4. ANALYSIS
1 Apr 2020
Critical care in the region is in a shambles - can the Global Fund help?

The COVID-19 pandemic is currently wreaking havoc in Western European countries and the United States of America (U.S.), according to the World Health Organization. As of 31 March, Corona Virus had infected more than 250 000 people in the U.S. and Italy combined, more than the 81 000 in China, where the epidemic originated in December 2019. Italy and Spain each had registered more than 8000 deaths, which is almost three times the number of deaths in China. These infections and deaths occurred within a matter of months during the first quarter of 2020, meaning countries did not have a lot of time to prepare and upgrade their health systems to face this pandemic.

COVID-19 symptoms are mild or moderate for a large proportion of the infected population. Still, the disease can be severe and even fatal for those with underlying medical conditions such as high blood pressure, diabetes, as well as for the elderly, according to research on early cohorts of people with COVID-19 in China. The study stated that, among those infected, 14% had severe enough symptoms to require hospital admissions, and 5% needed critical care, sometimes called intensive care. Critical care helps people with life-threatening injuries and illnesses, including severe breathing problems, which is a hallmark of this coronavirus. Critical care usually takes place in an intensive care unit (ICU).

Countries in Western Europe and the United States of America have health systems characterized by adequate numbers of health professionals—doctors, nurses, laboratory technicians, among others— as well as sound data systems, and good medical infrastructure, including enough critical care capacity. Some countries like the U.S. have national strategic stockpiles of hospital supplies and equipment in case of emergencies. Most of those countries have emergency preparedness departments that plan ahead for responses to emergencies.

And still, high-income countries in Western Europe and the U.S. appear caught off-guard by the severity of the pandemic, judging by the sheer numbers of people infected within a matter of weeks, those who have required critical care, and the number of people that have died. To date, most sub-Saharan African countries have confirmed fewer than two hundred cases of COVID-19 and fewer deaths, although the numbers are changing fast. A notable exception is South Africa, which has confirmed 1326 cases as of 31 March 2020. But the pandemic reached the continent about two months after it reached Europe, so the number of people infected in Africa may increase exponentially. Many will need critical care to survive.

Dismal critical care in sub-Saharan Africa

Except for South Africa, countries in sub-Saharan Africa have weak health systems. Medical infrastructure, health facilities, and numbers of staff qualified to provide care are insufficient. And critical care capacity is sorely wanting.

South Africa, the most developed country in sub-Saharan Africa, has 3000 critical-care beds available for COVID-19 out of about 7000, as critical care will still be needed for other life-threatening conditions like stroke, which was the reason given by a local newspaper. The population of South Africa is 59 million. The U.S. has 75,000 critical-care beds in 5200 community hospitals, which are defined as all hospitals excluding those belonging to the federal government, according to the American Hospital Association. (The federal government has about 200 hospitals for specific populations such as army veterans or prisoners). The U.S. population is about 331 million. Our back of envelope calculation dividing the number of beds by the total population gives 22 critical-care beds per 100 000 people in the US. But a recent article in Forbes put the number in the U.S. at almost 35 beds per 100 000 people. Our calculation also gives 12 critical-care beds per 100,000 people in South Africa. In Europe, critical-care bed numbers vary widely, according to a study conducted in 2012 that found 29.2 beds per 100 000 people in Germany, 12.5 in Italy, 11.6 in France, and 4.2 in Portugal.  

South Africa is an outlier in sub-Saharan Africa. While reliable data on available critical-care beds and staffing in the rest of Africa is hard to come by and in some cases not recent, a few elements paint a dire picture of the rest of the continent’s critical-care capacity. Information for Nigeria, the most populous country on the continent, is hard to find. Articles and reports often described challenges in the critical care sector in Nigeria, including the scarcity of beds and staff and subsequent mortality without providing official numbers for the country. In Niger, the main public hospital had four critical-care beds in 2014, according to a study on the use of critical care in that hospital; Niger had 18.4-million inhabitants in 2013. In March 2020, in the wake of COVID-19, the leading newspapers in Kenya and Uganda stated that their countries have 518 intensive-care beds for a population of 47 million (Kenya) and 55 intensive-care beds for 45 million people (Uganda).

These dismal numbers beg the question of the quality of care provided to people who live with HIV or are affected by TB and malaria, who require critical care. Recent research has shown that people living with HIV have higher risks of cardiovascular diseases than people who are HIV-negative. As people living with HIV are ageing, thanks to massive investments in antiretroviral treatment (ARV) made possible by the Global Fund, PEPFAR, other partners, and governments, there is a renewed need to pay attention to other diseases correlated with ageing. Those needs cannot be addressed without a robust health system.

Africans are often battling HIV, TB or malaria

African countries have a relatively young population: three-quarters of the population is below the age of 35, according to the United Nations Office of the Special Adviser for Africa. The relatively youthful population may help reduce the severity of COVID-19’s impact on the continent.

But a large proportion of this population is already fighting HIV, TB, malaria, and other diseases, many of them non-communicable. Eastern and Southern African countries face a generalized HIV epidemic with varying prevalence among 15- to 49-year-olds. The prevalence ranges from 1%  in Ethiopia to 27% in Eswatini, according to UNAIDS. TB is the most common illness among persons with HIV, according to the WHO. In West and Central Africa, where HIV prevalence is much lower, malaria is endemic with year-round transmission.

In other words, in sub-Saharan Africa, people are often busy fighting other diseases. They usually have poor access to running water. The World Bank estimated in 2008 that although 64% of households in sub-Saharan had access to running water, only 44% had private access; 22% shared a water point with their neighbors. Access to clean water to wash hands is vital to curtail the spread of diseases such as COVID-19.

Most governments have responded to the new coronavirus pandemic by closing their borders to try to contain imported cases while slowing down the propagation of the disease. Nevertheless, local or community transmission is ongoing in several countries. The WHO defines community transmission as the stage where health authorities are unable to trace a new COVID-19 infection to an existing case.

African health systems will be overwhelmed by widespread COVID-19 infection

Africa’s fragile health systems will be overwhelmed with COVID-19 if this current pandemic in Western Europe and the U.S. is any indication.

This prospect calls on African governments to make health a priority and invest heavily not only in specific disease programs but also in health systems, including epidemic preparedness. The Global Fund to Fight HIV, Tuberculosis and Malaria gives countries grants that can be used partly to build health systems. Aidspan has earlier documented that the Global Fund has invested 27% of all its resources in health systems since 2014. The Global Fund gives countries an allocation letter with an indicative split of the total amount among HIV, TB and malaria. The Global Fund leaves countries to decide whether they want to change the split and allocate some resources to health systems. In any case, most countries do not use all the resources allocated to them. The total Global Fund grants’ absorption was 83% in Eastern Africa during the 2015-2017 period but lower in West and Central Africa, as Aidspan has described. Meanwhile, the health systems of these countries lack adequate resources.

African governments should do better; Civil Society Organizations can help with outreach to the population and by keeping government accountable. In the wake of the COVID-19 pandemic, the Global Fund has allowed countries to spend up to 5% of their grant monies to fight COVID-19. The Global Fund gave a non-exhaustive list of the activities this 5% can fund. They are epidemic preparedness assessment, laboratory testing, sample transportation, use of surveillance infrastructure, infection control in health facilities, and information campaigns.

Together, the expanded possibility for countries to invest in RSSH and to use up to 5% of their Global Fund grants to fight COVID-19, represents an excellent opportunity for countries to direct additional resources to build their health systems, including epidemic preparedness and critical care.

Strengthening a country’s health system will benefit not only the people who live with or are affected by the three diseases but also the whole country. Not strengthening health systems will harm the people that the Global Fund aims to help.

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