International Development Committee
Oral evidence: Humanitarian crises monitoring: impact of coronavirus, HC 292
Tuesday 16 June 2020
Ordered by the House of Commons to be published on 16 June 2020.
Members present: Theo Clarke (Chair); Sarah Champion; Brendan Clarke-Smith; Mrs Pauline Latham; Navendu Mishra; Kate Osamor; Mr Virendra Sharma.
Questions 96 - 117
I: Dr Tamsyn Barton, Chief Commissioner, Independent Commission for Aid Impact; Amanda Glassman, Executive Vice-President and Senior Fellow, Centre for Global Development; Professor Charlotte Watts, Chief Scientific Adviser, Department for International Development; and Daniel Graymore, Board Member for UK/Qatar, Gavi and Head of Global Funds, Department for International Development.
Examination of witnesses
Q96 Chair: Hello and welcome to the International Development Committee’s evidence session on humanitarian crises monitoring on the impact of Covid-19. Today we will focus on the impact of Covid-19 on global health and the UK’s work with Gavi following ICAI’s latest information note. As Chair of the Sub-Committee, Sarah Champion has kindly called me to chair this evidence session due to its link with ICAI’s work.
Could we start with the witnesses briefly introducing themselves?
Dr Barton: My name is Tamsyn Barton. I am the chief commissioner of the Independent Commission for Aid Impact.
Professor Watts: Good afternoon. My name is Charlotte Watts and I am the chief scientific adviser at DfID.
Daniel Graymore: Good afternoon. My name is Danny Graymore. I am the head of DfID’s Global Funds Department and am also DfID’s senior representative based in Geneva.
Amanda Glassman: I am the chief executive officer and a senior fellow of the Centre for Global Development in Europe.
Q97 Mrs Pauline Latham: Tamsyn, before we go on to Gavi, what is your view on the announcement today of getting rid of DfID and going into the Foreign Office? How is that going to impact on ICAI? It was set up, I understand, to report to this Committee. If this Committee does not exist, what do you believe will happen?
Dr Barton: Thank you for that question. I should say first of all that, of course, it has been a matter for Government to decide on the machinery of government change, and it is a matter for Parliament to decide how Committee scrutiny will be done.
When I last gave evidence in relation to the inquiry on ODA effectiveness, I drew attention to the question of how scrutiny would work, and whether if there were to be a merger the Committee would, as normal in Parliament, have a counterpart Department. We hear there is a new Department to be established in the autumn, and I believe the Foreign, Commonwealth and Development Office is the name. There will perhaps be a Committee set up exactly as a counterpart to that Department.
In the past, when there were separate ministries, there was a Sub-Committee looking at overseas aid. I would say from our perspective we would hope to feed into whatever scrutiny there might be. It will be a matter for Parliament whether it is as a Sub-Committee of that departmental Committee or whether—like other Committees, such as Women and Equalities—there will be a cross-cutting Committee. However, what we would say at times like these, obviously with tight fiscal resources and economic challenge, is that it is more important than ever that there is scrutiny to ensure value for money for the taxpayer.
Q98 Mrs Pauline Latham: I completely agree, we must continue to scrutinise the 0.7%. I personally do not see how that will happen if it is just Foreign Office with a bit of DfID. How would you summarise ICAI’s overall findings in the information note on the UK’s work with Gavi?
Dr Barton: I should say first we were very pleased to be able to respond to the Chair’s interest in ICAI, providing some evidence to help you as a Committee in your scrutiny of this replenishment. Normally, of course, we always have robust criteria for deciding what topics to select, and we think Gavi scores very highly on our key criteria. Financial materiality, the UK has already invested £4 billion in Gavi up to now and this is a further £1.65 billion committed for 2021 to 2025. It is also of enormous strategic importance. I think that has been seen from what it has already delivered at the heart of the global health system in vaccinating 760 million children, which indicates the direct on-the-ground lifesaving impact that it can have.
I think more remarkable about Gavi is that it has been an innovative partnership that has developed innovative instruments. What you have seen as a result of that is systemic and transformational change for even more children because the cost of vaccines has been lowered, by more than half in some cases.
Of course its role has come more into the public eye in the context of a global pandemic, which on the one hand is disrupting its important routine work but, on the other, if you did not have a multilateral set-up like Gavi, able to use global co-operation to deal with this health threat, it would be much more difficult to respond. If you did not have the innovative instruments that have been pioneered under Gavi, it would be hard to see how a vaccine could raise the front-loaded resources to respond. Indeed, our note highlights that there appears to be a gap, however you look at it and despite the great success in the UK’s hosting of the replenishment, which succeeded in getting more pledges than planned. Nevertheless, estimates of the development and deployment of a new vaccine have ranged up to £20 billion and, at the moment, this replenishment was just based on Gavi’s original plans pre-Covid, where it was hoping to raise $7.4 billion. It is hard to see how, with the $2 billion that it hoped to have just for the most minimal vaccine deployment, it will be able to close that gap.
Our note helps to raise some of the questions that there will be whenever there is competition for restricted resources. There are major questions about Gavi’s mandate, whether it can continue to focus on its routine immunisations—which delivers very high value compared with the risk of excess Covid deaths—and also whether it can, as the UK has been trying to push it to do, actually reach the hardest to reach because, without reaching the hardest to reach, not only are you neglecting and leaving people behind but you are also creating reservoirs of disease. There are many questions that our note raises.
I should say, by way of closing, that this has not been a full-scale ICAI review. We have not been able to do the in-depth review that you would get for a standard year of work. We have only looked at this over a couple of months and picked up the key debates for you to consider. Nevertheless, we previously did a review of the UK’s preparedness for global health threats and we are able to draw on that in our work.
Q99 Mrs Pauline Latham: Could the other three briefly comment on their views on ICAI’s information note on the Government’s work with Gavi?
Professor Watts: Just to say, speaking on behalf of DfID—I am sure my colleague will also want to comment on DfID—and as Tamsyn has just said, how important Gavi is to us, both in terms of the lifesaving work it does around delivering childhood immunisations that save literally millions of children’s lives but also, increasingly, in terms of its work to support global health security. For example, around delivering cholera vaccines, Ebola vaccines in eastern DRC and now stepping up to use its expertise and its relationship with pharma to support the world as we look forward to think about how we deliver a future Covid vaccine to developing countries.
Amanda Glassman: ICAI did note the importance of Gavi’s new goal, which is on sustainable coverage with equity. However, when you look at the measures that it will be using to assess this goal, it is things like doses of vaccine or number of kids vaccinated. I think it is quite important to keep our eye on the ball of herd immunity, which is what delivers the public health benefits and the global health security benefits that Professor Watts has pointed out. When we look at a country like Ethiopia, which has had 15 years of Gavi support, for the pneumococcal conjugate vaccine that was introduced in 2011, the third dose of that vaccine for kids aged 12 to 23 months was only 50%. We have a way to go to ensure that herd immunity coverage.
Daniel Graymore: We really welcome the work of ICAI doing the information note on Gavi. As my colleague, Professor Watts, has said, Gavi is critically important for the UK Government and our international engagement more broadly, and obviously on delivering on our global health priorities in particular. Gavi has demonstrated enormous impact and innovation over the years, as others have set out. We may come back to some of the results but, as was mentioned at the beginning of the session, it has vaccinated 760 million children, saved 13 million lives and, working with private sector, civil society, Governments and others, developed really innovative outcomes. When you look at the ways in which vaccines that previously were either unaffordable, unavailable or the wrong sort of formulation, how they have been brought to become available and affordable in poorer countries, vaccines like the pneumococcal conjugate vaccine and bringing in pentavalent vaccines, there has been enormous success. I think most people here know that.
I agree entirely with Amanda that, of course, there is nonetheless a long way to go and it is critically important that we continue to focus on the child. Clearly, achieving herd immunity is at the heart of a successful immunisation programme, but we must make sure we redouble our efforts to reach those children, those communities and those families who are left behind for the reasons that others have explained, partly because of public health but also because of equity. If we are really going to deliver on our ambitions and genuinely leave no one behind, it has to be done in a way that works with some of the poorest communities worldwide.
We are also ensuring—again, ICAI was very helpful in identifying this and it is an area we are very aware of—that we are very alive to the impact of Covid on Gavi’s operations. We have seen, both in routine immunisation and in campaigns, significant disruption that is going to set back our mission, potentially quite significantly. One of the great opportunities we have, in having secured significantly more than the £10.4 billion minimum ask that was set out for the Global Vaccine Summit 2020, is that we have additional resources. We have additional resources to deploy against an incredibly challenging context, partly in terms of reaching those communities and those children left behind but partly in terms of reaching those communities when routine services, essential health services, primary healthcare services, have been disrupted by Covid, and partly in ensuring that we can really deliver on some of the health system strengthening ambition that we all have.
It is worth noting that Gavi’s resource mobilisation drive over the last year was always very clear that it was seeking at least $7.4 billion. The Gavi secretariat and the alliance—which of course is the World Health Organisation, UNICEF, the World Bank, the Bill and Melinda Gates Foundation and others working collaboratively—were always very clear that one of the great opportunities, if we could secure additional resources, was to focus on health system strengthening.
As a final point on that aside, as we look again in the context of Covid and understand ever more the importance of pandemic preparedness and response, we need resilient health systems that meet the needs of poor people and communities in the countries in which we work. That is partly for its own end but partly also because that creates a stronger global system, stronger global health security, and that is one of the key roles that Gavi plays. That is including through its emergency response work, as Professor Watts noted, on cholera, yellow fever and, perhaps most obviously, on Ebola, where Gavi was critical in bringing forward an Ebola vaccine that has been deployed highly successfully in eastern DRC and is now being deployed against the latest Ebola outbreak. A combination of those public-private partnership ways of working that are critically focused on the needs of the countries primarily, and of the communities in those countries, has delivered a great deal, and we now have a platform that can really help us at this particular time.
Chair: I ask the witnesses to keep their answers a bit shorter, because I know there are a lot of members who want to ask questions.
Q100 Mrs Pauline Latham: Does anybody want to add anything about how these findings are relevant to the Government’s response to the Covid-19 vaccine? You do not have to but, if you want to, there is an opportunity.
Amanda Glassman: One key point that Tamsyn raised is the sizing of the advance market commitment for the purchase of the Covid-19 vaccine for low-income countries. So far, I think they have received about $579 million in contribution, and it is well below what would be required to purchase, even at the $2.50 per dose amount that was named by AstraZeneca, and it is not clear that that is the vaccine that will get over the line.
The other worry I have is whether the existing facilities that are used to produce existing vaccines may be repurposed, which might affect the supply of Gavi’s regular vaccines that it buys on behalf of low-income countries. That is something we have to watch as we go into this period, because that could further constrain our supply situation.
Maybe a final issue is that, because we are in an unprecedented economic recession, the likelihood that some of the countries that are already transitioned or were carrying more of a share of their vaccine budgets themselves may fall back into low-income country status. That would require more funding for Gavi, according to its existing eligibility criteria, and I am not certain that has been reflected in the amounts that were asked for in the replenishment. However, of course, it is hugely good news that it received more than it asked for. Hopefully that will cover it, but it is worth watching.
Professor Watts: Amanda is raising really important points. In terms of our perspective on Gavi, we are committed both to supporting the core vaccination and also to looking at how we will be ready for Covid vaccine delivery. We are very clear that, along with preventing the impact of Covid, we really need to ensure that we are trying to prevent those secondary impacts that you are saying are a risk. We need to be saving lives from the vaccine-preventable diseases of today, as well as how we look forward in terms of thinking about future vaccine delivery. In our own analysis we very carefully—and very much from the Chief Economist’s office—tried to think about it and look ahead at what might be the implications of, for example, the economic shocks and what they might mean about eligibility criteria and those sorts of things.
Dr Barton: What has not been covered—I agree with what has been picked up by Amanda—is that the real risk is that the urgent might triumph over the important. A couple of ways this could happen is Gavi’s management time, the pressure it is receiving from donors and the challenges with the response to the new situation is likely to take them away, given the limited resources, from the really important questions that have been mentioned, by Danny, about health system strengthening and, by Amanda, about equity. It is really hard to reach the kids that have not been reached, so it is going to be much harder with this level of pressure, this level of economic damage, to the countries themselves and to the donors. Therefore, there is a real storm heading in Gavi’s direction in many ways, despite its importance at the moment.
Chair: Daniel, but keep it brief because I want to go on to the next question.
Daniel Graymore: Certainly. I have three quick points, partly on the Gavi advance market commitment that was launched at the Global Vaccine Summit on Thursday, 4 June. I totally agree that the amount of money that was secured was very positive. Against an initial ask of $2 billion, we secured about $560 million. The UK committed $60 million of that commitment, and a number of other countries and institutions came behind that too, which is hugely welcome. However, of course, when we look at the global need to ensure access and availability for any future Covid vaccine, it needs significantly increased financing.
It is also critically important that the advance market commitment, which is fundamentally a pull mechanism that is going to aggregate the demand of Gavi countries to enable them to purchase a vaccine, has been met of course by the work of CEPI, the Gates Foundation and the World Health Organisation under the ACT accelerator. That is the pull mechanism bearing on the push mechanism to invest in development of vaccines, manufacturing capacity scale up, et cetera. There is a large global effort that is making, I think, quite significant progress quite rapidly, of which the Gavi advance market commitment is a critically important part.
The second point is on the Covid response. Gavi, of course, in its own programme is looking very carefully at how it can flex and re-programme to support countries in their response to Covid—including around things like enabling more flexibility on financing to buy personal protective equipment or to invest in infection prevention and control, for instance, two of the largest areas that countries are using Gavi support to invest in at the moment as part of their immediate response to Covid—but also, of course, to look at how they maintain essential routine immunisation and, indeed, campaigns work. We know that, for instance, nearly 100 mass campaigns and outbreak responses have been affected by Covid, and about 68 Gavi-supported vaccine introductions have been affected by Covid, too. As everyone is saying, it is maintaining that focus on keeping those essential services running.
The last point, quite briefly, is we have been, as the UK Government, very clear for a long time that what we really want to see at the country level is the highest collaboration between institutions like Gavi, the Global Fund to Fight AIDS, TB and Malaria, UNICEF, the World Bank, the WHO and others. This is a prime example where coming behind countries’ Covid-19 national action plans—as required by the World Health Organisation under the strategic preparedness plans they have—as part of the UN Country Team is really important to Gavi, the Global Fund and others playing their part in maintaining essential services and helping countries respond directly to the threat of Covid. We are seeing some good progress on that side of things but, of course, it is relatively early days.
Q101 Sarah Champion: The Committee and I are still reeling from the merger that has been announced today, so that is going to influence my questions.
I turn first to Amanda, who is probably the most independent of our witnesses. Could you tell me, from the announcements today, what you think is likely to be the impact on Gavi? With the five-year strategy for Gavi, what do you think it ought to be putting in place to make it more robust in line with these changes?
Amanda Glassman: I hope this is one of those aid activities that will remain core, no matter what organisational framework is in place.
Obviously, it is hard to tell whether the emphasis on value for money and poverty alleviation are retained as part of the merger, so that is something we will be watching closely. We certainly hope that it will. That very important function of public scrutiny and oversight on value for money is also vitally important. The UK, particularly in the case of Gavi, plays an enormous role in its governance, in driving its direction and in assuring that it is accountable and delivering on the benefits that it set out, so I hope the merger will not affect any of that very substantially.
I hope the new focus on global health security as part of aid will also play to make Gavi at the centre of all this. It is the most basic element of global health preparedness to ensure that you have high levels of immunisation coverage, herd immunity, for the existing vaccines that are out there and, of course, to deploy Covid-19. That is the only way we will deal with the economic consequences of Covid and get back to something that looks like normal.
Q102 Sarah Champion: Tamsyn, ICAI scrutinises all ODA spend and is finding that some Departments are more transparent and more targeted in alleviating poverty than others. In relation to Gavi and its focus on vaccines, do you think the merger has any implications in terms of transparency of how that money, which is a considerable amount of money that the UK is leading on, is being spent?
Dr Barton: I certainly hope that there would be no backtracking on the transparency commitment. 2020 was, of course, the year in which all Departments were committed to achieving the same levels of transparency as DfID, which is judged one of the best. It is true that FCO is one of the Departments that was less transparent, but in a merger the hope would always be that the best systems are the ones that are preserved, rather than the less good ones, so there is no necessary reason to expect that there would be any less transparency.
On the question about whether there could be any diversion from the focus on poverty reduction, some of the commentary about the merger has associated it with more focus on short-term national interests. I do not think that is what we have actually heard from the Government. When the announcement was made on the vaccine, it was very much framed as a win-win, with benefits to the UK—short term insofar as the risk of Covid-19 and other global health threats, with this being a very good instrument to protect the UK—and global benefits. However, one of the possible lines of inquiry that we picked out in our note was whether that framing might also contain any trade-offs, as well as win-wins. There the sorts of things we had in mind were might it be less focused on poverty reduction if there was more focus on threats to the rich world, if you like; might there be potentially more focus on donor industries, and obviously there has been a lot of discussion about the UK role in vaccine development; might there be—as I have mentioned, partly because of the urgency related to the short term—a loss of focus on those long-term agendas. Health system strengthening is a long business, and you cannot switch around policies quickly in relation to that. Similarly, it has proved very difficult and challenging to achieve coverage, reach the hardest to reach and so on. If those were lost in a focus on the short term, that is where risks could lie in relation to Gavi. However, as I say, I would hope that the best of DfID’s evidence-based approach and focus on ultimate poverty reduction and sustainable development would not be lost in any merger.
Q103 Sarah Champion: Danny, you are the head of Global Funds at DfID, as well as the UK Gavi board member. Are you nervous about the long-term, the five-year and onwards, commitment of this Government towards vaccines and Gavi?
Daniel Graymore: I am not, as the UK has, of course, supported Gavi since its inception. It hosted the 2011 replenishment, was very active in 2015 when Germany hosted the next replenishment and, of course, on 4 June we hosted the Global Vaccine Summit 2020. We had an amazing outcome. As we have noted already, we secured $8.8 billion against a $7.4 billion ask, and there were many other great results. What that shows is the level of commitment from the UK Government as a whole.
We were able to work very closely, as DfID, with our colleagues in the Foreign Office, No. 10, the Cabinet Office, Department of Health, BEIS and other Departments to really mobilise the UK Government’s commitment to global immunisation and to Gavi, and to bring together very senior global leaders to recommit to Gavi’s future and the work in the 2021 to 2025 strategy. I think that really demonstrates that, across the whole of Government, an instrument like Gavi and the alliance of key partners is enormously valued and we are very much behind it.
This money we have just committed, which was announced in April by DfID Secretary of State, is for the 2021 to 2025 period, during which these issues we have talked about—reaching the very poorest, equity and gender—are really important priorities for the UK. Emergency response and global health security are really important priorities, as is utilising the private sector to create innovation, better prices and better access for poorer countries to critical vaccines. These are things that I think are firmly part of the UK Government’s engagement on global immunisation. They are reinforced if you look at our commitment just last year to the Global Fund to Fight AIDS, TB and Malaria or our long-term work with the World Health Organisation and other partners. The UK has a very strong strength on global health in academia, in industry and, of course, in Government, in civil society and in Parliament. It is a huge commitment, and I am confident that will be sustained in the future.
Q104 Sarah Champion: Professor Watts, I know you are both DfID’s chief scientific adviser and a CEPI board member, but your background is in preventing gender violence. Could you tie all of those together, throw in vaccine and throw in Gavi?
Professor Watts: I will do my best. I will make a quick comment to follow up on Danny as well, because if you look at the achievement of the replenishment, it was phenomenal. This is a time when many, many countries are feeling the pinch, yet they exceeded the target. That was the result of both DfID’s expertise and work, but also working very closely with the Foreign Office and across Government. I think that is the opportunity of the new Department, how you mobilise and deploy that diplomatic influence alongside the commitment to development. We have a Department that has development in it, it is Foreign, Commonwealth and Development, which is a really important aspect to be reassured by. Gavi basically shows with that replenishment what you can achieve when you can produce and use all of those levers in a really joined-up and effective way.
In terms of bringing in violence, if we are thinking about the response to Covid and about global health more broadly, Gavi is critically important but it is part of our response to global health pressures. We also need to be tackling the social, the economic and the gender-based inequalities that also lead to poor health. For example, if you look at our response to Covid, we are investing heavily in vaccines, diagnostics and treatment. However, we are also supporting programmes to work with more vulnerable groups of society to really give flexibility to our programmes, working on violence against women, recognising that it is likely there will be increased risk as a result of lockdown activities that are playing out around the world, but also as a result of the economic stresses and how that might play out.
That is one of the great powers of the ways in which we think about development. Clearly, technologies can be game changers, but also we fundamentally try to support and bring evidence to tackling some of those very knotty and complicated issues that, if we are going not to leave anyone behind and we are going to achieve equity, we really have to pay attention to as well.
Q105 Sarah Champion: Do you think you cannot leave anybody behind when shiny trade deals are dangling in front of the Prime Minister?
Professor Watts: I think we get into speculation about the negotiations. What I do know, to pick up the gender issue and violence, is the extent to which across Government, including very strongly in FCO, there is a keen interest in tackling issues of gender equality, both sexual and gender-based violence and factors such as girls’ education. That is in the Government’s manifesto and I am expecting that to continue to receive significant attention.
Q106 Kate Osamor: I am going to move on to ask a few questions about the impact of Covid-19 on other immunisation programmes, and this is to Professor Watts and Danny. What is the Department’s assessment of the impact of Covid-19 on other existing global health threats?
Professor Watts: That is an excellent and important question, because we are very concerned not only about how Covid might play out across the developing world—we are really starting to see infections rise across a number of countries, and we are not yet at the level where we start to see deaths potentially hit—and, alongside that, we are very concerned about the secondary impacts, and those are multiple. There are things like the impact on immunisation levels, but there are also other risks. For example, if people perceive that hospitals are a place of risk, that they might catch Covid there, it could impact on whether women go to health facilities to deliver babies or to access antenatal services. Therefore, the breadth of impacts from Covid are multiple and potentially, in some settings, bigger than Covid itself.
In the approach we have taken in terms of our programming, we very much tried both to invest in the Covid response but also to try to support flexibility and adaptation to ensure that you can continue the delivery of those other services. For example, our sexual and reproductive health services are both trying to ensure continued access to family planning across a number of countries, but also supporting those programmes to engage in Covid prevention. That combination not only helps tackle Covid but also makes people feel safer about accessing other services, which is probably going to be most effective.
Daniel Graymore: As Charlotte says, we can clearly see that Covid is a huge threat and challenge in the countries in which Gavi operates, and in which we operate more broadly in many of our global health initiatives. A few facts and figures, out of 73 Gavi-eligible countries, we now have reports of 840,000 confirmed cases and 20,000 deaths, and we are seeing a fairly rapid increase of 4% per day in the number of cases in those countries. So you can see that, although it has been a relatively slow spread so far, it is going to follow a curve and is going to be hugely challenging. As we noted before, we have seen quite a significant number of campaigns and introductions being impacted, disrupted and delayed in Gavi countries, and that is going to have a huge impact into the future. There are going to be children who have not been vaccinated for measles, who have not received pentavalent, and they are going to be more vulnerable, have ill health and all the problems that we look at.
We have also seen, as Charlotte said, a loss of confidence in coming to be vaccinated. Even where introductions and campaigns have been sustained, we have situations where people are not coming to the clinic and are not getting their children immunised. We have quite a lot of evidence and data on the impact that is having. There is also going to be an issue that we will have to deal with in rebuilding confidence. The Committee will be very aware of the risk of vaccine hesitancy or the anti-vax movement that can impact confidence anyway. With a situation like this, it is going to take longer to remobilise community commitment moving forward.
As I said earlier, the UK was very active in working on the Gavi board to secure this. We encouraged the Gavi secretariat to work with other donors to encourage them to come behind this. We encouraged Gavi to introduce additional flexibility. I mentioned earlier the investment in personal protective equipment and in infection prevention and control. Countries basically now have the opportunity to re-programme up to 10% of their health system grants to support their direct response. At the same time, one thing about which we will be talking to the Gavi board next week will be how you ensure that, alongside Covid, your support is being continued to essential services and routine immunisations, as I mentioned before.
If it is okay to repeat the point I made earlier, it is that we have also seen significant—
Chair: Daniel, sorry, could I just ask you to keep your answer short? A lot of members are still asking to ask questions, so if you could just wrap up.
Daniel Graymore: My last point is that the Global Fund and the Global Polio Eradication Initiative are doing much the same flexing of their programming. If you look at the global effort and the response, alongside WHO bilateral donors like the UK, you can see that these instruments, of which the UK is such a firm supporter, are really there at the frontline, both doing the direct response to Covid and also maintaining essential services to avoid the impact of disruption that we are so concerned about.
Chair: Kate, do you have any other questions, or shall I hand over to Brendan?
Q107 Kate Osamor: I have just one more question. Thank you for your answers, Danny and Professor Watts. This is to Tamsyn and Amanda, what should the Government be doing to mitigate those threats and avoid undoing decades of global health progress?
Dr Barton: I am sure Amanda will have a lot to say, so I will try to be very brief on what the Government should be doing.
It would be pertinent to go back to the review we did of global health threats. I have been struck, listening to the pleas from DfID’s side that other people should co-ordinate. I should probably mention that, although we gave a positive overall rating, an amber-green, to the work on global health threats—you can see how important it is now because, otherwise, WHO would have had no resources for its pandemic preparedness, et cetera—one area where we were very critical was in relation to co-ordination across the UK Government. In fact, in that context, we suggested that they work together on simulations if a global health threat should arise. The reason we wanted this to be across as many Departments as possible is because you can never tell, with different threats, which parts of Government are going to need to be part of the response, and of course there are so many variabilities to the type of threat it might be.
Therefore, I think it is back to my urgent versus important; everyone thought there were more urgent things to deal with but the Government’s investments in the long term at that time have turned out to be very important. Of course it was not done perfectly, so the shortcomings are more evident in the current situation.
Similarly, they should not lose the focus on health system strengthening and on having a global health security strategy. That is something we often recommend at ICAI, so we can come back to that question.
Amanda Glassman: One really important element of Gavi is that it is a partnership, and one of the members of the partnership is the World Bank. We have already talked about how Government revenues in low and middle-income countries are dropping precipitously. Gavi, the Global Fund and GPEI, what they finance are the materials—they will fund a vaccine mostly or they will fund bed nets—but it is Governments that pay the salaries of workers. We just posted something that looked at community health workers, who are really the backbone of delivery, and only 26% of those are remunerated right now. We are in a situation where public expenditures are falling very dramatically in countries, so we really have to pay attention to what the World Bank is doing to support countries. In particular, we want budget support because we want to be able to sustain salaries and things like that. Perhaps we could say we would like to see you protect spending on vaccination and we would like to see you increase vaccination coverage during this time, or at least sustain it. Those are the kinds of things we might think of in the context of Gavi and the alliance, and also in the context of the UK Government as a key donor and governor of the World Bank as well.
Health system strengthening is where the bilateral UK support to Governments is so important. Part of the merger announcement that worried me was the comment that juxtaposed assistance to Ukraine with assistance to Zambia. Zambia has a $4,000 per capita GDP compared with about $10,000 in the Ukraine; it is a different kind of resource constraint. It would be a pity to lose that focus on low-income countries that are going to be hit the hardest by this Covid-19 contraction and are, through no fault of their own, trying to cope with these fiscal consequences. I hope we will also watch what happens with bilateral aid and the focus on low-income countries during this period.
Q108 Brendan Clarke-Smith: Good afternoon, everybody. Dr Barton, what key lessons from previous global health threats do the Government need to learn and apply to the Covid-19 pandemic at the moment?
Dr Barton: Of course the previous global health threat that was most in view at the time when ICAI did its review in 2018 was the Ebola epidemic. That fortunately has, so far, been confined to a relatively limited geographical area but, as we observed in our review, you can never tell what the next global health threat might be. It was in that context that we strongly recommended having a global health security strategy and specifically recommended cross-Government simulation so you would go through in real time—these are exercises that Government has experience of doing in other contexts—what each Department would need to do and who they would need to contact, because there is global co-ordination but there is quite complex co-ordination across different parts of the Government. That came to the fore in a situation where the immediate threat to the health of people in the UK was more in focus. We should not lose sight of the fact that there is the potential for Ebola or other diseases to do the same.
Our shortest maxims on this would be very much to look to the long term, and credit to them for what they did do—more than other donors—in strengthening WHO and other global institutions. It is very important to invest in resilience and not only look to shorter-term investment. I think those will be the main things. Having a strategy helps work out exactly what the priorities are so you can focus on those and build them up, and so that the relevant Departments and actors can know clearly what their role is and what they are expected to do.
Q109 Brendan Clarke-Smith: Do the other members of the panel agree with ICAI’s view? What are the key lessons from previous epidemics for the Government’s response to the current situation?
Professor Watts: I think Tamsyn’s point about co-ordination and joined-up Government working is really critical and very important. For this outbreak, and also thinking most recently about the eastern DRC outbreak, the systems across Government have been really very joined up. There are regular meetings that involve everybody, and particularly close working between ourselves, FCO, the Department of Health and also bringing in other Departments as well. Even though we have not done the simulation, lessons were learned about ways of working that kick in very quickly as soon as a threat emerges.
I have just come from cross-Whitehall discussions, for example, on the latest Ebola outbreak. That is involving a range of stakeholders right from the beginning, because we know for any disease outbreak early action is critical and bringing all of our different lenses to what is happening and thinking forward, but particularly acting early, is really critical.
What we learned from the west Africa outbreak, which served us well for the east Africa Ebola outbreak and is now being used very heavily, is thinking about what are the systems, flexibilities and programmes that you need in place that can pivot and act quickly. For example, in the research and development space, we have supported WHO to develop the WHO Blueprint. That essentially—in peacetime, when there is no disease outbreak—is looking across the range of threats, mapping out what the priority research areas are, using resources to move that forward and is then able to move very quickly to start testing, be it diagnostic, be it vaccines or be it therapeutics. That has been part of the current response by WHO that has been really helpful. They already have that roadmap, they already have the relationships in place and it is now co-ordinating, influencing and triaging the types of technologies that need to be tested quickly, be that on diagnostics or treatments. That was one of the ways that we managed to get, for example, the Ebola vaccine—the Merck vaccine—deployed very quickly at large scale in the eastern DRC outbreak. It was because we had set those systems in place and could tap into the capability of Gavi alongside that.
Chair: I am conscious of time, as we have only 10 minutes left for this meeting. Brendan, do you have any other quick questions or am I going to turn to our colleague, Virendra?
Q110 Brendan Clarke-Smith: Dr Barton, very quickly, has DfID acted on previous global health recommendations from ICAI, and in what areas do you think there is still room for improvement?
Dr Barton: I was interested to hear Professor Watts’s reference to the fact it has not had simulations, because we had some trouble getting the evidence on this when we did our follow-up review. It appears that is something it has not managed to do. We have also not seen this global health security strategy. We are also waiting for something very relevant, which we followed up in the context of another review on maternal health, which is the health system strategy. You might think, “What is the point of all those bits of paper?” As I mentioned, they actually represent working out beforehand all the priorities for what needs to be done in a situation where you are under pressure and making it clear whose roles are what. In those areas, we feel it did not manage to follow up, but I have given credit to it in the areas where it did. I will stop there, given the shortage of time. I can see Professor Watts wants to come back.
Professor Watts: I wanted to make a factual correction, in terms of global health security. There is a cross-Whitehall senior-level meeting, and there are very clear ambitions linked to that. I do not want to misrepresent the extent of planning and activity that is happening on global health security.
Daniel Graymore: May I come in briefly? Sorry, I think I was frozen before.
Chair: Could you keep your response very brief? I need to go to the next question, and we have about six minutes left.
Daniel Graymore: Certainly. First, I was going to reinforce Charlotte’s point, which is that the global health oversight group is the critical cross-Whitehall group that discusses health threats, the global health security agenda and our broader work on global health.
Maybe, on a slightly more micro scale, it is worth noting for the Committee that, as I mentioned, I am the senior representative here in Geneva, so I run a Department in DfID, I work very closely with our Department of Health and Social Care colleagues, I work very closely with the Foreign Office here, and I work with our permanent representative, Julian Braithwaite, and others. That is an example of the way in which there is a very strong cross-Whitehall collaborative way of working. A good example of that is the six-year strategy that was signed off a couple of years ago by the World Health Organisation, which is a way that we combine our different Departments working together.
The second point, very briefly, is on the lessons from Ebola. I wanted to reinforce the lesson of drawing on the strengths of Gavi, because the use of a vaccine in the eastern DRC outbreak has been a game changer. It is a game changer because we have invested in Gavi, because we have invested in the Health Emergencies Programme at the World Health Organisation, because we have invested in a set of key partners and created those public-private partnerships, and because of the incentives to help the private sector to invest in an Ebola vaccine. That was really a game changer.
The other lesson from a previous global health security challenge that has been really important is, again, on Ebola and was employed in eastern DRC, which is how you need a whole UN response. You need to make sure that the really strong work of the World Health Organisation is complemented by other UN partners to help on the community engagement and security side. That is critically important.
My last point is that one of the big changes from west Africa and Ebola was the recommendation to create a strengthened Health Emergencies Programme, including a contingencies fund for emergencies that enables the World Health Organisation to respond in 24 hours to alerts of health emergency outbreaks. That has proven successful. It needs additional financing, it needs long-term Government commitment, but as an instrument it has been very helpful, as has been the integrated approach of the Health Emergencies Programme.
There are always lessons. There are always ways to strengthen these things, but the UK has been instrumental in investing in those systems. We have seen the impact over the last few years and in the response to Covid.
Q111 Mr Virendra Sharma: My question is to Tamsyn and Amanda. How achievable are Gavi’s goals for phase 5.0, particularly given the current coronavirus pandemic?
Dr Barton: I will be very brief, as I know Amanda can furnish a lot more detail.
Many of the goals and objectives were achievable before the pandemic hit. The ones that were hardest related to equity, reaching the children so far unreached, and health system strengthening and sustainability. All I would say is that they are much more challenging now because I am not confident that they will retain the resources. You have already seen that, as mentioned, some countries have had to substitute their normal use of Gavi resources for health system strengthening to buy short-term emergency PPE equipment which, as we know, soaks up huge amounts of money. If the pandemic were to kick off, it would have an enormous impact in, I suspect, shifting the focus and resources. That is my worry about how realistic they are.
Amanda Glassman: I agree with that assessment. I think the two goals that are most at risk are the one about transitioning a further 10 countries to self-financing. It might be just the opposite; we might not only have to retain those pre-transition countries in their eligibility status but also take into account that a number of countries may actually fall back.
The other piece is sustaining the provision of vaccines. We need to figure it out shortly. As Danny and others have pointed out, we have measles outbreaks in about half of the countries that have suspended measles vaccination efforts. This is not going to last a short period of time in low-income countries. Hopefully there is a vaccine, but it will take at least a year to get to low and middle-income countries. Therefore, we have to think about re-operationalising the system, which might mean a humanitarian response to get vaccination out.
Q112 Mr Virendra Sharma: Daniel, as the UK Gavi board member, do you agree with ICAI’s and CGD’s assessments? How can the UK use its position as a key donor to lead Gavi’s response to these challenges?
Daniel Graymore: I will be brief. There is a huge amount that we would agree with. We have spoken already about what Gavi has achieved and how it has driven up global immunisation rates to much higher levels than we had in the last period, up to about 81% global coverage, which is very impressive. However, we are in an unprecedented period, especially with Covid-19. As others have said, it represents a challenge to the model. One thing we are really keen to do next week at the Gavi board—as you said, I am a Gavi board member—is to talk about what Covid means for the new strategy, what needs to be different and what assumptions we have made that might need to be reassessed. We will look very carefully at that.
We think the transition model is a really important part of Gavi, it is part of its success. What we want to do is have a model that helps countries to invest in their primary healthcare, in their rates of immunisation, and of course to take on increasing investment from domestic sources and be in a position to move out of Gavi support in time. We fully recognise, of course, it has to be done in a way that really builds systems, is sustainable and can last into the future. This current situation on the health side, and increasingly on the socioeconomic side, represents a huge shock. We will definitely be taking that risk and that challenge on transition to the board discussion.
We will also be looking very carefully, as we said earlier, at this issue of equity and gender. How do we make sure that what we do not do, as we try to address the disruption and interruption of campaigns and rates of immunisation, is lose focus on leaving no one behind? We have to redouble our efforts. We have to look at how we work with other Government health partners, we have to look at how we use our instruments and how we build those systems. Fundamentally, for all of us, our objective is stronger, more resilient health systems that meet the needs of communities across a whole country. That is the long-term vision of what we want to achieve. Gavi has to be part of that, and we fully support that viewpoint.
Q113 Mr Virendra Sharma: Very briefly, Charlotte, from DfID’s perspective, do you agree with ICAI’s and the CGD’s assessments? What is the UK’s role in shaping Gavi’s response to these challenges?
Professor Watts: I agree in that the challenges are huge. The impact of Covid is vastly significant. The UK’s contribution is not only financial, it is also technical. It is being on the board, it is creating that space across donors and with Gavi leadership to really say, “What does this mean and how do we respond to this?” Coming into Government from academia, I am hugely impressed by what I see is the UK’s commitment to creating the space to have those honest conversations and trying to work with the leadership of Gavi and other donors to say, “How do we figure a way forward on this?” We do not come in necessarily with a predefined agenda, it is really trying to problem solve and support Gavi to respond and rise to that challenge. I am looking forward to seeing what the conclusions are from the Gavi board next week.
Q114 Chair: What difference will the Gavi Covax advance market commitment make to the global coalition for the development of a Covid-19 vaccine?
Dr Barton: I suspect others who will be more expert on the detail, but I just make two very brief points. First, if we did not have the model of the advance market commitment before, it would not be possible to look at such a quick scaling up through Gavi and CEPI. On the other side, as has been mentioned, against the target of $2 billion—I get my pounds and dollars mixed up—$567 million was committed, of which the UK committed £48 million, so there is a long way to go in terms of resources there. However, there was a hugely important UK role in establishing the model of the advance market commitment and, indeed, innovative financial instruments more generally.
Professor Watts: To reiterate what Tamsyn said, it has been demonstrated how important our advance market commitments are for providing incentives to pull through vaccines. In this we are very much learning from the experience and success we have achieved previously through AMCs.
Q115 Chair: Amanda, are there any other measures that you think are needed to ensure equitable access to a vaccine?
Amanda Glassman: The answer that Gavi has put forward in its new strategic framework is increased investment in health system strengthening. We have to look hard at what that means going forward. In the past, these grants have been small in size, and they have mostly gone to other partners of the alliance like UNICEF and the World Health Organisation. What will we be doing differently? I think the ICAI note sets it out clearly. What are we doing differently that will actually deliver these changes in effective coverage in these underserved communities? It is not an easy answer right now, but we will have to watch that space.
Chair: Great, thank you. For the final question, I turn to Navendu Mishra.
Q116 Navendu Mishra: This question is more about the role of the chief scientific adviser in the internal review of UK aid. Professor Watts, in the absence of a global health strategy, how can the Government’s performance against global health objectives be measured?
Professor Watts: In terms of the commitments on global health, there is a range of areas on results that the Government is committing to, and that is fundamentally how we should be measuring impact. More broadly, in responding to outbreaks and in thinking about global health security, science has a critical role to play, and that is both helping to understand and assess what those risks might be and also to identify and invest in effective solutions. If you look at, for example, our response to Covid, we have been very heavily investing not only in the technologies but in bringing science advice to the current response. We are commissioning a range of analyses, both social science input and modelling analysis, to support our country offices to assess what the situation looks like on the ground, to have access to projections of what might be the trajectories and to form their decisions based on that.
Q117 Navendu Mishra: For the second part—if you could keep it brief, please—I turn to Dr Barton and Amanda Glassman. Do you agree with that, and how should the Government’s performance on global health be assessed?
Dr Barton: To be super brief, I would say, yes, we need an overarching global health strategy. As you have already heard from us, we think that is enormously important. We obviously, as ICAI, believe that evidence is the basis on which allocation and policy decisions should be made, so the role of the chief scientific adviser and the professional cadre should be very important in making these decisions.
We do think that these strategies have to be published, and the Government should be held accountable for them. With the results that DfID is claiming, we had some quibbles about whether it was overclaiming in relation to what can be attributed to it. ICAI will continue to scrutinise carefully whether DfID is living up, or indeed UK aid is living up, to those commitments.
Amanda Glassman: I would agree with what Dr Barton has just said. I would also say that the big investments that UK aid makes in global health are well known and have very clear objectives, so the next step is saying, “How well are we doing against those objectives? How do we know?” I would like to see less modelling studies and more empirically observed impact on the ground. If we took the case of Gavi, we would like to see that vaccination coverage is at least sustained during this period, at least in those very large low to middle-income countries, which will matter for global spread of disease and ensure that excess deaths are minimised. Those are the kinds of things that one might look at in a second phase.
Navendu Mishra: Accountability is very important. Thank you.
Chair: Thank you very much. I am conscious we have run slightly over time. I thank all of our witnesses for coming to give evidence today, and I thank all of my colleagues. I would now like to call this meeting to an end.