Action for Global Health Written Evidence

Foreign Affairs Committee Inquiry on Global Health Security (GHS0016)

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.

Action for Global Health’s written evidence focuses on the lessons learned from the COVID-19 pandemic and the role that the UK Government and FCDO should play in bringing a resolution to the current pandemic and preventing/reducing the impacts of potential future pandemics.  

1.              Executive Summary

1.1              The COVID-19 pandemic is exacerbating and highlighting existing inequalities and weaknesses in health systems globally, impacting their ability to deliver essential health services and meet the targets outlined in Sustainable Development Goal 3 of achieving universal health coverage and health and wellbeing for all. These impacts affect the full spectrum of essential health services due to a mixture of supply and demand factors, lower demand for care, the impact of lockdowns and border closures, redeployment of personnel and health infrastructure to the COVID-19 response, insufficient PPE and financial difficulties. While the Prime Minister’s recent speech to the United Nations General Assembly had a welcome approach to global health security through their announcement of the ‘five-point plan’, this plan needs to integrate strengthening health systems globally and achieving universal health coverage to tackle both the primary and secondary health impacts of COVID-19.[1]

1.2              The one-year Spending Review, in November, saw the Chancellor announce a proportion reduction of the UK’s spend on aid from 0.7% of gross national income (GNI) to 0.5%. It is devastating that the UK Government is making a U-turn on its critical manifesto commitment to 0.7%, which could impact more than half of the world’s population who remain without access to essential, quality health services, or whose health needs are being neglected due to the COVID-19 pandemic response. This budget is essential in ensuring the UK Government can work in unity with other countries to fulfil the universal human right to health. This commitment should be sustained throughout crises, and especially during a global pandemic where global collaboration is paramount to combating the disease in the UK and globally.

1.3              In a longer-term vision for combatting COVID-19, preparing for future pandemics and addressing global health, it’s vital we learn from the work done so far, the challenges with the diversion of funding and the implications of travel restrictions; all of which demonstrate the benefit and need for international collaboration, community-based interventions and flexible funding.

1.4              The UK is a strong contributor in the management of national and global health risks, which is vital to achieve the UK’s commitment to global health security. An ICAI report found that the UK had ‘made good progress’ on its response to the Ebola crisis; however, it also outlined that areas, such as comprehensive health systems, were lacking and that there is a risk that health systems interventions are reduced to disease surveillance strengthening or other narrow approaches, which must be avoided. To mitigate, the UK Government should commit to publishing a cross-governmental global health strategy, ensuing this delivers against Sustainable Development Goal (SDG) 3, and live up to its promise to develop a “five-point plan to protect humanity against another epidemic”  as well as strengthening health systems globally and achieving universal health coverage for all. This will enable the UK to integrate the COVID-19 response as part of a broader and longer term vision for global health. 

1.5              With COVID-19 impacting the ability to deliver other essential health services, we recommend that the FCDO accounts for the significant secondary impacts of the pandemic. The government has an opportunity to embed COVID-19 response into the wider vision for global health and a collaborative and holistic approach - through health system strengthening,  universal health coverage, developing engagement across civil society, national and international actors  and protecting essential health services - is of vital importance to increasing pandemic preparedness. The UK’s upcoming G7 presidency is a key opportunity to display the UK’s leadership in the fight against COVID-19, and ending preventable deaths, and the UK should strengthen the multilateral system and ensure those leading the global response to COVID-19 have the resources they need.

1.6              The UK has demonstrated strong collaboration with multilateral organisations, via the Prime Minister’s pledge of an uplift to operating funding to the World Health Organisation (WHO) and funding for COVAX. As COVAX steers towards becoming the the largest procurer of vaccines, it is essential that this initiative takes a human rights based approach and is used to support the most marginalised via affordable prices, transparent maximised global supply and collaboration with civil society,

1.7              Lessons around health systems strengthening and UHC must also be applied to thinking around new and strengthened systems for pandemic preparedness. Establishing pandemic monitoring systems isolated from current global health challenges would result in a system unable to effectively monitor different populations’ vulnerability to pandemics or the interventions that could make a substantial contribution to increasing their resilience to outbreaks. There are efficiencies to be gained through ensuring that investments to strengthen diagnostic and monitoring capacity also support efforts to control established infectious diseases.

2.              What lessons has the COVID-19 pandemic taught us about the importance of international collaboration in securing global preparedness and resilience against biosecurity threats?

2.1              Global collaboration and coordination

2.1.1              Global collaboration and coordination should form the cornerstone of global pandemic preparedness. This should cover the whole continuum; from having refined and integrated mechanisms for global surveillance to facilitate timely decision making, through to ensuring a shared common approach and policy toolbox that can be deployed once certain thresholds (e.g. WHO alert system) are met.

2.1.2              In order to facilitate prompt action, this automatic policy response/toolbox should be accompanied by adequate innovative financial instruments that can release equity/resources needed in an agile and timely manner.

2.1.3              The COVID-19 pandemic has highlighted the need for the global community to reassess its global infrastructure around pandemic preparedness. This includes the need to assess joint policy frameworks - including community transmission and global movement - as well as financing instruments. An effective global response requires multilateral, innovative financial instruments that can be activated to release equity quickly. It is also vital to assess pharmaceutical/commodity security; COVID-19 has highlighted the global catastrophic impact that disease can have and that investing in a robust future pipeline for priority pathogens should be a core priority for all governments. This includes strengthening organisations, such as CEPI, as well as having the means to bring agile production capacity online covering PPE, vaccine, diagnostics and therapeutics.

2.2              Community-based interventions

2.2.1              Many of the countries significantly impacted by COVID-19 are also impacted by high HIV, TB and malaria occurrence, particularly India, South Africa, Bangladesh, Pakistan, Philippines, Indonesia, Ukraine and Kazakhstan. Early indications demonstrate that the response, so far, has mitigated many additional deaths, but that there has been an increase in HIV acquisitions.

2.2.2              According to a  World Health Organisation (WHO) survey conducted in July this year, during the April-June period 36 countries reported disruptions in the provision of antiretroviral (ARV) services, negatively affecting 11.5 million people (45% of global people on ART).[2] Fresh data remains sparse, however the Global Fund to Fight AIDS, TB and Malaria recently reported that 75% of their Global Fund programmes have reported moderate-to-high levels of disruption to HIV service delivery. To assess the potential impact of this, the WHO estimates that for every three months of medium-to-high disruption to casefinding, we can expect an additional 200,000-400,000 TB deaths in 2020 alone.[3]

2.2.3              For all three diseases, community-based services remain the most impacted, but also the most critical in sustaining essential services - demonstrating the need for an increased focus on enabling community-based services in the fight to combat COVID-19. Community-based interventions in Rwanda and Uganda, including community health workers who provide malaria diagnosis and treatment, also deliver essential information on COVID-19 by integrating social and behaviour change communication activities on malaria with COVID-19 messaging.

2.2.4              Community-based initiatives have also utilised digital spaces to ensure health workers can effectively respond to the pandemic and prevent future pandemics. In Mozambique, Malaria Consortium has adapted its digital platform, upSCALE, to support community health workers’ ability to respond to COVID-19 with new COVID-19 modules developed for the platform and the use of the app to keep health workers up-to-date on the most-recent government advice and symptoms of the virus. In Sierra Leone and the Gambia, mobile phone applications and data from malaria indicator surveys – used to efficiently distribute bed nets – have been used to support COVID-19 prevention efforts, which have significantly reduced the time and money spent, as well as reduced person-to-person exposure to the virus .

2.2.5              Service delivery disruption is not restricted to communicable diseases. In a WHO rapid assessment survey in May, 120 (77%) of the 155 countries that responded reported having partial or complete disruption of non-communicable disease services due to COVID-19, with rehabilitation services the most likely to be disrupted.[4] Similarly, a WHO survey in June–August of 130 countries of mental, neurological and substance use (MNS) services during COVID-19 found a third of respondents reporting complete or partial disruption across at least 75% of these interventions/services.[5] In particular, mental health services and programmes tackling prevention and promotion were most severely affected – for example, only 30% of mental health services for children and adolescents or for older adults were available with no disruption.[6] As with communicable diseases, primary care in the community is the place where NCDs are usually best addressed in terms of early diagnosis and early intervention, and investing in primary health care is the best way to build more resilient health systems and achieve continuous healthcare for all.[7]

3.               How effective is the UK’s current approach to global health security?

3.1              The UK is a strong contributor in the management of national and global health risks, and its continued investment in global health research, maintaining a broad portfolio approach to investments and supporting PDP is vital in order to achieve the UK’s commitment to global health security and in combating COVID-19. Global Fund initiatives provide examples of effective TB R&D being leveraged for COVID-19 innovation and delivering broader global health benefits, particularly given the similarities in transmission and public health responses to both diseases - with existing tools, concepts, capacity and infrastructure informing and assisting COVID-19 responses.[8]

3.2              The UK’s contributions range from investments in the development of new tools, research into effective delivery mechanisms to tackle epidemics, to support to surveillance and data to address antimicrobial resistance (AMR). Flagship initiatives include the Fleming Fund (£544 million), which is dedicated to helping low- and middle-income countries tackle AMR through improved data and surveillance, better AMR action plans and strengthened laboratory capacity. Another initiative is the UK Public Health Rapid Support Team (Rapid Investigation and Response - £7.68 million), which is a trained deployable force to support the rapid investigation and response to disease outbreaks at source and which also conducts rigorous research to aid epidemic preparedness and response.

3.3              The UK’s contribution to addressing AMR does not stop there, with further investments made in operational research capacity on the spread and impact of AMR, and research into AMR’s drivers. In terms of broader disease-response focused grants, the Tackling Deadly Diseases in Africa (£155.3 million) programme sets out to reduce the impact of disease outbreaks and epidemics through support to WHO Africa Office reform and its Health Emergencies Programme and strengthening countries’ adherence to International Health Regulations. The UK is also responding to the current Ebola outbreak in DRC (£85 million). In addition, the Department of Health and Social Care (DHSC) funds the International Health Regulations Strengthening Project (£18.97 million) supporting WHO to fulfil its leadership role in implementing the IHR.

3.4              An ICAI report investigating the UK aid response to global health threats found that the UK had indeed ‘made good progress in developing a coherent framework for addressing global health threats following the Ebola crisis, as well as rapidly establishing a relevant portfolio of programmes and influencing activities’. It also found the UK’s efforts were effective at filling gaps at the global level. However, the ICAI investigation identified that as in other areas, comprehensive health systems need more emphasis, and there is a risk that health system interventions are reduced to disease surveillance strengthening or other narrow approaches, which must be avoided. In light of COVID-19 and its impact on health systems around the globe, this learning is particularly noteworthy. In order to mitigate this risk, the UK Government should commit to publishing a cross-government global health strategy, covering all UK government health ODA spend, and ensuring this will deliver against Sustainable Development Goal (SDG) 3 (including outlining their approach to SDG 3 sub-target 3.D on global health security). The UK Government has not had a global health strategy or any comprehensive document outlining their approach to global health since 2013, despite repeated calls from the International Development Committee, former Chief Medical Officer Dame Sally Davies and Action for Global Health.

3.5              It has become clear that strong health systems and international collaboration are vital to responding to the pandemic and in the prevention of future pandemics, as the current response to COVID-19 relies on current infrastructures and response mechanisms for existing diseases. The UK’s investment and collaboration with multilaterals is vital in strengthening health systems and enabling future response. Existing structures, such as the Global Polio Eradication Initiative (GPEI) which has provided capacity and capability for epidemiological monitoring through disease surveillance networks, has been critical to understanding the spread of COVID-19 in low- and middle-income countries (LMICs). Multilaterals like the Global Fund to Fight AIDS, TB and Malaria and the GPEI are strong examples of how we can provide care for COVID-19 patients, whilst maintaining critical health services and running effective community-based public health messaging campaigns.

3.6              Despite commendable efforts from the UK Government and across other countries, it has become clear that these have been insufficient to prepare for a global health crisis of this magnitude. At the recent United Nations General Assembly, the Prime Minister also revealed plans to use the UK’s G7 Presidency next year to focus on a “global approach to health security” and a “five-point plan to protect humanity against another pandemic.” Whilst this plan includes a welcome emphasis on global cooperation and better pandemic preparedness, the UK should extend these efforts to strengthening health systems globally and achieving universal health coverage; a commitment that the UK made at the UN General Assembly last year.[9] In a world facing multiple health threats and crises, the UK Government has an opportunity to go beyond the COVID-19 response and a narrow global health security lens, to advocate for a bolder, broader, longer-term vision for global health. A cross-government global health strategy would support this endeavour.

4.              What role should the FCDO play in bringing about a resolution to the COVID-19 pandemic and preventing future pandemics?

4.1              Prioritise a holistic, comprehensive approach to global health

4.1.1              There is a risk that COVID-19 comes to represent global health to the UK Government, and that funding and attention is shifted from other health crises to the COVID-19 response, as referenced in the recent report of the International Development Committee.[cite] This approach fails to take into account the significant secondary health impacts of COVID-19, particularly on the most deprived and marginalised women and children.

4.1.2              The pandemic is exacerbating existing inequalities and weaknesses in many country’s health systems, impacting their ability to deliver other essential health services and meet the targets outlined in SDG 3, to achieve universal health coverage and health and wellbeing for all. The same issues which are negatively impacting the COVID-19 response – inadequate PPE and supplies, global shortages of health workers due to fear, low pay and incentives, low access to WASH services in health facilities, unclear public health information and communication – are also impacting the ability to maintain other essential health services, at potentially even greater cost. Since the start of the crisis, Action for Global Health have been collating case studies from across our member organisations, which document the impact of COVID-19 across child health services, immunisation, nutrition services, prevention, treatment and diagnostics for communicable diseases and non-communicable diseases, sexual and reproductive health (SRH) services, harm reduction, inappropriate use of antibiotics leading to increasing rates of drug-resistant infections, mental health services, rehabilitation services, palliative care, WASH, and health research and development.

4.1.3              The UK Government has an opportunity to envisage the COVID-19 response as part of a longer-term vision for global health. A holistic approach to global health, including through investing in health systems strengthening and efforts to achieve universal health coverage, will be critical to both respond to COVID-19 and provide long-term pandemic preparedness. In particular, the UK’s hosting of the G7 Presidency provides an opportunity for the UK Government to champion this holistic approach. In order to respond to COVID-19, future pandemics, and to continue delivering other essential health services, we need strong health systems everywhere and for them to be accessible to all. Action for Global Health also recommends that the UK should appoint a Special Envoy for Global Health to champion this work.

4.2              Protect Investments in Essential Health Services

4.2.1              As per the UK Government’s manifesto commitment to ‘end preventable deaths’ the UK must protect and maintain investments in other essential health services and build strong and resilient primary healthcare systems that will be equipped to address pandemics and broader health issues. This will be particularly important in the context of recent announcements cutting the UK’s aid budget from 0.7% to 0.5% of GNI. UK investment through bilateral funding and global health multilaterals is important to achieving this. In the case of the latter, the UK Government should use its role to influence strong collaboration between different institutions behind country-led plans for health system strengthening and investment. Continued investment in the prevention of diseases such as malaria is a ‘win-win’ for governments, and an important strategy for reducing the strain on health systems. Not only does it reduce the direct burden of disease on health delivery systems, it also reduces the confusion of managing fever cases. Investments in diseases like malaria can also play a critical role in building capacity and strengthening resilience that can be repurposed to deal effectively with current and future pandemics, for example by training tens of thousands of health care workers to conduct early diagnosis and treatment and integrated community case management, and building data systems to improve real-time surveillance of infectious diseases. Shifting funding from other health crises risks undoing years of progress improving global health outcomes, in which the UK has been a leading donor and global champion and leaving populations at greater risk of future pandemics.

4.2.2              The UK Government should also continue to advocate globally for sexual and reproductive health services to be designated as ‘essential services’ in Covid-19 responses and in-keeping with this to protect the supply of health workers delivering services to meet the needs of women, adolescents and children (through training, recruitment, remuneration, PPE, and more). 

4.2.2 Health systems are fundamental for the successful delivery and uptake of any tools developed in the three ACT-A pillars, and for protecting other essential health and nutrition services. This will require support for areas such as cold chains, supply chains, health worker training and support, data management, and community engagement. Ensuring appropriate resources are allocated now is critical for protecting the availability of services, scaling up the equitable distribution of tools, and for supporting and protecting lifesaving health systems after the acute phase of the pandemic has passed. The UK Government’s investment and support of the Access to COVID-19 Tools Accelerator (ACT-A) build on global efforts in the fight against COVID-19 and will allow countries to mitigate the impact of COVID-19 on health systems.

4.3              Speed, accountability and flexibility

4.3.1              The speed, accountability and flexibility of funding are critical factors in effective global health programmes. The faster that funds are disbursed to frontline health facilities in a transparent and accountable manner, the faster they are able to manage COVID-19 patients and create safe environments for non-COVID-19 patients. Furthermore, factoring in flexible-funding mechanisms, similar to those used by the Global Fund to Fight AIDS, TB and Malaria, enables countries to invest in priority areas based on need, however there is a need to mobilise additional funding outside of initial flexibilities to ensure that needs continue to be met. Collectively, these mechanisms have a positive effect on public confidence in the health system and uptake of essential services and, for those at greater risk of severe COVID-19, an increased resilience to COVID-19 - positively impacting health systems. 

4.4              Right-based Approach

4.4.1              Covid-19 is exacerbating the barriers faced by many in accessing essential health services, but this is not always reflected in prioritisation at the national level. To mitigate this, meaningful participation of affected communities/local civil society in COVID-19 response mechanisms is required. The UK Government can and should play an active role advocating for social accountability at the global, national and local level, and ensure widespread collection of disaggregated data in terms of access to essential health services. We also urge that a rights-based approach is taken, using every opportunity to call for partner governments to respect human rights and increase advocacy efforts in response to human rights violations carried out under the guise of the COVID-19 pandemic. 

4.5              Transparency

4.5.1              FCDO must protect its investments in the Covid-19 response from corruption by integrating anti-corruption measures, such as transparency and accountability mechanisms. Previous health emergencies have proved the detrimental impact of corruption on people’s lives. During the 2014-2015 West Ebola outbreak, corruption contributed to the disease’s outbreak primarily by weakening public health institutions in the preceding years. For example, Sierra Leonean government officials’ misappropriation of Gavi Vaccine Alliance donor funding led to medical personnel illegally charging for health services and medicines, reducing access to health care services. In Liberia, low trust levels contributed to the spread of rumors that the Liberian government had exaggerated or even concocted the Ebola crisis as a way to get access to international funding that could be siphoned off for private uses. This delayed the containment response, resulting in thousands of deaths.[10] To avoid mistakes from the past, it is key to acknowledge and address corruption risks in order to strengthen COVID-19 health responses, and increase public trust in governments’ delivery of public health services.

5.              Has the UK effectively used its position in multilateral organisations to promote international collaboration in response to COVID-19 and the global health security agenda?

5.1              The UK has shown continuing commitment to international collaboration in the COVID-19 response and ensuring access to a COVID-19 vaccine for all. At the recent United Nations General Assembly, the Prime Minister announced an uplift in operational funding pledged to the World Health Organisation (WHO), which plays an integral role supporting and guiding how countries across the globe respond to the myriad challenges that COVID-19 brings and also how they prevent, treat and protect their citizens from other diseases and promote good health.

5.2              The UK also recently pledged up to £571 million to COVAX, an effort led by the World Health Organisation (WHO) to develop, manufacture and distribute COVID-19 vaccines evenly across the world. This involves coordinating the COVAX Facility, a global collaboration to buy COVID-19 vaccines, once developed, and distribute them as equally as possible. The UK’s commitment to ACT-A and the use of match funding as a way to leverage other donors are promising signs. However, the UK Government’s recent announcement to reverse on their manifesto commitment to 0.7% is a disappointing sign that the UK Government is no longer committed to this international approach to the COVID-19 response, and is unwilling to play its part. The ODA budget is essential in delivering on the UK’s work on global health, including long-term health systems strengthening and pandemic preparedness, as well as the UK Government’s manifesto commitment to ‘end preventable deaths’.

6.              How can the FCDO ensure that COVAX is successful? What are likely to be the main challenges associated with worldwide distribution of a vaccine?

6.1              With support from donors like the UK, COVAX is set to become one of the biggest procurers of COVID-19 vaccines in the world. It is essential that this substantial market power is used to shape the market for the good of humanity and to secure the most affordable prices for, and equitable access to, COVID-19 vaccines, according to need. The UK Government can and should use its leverage as a key donor to ensure that the COVAX Facility delivers full transparency, guarantees affordable prices, maximises global supply and agrees to full civil society participation in the proposed governance bodies.

6.2               The UK Government must ensure public contributions to ACT-A tools including vaccines, oxygen and PPE come with conditions to guarantee fair global access. These must include full transparency of clinical trial data, research and development costs, and price, as well as open licensing to allow for maximum production.

6.3               There is no scenario in which immediate supply of any COVID-19 commodity will be enough to ensure equal access. To expand supply and improve access, the Government should support the operationalisation of the COVID-19 technology access pool (C-TAP).

6.4               The UK Government must deliver a strong message against vaccine nationalism and take a stand against export controls on COVID-19 commodities and the stockpiling of vaccines beyond the WHO’s equitable allocation quota.

7.              Development of a ‘global pandemic early warning system’

7.1              Lessons around health systems strengthening and UHC must also be applied to thinking around new and strengthened systems for pandemic preparedness. Establishing pandemic monitoring systems isolated from current global health challenges would result in a system unable to effectively monitor different populations’ vulnerability to pandemics or the interventions that could make a substantial contribution to increasing their resilience to outbreaks. For example, the rate of malnutrition can be understood as a risk for exposure to and deaths from infectious diseases and targeted nutritional support programmes could be critical in enabling outbreak control measures to be effective. Similarly, the UK Government would be missing out on critical efficiencies that could be gained by failing to ensure that investments to strengthen diagnostic and monitoring capacity also support efforts to control established infectious diseases like TB.

December 2020

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