International Development Committee
Humanitarian crises monitoring: Impact of coronavirus

Written submission on behalf of Oxfam GB on the current situation and immediate risks and threats

21 April 2020

Introduction

  1. Oxfam welcomes this inquiry. The rapid spread of Covid-19 has created an unprecedented global health crisis, which will impact people in the UK and across the globe. Oxfam is particularly concerned about the impact of Covid-19 on vulnerable people, including people living in poverty, those living in fragile and conflict affected states, and women and girls, who will be hit hardest.

 

  1. Oxfam is using its substantial expertise in public health and WASH to respond to the Covid-19 outbreak. Our preparedness for Covid-19 is informed by lessons from past disease outbreaks, including Zika and Ebola. We are working now to support our programme teams across more than 65 countries on how best to respond operationally to Covid-19 among the millions of people we support. Oxfam is already helping people to minimise the spread of infection by providing them with accurate information and advice in local languages. Our teams are increasing the delivery of soap, sanitation services including handwashing facilities, and clean water, especially to people in higher-risk environments such as refugee camps or crowded urban areas.

 

  1. This submission is divided into three substantive sections i) A global public health plan ii) Economic rescue package, and iii) The emergency humanitarian response, ending with case studies of the impact of the pandemic in Afghanistan and Yemen. Throughout, we address the disproportionate impacts of the crisis on women and girls, and recognise the importance of an intersectional gendered approach to Covid-19.

Priority recommendations

A global public health plan

  1. The UK government should work with other G20 leaders and the WHO to immediately double the current levels of public health spending in developing countries, amounting to an additional $160bn.
     
  2. The UK should scale-up its support in five key areas to strengthen public health systems capacity: prevention; health workers; removal of financial barriers; support and enable public sector requisitioning of private facilities for free treatment and care; and support to global efforts towards new, free and universally available Covid-19 vaccines and treatment.

Economic rescue package

  1. As well as providing its own financial support, the UK should support global efforts towards an economic rescue plan that includes debt relief, direct financial support to the poorest countries, and the creation of at least US$1 trillion in new international reserves, known as Special Drawing Rights (SDRs).
     
  2. The UK should call for continued action by the G20 and IFIs for the cancellation of developing country debt payments in 2020 and consider passing legislation to prevent any private lender from suing a developing country government for stopping debt payments in the 2020 emergency period.

The emergency humanitarian response

  1. The UK should commit to funding its fair share of the COVID-19 Global Humanitarian Response Plan. The UK's commitment on 12 April of £200 million to the United Nations, WHO and International Red Cross is welcome. However, DFID could consider whether the £20 million to INGOs could be increased to recognise their proven ability to quickly scale up existing community-level responses which is where action will be needed.
     
  2. The UK should support a locally led global response to Covid-19 that recognises the disproportionate impact of this pandemic on vulnerable groups in developing countries (including refugees, IDPs and women and girls).
     
  3. The UK must emphasise the importance of on-going humanitarian aid distribution and access in line with international humanitarian law and support humanitarian exemptions from movement restrictions, working with other countries and agencies to develop and facilitate the movement of humanitarian goods.
     
  4. The UK should support and encourage the full inclusion of refugees, Internally Displaced Persons (IDPs) and migrants into Covid-19 preparedness and response plans.
     
  5. The UK should ensure that humanitarian responses are rooted in robust gendered-conflict analysis and that aid is conflict sensitive, avoids harm and supports local capacities for peace.
     
  6. The UK should support women’s full, equal and meaningful participation and leadership in response structures. Violence Against Women & Girls (VAWG) organisations should be funded and these service providers should be exempt from movement restrictions.

Section 1: A global public health plan

  1. Projections from Imperial College London indicate that the difference between immediate action to suppress the virus, and delayed or minimal interventions to mitigate it, translates to tens of millions of lives saved or lost in developing countries. This research does not account for the likely much higher death rates in poor countries as a result of weaker and unequal health systems; impact of higher levels of co-morbidities and untreated or under-treated health conditions; or likely excess deaths from other causes as already buckling health systems pivot to focus on testing, treating and caring for Covid-19 patients. The research shows that the international community has an opportunity to save more than 30 million lives if urgent action is taken at an unprecedented scale.

 

  1. Many developing countries have responded far quicker than richer nations in implementing social distancing measures. Whilst welcome, this has brought additional health risks. In contexts where households depend on their daily income for food, lockdowns will increase levels of malnutrition and starvation, especially for women who are more likely to refrain from eating to ensure children are fed. This not only directly threaten lives but reduces people’s capacity to survive the virus.

 

  1. Lockdowns in many countries are being implemented without effective plans to ensure that non-Covid-19 related essential and emergency health care needs continue to be met. In Uganda, for example, women in labour cannot access transport to reach health facilities, which has already resulted in at least 10 unnecessary maternal deaths.
     
  2. Lessons learned from Oxfam’s Ebola response show that: prevention is key and early interventions to improve hygiene (e.g. handwashing) save lives; fear doesn’t change behaviour, but giving people tools for self-help does; communities must be included in how the response is planned and implemented; women will bear the brunt of health, social, and economic impacts; and emergency measures must be proportionate, non-discriminatory, and only in place for as long as necessary. Excess deaths from non-Covid-19 causes, but related to the crisis, could easily match or exceed the threat to life from Covid-19 due to interrupted or strained essential health care services.

Recommendations

  1. The UK should work with other G20 leaders and the WHO to immediately double the current levels of public health spending in developing countries, amounting to an additional $160bn. This increase should be paid for through a combination of debt cancellation and additional aid for health with full transparency and accountability to enable proper scrutiny of public spending by developing country governments and local actors.  The UK should use this funding and its existing technical capacity to scale-up support in 5 key areas to strengthen public health systems capacity:
     
    1. Prevention and ongoing essential health care: The UK should act with urgency to scale-up funding and practical action to support prevention activities. This includes testing capacity, contact tracing, public and community education information, awareness campaigns and water and sanitation provision. To avoid the very real danger of even greater loss of life from other causes, DFID’s support to health systems capacity in response to the virus must not come from repurposed existing aid for essential health care, or from UK aid for other essential services (including social protection). DFID should support governments and non-state, non-profit actors in continuing to provide essential health care, including sexual and reproductive health care and rights, during the period of the pandemic.
       
    2. The UK should contribute towards millions of new paid and protected front line health workers. Evidence from the Ebola response demonstrated the ability to recruit and train thousands of additional community health workers in a short time period. DFID should provide direct support for similar efforts now and provide long-term predictable aid that can be used towards the training and salaries of an expanded health workforce of nurses and doctors now and for the long-term.
       
    3. The UK should support the removal of all financial barriers to people accessing healthcare, including the delivery of free Covid-19 testing and treatment to all who need it. As health threats and impoverishment increase rapidly as a result of the virus, it is essential that governments act to avoid delays to or denial of access, or further impoverishment as a result of paying out of pocket for health care.  In line with new WHO guidelines, governments must act to remove all user fees, any insurance co-payments and ensure entitlement to all essential health care is universal and unconditional. The UK government should publicly communicate its support of WHO guidelines on the suspension of fees and offer specific financial support to help make this possible.
       
    4. The UK should support countries to requisition or otherwise take over private sector capacity in response to the crisis to provide Covid-19 testing and treatment and other essential healthcare free of charge. In many countries, private sector health care facilities own a high proportion of essential medical equipment, including ventilators and ICU beds. In Spain and Ireland, for example, the government has taken over the capacity of private facilities to increase their response capacity. Such actions are also needed in developing countries. The UK government has a particular responsibility here due to the high level of UK aid invested in private for-profit health facilities via CDC over the last decade. DFID should require CDC to use its leverage as an investor to ensure investee private health facilities are aligned to national responses, that profiteering plays no part in their response and no price gouging occurs. Any new CDC investments in health should focus on the equitable and affordable global supply of medical equipment and supplies.
       
    5. 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 a new Covid-19 vaccine. The race to develop a Covid-19 vaccine is an urgent priority.  UK support for vaccine and treatment development should be conditional on patent-free and affordable access worldwide. The vaccine and treatment should be made available free to everyone on the planet that needs it.

Section 2: Economic rescue package

  1. Without dramatic action to shore up economies of developing countries, as many as half a billion more people could be pushed into poverty. New research conducted by King’s College London and the Australian National University estimated that up to 8% more of the global population could be forced into poverty as governments shut down the majority of their economies in response to Covid-19. This threatens to set back the fight against poverty by a decade, rising to as much as 30 years in regions such as Sub-Saharan Africa, the Middle East and North Africa. Investors have already removed US$83 billion from emerging markets since the beginning of the crisis, and the UNDP has estimated that nearly half of the jobs in Africa could be lost.
     
  2. This pandemic threatens to exacerbate inequalities.  The better off are more likely to be in secure formal employment, enjoy effective labour protections like sick pay, to have savings, and be able to quarantine in a secure and connected home while continuing to work and educate their children remotely.
     
  3. Any economic rescue plan must also not further embed gender inequalities. Women account for 70% of the world’s health-workers, and more likely to have precarious jobs without labour protections. In the poorest countries 92% of women workers are informally employed.
     
  4. We must work across borders to overcome the twin crises of health and economy. The UN estimates that $2.5 trillion is needed to tackle the pandemic and keep poor countries and communities afloat. An economic rescue package would not only enable developing countries to invest more money in making their public health systems genuinely accessible to all, and responsive to gendered needs, but would also enable them to provide cash grants to those who have lost their income and to support vulnerable, small businesses.
     
  5. Any economic rescue plan should include:
     
    1. The immediate cancellation of developing country debt payments in 2020.  This should include bilateral debt to richer countries, multilateral debt to bodies such as the IMF and private debt to banks and other creditors. 
       
    2. An increase in direct financial support to countries now. Oxfam is calling on all donors to follow the lead of countries such as the UK and meet their pledge to give 0.7% of GNI in aid. Oxfam estimates $160 billion is needed to boost poor countries’ public health systems.
       
    3. The creation of at least US$1 trillion in new international reserves, known as Special Drawing Rights (SDRs), to dramatically increase the funds available to countries. This would, for example, give the Ethiopian government access to an additional $630 million – enough to increase their health spending by 45%.
       
  6. Oxfam welcomes the recent move by the G20 for a suspension of debt payments from 1st May to the end of 2020 for 77 low-income countries. While these are positive first steps, temporary debt suspension can lead to a debt crisis at a later date if debts are not cancelled outright. The list of countries eligible should also be expanded since many more will face financially crippling conditions. On multilateral debt, the IMF has made welcome moves to cancel debt to the world’s poorest countries for six months, but it could afford to go further. The IMF can sell some of its gold reserves that have risen in value by $20 billion in just the last three months —the windfall profits of that alone would more than cover multilateral debt payments owed this year by the poorest countries. Crucial will be the actions of the World Bank who hold much greater levels of developing country debt than the IMF. They too should act on debt cancellation.

 

  1. Beyond this bilateral and multilateral debt, huge sums are owed by developing country governments to private banks and investors – much of this debt is regulated under UK law. These private creditors should be pushed to cancel debts by enforcement and not left to voluntary action.

Recommendations

  1. The UK should support global efforts towards an economic rescue plan that includes direct financial support to the poorest countries, and the creation of at least US$1 trillion in SDRs.
     
  2. The UK should call for continued action by the G20 and IFIs towards cancellation of developing country debt payments in 2020, and cancel its own bilateral debt.
     
  3. The UK should consider passing legislation to prevent any private lender from suing a developing country government for stopping debt payments in the 2020 emergency period.

Section 3: The emergency humanitarian response

Communities on the front line of the crisis

  1. People and communities in fragile or conflict-affected countries will be hit hardest by this pandemic. As communities are at the front-line of the crisis, Oxfam is calling for a locally led global response. Quarantines and travel restrictions are shrinking the ability for the humanitarian community to respond, and the Covid-19 response is already increasingly reliant on local responders and volunteers. As a leading donor and member of UNSC, the UK is in a strong position to shape the international response. Funding decisions and what the UK chooses to prioritise will be crucial in determining the quality of the humanitarian response.
     
  2. Women and girls will also be disproportionately affected. Recent analysis by WHO from 104 countries shows that women make up to 70% of health and social care workers. Women are providing essential, lifesaving care services in their families, communities and the wider response – which increases their risk of exposure.
     
  3. Oxfam supports the Inter-Agency Standing Committee’s (IASC) Covid-19 guidance, which recognises the importance of local leadership and the need for localised solutions. National governments mounting a strong response will need funding to support their health services and social protection systems, whereas governments party to conflict or who are unable or unwilling to response require a different response.

Recommendations

  1. The UK should commit its fair share to the COVID-19 Global Humanitarian Response Plan which should be in addition to funding to existing humanitarian response plans.
     
  2. The UK should support locally led, rights-based inclusive responses, including through bilateral support to national government-led responses. It should ensure funding reaches local stakeholders, organisations and movements working on the frontline (especially those led by women and those focusing on women’s rights and protection).
     
  3. The UK's commitment on 12 April of £200 million to the United Nations, WHO and International Red Cross is welcome. However, DFID could consider whether the £20 million to INGOs could be increased to recognise their proven ability to quickly scale up existing community level responses which is where action will be needed.

Humanitarian access

  1. Covid-19 prevention measures are increasing barriers to humanitarian access. Recent years have seen a steep escalation in the obstruction of access to humanitarian aid through bureaucratic impediments, conflict and armed violence, including deliberate targeting of health workers and humanitarian actors in certain contexts. The pandemic is increasing humanitarian needs whilst making it more difficult for populations to access assistance. The most vulnerable groups already tend to be socially excluded, such as women and girls, undocumented displaced individuals, youth, or those perceived to be affiliated with armed groups.

 

  1. In some areas, border closures are squeezing relief supply and procurement chains. Elsewhere, lockdown and quarantine are blocking relief operations. Travel restrictions mean humanitarian workers cannot be deployed to emergency response programmes. Humanitarian workers are likely to experience increased context-specific stigma faced by doctors and others operating in a restricted space.

 

  1. Lifesaving humanitarian operations (including provision of protection, gender-based violence support and other services targeting women and girls) will continue to be necessary to respond to both existing needs and Covid-19. Local humanitarian leadership is critical.

Recommendations

  1. The UK must emphasise the importance of on-going humanitarian aid distribution and access in line with international humanitarian law and support humanitarian exemptions from movement restrictions.

 

  1. The UK should work with other countries and humanitarian agencies to develop and implement special protocols that facilitate the movement of humanitarian goods and personnel between and within countries. This should include quarantine protocols for humanitarian staff; use of UNHAS flights; alternatives for transporting humanitarian goods previously carried on passenger flights; and access to tests and certification.

 

  1. The UK must condemn and introduce targeted diplomatic sanctions against states and other actors that knowingly take actions that lead to the spread of Covid-19 (such as denial of access for humanitarian actors and supplies), while ensuring where existing sanctions are in place emergency exemptions are found if they are hampering efforts to stop the disease.

 

Forcibly displaced and camp-based populations

  1. At the end of 2018, 70.8 million people had been forcibly displaced from their homes by violence, conflict and persecution, a number that likely increased in 2019. Forced displacement creates its own set of vulnerabilities, which play out differently as they intersect with other facets of identity (such as race, gender, age and education).

 

  1. People already living in crisis situations are extremely vulnerable to the primary impacts (infection), emergency health measures (lockdown, isolation and quarantine) and economic consequences (food insecurity, loss of livelihoods) of Covid-19. Many refugees and IDPs are already unable to meet their basic needs, including health care, due to flawed policies and insufficient responses.

 

  1. There is an increased risk of infection in refugee, IDP and informal communities. Prevention and response are more challenging in these circumstances and lead to increased mortality rates. Oxfam’s teams on the ground have raised concerns about the worrying density of settlements and limited access to water, sanitation (including soap) and health services.  Oxfam’s humanitarian staff are hearing the main concerns are limited or denied access to healthcare; and lack of access to livelihoods, markets, basic needs and resources (including humanitarian aid).

 

  1. Following prevention advice and best practices on handwashing, social distancing and hygiene activities will be extremely difficult in these contexts, especially for women who shoulder the majority of unpaid care work, such as caring for sick household members. 

 

  1. It is likely that measures implemented elsewhere to slow the spread of disease will be of limited efficacy and may worsen pre-existing vulnerabilities, particularly for those reliant on informal work to meet their basic needs. Refugees and displaced people have the least opportunities to grow food, find work and cover their basic needs during crises. Many will have already exhausted their limited financial reserves and be reliant on humanitarian assistance.

 

  1. In Myanmar, for example, Rohingya IDPs in confined camps have extremely limited access to basic healthcare, with access to nearby hospitals controlled through a system of permits and costly journeys through multiple check points. It is still uncertain if they will be able to access services in Sittwe General Hospital if they require specialised care. The situation is similar in closed camps created around ‘counter-terror’ operations in Iraq and Syria. 

Recommendations

  1. The UK should support and encourage the full inclusion of refugees, IDPs and migrants into preparedness and response plans. This should not only explicitly consider their needs and vulnerabilities but should also include refugee and migrant-led organisations as a vital part of the response.
     
  2. Community engagement must be at the heart of the response, ensuring access to information and services meet community needs. Lessons from the Ebola response tell us that heavily medicalised and securitised responses do not work.
     
  3. The international response must take into account and address intersectional gendered differences in risks and vulnerability from the outset and ensure that dedicated resources are provided to support women and girls. Women play a vital role in response, which must be funded at all levels, and women’s rights organisations must be meaningfully included in decision-making structures.
     
  4. The UK must ensure that funding going to countries with significant populations of displaced people is allocated based on need and vulnerability and not support or further discrimination based on identity or legal status. This should go beyond the health response to Covid-19.

 

  1. The UK should reaffirm its commitment to working with UNHCR and IOM to re-start resettlement as soon as possible.

Conflict sensitivity and peace

  1. In many places, a combination of longstanding conflict, inequality and failed diplomacy means that national and local social protection and health systems were already unable to respond to existing needs – even before the Covid-19 pandemic. Some conflicts have seen a pause in hostilities in response to the pandemic, while violence and tensions have increased in other places.
     
  2. Delivering a conflict-sensitive response would allow the UK to ensure foreign policy, including aid objectives, avoid unintended harm while supporting local capacities for peace and development. Using its wealth of experience and capacities, the UK must ensure global ceasefire calls do not translate into negative peace on the ground that excludes women and other stakeholders.
     
  3. Ceasefires are too often a top-down, male-dominated exercise in political settlement and elite bargaining. A grassroots approach to inclusive peace and support to transparent and accountable democratic institutions is critical to building the type of public trust needed to address the twin health and economic crisis of Covid-19.

Recommendations

  1. The UK should ensure that humanitarian responses are rooted in robust, gendered conflict analysis and that responsible agencies collect sex, age and disability disaggregated data. Peacebuilding funding and interventions must not be deprioritised.

 

  1. The UK must work with other members of UNSC to gain support and deliver concrete progress towards inclusive peace, particularly following its endorsement of the UN Secretary General’s call for a global ceasefire in the wake of Covid-19. 

Gender vulnerabilities and Violence Against Women & Girls (VAWG)

  1. Women, men, girls and boys experience both the primary and secondary impacts of an epidemic in different ways. While in many places, women make up the majority of the healthcare force, in other places the absence of women in the health services is a barrier. The critical role that women and women-led organisations are playing in the response needs to be recognised, funded and supported.
     
  2. Structural gender inequalities and pre-existing social and cultural norms intersect with other identities (age, ability, legal status, ethnicity and socio-economic status) to determine access to resources, information and services as well as safety, security and care responsibilities.
     
  3. Studies of conflict and crises, including epidemics, show that gender-based violence (GBV) increases during emergencies, including intimate partner violence, sexual exploitation and abuse and child marriage. Emerging evidence from a growing number of Covid-19-affected countries, including the UK, shows the same worrying trend. In China, reports are already showing that domestic violence has doubled in confined provinces. Social distancing, self-isolation and quarantine measure are confining women and girls and putting them at increased risk.
     
  4. Evidence is also emerging that social distancing measures are inadvertently putting women and girls at increased risk of sexual exploitation, abuse and harassment from male-dominated security forces and other state officials tasked with enforcing movement restrictions. At the same time, critical response services are at risk of being shut down, cutting off lifesaving sources of support.

Recommendations

  1. The UK should support women’s full, equal and meaningful participation and leadership in response structures and during revision of the COVID-19 Global Humanitarian Response Plan. Responses need to be rights-based and age-, gender- and disability-sensitive, which requires the collection of sex, age and disability disaggregated data. A gender and protection integrated response must meet the IASC’s minimum standards for integrating gender equality.
     
  2. Responses should take into account and address intersectional gendered differences in risk and vulnerability that is based on robust gendered conflict-analysis.
     
  3. The UK should fund specialist VAWG organisations to deliver awareness and prevention campaigns and support services, such as shelters and hotlines. GBV and VAWG service providers should be exempt from movement restrictions and be provided with other services that are available to essential workers.
     
  4. The UK should adopt a multi-sectoral approach that integrates ending VAWG and GBV across health, education, economy and security response plans.

Country case study: Afghanistan

  1. Afghanistan is particularly vulnerable to Covid-19 due to long-standing conflict, proximity to regional Covid-19 hotspots and ongoing violence. A quarter of Afghani people already need humanitarian assistance and half live under the national poverty line. Water and soap, two of the most important measures for preventing Covid-19, are unavailable for the majority of the population. For many, social distancing is impossible. An already weak health system is expected to lead to a higher mortality rate than in developed countries. Furthermore, the immune systems of over 12 million people are compromised due to severe acute food insecurity.
     
  2. Women are likely to be impacted the most. As only 15% of nurses and 2% of doctors are women and cultural restrictions restrict male doctors from attending to female patients, women and girls have minimal access to health care. They are also expected to be the primary care givers for sick relatives. Furthermore, Afghan women have expressed the concern that mandatory lockdowns will lead to a loss of the gains made in terms of women’s mobility outside of the household in the long term, with families reverting back to old perceptions that women should stay in the home. 
     
  3. Substantive migratory flows will affect the management of a shared Iran-Afghanistan border during this pandemic. In March 2020 alone, over 115,000 Afghans returned from Iran. Internal displacement due to a number of factors, including violence, is pervasive and will make it particularly difficult in managing the pandemic. Thousands are forced to move monthly to seek shelter, often in overcrowded settlements.
     
  4. Covid-19 has created a further barrier for successful peace talks towards a potential ceasefire and framework for peace between the Afghan government and the Taliban, which were meant to start last month.
     
  5. Given historic engagement with Afghanistan, the UK has a key responsibility to continue and even increase support to Afghanistan at this critical juncture. The UK should support and enable public sector requisitioning of private facilities for free treatment and care, and patent-free universal access to medical technologies, supplies and equipment.

Country case study: Yemen

  1. After 5-years of conflict, only 50% of health centres in Yemen are functioning. Those open are already facing severe shortages of medicines, equipment, treatments and even staff. Around four million people live in camps and informal settlements, so the implementation of public health measures is extremely difficult. Humanitarian workers are still unable to access and operate in many areas of the country and, community organisations are telling Oxfam they are being ignored in the coordination, design and monitoring of the impact of the Covid-19 response. Furthermore, fear among the population of poorly maintained health centres could discourage them from seeking medical care.
     
  2. As a likely result of Covid-19, remittances to Yemen have suddenly collapsed (according to recent interviews conducted by Oxfam). Food and fuel shipments are currently being blocked from entering Yemen by the Coalition, and Covid-19 is expected to cause further movement restrictions and illness, which will stop farmers from being able to produce and distribute food. This could have a catastrophic impact on vulnerable people, many of whom are already severely food insecure. There is an immediate risk of loss of income and livelihood for many of the Yemeni population, 80 per cent of whom already depend upon emergency humanitarian aid to survive.
     
  3. Whilst Oxfam welcomes the temporary 2-week ceasefire announced in Yemen, a fortnight is not enough time to defeat Covid-19. The UK government must immediately suspend arms exports for use in Yemen, as continuing this whilst supporting a global ceasefire sends a contradictory message.