In developing countries, communities and primary care providers—not hospitals—hold the key to successful pandemic response

Nachiket Mor in this blogpost:

Almost uniformly across the developing world, pandemic policy responses so far have tried to replicate the typical developed country strategy: social distancing coupled with national lockdowns, quarantining suspected cases in centralized locations, and increasing hospital capacity of hospitals by shoring up their intensive care units (ICUs) and increasing the supply of invasive mechanical ventilators. This will almost certainly have to change.

To be sure, the steps being taken by advanced countries are significant and they could prove to be adequate if the caseload remains between 10-20 per 100,000 and the associated mortality between 0.5-1.0 per 100,000. But to help poorer countries deal with infection rates in the neighborhood of the 30,000 per 100,000 being predicted by the modeling work of the Imperial College COVID-19 team—even with social distancing—these strategies will have to be supplemented by an entirely different set of measures. This is because there is a concern that—as the Italians discovered much later than they should have—with infection rates of about 300 per 100,000, even well-equipped hospital systems become overwhelmed. In such conditions, mechanical ventilation is not an effective strategy even for those individuals fortunate enough to get access to one, and hospitals themselves become lethal transmitters of infection back into the community.

Many low- and middle-income countries (LMICs) lack adequate hospital and emergency transportation infrastructure, but most have strong community-based structures, such as community-based organizations and local nonprofits. LMICs could benefit from the near ubiquitous presence of these nonprofit organizations if their governments empower them to, among other things:

    1. Identify the most vulnerable, such as individuals over the age of 60, and guide their families on how to protect them over the next several years until a good adult vaccine is developed;
    2. Communicate home care and isolation guidelines even for the very sick, including the development of collaborative arrangements between families where space within a single home is limited;
    3. Map the local primary care provider (PCP) network, including private and the nonprofit providers and, wherever possible, assign households to specific PCPs so that when the numbers start to rise, there is no confusion as to who is responsible for taking care of particular families;
    4. Ensure that these PCPs are well prepared to manage all but the sickest of the cases; and
    5. Provide essential support to those families that are in the greatest economic need.

Additionally, while PCP availability varies greatly across LMICs, given the high levels of out-of-pocket expenditures in most of them, the supply of independent formally qualified PCPs is likely to far exceed the numbers within government facilities, even in relatively remote areas


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