COVID-19: the rude awakening for the political elite in low- and middle-income countries

Summary Box.

• Decades of bad political choices by the elite class has resulted in weakened health systems in many low- and middle-income countries

• The resulting lack of high-quality care and poor health outcomes are typically only borne by those of lower socio-economic standing - with the elites and their families being able to seek care in high-income countries.

• COVID-19 may change all that—a highly transmissible virus and restrictive measures that prevent elites from flying abroad has forced them to depend on an ill-equipped health system at home.

• COVID-19 presents a stark illustration that we are all interconnected; social class, personal status or borders do not help to evade health vulnerability.

• Enlightened self-interest of political elites may finally provide sufficient motivation to invest in an effective and integrated health system.

Political choices determine the conditions under which people can be healthy, including how COVID-19 spreads and its impact on populations. Decades of political corruption¹ and the permeation of neoliberal political ideology² have left health systems, especially in low- and middle-income countries (LMICs), chronically underfunded, insufficiently regulated, inadequately staffed and unable to deliver high-quality care.^3–5 The resulting consequences are poor health outcomes, financial waste, increasing inequality, disproportionate share of global disease burden and immeasurable human suffering—especially for the most disadvantaged and vulnerable.^6–9

But not for political elites in LMICs. What is politically feasible seems to rarely extend beyond what is needed to maintain an establishment that continues to protect their self-interests. Their ability to use their wealth, power and privilege to receive treatment in local private healthcare institutions or to hop on a jet to fly to a high-income country (HIC) to purchase treatment has meant their efforts to undermine and underfund universal health coverage rarely impacts them. COVID-19, however, has changed all that.

With traditional disease outbreaks, we expect to see transmission primarily occur in densely populated, socially deprived settings—not in luxury hotels or the corridors of political power. The SARS-CoV-2 virus has no regard for social class, personal status or borders; its high transmissibility makes it difficult for political elites to evade. This is already evident from the continuing news coverage of the pandemic showing social and political elites are getting infected around the world. For example, heads of government and senior government cabinet members (in Afghanistan, Australia, Brazil, Burkina Faso, France, Guinea, Guinea-Bissau, Iran, Israel, Russia, Somalia, Spain and UK), senior government officials and their aides (in Brazil, Iran, Nigeria, Poland, Russia, Spain and UK), and members of regional and national parliaments (in Australia, Brazil, Burkina Faso, Guinea, Iran, Ireland, Italy, Nigeria, Pakistan, Philippines, Serbia, Ukraine and USA) have either been infected with SARS-CoV-2 or died as a result of COVID-19.^{10 11} Lockdowns, travel bans and airport closures have prevented elites in LMICs from being able to fly abroad to receive high-quality care in countries with functional healthcare systems—something they typically do when they or family members are ill.¹²

It is also difficult for them to get the necessary medical equipment shipped in for personal use because resource and pricing demands in the current global market makes competing against HICs, who have far greater economic clout and can attach other benefits to being provided such goods, almost impossible.¹³ News outlets report that in desperation, some political elites may even resort to confiscating or reselling essential items from public supplies,¹⁴ but such grasping efforts will likely not confer the self-protection they are used to. For the first time, the elite political class in LMICs will have to face an unfamiliar reality: they have no other choice but to experience the same weak and ill-equipped health system that they perpetuated—one that the rest of their society have had to cope with for a long time. COVID-19 has made it clear that we are all interconnected, with health vulnerability no longer being primarily a concern for the less privileged in society. This reality is even more grim as the end of the current pandemic is nowhere in sight.

Amidst all its ongoing negative effects around the world, one potentially positive outcome from the COVID-19 pandemic will, hopefully, be the recognition that the political choices to decrease or limit health funding, especially for public health and the social determinants of health, have real and inescapable consequences for all. The actions (and inaction) of the ruling classes resulting in weak healthcare systems in LMICs will have a direct negative impact on them through the severe health and economic crisis being imposed by this pandemic. One has to wonder what else would be needed to impress on leaders and political elites in many LMICs, particularly in Africa, of the need to strengthen and invest in healthcare capacity, public health systems and pandemic preparedness?

In the past, equity-based arguments for responsible governance and for investing in health systems have been inadequate to achieve the results that would have placed LMICs in a much stronger position to respond to and cope with the effects of COVID-19. The current circumstances may reveal enlightened self-interest as the only motivational consideration strong enough to awaken political elites from their corrupt or ideological slumber. Perhaps they will now feel compelled to adequately invest in an effective and integrated health system. It remains to be seen though, whether the tendency of political elites to have short memories will, a few years after the pandemic has waned, find them reverting to familiar calls for deep austerity and individual responsibility for health. For everyone’s sake, including their own, we hope they do not make the same mistake again.