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AVI POLICY BRIEF ISSUE: 2020, No. 04 | How Lower-Middle Income Countries Respond to Covid-19: From the Perspective of Health System Strengthening



How Lower-Middle Income Countries Respond to Covid-19: From the Perspective of Health System Strengthening

ISSUE 2020
No 04
Release 10 March 2020
By Ms. Vong Sreytouch

Executive Summary

❖ Limited capacity of health system in Lower-Middle Income Countries (LMICs) is a constraint to respond to Covid-19 in a timely manner. Therefore, enhancing the Health System Building Blocks can help the countries to be well prepared for the current and future outbreak of infectious diseases.

❖ At the supply side of the health system, motivation and mental support for frontline health workers are crucial. Similarly, at the demand side of the system, raising awareness about the prevention, providing mental support, and keeping the population calm and ready for the outbreak are critical to address the Covid-19 crisis.

❖ Addressing the Covid-19 crisis requires cooperation at the global, regional and country levels. At the country level, cross-sectoral collaborations, where relevant stakeholders’ roles and scope of their contributions to the prevention and control of the virus outbreak are clearly determined, are necessary.

❖ Global health agenda and its performance need to be reviewed to ensure Health Security is integrated for further planning and funding to be prepared for future outbreak. 


Covid-19 or Coronavirus disease 2019 is a respiratory disease caused by novel coronavirus, namely called “SARS-CoV-2”. It was first detected in China in December 2019.1 However, it was not until the pre-Lunar New Year that authorities in Wuhan, the epicentre of Covid-19, announced the new outbreak, which has later become known as global pandemic and has impacted societies and economy at a global scale. To date, the virus has spread and infected more than 100 countries and places around the world. There has not been any clear conclusion about what constitutes the main reservoir of virus. However, available evidence shows the virus causing Covid-19 is from an animal reservoir.

Countries with weak health system face challenges in responding to Covid-19. This article provides some reflections on how countries with weak health system, mainly the Lower- Middle Income Countries (LMICs), could prepare to respond to Covid-19 by using the Health System Building Blocks framework. It highlights that there is a need for reflections on the performance of Global Health and health system agenda to give more focus on emergency responses. Health Security agenda should be incorporated into the System Building Blocks and the global health agenda to ensure responsiveness to further outbreak.

The article has two main sections. First, it provides some facts about Covid-19 in comparison with other global outbreak. Then, it offers perspectives and recommendations on how to prepare the Health System Building Blocks in LMICs for the crisis. It also provides additional thoughts on the psychological effects to prove that under emergency situation and crisis, both frontline workers and communities, particularly those who would stay under quarantine would need motivation and mental support. Tackling the outbreak like Covid-19 requires strong cooperation at all levels. At the country level, cross-sectoral collaborations among relevant stakeholders with clearly defined roles and scope of work are extremely crucial to prevent and control the outbreak.

Some Facts about Covid-19

Covid-19 or formerly known as Coronavirus has been a major cause of global instability. Started in China in December 2019, the virus outbreak has so far hit more than 100 countries and places, with more than 110,000 infected cases and about 3,800 of fatality cases around the world. Though Covid-19 is a global threat to many countries, its fatality rate is relatively low compared with previous global outbreak, namely Ebola, Middle East Respiratory syndrome (MERS) and SARS. However, Covid-19 seems to be efficient in transmission, and it spreads much faster than other previous outbreak. Consequently, it would have greater impact on social and economic stability of countries relying on Chinese supply chain.

Covid-19 is not only a concern for LMICs, whose health capacity system are still limited, it also provides an opportunity for reflection of the performance of health system in industrialised countries and of the global health performance in tackling epidemic. As said, “viruses have no passports”,3 it is clear that the Emerging Infectious Disease (EID) has no boundary. Evidence has shown that Southeast Asian region has been recognised as a “hot spot” for the emergence and re-emergence of infectious diseases on animals and human.4 Tackling epidemic is a global effort requiring strong cooperation at the global, regional and country levels, particularly when most of the cases of global outbreak happened involving animal and human health. The many lessons learned from Covid-19 suggest that there is an urgent need to review not only the health system at a country level but also the global health agenda, where Health Security should be given more attention in the global health agenda so that the system can be prepared to address future outbreak.

Preparing LMICs for Covid-19 and Future Outbreak

WHO’s Health System Building Blocks are the backbone to respond to the needs for the improvement of health services and well-being for the population. Countries should revisit the component of the building blocks (system inputs) and be prepared to respond to virus outbreak.

Health service delivery under emergency response may include screening or detection services at “hot spots”, designation of quarantine places, and provision of treatment and support services for people under quarantine period. The service delivery needs to be prepared for screening and detection of suspicious cases at “hot spots”, including at airports and international ports, where there are flows of international movement. The timely referral of suspicious cases to the right places and right level of care is critical in preventing and controlling the transmission. Health system of the country should re-enforce the referral services, especially the suspicious cases of Covid-19 to designated places. As about 78% of Cambodians’ seeking first treatment mainly happened at private health facilities,6 enhancing the referral of suspicious cases of Covid-19 from private to public health facilities could support patients to get the right level of care and could control the transmission among people.

Health workforce, especially frontline health workers, should be “rapidly” trained and provided with instructions on how to support the entire process of screening, detection and referral of suspicious cases. Frontline workers are the backbone of health system. With strong management of human resource, the health workforce could play effective roles in responding to emergency. Moreover, an enabling environment to motivate workers to work hard to fight against Covid-19 is critical to keep the workforce remain dedicated to working to address the crisis. Lessons from the 2014 Ebola in Sierra Leone show that under crisis of the outbreak, health workers need supportive supervision and peer support networks and better use of communication technology for rebuilding trust with communities.

Information is very essential to tackle Covid-19. LMICs face constraint in providing more responsive information. However, identifying and designating specific relevant stakeholders or departments to be focal points in providing accurate information to the public on time is critical. At the same time, collaboration on reporting and information sharing between relevant ministries, mainly the Health Ministry and Information Ministry, should be made so that a sole source in the country can provide accurate information to the public.

Sufficient medical supplies can support the mission of preventing and controlling the transmission from infected individuals to the public. Even though the medical supplies and equipment are less advanced and may not be sufficient in countries with weak health system, those countries should be proactive in mobilising supports from international communities to support the local’s needs for responding to the outbreak. It is a matter of how the countries open window of opportunity to more emergency supports. The countries should also re-visit the supply and equipment plans and think about how to incorporate supplies and equipment to support emergency responses in the future.

Where to obtain funding to respond to the emergency of Covid-19 is a constraint, particularly in countries where resources supporting the health security or emergency are limited. Effective responses to health emergency require strong financial coordination among key players, including government stakeholders, multilateral donors and non-governmental organization.8 Therefore, rapid resource mobilisation among different stakeholders to support the provision of supplies and equipment as well as the support to health workforce to work in the outbreak crisis is important.

Strong leadership from Health Ministry and collaborative supports from relevant ministries are essential for the prevention and control of the transmission of Covid-19. As Covid-19 is a global outbreak severely hitting more than 100 countries and places around the world, strong leadership exercised by individual countries in sharing and keeping information updated and working together to tackle the cross-border transmission is critical.

Beyond the System Building Blocks, the social and mental supports provided to both health workers, who are currently working under threat of Covid-19, and communities play important roles during times of crisis. Lessons learned from Ebola show that the intensive focus on the response to the virus transmission made individuals and communities overlook the trauma and psychosocial damage during and after the epidemic.9 The psychological effect would occur particularly on the frontline health workers, who were mostly at risk performing their duties under the epidemic crisis. Health workers would particularly suffer from some mental health effects as a result of the implementation of protocols for epidemic, including isolation, quarantine and exposure to Personal Protective Equipment (PPE) and biohazard suits. The mental health effects also happened to patients and the community, particularly to those who were put under quarantine. Experiences from patients with SARS show that patients feel​fearful, lonely, bored, angry and worried about the effect of quarantine and contagion on their relatives and friends.10 The community may also face anxiety and stress, resulting from being panic and over worried about personal risk of infection. Social stigmatisation would be another form of pressure for other patients having similar symptoms to Covid-19. Integrating the provision of mental supports in emergency responses to the outbreak to those in need, particularly the people put under quarantine, would be a crucial intervention. Strong leadership and governance to give clear directions and keep the workforce and public less nervous and mentally ready to confront the crisis may be the most crucial part when the health system tries to respond to the crisis.​


Tackling Covid-19 requires strong leadership, governance and coordination at all levels of health system at global, regional and country levels. The System Building Blocks, particularly the frontline health workers, are the backbone of health system. How to provide sufficient support in a timely fashion and ensure that frontline health workers are motivated to work under the outbreak are important. Meanwhile, providing sufficient and timely support to the public about information of prevention and control is critical. Additionally, integrating mental support for people under crisis, particularly those staying under quarantine, is another crucial element to minimise tension and rebuild social trust in the community when a country is under crisis.

Covid-19 is a global threat, especially for countries with limited capacity in health system. However, it opens the window of opportunity for the countries to revisit their health system preparedness for health security. The global health agenda and the system building blocks should revisit its performance, especially the global health security agenda, which has been introduced since 2014. It should rethink about how global health players could work together to prepare for future global epidemics.

The opinions expressed are the author’s own and do not reflect the views of the Asian Vision Institute.