Critical questions

Each week, an Every Breath Counts Coalition partner will respond to a ‘critical question’ relating to an aspect of COVID-19 preparedness and/or response in low- and middle-income countries

How to protect maternal, newborn, child and adolescent health and nutrition services in low- and middle-income countries during the COVID-19 pandemic?

Answer provided by John Borrazzo, Senior Health Specialist at the Global Financing Facility (GFF), which is hosted by the World Bank.

As the COVID-19 pandemic escalates in low- and middle-income countries, there is a growing risk of widespread disruptions in access to maternal, newborn, child and adolescent health and nutrition services.

A pulse survey of the 36 GFF-supported countries found that nearly half are already reporting life-threatening service disruptions. The findings revealed that the COVID-19 pandemic is disrupting delivery of essential services such as ante-natal care visits, attended births and delivery of child vaccinations. These disruptions are likely to lead to significant increases in preventable maternal and child illness and death.

There is also the beginning of systematic problems such as the ability of families to secure transport to health facilities. Limited supplies of personal protective equipment for health workers result in both risks to the health workforce delivering RMNCAH-N services as well as suppressing demand for facility-delivered services because of fears of virus transmission.  

The COVID-19 pandemic is likely to be an ‘inequity multiplier’ – disproportionately affecting availability, accessibility, and utilization of RMNCAH-N services by the poorest and most vulnerable populations.

It is vital that countries do not fall backwards on the improvements that have been made to maternal, newborn, child and adolescent health and nutrition services in recent years.

The GFF is protecting essential health and nutrition services in GFF partner countries as part of the COVID-19 response by:

  • Supporting frontline healthworkers, through flexible funding and technical assistance, for training and other activities that complement efforts by the World Bank Group and other partners to supply personal protective equipment (PPE); 
  • Supporting leaders in eligible countries to develop cross-cutting plans to maintain essential services during the pandemic.
  • Supporting effective coordination of financing – such as through resource mapping and expenditure tracking to ensure resources are used efficiently.
  • Sharing good practices, lessons learnt and guidance among leaders and health workers, including the latest information to inform service delivery, using existing GFF knowledge and learning support to Country Platforms.
  • Providing technical support to leverage COVID-focused investments to ensure availability of critical supplies that also support RMNCAH-N, such as sustainable oxygen systems and blood supply.
  • Assisting countries to introduce service delivery changes – such as by separating patients seeking routine health care from those with COVID-19, scaling up the use of telemedicine and other digital health channels.
  • Developing strategies to ensure that essential health products reach local communities, including via partnerships with the private sector.
  • Developing innovative approaches to social and behaviour change communication to help communities respond to the pandemic and continue to access critical RMNCAH-N services.
  • Supporting actions to avoid disruptions to supply chains for essential RMCNAH commodities. 

To find out more read: Emerging secondary global health crisis from disruptions in primary health care due to COVID-19(23 April 2020).

How do we prioritize invasive versus less-invasive respiratory therapies in low-resource settings?

The answer is provided by Tim Baker, a critical care doctor affiliated with the Karolinska Institutet in Sweden and the Muhimbili University of Health & Allied Sciences in Tanzania.

The headline figures of intensive care unit (ICU) requirements for COVID-19 patients in wealthy countries are masking the need for essential care in low-resource settings. 

Expensive, high-tech equipment demands highly trained health workers and an extensive supply of medical oxygen and, moreover, serves a tiny proportion of the population. This is not feasible in low-resource settings and can be dangerous if not properly supported. 

Indeed, most critically ill patients in poorer countries are cared for in emergency units and general wards and do not have access to advanced care in ICUs. Data from hospital wards in Malawi showed an alarming 89% of hypoxic patients were not receiving oxygen. Such capacity cannot support widespread mechanical ventilation.

We need to move away from high-tech mechanical ventilation to low-cost essential care which serves a larger proportion of the population. This requires a comprehensive integrated approach – where oxygen is the key element that helps many diseases – and support to ongoing health services provisions to non-COVID patients.

Essential care in low resource settings should include the following elements:

  • Improving community case management and hospital readiness; 
  • Ensuring good quality clinical practice for both identifying and caring for critically ill patients;
  • Hospitals establishing effective systems for triage and essential care in emergency units and wards, including patient separation and staff safety; 
  • Emphasizing the central role of oxygen therapy – and ensuring oxygen supplies and delivery systems and guidelines for sustainable and appropriate use;
  • Head-up or prone patient position, suction, and simple chest physiotherapy; and
  • When human resources are limited, ensuring less trained health workers or vital signs assistants implement and share such care.

Quality essential care of critical illness could have a significant impact on reducing COVID-19-related mortality even without ICUs. We must urgently enhance the ability of health services in low-resource settings to provide good quality essential care of critical illness. 

For further information see: Essential care of critical illness must not be forgotten in the COVID-19 pandemic, The Lancet, 1 April 2020

How can international actors best support local manufacturing of WHO-recommended COVID-19 technologies, where appropriate and feasible?

The answer is provided by: Dr Paulin Banguti, University of Rwanda, King Faisal Hospital, and the Rwanda Society of Anesthesiologists.

As the world scrambles to buy ventilators in the COVID-19 pandemic Rwanda has come up with its own solution: the first locally produced ventilator.

After observing how the pandemic has ravaged the world, and the importance of oxygen in the treatment of the virus, biomedical engineers, from the Integrated Polytechnic Regional Centre in Kigali, challenged themselves to produce the ‘Rwanda Emergency Ventilator’.

The ventilators are made from locally sourced materials and can be produced at a much lower cost.  They are also more appropriate for low-resource settings – the ventilator does not need oxygen tanks (it uses natural oxygen), can run on a battery and is easily maintained.

The engineers have produced two types of ventilators – for hospitals and portable use in ambulances. The plan is for the ventilator to be made available at an affordable market price, and the prototype is now being shared with other low- and middle-income countries.

The COVID-19 pandemic has underlined the need for cost-effective local solutions. 

But there are many challenges. It is difficult to purchase components (such as sensors), as global supply chains become overloaded, and oxygen supply is limited.  Support to train technicians, clinicians and health workers to use and maintain the equipment, is hard to find.

Rwanda has the technical expertise – the engineers, scientists, physicians and IT developers – to design and test COVID-19 technologies. What is urgently needed now is support from governments, donors and private investors to manufacture and distribute them at scale. With this support – financial and technical – Rwanda would not only be in a stronger position to control the pandemic, but it would ensure that respiratory care technologies are available in the health system for the long term.


For further information watch Dr Banguti and the team of biomedical engineers from the Integrated Polytechnic Regional Center (IPRC) in Kigali discuss the first locally-made ventilator

In you have an innovative product that is approved for emergency use or already commercially available, submit your product for consideration to WHO:


We all have a role to play in ending preventable child pneumonia deaths by 2030

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