# Introduction

The number of cases of the novel coronavirus 2019-nCoV (COVID-19) is increasing across low- and middleincome countries (LMICs), raising concerns about the ability of the health systems in these countries to mount an effective response and the potential direct and indirect health and economic impacts of the pandemic. Modeled predictions of the global impact of this pandemic suggest that demand for critical care will vastly exceed capacity in all countries, regardless of the mitigation scenario.<sup>2</sup> LMICs are at a disadvantage from the outset: from the supply side alone, it is well-documented that public spending in health is low, critical deficiencies in provision of high-quality routine care exist, and preparedness to respond to outbreaks is weak.<sup>3</sup> Given these considerations, it is anticipated that health system failure, in addition to lack of adequate care for severe cases of COVID-19, will exacerbate the degree of excess mortality in countries with already weak health systems.

The 2014 Ebola epidemic in Guinea, Liberia and Sierra Leone highlighted the importance of an effective national health system as the first line of defense against pandemics and the importance of health system resilience, that is, “the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learnt during the crisis, reorganize if conditions require it.”<sup>4</sup> Unfortunately, five years later, countries find themselves ill-prepared and vulnerable to the threat of pandemics and large-scale disease outbreaks, let alone able to move beyond a narrow preparedness agenda to build resilient health systems.

While the task of responding and adapting to health shocks in the face of the COVID-19 pandemic in LMICs appears daunting, a nuanced, evidence-based approach could inform targeting of interventions to address short-term demands, and in the process integrate pandemic preparedness and resilience as a part of overall strengthening of national health systems.

# Background on pandemic preparedness and response

The objective of pandemic preparedness is to enable countries to swiftly mobilize resources to recognize and manage a pandemic. Adequate preparedness and effective response may help reduce transmission of the pandemic virus strain; decrease cases, hospitalizations, and deaths; maintain essential services; and reduce the economic and social impact of a pandemic.<sup>5</sup> Pandemic preparedness, however, is not a shortterm or quick process. A detailed and comprehensive pandemic plan requires a multisectoral, whole-ofsociety approach to engage people and build the commitment needed for policy decisions.

Provision of essential health services is critical to minimizing morbidity and mortality during pandemics. In line with general health emergency preparedness planning, rational personnel management, optimal use of facilities, medical supplies and pharmaceutical products are important steps in ensuring that health services are effectively functioning and responding to emerging health challenges during pandemics. To achieve these, the World Health Organization guidance suggests focusing on 18 broadly defined tasks

> 2 Patrick GT Walker, Charles Whittaker, Oliver Watson et al. The Global Impact of COVID-19 and Strategies for Mitigation and Suppression. Imperial College London (2020), doi: https://doi.org/10.25561/77735

> 3CSIS Commission on Strengthening America’s Health Security. Harnessing Multilateral Financing for Health Security Preparedness. CSIS Briefs. April 2019. Accessed on April 8, 2020. <u>https://www.csis.org/analysis/harnessing-multilateral-financing-health-security-preparedness</u>

> 4 Kruk ME, Myers M, Varpilah ST, Dahn BT. What is a resilient health system? Lessons from Ebola. Lancet 2015;385:1910-2.

> 5 World Health Organization. WHO checklist for influenza pandemic preparedness planning. 2005. Accessed April 8, 2020 https://www.who.int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_2005_4/en/

2