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Submission to the Foreign Affairs Committee inquiry

‘Global Health Security’ (GHS0008)

Independent Commission for Aid Impact

December 2020

As the extraordinary human and economic costs of the global COVID-19 pandemic continue to unfold, the question arises as to whether the UK aid programme is doing enough to prevent future global health crises. This evidence submission to the Foreign Affairs Committee’s inquiry on global health security summarises the findings of past ICAI work on the subject and identifies some key issues that the Committee may wish to pursue. The submission draws on a January 2018 ICAI review of The UK aid response to global health threats[1] (hereafter: GHT review) and the follow-up report on our recommendations published in July 2019.[2] It also draws on past ICAI reviews of UK global research programmes,[3] our June 2020 information note on UK support for Gavi, the Vaccine Alliance,[4] and a forthcoming information note on how aid-spending departments have managed procurement during the COVID-19 response (due for publication in early December 2020).

How does UK aid support global health security?

The 2015 UK aid strategy was published in the midst of the West Africa Ebola epidemic. It clearly identified global health threats as a challenge to both UK national interests and to global development. Under the strategic objective of “strengthening resilience and response to crises”, it pledged to increase “science and technology spend on global public health risks”.[5] The former Department for International Development (DFID) and the Department of Health (later the Department of Health and Social Care – DHSC) led the response, working under a Stronger, Smarter, Swifter strategy developed in 2015.[6] At the time of our GHT review, at least £500 million had been invested in global programmes in line with that strategy and DFID was supporting health security in nine countries. The investments included:

• Support for the World Health Organisation (WHO) and a range of developing countries on epidemic preparedness, surveillance and emergency response (‘Stronger’).
• A major scale-up of research and development for new vaccines, tests and treatments for epidemic diseases, and to tackle antimicrobial resistance (‘Smarter’).
• Support to build emergency response capacity, including the creation of the UK Public Health Rapid Support Team, which deploys experts from Public Health England and UK universities to respond to outbreaks of disease (‘Swifter’).

The 2014-2016 Ebola crisis had exposed various weaknesses in global preparedness, including a slow response by WHO surveillance and response systems, major gaps in national health systems, a neglect of basic research on diseases not considered a priority in donor countries, slow mobilisation of funding, a lack of deployable expertise, and poor communication and coordination.[7] ICAI awarded the responsible departments a green-amber score for their efforts to diagnose and address these weaknesses, including supporting WHO reform, building surveillance capacity in high-risk countries, promoting vaccine development and building international capacity to respond to outbreaks. We also identified areas for improvement, which are discussed below.

The UK has a longstanding partnership with Gavi, which is a public-private partnership of governments, multilateral agencies, NGOs and the private sector to vaccinate children in the world’s poorest countries. The UK has contributed some £4 billion to Gavi since its inception in 2000, making it the largest bilateral donor, and recently pledged a further £1.65 billion for the period 2021 to 2025. While Gavi’s work is broader than the global health security agenda, it plays a crucial role in ensuring that poor countries have access to vaccines at affordable prices, and it is expected to be a key player in the distribution of COVID-19 vaccines, once ready.

Over recent years, the UK has developed a large portfolio of aid-financed investments in health research and development. Both the Global Challenges Research Fund and the Newton Fund provide resources through the Medical Research Council and the Academy of Medical Sciences for research on a wide range of health issues in developing countries, often carried out in partnership with Southern research institutions.[8] In our review of the Newton Fund, while we awarded an amber-red score overall,[9] we were complimentary about a joint project between the University of Glasgow and Brazilian research institutions which had been the first in the world to study Zika virus epidemiology and had helped shape Brazil’s response to the Zika crisis.

In response to COVID-19, the UK has scaled up its aid investments in the development of vaccines, tests and treatments. It contributed £250 million to the Coalition for Epidemic Preparedness Innovations (CEPI) to support the development of COVID-19 vaccines. Other investments included:

• A £5 million contribution to the Wellcome Trust to support the development of new diagnostics.
• A £40 million contribution to the Wellcome/Gates Foundation/Mastercard Therapeutics Accelerator, which supports the accelerated development, manufacturing and distribution of COVID-19 treatments in developing countries.
• £23 million for the Fund for Innovative and New Diagnostics (FIND) to support the development of rapid diagnostic tests.
• A £50 million joint campaign with Unilever to promote better hygiene in developing countries, to slow the spread of the virus.[10]
• A contribution of £71 million to COVAX, the vaccines pillar of the Access to COVID-19 Tools Accelerator, a multilateral risk-sharing mechanism led by WHO, Gavi and CEPI for the procurement and equitable distribution of COVID-19 vaccines.[11]

The unprecedented speed and scale of the research effort on COVID-19 and the high level of collaboration that has emerged within the global scientific community is potentially a major addition to global health security capacity, if it can be sustained beyond the COVID-19 pandemic.

The need for a global health security strategy

One of the recommendations from our GHT review was that the UK government should refresh its global health security strategy. During our follow-up review in 2019, we found that work was underway on a new strategy, based on the internationally recognised ‘Prevent, Detect, Respond’ terminology so as to facilitate international cooperation. We were informed that the strategy would recognise the central role of national health systems in developing countries, including in fragile and conflict-affected settings, as building blocks of a global approach. No strategy has yet been published.

UK government coordination and in-country capacity

Recent changes in UK government architecture raise questions as to global health security mandates and coordinating processes. At the time of our GHT review, the responsible departments had created coordinating networks to collect and share intelligence on new global health threats, and we found good collaboration between DFID and DHSC. However, we recommended improvements to partnerships and coordination mechanisms, including through the introduction of regular simulations of how the departments would work together, and with international partners, in response to future global health threats, including pandemics.

During our follow-up, we found that there had been improvements in coordination, including through expanded membership of the cross-government Global Health Oversight Group. Furthermore, DFID and Public Health England had strengthened their collaboration at country level, which had proved valuable during the Ebola outbreak in the Democratic Republic of the Congo. With the merger of DFID and the FCO and the planned abolition of Public Health England, however, there is a question as to whether these coordination mechanisms need to be revisited.

There had been no change of approach in response to our recommendation for regular UK-based simulations to rehearse how departments would respond to future epidemic outbreaks overseas, including engagement with WHO. However, the government informed us that it carries out periodic simulations of its response to domestic health threats (such as a 2016 simulation of pandemic influenza, although neither DFID nor FCO participated[12]) and in certain high-risk countries, such as Sierra Leone.

We also recommended ensuring that departments have sufficient expertise in place in priority countries to coordinate global health security initiatives and support health system strengthening. During the follow-up, we were informed that seven new UK government posts were being established across Africa and that Public Health England was boosting its presence in key countries to support their implementation of the International Health Regulations. Again, it would be useful to confirm whether this building up of in-country capacity is continuing despite the changes to the UK government architecture.

UK support for the multilateral global health system

The UK government informs us that, by the beginning of November 2020, it had committed £1.3 billion in aid to a package of responses to the COVID-19 pandemic. Most of this was directed through multilateral channels, including WHO, the UN High Commissioner for Refugees (UNHCR), the World Food Programme (WFP) and the Red Cross (ICRC), and through global initiatives such as CEPI and COVAX. According to Baroness Sugg, then Parliamentary Under-Secretary of State, the response recognised and helped to support the central role of the multilateral system in responding to the crisis.[13] The UK support for WHO was particularly significant in light of the US government’s threat in May 2020 to sever its relationship with the organisation,[14] signalling the UK government’s view that WHO was central to the global response.[15] This reinforces our positive findings from the GHT review on the UK’s efforts to promote WHO reform and strengthen its global health security role.[16] However, as with the Ebola crisis in West Africa, it is not surprising that the COVID-19 pandemic has revealed further need for reform of the multilateral health system, with an even greater emphasis on health security.

Outstanding issues

Overall, ICAI reviews over recent years have found that, through the aid programme, the UK has shown international leadership on global health threats.[17] It has contributed to WHO reform, increased poor countries’ access to affordable vaccines, and supported a major scaling up of international research on vaccines, testing and treatment. However, the threat of global pandemics will continue beyond COVID-19, and the need for continuing investment in global health security remains clear.

Our findings over recent years pose a number of important questions about the future of UK aid support for global health security, which may be useful for the Committee to explore.

• What is the status of the new global health security strategy that the UK government committed to developing?
• Given recent and projected cuts to UK aid, is the scale of the UK’s investment in global health security and building national health systems commensurate with the threat to developing countries and to the UK?
• Are the responsible departments undertaking regular risk assessments, scenario-based planning and simulations, to ensure their readiness to respond to new epidemics around the world?
• Following the DFID-FCO merger, is there clear leadership and a cross-government coordination structure in place for global health security?
• What are the implications of the planned abolition of Public Health England and establishment of a new National Institute for Health Protection[18] for the work on building epidemic preparedness in developing countries?

December 2020