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

There is growing concern about the potential impact of COVID-19 in low and middle income countries (LMICs), particularly those in sub-Saharan Africa, which, outside of China, have thus far reported relatively few cases. While it is not clear if this is due to a lack of testing, because they may be at an earlier stage of the epidemic, or other factors, cases have now been reported in many LMICs and are rising rapidly in some. Should coronavirus spread significantly in sub-Saharan Africa and elsewhere, the impact could be extreme, given already low-resourced health systems and multiple other health challenges. As the COVID-19 pandemic has already demonstrated, the global response is highly interdependent, and a widespread outbreak in LMICs will not only impact their populations and health systems but would likely have significant health and economic impacts worldwide. The U.S. government has a critical role to play in this regard, through its long-standing global health programs as well as specific emergency efforts to address COVID-19 in LMICs.

To assess where the U.S. government has existing global health assets that could be mobilized when and if needed, we identified all countries that received U.S. government bilateral global health assistance in FY 2018. We also identified LMICs that the U.S. has designated as high-priority for receiving COVID-19 assistance. Table 1 provides a summary of global health program countries. Table 2 provides a full list of all countries identified. Also included are reported cases of COVID-19 as of March 19, 2020, and total funding for global health programs (country-level funding for the COVID-19 response is not yet available). Key findings are as follows:

  • There are a total of 68 countries that either received U.S. bilateral global health assistance in FY 2018 (64 countries) and/or have been identified as high priority COVID-19 countries (25 countries).
  • More than half of these countries (47 of 68) had reported COVID-19 cases as of March 19, 2020.
  • Of the 25 COVID-19 high priority countries, 20 are also countries that received U.S. global health assistance in FY 2018.
  • 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 the East Asia and Pacific region, followed by Latin America and the Caribbean.
  • 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). About a third of countries in each of these program areas are also COVID-19 priority countries.

Overall, we found significant overlap between the countries identified as high priority for COVID-19 and those with existing U.S. global health assets, suggesting an opportunity to leverage long-standing programs and expertise.  At the same time, however, it is highly likely that many other LMIC countries not identified as COVID-19 high priority will experience growing case-loads 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. The recent emergency supplemental COVID-19 bill signed into law on March 6 provides an infusion of $1.29 billion specifically for U.S. global health and other assistance for the 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 Cases in Countries Receiving U.S. Global Health Assistance, by Region
Region Countries Receiving U.S. Global Health Assistance # of COVID-19 Cases
(as of 3/19/20)
# # with COVID-19 Cases
Europe/Eurasia 1 1 16
Africa 34 21 565
East Asia/Pacific 10 6 1,822
Latin America/Caribbean 9 8 1,132
South/Central Asia 8 7 714
Near East 2 1 69
TOTAL 64 44 4,318
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. # of cases includes confirmed and presumed positive cases.
SOURCES: Johns Hopkins University, Coronavirus Resource Center, accessed: https://coronavirus.jhu.edu/map.html, as of March 19, 2020; Kaiser Family Foundation 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.
Table 2: COVID-19 Cases in Countries Receiving Bilateral U.S. Global Health Assistance (FY 2018*)
Region Country # of COVID-19 Cases
(as of 3/19/20)
Total FY 2018 Funding^ # of USG Programs Program Presence
Family Planning/
Reproductive Health
PEPFAR
(HIV)
Malaria Maternal & Child Health Nutrition Tuberculosis Global Health Security NTDs/Other Public Health Threats COVID-19 Priority Countries
South/Central Asia Afghanistan 22 $39,500,000 3 X X X X
Africa Angola $37,418,000 3 X X X X
South/Central Asia Bangladesh 17 $66,000,000 6 X X X X X X X
Africa Benin 2 $24,000,000 4 X X X X
Africa Botswana $64,764,000 1 X
Latin America/Caribbean Brazil 621 $300,000 2 X X
Africa Burkina Faso 33 $29,000,000 5 X X X X X
East Asia/Pacific Burma $30,482,000 4 X X X X X
Africa Burundi $31,340,000 4 X X X X
East Asia/Pacific Cambodia 37 $33,911,000 8 X X X X X X X X X
Africa Cameroon 13 $63,674,000 4 X X X X
Latin America/Caribbean Colombia 102 1 X
Africa Côte d’Ivoire 9 $135,876,000 6 X X X X X X
Africa Dem. Rep. of the Congo 14 $181,458,000 8 X X X X X X X X
Africa Djibouti 1 $300,000 1 X
Latin America/Caribbean Dominican Republic 34 $13,901,000 1 X
Latin America/Caribbean Ecuador 199 1 X
Africa Egypt 256 $10,050,000 2 X X
Africa Eswatini 1 $65,768,000 1 X
Africa Ethiopia 6 $204,363,000 8 X X X X X X X X X
Africa Ghana 11 $68,233,000 7 X X X X X X X
Latin America/Caribbean Guatemala 9 $13,000,000 4 X X X X
Africa Guinea 1 $23,000,000 5 X X X X X
Latin America/Caribbean Guyana 7 1 X
Latin America/Caribbean Haiti $123,586,000 5 X X X X X
South/Central Asia India 194 $66,216,000 5 X X X X X
East Asia/Pacific Indonesia 311 $35,962,000 5 X X X X X X
Near East Iraq 192 X
Near East Jordan 69 $21,000,000 2 X X
South/Central Asia Kazakhstan 44 X
Africa Kenya 7 $523,112,000 7 X X X X X X X X
South/Central Asia Kyrgyzstan 3 $4,300,000 1 X X
East Asia/Pacific Laos $3,500,000 2 X X X
Africa Lesotho $79,574,000 1 X
Africa Liberia 2 $34,500,000 5 X X X X X
Africa Madagascar $52,000,000 4 X X X X
Africa Malawi $194,893,000 6 X X X X X X
East Asia/Pacific Malaysia 900 1 X
Africa Mali $66,300,000 7 X X X X X X X
Latin America/Caribbean Mexico 118 1 X
East Asia/Pacific Mongolia 6 X
Africa Mozambique $427,685,000 7 X X X X X X X
Africa Namibia 3 $66,879,000 1 X
South/Central Asia Nepal 1 $43,866,000 6 X X X X X X X
Africa Niger $22,000,000 4 X X X X
Africa Nigeria 8 $398,561,000 7 X X X X X X X X
South/Central Asia Pakistan 454 $7,000,000 1 X X
East Asia/Pacific Papua New Guinea $5,474,000 1 X
East Asia/Pacific Philippines 217 $28,500,000 3 X X X X
Africa Rwanda 8 $114,591,000 6 X X X X X X
Africa Senegal 31 $59,035,000 7 X X X X X X X
Africa Sierra Leone $19,500,000 6 X X X X X X
Africa South Africa 150 $580,905,000 2 X X X
Africa South Sudan $36,545,000 3 X X X
South/Central Asia Tajikistan $7,750,000 3 X X X X
Africa Tanzania 6 $480,839,000 8 X X X X X X X X
East Asia/Pacific Thailand 272 1 X X
East Asia/Pacific Timor-Leste $2,000,000 2 X X
Africa Togo 1 1 X
South/Central Asia Turkmenistan X
Africa Uganda $463,396,000 8 X X X X X X X X
Europe/Eurasia Ukraine 16 $34,644,000 3 X X X
South/Central Asia Uzbekistan 23 $4,000,000 1 X X
Latin America/Caribbean Venezuela 42 1 X
East Asia/Pacific Vietnam 85 $31,349,000 4 X X X X X
Near East Yemen $3,500,000 1 X
Africa Zambia 2 $415,961,000 6 X X X X X X X
Africa Zimbabwe $170,107,000 5 X X X X X X
Number of Countries 68 4,560 $5,765,368,000 36 38 27 38 20 23 26 32 25
NOTES:  * 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.  ^ 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 not reflected in this table. “–” indicates country-level funding is not available on ForeignAssistance.gov, country does not have a USG program that is supported by country-level funding available on ForeignAssistance.gov, or no cases have been reported. # of cases includes confirmed and presumed positive cases.
SOURCES: Johns Hopkins University, Coronavirus Resource Center, accessed: https://coronavirus.jhu.edu/map.html, as of March 19, 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.