Preparing for COVID-19 in Low- and Middle-Income Countries: Leveraging U.S. Global Health Assets

As the COVID-19 pandemic continues to worsen, there is growing concern about its impact in low- and middle-income countries (LMICs), particularly those in sub-Saharan Africa, home to more than one billion people. Cases have now been reported in many LMICs and are rising rapidly in some. Should coronavirus spread even more significantly in sub-Saharan Africa and elsewhere, the impact could be extreme, given already low-resourced health systems and multiple other health challenges.

The United States has begun to respond, with Congress appropriating more than $2 billion in emergency funding to address COVID-19 in LMICs and the State Department and USAID providing resources to a growing list of countries. This data note updates an earlier analysis that examined where the U.S. government already had existing global health assets that could be mobilized to address COVID-19. It includes the latest case numbers, expands beyond health to identify countries where the U.S. also provides (non-health) development assistance, and identifies the most recent list of countries receiving COVID-19 assistance from the U.S. In addition, it indicates the level of COVID-19 preparedness in each country, based on the World Health Organization’s country preparedness and readiness assessment index (which rates countries from Level 1, least prepared to Level 5, most prepared).

Table 1 provides a regional summary of where the U.S. supports global health programs and/or provides COVID-19 assistance. Table 2 provides a full list of all countries identified, including reported cases of COVID-19 (as of April 21, 2020), total bilateral U.S. funding for global health programs, country-level U.S. COVID-19 funding, and COVID-19 preparedness capacity level.1 It also indicates whether the U.S. provides other (non-health) development assistance. Key findings are as follows:

  • There are a total of 108 countries that received either U.S. bilateral global health assistance in FY 2018 (64 countries) and/or are receiving U.S. COVID-19 assistance (102 countries).2
  • Almost all of these countries (105 of 108) had reported COVID-19 cases as of April 21, 2020.
  • Of the 102 countries receiving U.S. COVID-19 funding, 52 are also countries that received U.S. global health assistance in FY 2018.
  • Almost all of these countries (103 of 108) receive other, non-health, U.S. development assistance, which may include assistance for agriculture, education, peace and security, etc.
  • Most of the countries receiving U.S. assistance are in Africa, followed by Asia and Latin America and the Caribbean. Most of the reported cases in these countries are in Latin America and the Caribbean, followed by South/Central Asia.
  • PEPFAR and the maternal and child health program, respectively, operate in the greatest number of countries (38 each), followed by the family planning and reproductive health program (36). Most countries (over 90%) in each of these program areas are also receiving U.S. COVID-19 funding.
  • Of the 107 countries assigned a COVID-19 preparedness capacity level by WHO, almost all (94) are at Level 3 or below, with more than half (57) designated as Level 3 (capacity is ≤60%), a third (36) as Level 2 (capacity is ≤40%), and one as Level 1 (capacity is ≤20%). The remaining 13 include 11 countries designated as Level 4 (capacity is ≤80%) and two designated as Level 5 (capacity is >80%).

Overall, we found much overlap between the countries being provided with COVID-19 support by the U.S. and those with existing U.S. global health assets, suggesting an opportunity to leverage longstanding programs and expertise. At the same time, however, it is highly likely that many other LMIC countries not currently receiving U.S. COVID-19 funding will experience growing numbers of cases and require enhanced assistance. Further, it remains unclear how ongoing U.S. global health efforts will be impacted, including whether some will be scaled back as resources, including personnel, are diverted to address COVID-19 and/or if country health systems become overwhelmed by COVID-19, undermining their ability to continue. Through two of the three emergency supplemental bills for the coronavirus response passed thus far, the U.S. has allocated approximately $2.4 billion in funding specifically for U.S. global health and other assistance for the global outbreak, although it is likely that additional funding will be needed. Still, given the need for the U.S. (and other donors) to confront their own COVID-19 epidemics, any additional foreign assistance may face stiff competition with growing domestic demands, including for stimulating the economy.

Table 1: COVID-19 in Countries Receiving Bilateral U.S. Global Health and/or COVID-19 Assistance, by Region
Region Countries Receiving U.S. Global Health and/or COVID-19 Assistance
# of Countries: # of COVID-19 Cases
(as of 4/21/20)
Overall Receiving U.S. Global Health Assistance Receiving U.S. COVID-19 Assistance
With COVID-19 Cases
(as of 4/21/20)
With Low COVID-19 Preparedness Capacity Level
(Levels 1-3*)
Africa 45 34 41 44 42 24,088
East Asia/Pacific 11 10 11 11 8 22,621
Europe/Eurasia 17 1 17 17 11 321,552
Latin America/Caribbean 17 9 15 17 15 96,420
Near East 6 2 6 6 6 3,216
South/Central Asia 12 8 12 10 12 38,741
TOTAL 108 64 102 105 94 506,638
NOTES: Reflects countries receiving bilateral assistance through USAID and the Department of State in FY 2018 except NTD countries, which reflect information available on Nov. 13, 2019, and GHS countries, which reflect FY 2019 presence. Reflects all countries receiving COVID-19 assistance from the U.S. government as announced as of April 16, 2020 and includes some high-income countries. * WHO-designated level of a country’s ability to respond to COVID-19 based on capacity and risk assessments: Level 1 indicates that the country’s health system is ≤20% prepared, Level 2 is ≤40%, Level 3 is ≤60%, Level 4 is ≤80%, and Level 5 is >80%. # of cases includes confirmed and presumed positive cases.
SOURCES: KFF analysis of data from U.S. Foreign Assistance Dashboard (foreignassistance.gov, accessed 11-12-19); USAID NTD Program website (NeglectedDiseases.gov, as of 11-13-19); KFF personal communication with USAID, 12-19; U.S. Department of State, “UPDATE: The United States Is Continuing to Lead the Humanitarian and Health Assistance Response to COVID-19,” fact sheet, April 16, 2020; WHO, COVID-19 Strategic Preparedness and Response Plan: Country Preparedness and Response Status for COVID-19 as of 13 April 2020; Johns Hopkins University, Coronavirus Resource Center, accessed: https://coronavirus.jhu.edu/map.html, as of April 21, 2020.
Table 2: COVID-19 in Countries Receiving Bilateral U.S. Global Health and/or COVID-19 Assistance
Region Country
# of COVID-19 Cases
(as of 4/21/20)
U.S. Global Health Assistance
(FY 2018^)
# of U.S. Global Health Programs Global Health Program Presence* U.S. COVID-19 Assistance^
(as of 4/16/20)
COVID-19 Preparedness Capacity Level+ Recipient of Other U.S. Foreign Assistance
(FY 2018)
Family Planning/ Reproductive Health PEPFAR (HIV) Malaria Maternal & Child Health Nutrition Tuberculosis Global Health Security NTDs/Other PH Threats
South/Central Asia Afghanistan 1,092 $39,500,000 3 X X X $18,000,000 2 X
Europe/Eurasia Albania 609  —  — $1,200,000 3 X
Africa Algeria 2,811  —  — $500,000 4 X
Africa Angola 24 $37,418,000 3 X X X $570,000 3 X
Europe/Eurasia Armenia 1,401  —  — $1,700,000 3 X
Europe/Eurasia Azerbaijan 1,480  —  — $1,700,000 3 X
South/Central Asia Bangladesh 3,382 $66,000,000 6 X X X X X X $9,600,000 3 X
Europe/Eurasia Belarus 6,723  —  — $1,300,000 3 X
Latin America/Caribbean Belize 18  —  — $300,000 3 X
Africa Benin 54 $24,000,000 4 X X X X  — 2 X
South/Central Asia Bhutan  6  —  — $500,000 3  –
Latin America/Caribbean Bolivia 598  —  — $750,000 2  –
Europe/Eurasia Bosnia and Herzegovina 1,342  —  — $1,200,000 2 X
Africa Botswana 20 $64,764,000 1 X $1,500,000 2 X
Latin America/Caribbean Brazil 43,079 $300,000 2 X X  — 4 X
Europe/Eurasia Bulgaria 975  —  — $500,000 4 X
Africa Burkina Faso 600 $29,000,000 5 X X X X X $6,000,000 2 X
East Asia/Pacific Burma 121 $30,482,000 4 X X X X $7,300,000 3 X
Africa Burundi 5 $31,340,000 4 X X X X  — 2 X
East Asia/Pacific Cambodia 122 $33,911,000 8 X X X X X X X X $4,000,000 3 X
Africa Cameroon 1,163 $63,674,000 4 X X X X $8,000,000 3 X
Africa Central African Republic 14  —  — $5,200,000 1 X
Africa Chad 33  —  — $3,000,000 2 X
Latin America/Caribbean Colombia 4,149 1 X $10,400,000 3 X
Africa Côte d’Ivoire 916 $135,876,000 6 X X X X X X $1,600,000 3 X
Africa Dem. Rep. of the Congo 350 $181,458,000 8 X X X X X X X X $14,400,000 3 X
Africa Djibouti 945 $300,000 1 X $500,000 2 X
Latin America/Caribbean Dominican Republic 5,044 $13,901,000 1 X $1,400,000 3 X
Latin America/Caribbean Ecuador 10,398 1 X $2,000,000 3 X
Africa Egypt 3,490 $10,050,000 2 X X  — 4 X
Latin America/Caribbean El Salvador 225  —  — $2,600,000 3 X
Africa Eswatini 31 $65,768,000 1 X $750,000 3 X
Africa Ethiopia 114 $204,363,000 8 X X X X X X X X $9,000,000 3 X
Europe/Eurasia Georgia 408  —  — $1,700,000 3 X
Africa Ghana 1,042 $68,233,000 7 X X X X X X X $1,600,000 3 X
Europe/Eurasia Greece 2,401  —  — $500,000 4 X
Latin America/Caribbean Guatemala 294 $13,000,000 4 X X X X $2,400,000 2 X
Africa Guinea 688 $23,000,000 5 X X X X X $500,000 3 X
Latin America/Caribbean Guyana 81 1 X  — 3 X
Latin America/Caribbean Haiti 57 $123,586,000 5 X X X X X $13,200,000 2 X
Latin America/Caribbean Honduras 494  —  — $2,400,000 2 X
South/Central Asia India 20,080 $66,216,000 5 X X X X X $5,900,000 3 X
East Asia/Pacific Indonesia 7,135 $35,962,000 5 X X X X X $5,000,000 3 X
Near East Iraq 1,602  — $25,600,000 2 X
Europe/Eurasia Italy 183,957  —  — $50,000,000 5  –
Latin America/Caribbean Jamaica 223  —  — $700,000 3 X
Near East Jordan 428 $21,000,000 2 X X $8,000,000 3 X
South/Central Asia Kazakhstan 1,995  — $1,600,000 3 X
Africa Kenya 296 $523,112,000 7 X X X X X X X $4,500,000 3 X
Europe/Eurasia Kosovo 510  —  — $1,100,000  — X
South/Central Asia Kyrgyzstan 590 $4,300,000 1 X $900,000 2 X
East Asia/Pacific Laos 19 $3,500,000 2 X X $3,500,000 2 X
Near East Lebanon 677  —  — $13,300,000 3 X
Africa Lesotho $79,574,000 1 X $750,000 2 X
Africa Liberia 101 $34,500,000 5 X X X X X $1,000,000 3 X
Africa Libya 51  —  — $6,000,000 2 X
Africa Madagascar 121 $52,000,000 4 X X X X $2,500,000 2 X
Africa Malawi 18 $194,893,000 6 X X X X X X $4,500,000 3 X
East Asia/Pacific Malaysia 5,482 1 X $200,000 5 X
Africa Mali 258 $66,300,000 7 X X X X X X X $5,700,000 3 X
Africa Mauritania 7  —  — $250,000 2 X
Africa Mauritius 328  —  — $500,000 4 X
Latin America/Caribbean Mexico 8,772 1 X $500,000 4 X
Europe/Eurasia Moldova 2,614  —  — $1,200,000 3 X
East Asia/Pacific Mongolia 34  —  — $1,200,000 3 X
Europe/Eurasia Montenegro 313  —  — $300,000 3 X
Africa Morocco 3,209  —  — $1,700,000 3 X
Africa Mozambique 39 $427,685,000 7 X X X X X X X $5,800,000 3 X
Africa Namibia 16 $66,879,000 1 X $750,000 2 X
South/Central Asia Nepal 43 $43,866,000 6 X X X X X X $1,800,000 3 X
Africa Niger 657 $22,000,000 4 X X X X $4,000,000 3 X
Africa Nigeria 665 $398,561,000 7 X X X X X X X $21,400,000 3 X
Europe/Eurasia North Macedonia 1,231  —  — $1,100,000 3  –
South/Central Asia Pakistan 9,565 $7,000,000 1 X $9,400,000 2 X
Latin America/Caribbean Panama 4,658  —  — $750,000 2 X
East Asia/Pacific Papua New Guinea 7 $5,474,000 1 X $1,200,000 2 X
Latin America/Caribbean Paraguay 208  —  — $1,300,000 2 X
Latin America/Caribbean Peru 17,837  —  — $2,500,000 3 X
East Asia/Pacific Philippines 6,599 $28,500,000 3 X X X $6,000,000 3 X
Africa Republic of Congo 165  —  — $250,000 3 X
Europe/Eurasia Romania 9,242  —  — $800,000 4 X
Africa Rwanda 150 $114,591,000 6 X X X X X X $2,000,000 3 X
Africa Senegal 412 $59,035,000 7 X X X X X X X $3,900,000 3 X
Europe/Eurasia Serbia 6,630  —  — $1,200,000 3 X
Africa Sierra Leone 50 $19,500,000 6 X X X X X X $400,000 3 X
Africa Somalia 286  —  — $12,500,000 2 X
Africa South Africa 3,465 $580,905,000 2 X X $8,400,000 3 X
Africa South Sudan  4 $36,545,000 3 X X X $13,100,000 2 X
South/Central Asia Sri Lanka 310  —  — $1,300,000 3 X
Africa Sudan 107  —  — $13,700,000 3 X
Near East Syria  42  —  — $18,000,000 2  –
South/Central Asia Tajikistan $7,750,000 3 X X X $866,000 2 X
Africa Tanzania 254 $480,839,000 8 X X X X X X X X $1,400,000 3 X
East Asia/Pacific Thailand 2,811 1 X $2,700,000 4 X
East Asia/Pacific Timor-Leste   23 $2,000,000 2 X X $1,100,000 2 X
Africa Togo 86 1 X  — 2 X
Africa Tunisia 884  —  — $600,000 3 X
Europe/Eurasia Turkey 95,591  —  — $800,000 4 X
South/Central Asia Turkmenistan  — $920,000 3 X
Africa Uganda 61 $463,396,000 8 X X X X X X X X $3,600,000 3 X
Europe/Eurasia Ukraine 6,125 $34,644,000 3 X X X $9,100,000 2 X
South/Central Asia Uzbekistan 1,678 $4,000,000 1 X $848,000 2 X
Latin America/Caribbean Venezuela 285 1 X $9,000,000 2 X
East Asia/Pacific Vietnam 268 $31,349,000 4 X X X X $4,500,000 4 X
Near East West Bank/ Gaza 466  —  — $5,000,000 2 X
Near East Yemen 1 $3,500,000 1 X $500,000 2 X
Africa Zambia 70 $415,961,000 6 X X X X X X $3,400,000 2 X
Africa Zimbabwe 28 $170,107,000 5 X X X X X $3,000,000 3 X
Number of Countries 108  506,638
cases
$5,765,368,000 64 36 38 27 38 20 23 26 32 $463,054,000
(102 countries)
107 103
NOTES: # of cases includes confirmed and presumed positive cases. ^ Total does not include some country-level funding (i.e., NTD and global health security program funding) that is not available on ForeignAssistance.gov; it also does not include funding for regional or “worldwide” program efforts that may reach additional countries. NTDs are neglected tropical diseases. * X indicates country receiving bilateral assistance through USAID and the Department of State in FY 2018 except NTD countries, which reflect information available on Nov. 13, 2019, and GHS countries, which reflect FY 2019 presence. ^ U.S. COVID-19 Assistance reflects all countries receiving COVID-19 assistance from the U.S. government and includes some high-income countries. Does not include funding specified for regional programs that may reach additional countries. + The COVID-19 Preparedness Capacity Level indicates the WHO-designated level of that country’s ability to respond to COVID-19 based on capacity and risk assessments: Level 1 indicates that the country’s health system is ≤20% prepared, Level 2 is ≤40%, Level 3 is ≤60%, Level 4 is ≤80%, and Level 5 is >80%. “–” indicates no cases have been reported, country-level funding is not specified for this country, country does not have a USG program that is supported by country-level funding available on ForeignAssistance.gov, or COVID-19 preparedness capacity level not specified for country.
SOURCES: Johns Hopkins University, Coronavirus Resource Center, accessed: https://coronavirus.jhu.edu/map.html, as of April 21, 2020; KFF analysis of data from U.S. Foreign Assistance Dashboard (foreignassistance.gov, accessed 11-12-19); USAID NTD Program website (NeglectedDiseases.gov, as of 11-13-19); KFF personal communication with USAID, 12-19; U.S. Department of State, “UPDATE: The United States Is Continuing to Lead the Humanitarian and Health Assistance Response to COVID-19,” fact sheet, April 16, 2020; WHO, COVID-19 Strategic Preparedness and Response Plan: Country Preparedness and Response Status for COVID-19 as of 13 April 2020; KFF analysis of data from U.S. Foreign Assistance Dashboard (foreignassistance.gov, accessed April 6, 2020).
Endnotes
  1. The preparedness and response categorization (Levels 1-5) is based on the country’s 1) operational readiness capacities based on the International Health Regulations (IHR) State Parties Annual Reporting self-assessment tool and 2) position on a continuum of response scenarios including country preparedness, risk of imported cases, number of imported cases, and localized and community transmission. This categorization will be updated regularly based on each country’s COVID-19 situation as the epidemic evolves. Level 1 indicates that the country’s health system is ≤20% prepared; Level 2 is ≤40%; Level 3 is ≤60%; Level 4 is ≤80%; and Level 5 is >80%. WHO, COVID-19 Strategic Preparedness and Response Plan: Country Preparedness and Response Status for COVID-19 as of 30 March 2020.

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  2. Two of the 102 countries receiving U.S. COVID-19 assistance are high-income countries that are facing particularly significant outbreaks – Greece and Italy.

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