What are the challenges to scaling up a national covid-19 response for low-and middle-income countries (LMICs)?

Debbie Hillier, Executive Director of the OPM-managed Maintains programme explores the pandemic response in Bangladesh, Kenya, Pakistan, Sierra Leone, and Uganda


Covid-19 continues to be an unprecedented challenge globally, affecting multiple sectors in every country. As part of its research, the Maintains programme has conducted a rapid review of the experiences and challenges of scaling up the response to covid-19 in the first three months (March to May 2020) of the outbreak in five countries: Bangladesh, Kenya, Pakistan, Sierra Leone, and Uganda. The full report is here, while a standalone summary can be found here.

Reviewing a moving target…..

This review focused on Maintains’ core social sectors of health, nutrition, social protection, and education, as well as cross-cutting themes of gender and inclusion, disaster risk finance, and governance. We developed an analytical framework for the review, and we would welcome input to refine and strengthen this.

This has been quite a tricky exercise – the impacts of covid-19 are so massive, across all sectors and all countries, and it is a highly dynamic context, with new information and approaches shifting on an almost daily basis. We have tried to do this work quickly to provide some real-time learning and to summarise things in a (relatively!) concise report. We hope this provides a substantive contribution to our collective understanding of how countries are able to manage scale-up, and where further work is required to strengthen systems.

Covid-19 snapshot across the countries

The pandemic has played out differently in the five countries. Pakistan and Bangladesh were hit first (on 26 February and 8 March, respectively) and hard (with the highest number of both confirmed cases – 72,000 and 47,000 by 31 May, respectively – and cases per capita). Lockdowns were imposed but then significantly eased due to economic pressure after about two months, during May, even whilst daily cases were continuing to rise.

In Kenya, Uganda, and Sierra Leone, the first cases were confirmed slightly later (13, 21, and 31 March, respectively) and all three countries have had far fewer confirmed cases – all below 2,000 by the end of May. They all took swifter response measures, and lockdowns in Uganda and Kenya have been slower to ease. Sierra Leone’s response has been severely limited by resources, and although absolute numbers are low, it has the highest fatalities per capita. In all countries, the number of cases per capita have measured highest in the capital city.

Early findings – successes and challenges so far

On the success side:

  • Countries worked hard to prepare and respond quickly – Kenya developed a preparedness plan in December 2019, Sierra Leone brought in handwashing at the airport in January, and Uganda shut schools even before the first case.
  • All countries have developed their social protection programmes, with major successes in terms of the speed (Pakistan) and scale (Bangladesh) of scale-up. We expect to see improved social protection programmes and increased enrolment as one real positive emerging out of the covid-19 crisis.

There have also been lots of challenges, as you would expect in such a complex and multifaceted crisis, especially in balancing the covid-19 health response with other impacts:

  • Leadership models have not all been successful – too centralised in Kenya, too fractured in Pakistan, and with some tensions between the Ministry of Defence and technical leadership in Sierra Leone.
  • One major gap across all of the countries has been the lack of focus on gender and inclusion; this means that those who were disadvantaged before will be hit even harder now. Gender is a blind-spot in terms of leadership, funding, policy commitments, understanding of differential impacts, and engagement of women’s groups.
  • Developments in social protection – expanding schemes to new people and providing increased funding – have been positive but are not adequate considering that more than 80% of people work in the informal sector in all countries (as high as 93% in Uganda), and with a higher proportion for women.
  • We expect to see drops in educational outcomes – particularly for girls, and particularly in Kenya and Uganda, where schools will be shut for nine months, representing a ‘lost year’ in education.
  • No country appears to be getting ready for the increase in malnutrition and non-covid health problems that are just around the corner.

Course corrections are needed now

Governments have directed their focus and resources to managing covid-19 but the complexity of the issues and their multi-sectoral nature have challenged often limited state capability. In particular, it is a clear challenge to balance strategies to contain covid-19 infection with the secondary effects caused by these strategies. A crucial course-correction is needed now to address the challenges highlighted above and thus to improve the future for vulnerable and disadvantaged people.

What Maintains will do

Our report considers how to deliver a well-coordinated and balanced response to a major shock across social services, highlighting some key issues. In keeping with its multi-sectoral mandate, Maintains will continue to work with others to refine and strengthen the analytical framework used for this review, and to address some of the knowledge gaps about shock responsiveness against this framework. Further studies and surveys coming soon include:

  • a household survey in Ethiopia, exploring the impact of the lockdown on urban populations;
  • a short study that will explore the role of traditional leaders in supporting the government response in Sierra Leone; and
  • a study looking across the six Maintains countries, to explore, document, and evaluate the different social protection approaches taken to covid-19 .

This blog was originally written for the Maintains website. Maintains is a five-year programme, launched in 2018, led by Oxford Policy Management and funded by the UK Department for International Development (DFID).

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