A global health crisis: responding to Covid-19

Action for Global Health (AfGH) is a UK-based network of more than 50 organisations working towards a world where the universal right to health is realised. AfGH acts as the coordinator between the UK government and global health civil society, convening regular meetings and sharing learning from across our network.

This briefing was created to lay out a set of urgent recommendations from UK global health civil society for how the UK government should respond to the Covid-19 crisis internationally, based on learning and evidence from previous crises and expertise from across our membership. This briefing has already been shared with the UK government directly, including relevant stakeholders at the Department for International Development and Department for Health and Social Care. 

AfGH coordinates a working group of other UK global health-related networks, and this submission was also created in consultation with these partner networks, including the UK SRHR Network, STOPAIDS, ICAN, UK Working Group on Non-communicable Diseases (NCDs) and the UK Coalition Against NTDs.

Summary

As the virus spreads around the globe, we must quickly learn from the experiences of those countries first affected. These have largely been higher income countries with more advanced and resilient health systems and they have been pushed to, and in many cases beyond, breaking point. We have a small window to distil lessons from the response to COVID-19 and other pandemics and provide meaningful support to low- and middle- income countries with fragile health systems to prevent potential devastation.

Some lessons are already painfully clear. We need strong, resilient health systems everywhere to be able to respond to critical threats to global health security. We rely on a well-trained, well-resourced and protected health workforce to fight tirelessly to protect the public. We require the most vulnerable to be put at the heart of the response. We depend on leaders to champion international solidarity, through the crucial role of the World Health Organisation, civil society and community responses, and working together to reach the most marginalised.

We urge the UK government to respond to this crisis through protecting critical investments and the most vulnerable and marginalised groups, expanding and scaling up investments in strengthening health systems, health workers, preventative and community-based interventions, and improving existing bilateral and multilateral health investments and global relationships, as outlined in the recommendations below.

1. Protect

Protect other essential health services

Even before the COVID-19 crisis, evidence from the Ebola epidemic in 2014-16 showed the detrimental impact of resources being diverted from routine health services, damaging the already limited access to routine and otherwise neglected services. In all there were about 12,000 Ebola deaths in Upper West Africa (Guinea, Liberia, Sierra Leone) in 2014-15 but many additional fatalities resulted from, for example, closure of facilities such as maternity clinics and a doubling of the TB mortality rate in Guinea. The secondary impacts of epidemics have far reaching consequences exacerbated by existing inequalities within and between countries. For example the closure of schools, increased rates of child, early and forced marriage, increased levels of sexual violence and limited access to sexual and reproductive health information and services (including contraception and safe abortion) all during Ebola contributed to the rise in teenage pregnancy rates and the number of maternal and child deaths.

As such, we urge the UK Government to sustain their support to all existing health programmes, including through supporting the resilience of health systems, ensuring a continued supply of all essential medicines and commodities, and ability to maintain basic services to prevent further, indirect, loss of lives.

Failure to do this now will squander the significant gains that have been made in a number of areas of health over the last two decades, as well as leading to further loss of life.

Additionally, there were a number of key summits and opportunities planned over the next year for the UK Government to show their continued commitment to essential health interventions, which are now in danger of being impacted by the Covid-19 crisis.

Firstly, the upcoming replenishment of Gavi, the Vaccine Alliance, which the UK Government are hosting in June, provides a critical opportunity for countries to invest strategically in efforts that build global resilience against novel pathogen epidemics. Gavi plays a key role to help build resilient and well-supported health systems, with the capacity to prevent, detect, and respond to disease outbreaks in the world's poorest countries. Gavi also plays a critical role in establishing vaccine stockpiles to help safeguard against epidemics and strengthen global health security.

We urge the UK Government to maintain their role as a leading donor of Gavi, incentivise support from other donors, and secure a successful replenishment so no one is left behind with immunisation. 

Secondly, the UK’s existing commitments to nutrition end this year. It is vital that the UK maintains the same scale of commitment dedicated to nutrition in all its forms into 2021 and beyond, regardless of whether the Nutrition for Growth Summit is able to take place this year. Malnutrition weakens immune systems making this work even more relevant given the need to respond to COVID-19 effectively.  A severely undernourished child is nine times more likely to die from common infections than a well-nourished child.

Therefore, we urge the UK Government to lead by example with an early pledge to invest £800 million per year in nutrition interventions over the next 5 years and increase the impact of this investment.

Finally, the Kigali Malaria and NTDs Summit planned to put a spotlight on the need for continued investment tackling malaria and NTDs.

We urge the UK Government to protect and sustain current levels of investment in malaria prevention and control, as well as NTDs through the Ascend programme (providing a costed extension). We also encourage the UK Government to support the implementation of the new WHO Roadmap on NTDs 2021-2030, emphasising health systems strengthening, investment in technology, drugs and vaccines, and drawing links with other areas of DFID health and development investment.

Human rights-based approach

Responses to COVID-19 must be based on fundamental human rights principles. There is a very real threat during this crisis of stigma and human rights violations towards people who have or who may be perceived to have contracted COVID-19. We recognise that older people and those with underlying health conditions are disproportionately impacted by COVID-19 and we must ensure that everybody’s human rights are realised and upheld. Stigma, discrimination, undue or un-evidenced restrictions and harmful criminal sanctions and policy environments threaten our ability to realise the right to health for all.

The right of everyone to the enjoyment of the highest attainable standard of physical and mental health at any age must include:

·      The removal of barriers to access free screening, testing and care for the most vulnerable and hard to reach;

·      Combatting all forms of stigma and discrimination that prevent individuals from accessing care;

·      Engaging communities in all steps of the response measures, and to ensure the frequent and effective sharing of information.

We urge the UK Government to play an active role in encouraging governments that are recipients of UK aid and beyond to uphold dignity and human rights for all people of all ages throughout the COVID-19 crisis.

Leave No One Behind

In the UK, we are seeing the disproportionate impact of COVID-19 on older people and on those with compromised immune systems and other health conditions. As the pandemic spreads to poorer countries, its impacts on these groups will be even more acute, due to poverty, weak healthcare and weak social systems.

We will also see an increasingly marked impact on those who are vulnerable or marginalised in other ways – for example by gender, age, employment status, health status (including HIV status and other underlying chronic conditions), or other drivers of inequality. Targeting needs to be routine - in a response heavily focused on information and behaviour change, making information available for people with different language and accessibility needs is crucial. For many people in developing countries, housing conditions do not enable social distancing or self-isolation, while those in insecure work will have no choice but to continue working – even when they are ill.

As such, we urge the UK Government to ensure an inclusive global response that prioritises the most marginalised and vulnerable populations. The response must recognise the intersectional inequalities, including, but not exclusively, age, health status, poverty, geography, gender, race, disability, sexual orientation and gender identity, that will drive vulnerability to the impact of COVID-19, and ensure that any data used and gathered is disaggregated to reflect this and enable a targeted response.

Additionally, the quarantine measures used by Governments to prevent and control the spread of COVID-19 are exposing older people, persons with disabilities, children and women to increased protection risks, particularly within the home, owing to increased stress caused by the outbreak exacerbating existing gender inequalities. Simultaneously, there is a risk that protection services will be withdrawn or diverted owing to the need to mitigate the spread of the virus and the need for increasing resourcing to respond to the outbreak. National and local authorities must ensure that protection risks are assessed and monitored during the planning and implementation of responses to COVID-19, including in quarantine situations and communities facing restrictions on movement. This should include disaggregated data (age, sex and disability), and monitoring of older people, persons with disabilities and existing underlying conditions,children and women at increased risk of violence, exploitation, abuse and neglect.

We urge the UK Government to ensure protection and social welfare services remain open and central to preparedness and response to COVID-19, that they are accessible to the most vulnerable groups including persons with disabilities, and that they are funded adequately throughout all stages of response. A strong gender, age and disability analysis should be undertaken in the development of response plans, funding proposals, and delivery of protection and welfare services, to ensure that the unique needs of all people are met.

2. Expand

Strengthening health systems

Covid-19 puts a spotlight on the need for strong, resilient health systems everywhere. With roughly one-third of hospitalised patients requiring intensive care, Covid-19 is overwhelming hospitals, health workers and medical infrastructure. In many low and middle income countries, where more than half the world’s population still do not have access to essential health services, weaker health systems are not prepared to respond to Covid-19. Investment in primary health care and hospital preparedness needs to be scaled up and procured transparently, including the number of oxygen concentrators, isolation and ICU beds, as well as infection prevention control and essential palliative care medications for breathlessness and end of life care.

We urge the UK Government to scale up support to strengthen health systems, including community-led systems as the integral part of health systems, in low and middle income countries, as well as ensuring that humanitarian responses strengthen rather than undermine local health systems.

Experience in the Democratic Republic of Congo during the Ebola crisis also demonstrated that the removal of user fees not only prevented the disaster of delayed diagnosis due to financial barriers but also actually increased access to other services including maternal health. People living with underlying conditions are more at risk of severe COVID-19 outcomes - so ensuring their continued access to prevention and treatment (including in humanitarian settings) will increase the resilience of this vulnerable population.  

As such, we urge the UK Government to work with WHO and support and enable governments to remove all financial barriers to people accessing healthcare and deliver free testing and treatment to all that need it.

Additionally, governments will need to surge the capacity of public health systems to treat Covid-19 affected patients (as well as existing essential health needs) by supporting the alignment of private healthcare facilities. The scale of the challenge means that in addition to rapidly expanding the public health care system, governments have a duty to urgently requisition all existing available health care capacity in their countries. Public and private facilities must be aligned and co-ordinated in fighting the virus and simultaneously meeting all other urgent health needs of the people. Via CDC, DFID has heavily invested either directly or indirectly in a large number of for-profit private health care facilities in low and middle income countries.

As a direct or indirect shareholder in these companies, we urge the UK Government to instruct the CDC to enable these private sector facilities to align to the national effort providing free treatment and care and sacrificing profits in the process. If necessary, and where the UK Government is a direct shareholder, the CDC could pass their stake in these hospitals to national governments with the requirement they be used for public use.

Health workers

Healthcare workers are key in an effective response. We know the challenges all low and lower-middle income countries currently face in training, employing and retaining adequate health workforces. There are, for example, just seven hospital beds and one doctor for every 10,000people (Italy has over 34 beds and 40 doctors)[1].Additionally, there is a predicted 2030 health worker gap of 18 million people.

As previous emergencies such as Ebola have demonstrated, huge numbers of community health workers can and must be rapidly and effectively trained and deployed to boost public education and community outreach efforts, conduct free testing and contact tracing at scale; whilst simultaneously bolstering buckling primary health care to meet neglected wider health needs. These workers, historically mostly women, must be trained, paid and protected and retained for the long-term as valued members of the government health care workforce. This will also provide a much-needed boost to employment and economies. Health workers must also be adequately protected and supported, including through supplies of personal protective equipment and access to diagnostic testing, so that they feel safe and confident to continue to work.

We urge the UK Government to support a bold and dramatic scale-up of health workers, as well as ensuring any public spending caps, including wage bill ceilings are immediately removed from poor countries. We urge the UK Government to encourage and help finance LMIC governments to recruit and provide refresher training to any willing trained but currently unemployed or retired health workers.

Community response

In many developing countries, communities are an integral part of their health systems and they can also play a critical role in tackling COVID-19. Already, we are seeing communities on the frontline of the COVID-19 response – providing information, setting up handwashing points, shielding most vulnerable from increased levels of violence, protecting human rights and providing care and support to those who are most vulnerable. But grassroots organisations need support and flexibility from donors just to keep going at this time, and to do this work.  They also urgently need access to information and to equipment such as masks, sanitiser etc to keep themselves and their communities safe.

We encourage the UK Government to make investments in community-led systems and community-based strategies to improve outreach and education, dissemination of messages, contact tracing, surveillance, WASH, address stigmatisation, social distancing and preparedness as well as setting up of community-based testing centres with appropriate supply of tests.

Prevention

WASH is the first line of defence against COVID19, and poor WASH conditions and lack of

hygiene practices contribute to the spread of infections and make it very difficult to control outbreaks such as COVID-19. DFID need to step up their investment in WASH, particularly hygiene promotion, and improving access to handwashing facilities and service. Frequent handwashing with soap and water is one of the key components of controlling the spread of infectious diseases, including COVID-19. However, analysis indicates access to handwashing facilities and handwashing practices are lagging (one in six healthcare facilities globally do not have both soap and water available for patients, doctors and nurses to wash their hands and three-quarters of households in Sub-Saharan African have no handwashing facilities and are therefore already in an incredibly vulnerable situation).

We urge the UK Government to step up their investment in WASH, particularly hygiene behaviour change, including handwashing.  In the short-term, they must provide rapid, flexible funding and technical assistance to government-led efforts to promote good hygiene and build WASH systems (we note and welcome the recent £100m commitment for mass hygiene campaigns).

Gender-responsive leadership and SRHR

We urge the UK Government to ensure gender-responsive leadership, noting the particular vulnerabilities that both men, women and gender nonconfirming and binary populations face due to COVID-19. This means including women in health security and response decision-making structures and public discourse, protecting frontline health workers and unpaid caregivers (most of whom are women), and collecting/analysing data that is sex-disaggregated.

We urge the UK Government to invest in strategies to manage the secondary effects of the pandemic including classifying sexual and reproductive health services, including contraceptive, safe abortion services and HIV medication, as essential health services and ensuring their inclusion in basic packages of health services provided as countries respond to COVID-19. If SRH services are not provided in times of crisis, subsequent health outcomes and strains on the health system can be severe.

3. Improve

Access to new treatments and vaccines

We need high-level political efforts to ensure equitable access to diagnostics, vaccines, and medicines, in order to be able to respond to COVID-19 and ongoing pandemics. The UK should support global coordination to improve global and public capacity for vaccines production and ensure that public health priorities drive the production and distribution of any new COVID-19 vaccine.

As such, we urge the UK Government to support the proposal from the President and Minister of Health of Costa Rica for the WHO to create a global pool for rights in COVID-19 related technologies for the detection, prevention, control and treatment of the COVID-19 pandemic.

We also call on the UK Government to impose public interest conditions on all UK funding committed to developing a vaccine for Covid-19 and any other potential Covid-19 treatments and diagnostics. As a donor country and board member of CEPI, the UK government should particularly support CEPI’s continued efforts to ensure equitable access to vaccines globally. These should:

-          Ensure that the final product is affordable, accessible and available for everyone who needs it, within the UK as well as in other countries, including but not limited to low- and middle- income countries.

-          Stipulate, as a condition of public funding, that any vaccine or medical product developed is licensed according to the principles of socially responsible licensing, which includes but is not limited to preventing exclusive licensing. Socially responsible licensing could include licensing to the Medicines Patent Pool.

-          Ensure that clinical trial results from all publicly funded research are uploaded onto a WHO primary clinical trial registry or onto clincialtrials.gov.

-          Commit to full price transparency of any products deriving from UK government funding.

-          Ensure the research and development costs of any product produced using public funding are publicly available and shared with other governments and the WHO - for example through the WHO’s Global Observatory on Health R&D.

-          Introduce ‘step-in’ rights for the UK government to issue non-exclusive licenses if a licensing partner fails to comply with the requirements of providing the health technology at an affordable and fair price.

The role of the multilateral system

The UK should support existing institutions and multilaterals to respond to Covid-19. In particular, the UK should support the World Health Organisation (WHO) to play a global leadership role. There is an urgent need to finance and support a coherent WHO global plan to support national plans and prioritise the procuring and distributing personal protective equipment, infection control, contact tracing, laboratory surveillance and training, emergency operation centres and preparedness, and education and outreach.

We urge the UK Government to support WHO to take a leadership role responding to Covid-19. We urge the UK Government to promote collaboration and inclusiveness within global COVID-19 response mechanisms, such as the joint inter-agency UN meeting on COVID-19. We also urge the UK Government to use other existing multilaterals to respond to Covid-19, including the Global Fund and Gavi to channel resources to support the most vulnerable, CEPI and UNITAID to develop new tools, and GPEI for surveillance.

The Global Fund has extensive experience to address diseases among the most vulnerable and will have valuable contribution to the UN inter-agency response to COVID-19. Therefore we encourage the UK government to promote participation of the Global Fund within the joint inter-agency UN meeting on COVID-19 and other global COVID-19 response mechanisms.

Integrated response

It is critical that the UK Government’s response to Covid-19 is fully integrated across relevant cross-cutting areas, including WASH, gender and nutrition (many of which have been outlined in more detail above). The UK Government should also incorporate analysis of the differential impacts that COVID-19 has on women and girls into all responses, in line with the Gender Equality Act 2014 and in line with DFID’s strong commitment to a comprehensive approach to SRHR.

We urge the UK Government (and other relevant government departments) to take an integrated approach to COVID19. This should be reflected in the membership of government response groups and mechanisms, which should include relevant expertise, including across WASH, gender and nutrition. The UK Government should also support LMIC governments to take a similar cross-ministerial and cross-sectoral approach. 

Externally, the UK Government should also ensure meaningful engagement of civil society and communities in the planning, delivery, monitoring and evaluation of the Covid-19 response, including (but not limited to) Action for Global Health and Bond.

[1]https://www.project-syndicate.org/commentary/africa-race-against-covid19-by-kevin-watkins-2020-03

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