How can African countries use their resources better in responding to COVID-19 pandemic?
Date of Publication: April 7, 2020
The global COVID-19 pandemic has brought to the fore the immense short comings of health systems globally. As a novel disease, whose ultimate course and eventual impact remains unknown, It has been referred to as most challenging human crisis since World War II attacking societies at their core. While the world is navigating an uncharted area, the lessons learnt from previous epidemics show that the effect will mostly affect health systems especially those that are unprepared.
Health systems especially in Africa are still grappling with the known “usual suspects” that compromise health system performance (under-funding, corruption, mismanagement, and wrong priorities). As the number of COVID-19 cases continues to increase, most of the commentary on improving health system preparedness and response to COVID-19 has argued for an urgent need for increased health system investments combined with a whole of government response. Without taking exception to these arguments, in this article, we further argue that as we respond to COVID-19 and prepare for the next epidemic, African health systems should use this window of opportunity to:
- Emphasize the need for better prioritization of the resources available for the response
- Highlight the fact that (mis)prioritization is an ethical choice whose actions or omissions should be equal to a choosing between whether or not to save a life
A case for better prioritization of resources in response to COVID-19
African countries have been able to mobilize additional resources for preparedness and response through: leveraging their budget laws to effect re-allocations of existing funds, setting up contingency funds (such as in Kenya), supplementary budgets (Uganda) to obtain additional resources from government and development partners who have dedicated funding to COVID-19 such as the World Bank and International Monetary Fund through both grants and loans. There has also been impressive involvement by the private sector in all countries. However, translating the resources to an effective response that will not only lead to an end for COVID-19 but will leave a stronger health system post COVID-19 will require very smarter spending.
The starting point is obvious –better priority setting is needed now because it has been seriously lacking—isn’t the lack of prioritization of the health sector but also within the health sector, how we got here in the first place? The less obvious point is that prioritization can itself increase resources especially from the non-traditional sources based on trust built from implementing an effective response. In making this same argument, Daniel Wikler states that, “There is no point to handing over money if it will be stolen, squandered, or frittered away. Providing assurance that priorities have been set wisely is one way to reassure donors and to maintain or increase the flow of funds.”
Since epidemic preparedness and response is a government wide effort, a fair and transparent allocation of resources across sectors/ government agencies needs to be guided by a well costed contingency plan that captures the roles of all agencies involved in both preparedness and response. This plan must be informed by a costed National Action Plan for Health Security developed based on an evaluation of readiness in line with the International Health Regulations. Resource allocation that is guided by well costed preparedness and response plans is more likely to be judged as fair and will gain the trust of both the funders and the beneficiary population. On the other hand, allocations which are considered adhoc may judged by the public to be neither fair nor transparent as is the case with some of the current allocation resources for COVID-19.
Extending the ethical dilemma in COVID-19 resource allocation to everyday decision making
The grim dilemma associated with making resource allocation decisions in the context of scarcity has been brought to the fore in the Covid-19 Pandemic. Leading experts recommend approaches for allocating covid-19 resources as: maximizing benefits by prioritizing those most likely to benefit from the interventions; prioritizing health workers as a means of promoting and rewarding instrumental value in the response; prioritizing the worse off as opposed to allocating resources on a first-come, first-served basis (or even worse ability to pay); being responsive to evidence; recognizing research participation; and ensuring that these same principles are applied to both Covid-19 and non–Covid-19 patients during this response. Operationalization of some these allocation principles through the way a health system is financed has been expounded in a blog by the World Health Organization health financing team especially on the issue of removing financial barrier to access that may result into allocating resources neither to those most likely to benefit nor the worse off.
While most of the ethical choices in COVID-19 response are perceived as decisions that have to be made by the health worker at the point of service delivery, that should not be the case. In fact, the people whose actions and/or omissions are responsible for whether a health system will successfully manage an epidemic never consider it a choice between life and death. For instance, we know that the survival rate of severe patients with COVID-19 depends on availability of functional intensive care units(ICUs). However, our capacity for critical care treatment is very limited as has been shown by the lack of ICU beds. How would one explain some African countries having zero ICU beds while even those that have, the numbers are very minimal when compared to the population sizes. This shows an example of wrong priorities, when decision makers are blind to the consequences of their decisions. Being able to identify and address such unethical use of resources should be a lesson that will leave our health system stronger post COVID-19.
Envisioning health systems beyond COVID-19
In these challenging times, countries need to utilize the opportunity that comes through crisis to shape the way our health system, as well as how people within it work. If we are able to use our resources better but also be aware of the consequences of our choices, then we will respond better to this epidemic and better prepared for the next. The lessons learnt from the previous pandemics such as the most recent Ebola outbreak in West Africa seem to have been forgotten. A case was made then to build resilient health systems which up to now remains a pipe dream for most of the African countries.
Resilient health systems are able to prepare for and respond effectively to a crisis while maintaining the delivery of essential health services. Had we heeded the call then, we would not only be able to respond effectively to this pandemic but we would also be less worried about how to maintaining patients with chronic diseases including HIV on medication, ensuring safe delivery for pregnant mothers or children dying of malaria as we respond to the Covid-19 outbreak.
This is the time to move from lip service to action, let’s build resilient health system through ensuring that our allocation decisions reflect this commitment.
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Profile of Author(s)
About Brendan Kwesiga
Technical Officer (Health Financing for UHC)
WHO Kenya Country Office
About Juliet Nabyonga-Orem
Health systems Expert, WHO