Health system capacity for infectious disease pandemic response in low- and lower-middle-income countries: Insights from national health facility surveys.

OBJECTIVE

Despite growing recognition of pandemic preparedness gaps in low- and lower-middle-income countries (LLMICs), empirical evidence on facility-level capacity remains limited. This study assesses the capacity of health facilities in LLMICs to respond to infectious disease pandemics and identifies structural determinants influencing that capacity.

METHODS

We used a secondary analysis of pooled Service Provision Assessment (SPA) survey data conducted in nine LLMICs between 2013 and 2022. Thirty-one facility-level indicators were grouped into four domains (infection prevention, personal protective equipment, diagnostic capacity, and therapeutic capacity) to construct an overall capacity index. Machine learning algorithms and hierarchical regression models were applied to identify key facility characteristics associated with pandemic response capacity.

RESULTS

This study evaluated health system capacity in 9632 facilities across nine LLMICs comprising 834 hospitals (7.9%) and 8868 non-hospital facilities (92.1%). Overall capacity was low: only 22% of facilities achieved a capacity index above 50%. Therapeutic capacity emerged as the weakest domain across all countries. The strongest predictors of pandemic preparedness capacity were facility type, ownership, and location, reflecting system-wide challenges of LLMIC health systems and providing strategic intervention points.

CONCLUSION

Therapeutic capacity represents a critical vulnerability in LLMIC health systems. Non-hospital facilities, which serve as the backbone of service delivery in these settings, demonstrated particularly low capacity levels. These findings underscore the urgent need for targeted investment in facility-level infrastructure, particularly therapeutic resources in non-hospital facilities, to strengthen pandemic preparedness in LLMICs.