnam, citizens were encouraged—via social media, text messages and TV broadcasts—to donate to the campaign to buy medical and protective equipment for doctors, nurses, police and soldiers in close contact with patients, and for those quarantined.Footnote 21
Both the Kerala and Vietnam governments took measures to prevent stigmatization. The Kerala government organized hundreds of community kitchens with the help of CSOs and local-level leaders to discreetly deliver free meals to those infected with the virus, without publicly identifying them to avoid possible social stigmatization (Krishna 2020).
In Vietnam, the identities of those infected were protected by only referring to them by their case numbers. When local businesses were reportedly ostracizing foreigners, Vietnam’s prime minister spoke out against such discrimination.Footnote 22 Such measures encouraged people to be more open and cooperate fully in contact-tracing, testing and treatment.
All of Government Approach
Administrations that have successfully managed the pandemic have mobilized the all of government and demonstrated effective coordination among government departments and between their various layers. For example, the Kerala government set up 18 inter-departmental committees involving all branches of government, which meet daily to evaluate the situation. Vietnam’s National Steering Committee for COVID-19 Prevention and Control was nicknamed the ‘General Headquarters’—a reference to a military coordinating body in existence until the War ended in 1975. In Argentina, the Chief of the Cabinet of Ministers has responsibility for the ‘General Coordination Unit of the Comprehensive Plan for the Prevention of Public Health Events of International Importance’.
Transparency and Communication
The Kerala government organized daily press conferences, when the state Health Minister and Chief Minister calmly explained what was going on and what her department was doing. Communities were provided with essential epidemiological information to better understand the threat and related issues, to ensure compliance with prescribed precautionary measures and to avoid inadvertently causing panic.
Vietnam has not shied away from broadcasting the seriousness of the COVID-19 threat, with the Ministry of Health’s online portal immediately publicizing each new case with details including location, mode of infection and action taken. Exceptionally, Vietnam’s communist party-led government published the identity and itinerary of a prominent party figure who had tested positive (Vinh Le and Nguyen 2020). Instead of communicating in traditionally formal ways, the government has been creative, e.g., by teaming up with two famous pop singers to produce, promote and broadcast an effectively educational song about the threat. It has also commissioned artists to create posters, and mobilized influential youth figures to broadcast supportive messages to raise the morale of those quarantined and others as appropriate (Bui 2020).
Lockdown with a Human Face
Some governments and other authorities designed effective relief measures with consideration of challenges posed by specific conditions, including urban slum environments. For example, Argentina’s President Alberto Fernández ensured that no essential services—electricity, gas, water, mobile services, fixed landlines, internet and cable television—were cut for retirees, social welfare recipients and low-income households on account of non-payment of bills (Sugarman 2020). Argentina’s government has devoted over US$30 million for food assistance alone. At national, provincial and municipal levels, the government has supported public kitchens, while the President has promised those in desperate circumstances the food and other resources needed to survive (Alcoba 2020).
In a similar vein, the Kerala state government has organized the physical delivery of food, medicine and other essentials as well as necessary services to those under lockdown (Krishna 2020). It took immediate actions to reduce the risk of hunger and starvation of the poorest segments of the population by organizing free rations for all for a month, distributing food kits, consisting of 17 items for every household, irrespective of income status (Pothan et al. 2020).
Kerala and Vietnam have been internationally acclaimed as role models, especially as they are both considered poor, and suffering resource constraints. By acting early, decisively and inclusively, Kerala and Vietnam successfully avoided highly disruptive total lockdowns as well as associated human and economic costs. They achieved a high level of buy-in and popular support for their governments’ COVID-19 containment measures. As they achieved a high degree of voluntary compliance, draconian enforcement measures to ‘flatten the curve’ did not have to be imposed.