Countries with weaker health systems must not be left behind in the global emergency response to covid-19, says Keerti Gedela

With the outbreak of the covid-19 novel coronavirus, we’ve heard a lot about the public health responses that high income countries with strong health systems have implemented to protect their populations, along with expressions of concern for countries with weaker systems. One reason for the World Health Organization’s declaration of this outbreak as a public health emergency of international concern was to try to limit the virus from spreading to densely populated countries with weaker health systems. Since the first case of covid-19 in Africa was confirmed in Egypt, many people are asking, how will health systems in many African countries cope if covid-19 affects them. 

The practical application of an emergency response depends on countries having existing health systems that are effective. But what makes a health system effective is complex. It is about more than just a country’s financial resources, and there are other nations outside of Africa and closer to China that may need more strategic assistance that goes beyond financial and diagnostic support. The global emergency response must equip those countries with weaker or complex health systems with greater strategic guidance, which covers preparedness, implementation tools, and capacity building within healthcare systems. 

To date, the majority of cases outside of China have occurred in Asia. Some countries in Asia have not reported any cases, which may indicate that the virus has not spread to these locations. However, it may also point to the lack of an appropriate public health response and a limited testing capacity. 

Indonesia, for example, has to date not diagnosed any covid-2019 infections, but commentators have questioned whether it seems likely that this is because there are not any. Indonesia sits centrally within southeast Asia, and is the world’s fourth most populated country, with the capital Jakarta one of the most densely populated regions. It has strong travel connections to China and data suggest that large numbers of people have been travelling between China and Indonesia during this outbreak. Indonesia has a decentralised healthcare system in which most healthcare provision is managed at the district level, with large variation in provision and healthcare equity across and within provinces and districts. 

Last month Indonesia outlined its commitment to a prepared response to this outbreak and the steps the government had taken to this end. However, the country’s current diagnostic capability may not be sufficient for this large and geographically diverse island nation. As of a couple of weeks ago, only one lab in Jakarta was able to run tests for covid-19 for the whole of Indonesia, and getting diagnostic resources to and from provinces is likely to prove difficult. The country is understood to be working on their laboratory capacity in other provinces. 

While we have an insufficient understanding of the extent of possible transmission within settings like Indonesia, experts from Singapore, a high income country that neighbours Indonesia and which is a major international hub, have highlighted the challenges their country has faced in deploying public health interventions during this outbreak. These difficulties have come despite Singapore strengthening its capacity and building costly infrastructure to manage an emerging infectious disease outbreak after SARS. They highlight the need for countries and institutions to work closely together and share knowledge to improve capacity; importantly, this should take the form of countries with expertise helping countries that are resource limited.

A global health emergency response must include arming countries with weaker health systems to be more prepared to protect the health of their populations and reduce worldwide transmission. We should be clear that although providing international funding and laboratory resources are essential, this doesn’t immediately translate to achieving an effective public health response.  

Outbreaks such as this spark fear and concern in neighbouring governments. Travel restrictions to and from a nation can cause chaos for business and tourism and have severe economic consequences. As the numbers of cases and deaths rise, panic among the general population can spread. With the knowledge that more than 1700 healthcare workers have been infected in China, we must also recognise the worries that frontline staff may have when assessing suspected cases, especially in hospital/clinic settings that can’t support sufficient care. 

Low and middle income settings with weaker or more complex healthcare systems will need more guidance, which covers capacity building, and direct strategic support and tools to implement a prepared, effective response. This translates to every level within the system including speeding up bureaucratic processes; increasing capacity of central hospitals with skilled responders; rolling out personal protective equipment (PPE) and education for healthcare staff, so that they are prepared and resilient enough to act as immediate responders; and supporting access to, and best practice management and processing of diagnostics, contact tracing, and quarantine capability. This outbreak marks a vital moment where countries with expertise need to work together and share information with countries that lack the means to respond effectively.

Keerti Gedela is an NHS consultant physician and researcher from London. She is living in Indonesia, where she is leading an implementation research project within a UK-Indonesian joint partnership in infectious diseases, funded by the MRC/Newton Fund. Twitter @DrKeertiGedela

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.