Ethical health leadership: Lessons from low- and middle-income countries during COVID-19

Abstract

We adopt a holistic—micro, meso, macro—approach to health leadership ethics to examine how low- and middle-income countries have responded to the COVID-19 pandemic. Healthcare delivery happens within complex settings in low- and middle-income countries and high-income countries. These settings are riddled with systemic political and economic challenges which, in some instances, make it difficult for health leaders to be ethical. These challenges, however, are not unique to low- and middle-income countries. Globally, countries can learn from ethical health leadership missteps that occurred during low- and middle-income countries’ responses to COVID-19. We discuss the implications of problematic ethics in health leadership on managing pandemics in low- and middle-income countries, using Zimbabwe as an example. We offer suggestions on what can be done to improve ethical health leadership in response to future health crises in both high-income and low- and middle-income nations.

Introduction

The COVID-19 pandemic challenged the definition of ethical health leadership worldwide.¹ Low- and Middle-Income Countries (LMICs) bore a significant burden in maintaining good ethics in their healthcare systems during the COVID-19 pandemic. Fragile economies, scarce resources, conflicts, political uncertainties, fragmented healthcare systems, and corruption tested the ethical response to the pandemic from health leadership in these regions.² The case of Zimbabwe provides a quintessential example of the perils of mismanaged micro, meso, and macro healthcare ethics in response to a pandemic.

We adopt a population health approach to define health leadership which focuses on health and wellness rather than illness.³ This definition recognizes that health leaders work in clinical and non-clinical settings to understand the needs and find solutions for the delivery of clinical services, community outreach, intersectoral partnerships, and social determinants of health.⁴ The traditional definition of ethical health leadership narrowly focuses on the dyadic relationship between clinicians and patients. Albeit dichotomous and somewhat cloistered, this relationship occurs in a larger setting of healthcare systems run by institutions and governments. We would be remiss not to adopt a holistic definition of ethical health leadership that focuses on the micro, meso, and macro levels of healthcare systems⁵ to examine the response to COVID-19 in LMICs. The micro level deals with systems at the individual level, the meso level focuses on the middle level of systems including organizations and communities, and the macro level focuses on large national systems.⁵

While medical ethics are as old as medicine itself, the four commonly adopted biomedical ethics principles of respect for autonomy, beneficence, non-maleficence, and justice were developed by Beauchamp and Childress in 1989.^6,7 For the better part of the past few decades, these principles have been maintained as the ethical foundation of the clinician-patient relationship. COVID-19 demanded an overarching systematic healthcare response with population-oriented ethical healthcare principles. In addition to the four biomedical ethics principles, health leaders were called to consider principles of planning, safeguarding, and guiding in ethically managing the COVID-19 pandemic.⁸ Given these ethical principles, what remains to be understood is how well leaders in LMICs responded to the COVID-19 pandemic and how ethical their response was in preventing the spread of the pandemic, and the aim of this paper was to address these questions.

Challenges to managing COVID-19 in LMICs

The challenges related to ethical leadership while managing COVID-19 and other pandemics are shaped by LMICs’ fragile political and economic systems. When COVID-19 struck, many health leaders in LMICs had not planned for the pandemic, could not properly safeguard their population, and faced challenges in guiding the healthcare response.⁸ Low- and middle-income countries are home to more than 80% of the global population, but their share of the world’s resources is about 30% of the global domestic product.^9
–11 COVID-19 added to all these pre-existing resource constraints and contested health leadership ethics in the pandemic response.

Lack of good governance, including corruption (note 1), incompetence of public officials, and mismanagement of healthcare resources, plagues countries worldwide, but it is amplified in LMICs because of their tenuous domestic economic and political positions.^12,13 In some LMICs, public officials in key positions lack the capacity to address the issues they face including health crises. Incompetence and mismanagement of healthcare resources translates to poor health delivery outcomes. Some public health officials spend resources on non-essential services and leave little resources left over to spend on essential services due to the lack of capital budgeting skills or the ability to prioritize expenditure given a constrained budget. Different forms of incompetence and mismanagement of resources contributed to the spread of COVID-19 in LMICs.

Corruption, which consists of deliberate incompetence for personal gain, has been characterized as the ignored pandemic in the healthcare setting.^14

–17 The ultimate ethical obligation for leaders in any healthcare system is the well-being of the patient and population. However, corruption superseded ethics for some health leaders in LMICs who had an opportunity to reduce the spread of COVID-19 but resorted to corruption instead and failed to safeguard their population’s well-being. Health systems in High-Income Countries (HICs) are not immune to corruption. Large investments in the healthcare systems provide a protective veil on corruption in HICs. Nevertheless, the persistent inequalities in managing COVID-19 revealed that corruption as the ignored pandemic is very much alive in both LMICs and HICs.¹²

Foreign aid to LMICs in response to COVID-19 was not spared from the lack of good governance. An abundance of aid resources and a tangled bureaucratic chain of command to distribute aid is an impetus for corruption and mismanagement of resources for some unethical healthcare leaders in LMICs.¹³ Aid that comes without added interventions such as building robust public investment systems to safeguard resources from misuse and training on how to best utilize resources is as good as throwing away money and resources. Most LMICs do not have the institutional capacity to administer aid funds. Furthermore, funds may be diverted for other purposes given the lack of resources within the healthcare sector. Providers of foreign aid need to build the capacity of healthcare systems and leaders in LMICs to address the health priorities targeted by the aid. Corruption and resources mismanagement affected health service delivery, research and development, health workforce management, and procurement of COVID-19 supplies.¹⁸ Globally, there have been calls to mark 2020-2030 as the decade of anti-corruption in healthcare,¹⁹ but the COVID-19 response presented an opportune but missed moment to begin to address corruption in healthcare.

Most LMICs rely on the informal economy,^20,21 and their populations do not have Universal Health Coverage (UHC). When COVID-19 struck and imposed lockdowns globally, many people lost their jobs. Job losses in HICs differed significantly from job losses in LMICs because many HICs with stable economies had contingency measures to provide social support for their unemployed populations, UHC for their populations, and functioning healthcare systems. In LMICs, COVID-19 lockdowns were almost impossible to institute and not sustainable for longer than a few days. Individuals faced the debilitating choice of either dying from hunger or taking the risk to work in the informal sector without physical distancing or protection from the spread of COVID-19.²² Worldwide, political leaders were called on to enact physical distancing rules that do not bias against any population group.²³ This was not feasible in most LMIC economies. Being accosted into choosing between livelihoods and appropriate measures for preventing the spread of a pandemic is obviously a choice which no individual has to make if healthcare leaders are deliberate and ethical about healthcare equity and equality.

The case of Zimbabwe

Zimbabwe is a low-middle-income country in Southern Africa with a population of 14.6 million.²⁴ It has experienced more than its fair share of political and economic turmoil.²⁵ A few months after COVID-19 began to spread globally, some government officials were alleged to be at the centre of an elaborate corruption scandal, where they misappropriated close to $60 million in funds that were earmarked to procure COVID-19 supplies for the public.^26,27 Until the end of May 2020, Zimbabwe had less than 100 confirmed cases and 4 deaths from COVID-19. By September 2020, confirmed cases had risen to more than 6,000 and deaths from COVID-19 rose to more than 200.²⁸ These data only reflect known official cases and deaths from COVID-19; they may underestimate the actual data as a result of under-reporting or inadequate testing in some Zimbabwean communities, especially rural areas. While these numbers are relatively low compared to the prevalence and mortality rates in other HICs and LMICs, healthcare leadership in Zimbabwe missed an opportunity to ethically lead the COVID-19 response early on to prevent the spread of the pandemic.

Lack of good governance in the form of corruption, incompetence, and mismanagement of healthcare resources in the pandemic response happened in the milieu of a failing economy where nurses and doctors did not earn a living wage and struggled to make ends meet. Doctors and nurses went on strike to protest for better wages and proper protective gear amid COVID-19.²⁹ Some frontline workers in Zimbabwe did not have personal protective equipment during COVID-19. It was unethical for health leaders and public leaders to send health workers to the frontlines to fight the pandemic without protective gear. Doing so exponentially increased the odds of spreading COVID-19 since frontline workers came into contact with a lot of people.

Most of Zimbabwe’s COVID-19 cases were imported from other countries. When travellers arrived back in Zimbabwe after the lockdown went into effect, they did not have access to good accommodation for the designated quarantine period. Even though Zimbabwe quarantined travellers and returning residents, the quarantine facilities were inhabitable and forced many returning residents to escape quarantine. Failure to properly quarantine returning residents potentially increased community transmission of COVID-19 from imported cases.

About 98% of Zimbabwe’s working population is employed in the informal sector.²⁹ When COVID-19 struck, the informal sector ground to a halt and the government was not able to provide a social and economic safety net for informal workers. Without some kind of government assistance in cash or in-kind, employees in the informal sector were left with the difficult choice of staying home with no livelihood or going to work and risking contracting COVID-19. In instances where workers chose to continue working in the informal sector, they also risked being victimized by law enforcement or being arrested for not following the lockdown rules. The majority of the public who work in the informal sector should have never been put in such a compromising position. In all the confusion and when healthcare leaders failed to uphold their ethics in responding to the pandemic, ordinary Zimbabweans used on-line crowdfunding to raise funds for COVID-19,³⁰ but it was not adequate to compensate for failures of the health system.

The response to COVID-19 from healthcare leaders in Zimbabwe failed to fulfill the ethical principles of respect for autonomy, beneficence, non-maleficence, justice, planning, safeguarding, and guiding at the micro, meso, and macro levels. Misappropriation of already insufficient pandemic resources failed to fulfill the four values of maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.^31,32 Without the poor governance, incompetence, mismanagement of resources, corruption, political uncertainty, and economic instability, the number of COVID-19 cases and deaths in Zimbabwe could have been contained.

While few countries experience political, economic, and healthcare problems at the magnitude that Zimbabwe does, some nations in both HICs and LMICs have experienced some version of these issues. Zimbabwe’s case may not be generalizable to all countries, but some of the ethical health leadership missteps in managing COVID-19 are perhaps similar to what transpired in other countries globally. Efficient and effective ethical health leadership in managing COVID-19 was found wanting in both HICs and LMICs. In 2019, the United States ranked first, and the United Kingdom ranked second on the Global Health Security Index (GHSI), an assessment of 195 countries’ capacity to deal with infectious diseases.³³ However, the United States and the United Kingdom failed to plan, safeguard, and guide their populations in response to the COVID-19 pandemic and underperformed compared to countries that ranked lower on the index such as Germany and Canada. In principle, the GHSI was a poor predictor of performance in a pandemic response for some HICs. The GHSI predictions can only become true if there is a political will to achieve the predictions from leaders at all levels.

The lessons to be learnt from Zimbabwe apply in all countries with similar ethical healthcare management issues. These lessons include:

The need for nations to be prepared to deal with health crises such as pandemics.

Healthcare leadership ethics training at the micro, meso, and macro levels of leadership.

The importance of ethical leadership and political will to achieve healthcare equity and equality.

The need for good governance that addresses corruption, incompetence of public leaders, and mismanagement of resources in healthcare through research, policy, and strengthening oversight and accountability locally and globally.

The importance of concerted efforts between the political sector and the economy to address health crises.

Lessons learned

If we are to achieve Goal 3 of the UN’s 2030 Agenda for Sustainable Development for All, which is to ensure healthy lives and promote well-being for all at all ages,³⁴ health leaders worldwide at the micro, meso, and macro level need to uphold principles of ethical health leadership.

First, LMICs have been plagued by more health calamities including infectious and viral epidemics and pandemics than HICs. Diseases such as SARS, HIV and AIDS, cholera, and Ebola have ravaged these countries at various times in history. In this regard, LMICs should have been more prepared to mobilize resources to respond to COVID-19.³⁵ Even though the response may not have stopped the spread of COVID-19, nations globally can learn that they need to be more prepared for pandemics in order to be agile when they strike.

Second, inadequate regard for ethics in the public health sector’s response to COVID-19 in some countries highlights the importance of ethics training in response to health crises. Most health leadership training programs target physicians,^36,37 and they are usually relegated to electives in the curricula.³⁸ We have unpacked the fact that health leadership transcends the clinical setting to include health budgets in the economy. This calls for action that has not been considered before where health leadership ethics training and refresher courses are essential to all leaders to deliver healthcare programs that can ethically respond to emergencies.

Third, lack of good governance including corruption, incompetence, and mismanagement of resources in healthcare costs lives. It is essential to ensure that health resources are distributed fairly and to those who need them the most during health crises.³² Setting a precedence of equity and equality in distributing healthcare resources has the potential to reduce the spread of diseases and reducing the negative impact of health crises on the economy.

Fourth, health professionals and patients need guidance, assurance, and compassion from their health leaders,³⁹ especially in times of health crises. When the principles of ethical health leadership are contravened, healthcare workers are demotivated and mistrust is born between the system, the workforce, and the population; once trust is lost, it is difficult to regain it.³⁸ Failed health leadership means increased illness and mortality which both have ripple effects on all sectors of the economy.

Finally, given the importance of ethics in health leadership, we can infer that a nation’s political health plus its economic health will equal excellent public health. To this end, ethical health leadership that responds well to pandemics and health crises cannot happen in isolation. COVID-19 has underscored the importance of UHC for all. Faced with a health crisis, having health coverage would have helped populations access health services to reduce mortality from COVID-19. According to the World Health Organization, implementation of UHC requires effective health systems governance to ensure that strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system design, and accountability.⁴⁰ The interlocking nature of government sectors, such as finance, education, and health, for instance, requires that governments ensure full functionality in order to achieve equitable and ethical healthcare responses to future pandemics.^41,42 Lack of political will can indeed make science obsolete.

Implications on pandemic management

Compromised ethical health leadership in response to COVID-19 in LMICs led to lagged responses to pandemic management that were reactionary rather than proactive. This lackluster health leadership resulted in resources intended to prevent the spread of COVID-19 not reaching the public.⁴³ Incompetence, mismanagement of resources, corruption, and theft of COVID-19 resources potentially increased COVID-19 cases and widened the persistent health inequalities between the rich and the poor.

Lack of health leadership ethics in the COVID-19 pandemic response in LMICs undoubtedly increased instances of underreporting of COVID-19 cases and deaths.⁴⁴ Failure to account for pandemic illness and deaths infringed on healthcare ethics because healthcare data and information are important baseline tools to support the ethical principles of planning, safeguarding, and guiding a national pandemic response.⁸

What has worked well

We would like to assert that even though ethical health leadership in response to COVID-19 seemed absent in some LMICs, by design or default, some things worked well in managing the pandemic. Stuck between a rock and a hard place in deciding whether to stay safe in lockdown or to go and work in the informal sector, most employees in LMICs chose to go to work. Breaking physical distancing rules imposed by public health officials meant full exposure to COVID-19. This forced the public to be vigilant about wearing masks in public as a form of self-preservation without the need for enforcement and it may have contributed to the low spread of COVID-19 infection in some LMICs.

Low- and middle-income countries are rich with a culture of social capital structures that carry a fabric of caring which is called ubuntu in sub-Saharan Africa.⁴⁵ Among other things, ubuntu is about community, acknowledging that your pain is my pain, your wealth is my wealth, and your salvation is my salvation. These social structures were crucial in providing support in the face of the uncertainties presented by COVID-19 in LMICs and they probably did not exist to a great extent in HICs. In the case of Zimbabwe cited earlier, the community-led fundraising efforts show the concept of ubuntu in micro-level ownership of healthcare ethics.

Conclusion

The essence of ethical health leadership lies in the fact that delivering quality healthcare to the population occurs when health inequalities are reduced. Health inequalities driven by the lack of good governance including corruption, incompetence, and mismanagement of resources were persistent during the COVID-19 pandemic worldwide. The pandemic was a missed opportunity for HICs and LMICs to address healthcare priorities. Improving health leadership ethics has the potential to reduce healthcare inequalities and enhance future pandemic responses in particular and healthcare systems in general. Ethical health leadership in response to health crises for all nations does not occur in a vacuum, and it requires concerted ethical economic and political leadership.

Footnotes

Note

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