The impact of Coronavirus disease 2019 (COVID-19) on health systems and household resources in Africa and South Asia

Abstract

Background

Coronavirus disease 2019 (COVID-19) epidemics strain health systems and households. Health systems in Africa and South Asia may be particularly at risk due to potential high prevalence of risk factors for severe disease, large household sizes and limited healthcare capacity.

Methods

We investigated the impact of an unmitigated COVID-19 epidemic on health system resources and costs, and household costs, in Karachi, Delhi, Nairobi, Addis Ababa and Johannesburg. We adapted a dynamic model of SARS-CoV-2 transmission and disease to capture country-specific demography and contact patterns. The epidemiological model was then integrated into an economic framework that captured city-specific health systems and household resource use.

Findings

The cities severely lack intensive care beds, healthcare workers and financial resources to meet demand during an unmitigated COVID-19 epidemic. A highly mitigated COVID-19 epidemic, under optimistic assumptions, may avoid overwhelming hospital bed capacity in some cities, but not critical care capacity.

Interpretation

Viable mitigation strategies encompassing a mix of responses need to be established to expand healthcare capacity, reduce peak demand for healthcare resources, minimise progression to critical care and shield those at greatest risk of severe disease.

Funding

Bill & Melinda Gates Foundation, European Commission, National Institute for Health Research, Department for International Development, Wellcome Trust, Royal Society, Research Councils UK.

Research in context

Evidence before this study

We conducted a PubMed search on May 5, 2020, with no language restrictions, for studies published since inception, combining the terms (“cost” OR “economic”) AND “covid”. Our search yielded 331 articles, only two of which reported estimates of health system costs of COVID-19. The first study estimated resource use and medical costs for COVID-19 in the United States using a static model of COVID 19. The second study estimated the costs of polymerase chain reaction tests in the United States. We found no studies examining the economic implications of COVID-19 in low- or middle-income settings.

Added value of this study

This is the first study to use locally collected data in five cities (Karachi, Delhi, Nairobi, Addis Ababa and Johannesburg) to project the healthcare resource and health economic implications of an unmitigated COVID-19 epidemic. Besides the use of local data, our study moves beyond existing work to (i) consider the capacity of health systems in key cities to cope with this demand, (ii) consider healthcare staff resources needed, since these fall short of demand by greater margins than hospital beds, and (iii) consider economic costs to health services and households.

Implications of all the evidence

Demand for ICU beds and healthcare workers will exceed current capacity by orders of magnitude, but the capacity gap for general hospital beds is narrower. With optimistic assumptions about disease severity, the gap between demand and capacity for general hospital beds can be closed in some, but not all the cities. Efforts to bridge the economic burden of disease to households are needed.

Article activity feed

SciScore for 10.1101/2020.05.06.20092734: (What is this?)

Please note, not all rigor criteria are appropriate for all manuscripts.

Table 1: Rigor

NIH rigor criteria are not applicable to paper type.

Table 2: Resources

No key resources detected.

Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:

There are a number of important caveats to our findings. The first is that we are examining health care worker capacity considering only doctors, nursing and midwifery staff who are currently available. We do not consider the possibility that staff with less formal training might receive on-the-job training to manage COVID-19 patients. However, we also do not consider that health care workers may themselves be unavailable due to COVID-19 or responsibilities to family members with COVID-19, as has been reported in many countries facing COVID-19 epidemics21. Second, our capacity figures show resources available for all healthcare needs, but not all of these can be allocated to COVID-19 patients even if elective procedures are postponed for as long as possible. Indeed, most hospital beds in these cities are near full occupancy, and many health care workers work outside the hospitals. Further work needs to be done to further examine and understand real capacity constraints and the opportunity costs of transferring capacity to COVID-19, where the proportion of hospital admissions that are acute may be higher in high-income settings. Third, our cost results suggest that substantial additional financing is required. However, even where financing may be made available, we do not account for the absorption capacity to use this financing quickly to purchase commodities, construct new infrastructure, train new staff and institute substantial service delivery changes, which will challeng...

Results from TrialIdentifier: No clinical trial numbers were referenced.

Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

Results from JetFighter: We did not find any issues relating to colormaps.

Results from rtransparent:

Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
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