Action for Global Health Written Evidence
International Development Committee Inquiry on the Future of Aid
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.
1. Executive Summary
1.1. COVID-19 has underscored how good health is the foundation for every aspect of human and societal wellbeing. Without sustained global collaboration and sustainable financing in health systems globally, it will be impossible to achieve the FCDO’s priorities, the manifesto commitment on ending preventable deaths and the Sustainable Development Goals (SDGs) to create a better, healthier world. However, through its recent cuts to global health spending, the UK ignores this hard-learned lesson of the pandemic at the world’s peril and at the risk of its own reputation.
1.2. As other countries increase their spending on health, the UK Government’s severe cuts strike a devastating blow to the COVID-19 response and the delivery of essential health services to the most marginalised people around the world at a time when it is needed the most. As COVID-19 continues to weaken fragile health systems and exacerbate barriers in access to care, now is not the time to be stepping away. These cuts will lead to a decades-long rollback on progress towards improving health.
1.3. These cuts will lead to the severe rollback in progress to the SDGs and render the achievement of the most pressing global challenges unattainable. The severe nature, abrupt implementation and lack of transparency of the cuts, deepen the negative impact of the cuts, and provide the future return to 0.7 facing additional compounding and unnecessary challenges in the reinstatement of programmes.
1.4. The sudden nature of the cuts and the confusion on the new budget allocations has led to abrupt closures and/or severe cutbacks to programmes, meaning many people have been left suddenly unable to access a myriad of healthcare, including emergency healthcare, polio vaccines and family planning services. This lack of transparency and sudden nature of the cuts will further deepen the rollbacks to global health and leave so many more marginalised people facing health inequity and its corresponding issues, such as poverty and lack of education.
1.5. The lack of transparency around multilateral and bilateral spending, and how this fits into the wider global health spending, has led to confusion on the continuation of various programmes and the connection with COVID-19 response, and how this spend contributes to achieving the FCDO’s strategic priorities, the manifesto commitment on ending preventable deaths and the SDGs.
1.6. Analysis developed by Action for Global Health indicates that the reduction in UK global health spending represents a cut of up to 40%1 overall. As the below table outlines, we’re already witnessing the impacts of the cuts on health services around the world – from the sudden closure of ambulance services, leaving people unable to reach emergency healthcare, to cuts of 80% to UNAIDS, jeopardising the effective delivery of the 2021-2026 Global Aids Strategy which the UK endorsed only two months ago. Startlingly, many health projects that were on the cusp of success now face devastating setbacks. For example, a 95% cut to the Global Polio Eradication Initiative that was so close to achieving its goal will no doubt result in a resurgence of polio.
2. The strategic targeting of UK aid spending, including the focus areas set out by the FCDO’s seven global challenges and their alignment with the conclusions of the Integrated Review
2.1. FCDO’s Seven Strategic Priorities
2.1.1. Last year, the Foreign Secretary announced seven strategic priorities for the aid budget, including commitments to combat COVID-19 and support the achievement of broader health goals. Initial analysis of the budget cuts allocation predicts there has been a large cut to programmes that contribute to these priorities, significantly compromising the UK’s ability to achieve its own objectives.
2.1.2. Whilst the UK Government has a body for overseeing ODA to health, the Global Health Oversight Group, it does not have a dedicated, public strategy – or any current comprehensive document - guiding its work in global health or targeting ODA spending on health. A Health Systems Strengthening Position Paper, which would outline the UK’s approach, has been under preparation for over four years, but no date for publication is as yet confirmed. Similarly, no date for publication has been confirmed for the UK Government’s ‘Action Plan’ on ‘ending preventable deaths’. We believe that it is essential that the UK government has a coordinated approach to global health, and that this is best articulated through a global health strategy. The previous global health strategy, which expired in 2015, was widely considered to be an innovative model of cross-departmental collaboration.
2.1.3. Despite being a strategic priority, global health has still seen dramatic and devastating cuts of up to 40% overall. In addition, as global health inequality is a structural driver of a range of other development concerns – such as reducing access to education, diminishing gender equity and increasing poverty – these cuts to health will have direct impacts on all other government priorities and deepen poverty for many around the world (and, in turn, the impacts on these other issues will have an impact on health inequality). For example, cuts to health will directly inhibit the UK Government’s goal of improving girls’ education, as lack of access to health services increases poverty and results in more girls leaving school.
2.1.4. Moreover, these cuts will lead to a decades-long rollback in progress towards the Sustainable Development Goals (SDGs) on global health and poverty elimination, hinder the global recovery from COVID-19, and disrupt the Government’s own G7 Presidency ambitions.
2.2. Conservative manifesto commitments on Ending Preventable Deaths
2.2.1. In 2019, the International Development Secretary, Alok Sharma, announced a manifesto commitment to prioritise ending preventable deaths of women newborn babies and children by 2030, including promises to prioritise access to healthcare for women and girls around the world.5 Despite this commitment, the funding to global health – a key factor in reducing preventable deaths – has seen devastating cuts of up to 80% to nutrition programmes and the withdrawal of funding for sexual reproductive programmes. This will result in an increase in child death and maternal mortality – in direct contradiction to the Conservative manifesto commitment to end the preventable deaths of women, newborns and children.
2.3. UK’s G7 Presidency Ambitions
2.3.1. This June, the UK will host the Presidency of the G7 Summit. The Summit will have a significant focus on the global response to COVID-19, and creating a safer, healthier world. The Prime Minister’s five-point plan on global health security, the G7 Leaders’ statement and the recent Foreign Ministers’ Communique all provide welcome indications of the UK’s ambitions on global health.
2.3.2. And yet, implementing these cuts runs entirely counter to these ambitions and risks the UK’s G7 Presidency becoming little more than positive rhetoric. The UK needs to match its ambition with the necessary financing. At a time when other G7 nations are stepping up their funding, the UK’s cuts are undercutting this ambition. COVID-19 has highlighted the interconnections between the health of people all around the world and between different health issues. Now is the time for us to learn these important lessons from the pandemic; yet, these cuts show the UK walking away from the global approach they espouse.
3. Do these focus areas address the most pressing global development challenges?
3.1. Whilst the government’s ambitions are a step towards addressing these most pressing global development challenges, these recent cuts to ODA will render the achievement of these goals impossible. Furthermore, these cuts will lead to a decades-long rollback in progress towards the Sustainable Development Goals, hinder the global recovery from COVID-19 and leave the world more vulnerable to the impacts of climate change. These cuts also stand in stark contrast to other G7 nations’ approaches – for example, the US has increased its funding to global health by 66% over the past year2 despite its economy contracting at its deepest pace since World War II
3.2. Given the positive, long-term impacts ODA has had on the UK and beyond, we suggest that these cuts – which equal just 1% of the current UK deficit – will only cause harm to hard-won progress on global health and irreversibly damage the UK’s position as a global leader. The sudden implementation of these massive cuts is also resulting in multiple programmes being cancelled mid-way through their work – losing gains to health, leaving many people unable to access or continue their healthcare and wasting money already spent.
3.3. At a time when COVID-19, future pandemics and climate change pose the greatest threat to the health of people in the UK and around the world, these cuts are short-sighted and will undoubtedly increase the UK’s vulnerability. Whilst we recognise there have been fiscal restraints caused by COVID-19, cutting global health spending as a result of the pandemic will hinder the progress of global health, as well as all of the most-pressing global development challenges.
4. The effectiveness of the Government’s policy to focus ODA spending on countries where UK economic, security and development interests align
4.1. COVID-19 has underscored how good health is the foundation for every aspect of human and societal wellbeing and outlined that investments in health are critical for healthy societies and health economies globally. Without sustained global collaboration and sustainable financing in global health systems, it will be impossible to achieve the Sustainable Development Goals (SDGs) and create a better, healthier world. However, through its recent cuts to global health spending, the UK ignores this hard-learned lesson of the pandemic at the world’s peril.
4.2. In 2015, the UK committed to the SDGs – a global initiative to improve the lives of the most marginalised around the world through commitments to reduce poverty and inequality globally, improve health, build peace and more. As mentioned above, to accelerate progress on these goals, Prime Minister Johnson also pledged in his manifesto to prioritise ending the preventable deaths of women, newborns and children by 2030, through improving access to healthcare around the world.4 Yet, as we move closer to the SDG’s delivery deadline of 2030, the UK’s budget cuts render the achievement of these goals impossible.
4.3. With health a causal factor of a range of issues, these cuts will also have a ripple effect on a range of other factors for wellbeing, such as the ability to access education or go to work. At a time when people living all around the world are struggling with the pandemic on top of other heightened challenges – from financial insecurity to social injustices – it is becoming clear that these cuts will result in the fuel of new crises. These will be in the shape of mental health crises; the resurgence of other communicable diseases, like polio, TB and HIV; or an increased risk of ill health due to reduced funding for preventative measures such as water, sanitation and hygiene.
4.4. As COVID-19 continues to weaken fragile health systems and exacerbate barriers in access to care, now is not the time to be stepping away - now is the time to stand in solidarity with countries around the globe and continue our work building strong health systems and eradicating deadly diseases. These cuts will lead to a decades-long rollback on progress towards improving health and achieving our own FCDO goals.
4.5. This June, the UK will host the Presidency of the G7 Summit - an opportunity for leaders to come together in the response to COVID-19 and reaffirm their commitment to building a better world. The Prime Minister’s five-point plan on global health security, the G7 Leaders’ statement and the recent Foreign Ministers’ Communique all provide welcome indications of the UK’s ambitions on global health. However, implementing these cuts runs entirely counter to these ambitions and risks the UK’s G7 Presidency becoming little more than empty rhetoric. The UK must walk the talk and reinstall the 0.7% commitment without delay, or risk ignoring the vital lessons this pandemic has taught us.
5. Changes to the administration of UK ODA, including the FCDO assuming responsibility for deciding the final departmental allocation of ODA and administering the majority of UK ODA
The split between bilateral and multilateral ODA spending, and the effectiveness of these channels for the delivery of UK aid
5.1. In order to achieve the international and UK targets in improving global health, it is critical that defining priorities for funding is dictated by global public health needs and not by diplomatic or political factors. The COVID-19 crisis poses challenges to increasing the financing of resilient health systems that can deal with COVID-19 and other potential infections, as well as dealing with other health issues.
5.2. Bilateral aid enables governments to invest in sustainable and resilient health systems, and multilateral aid is essential in setting norms and guidelines as well as directly support or fund specific programmes (such as the WHO, UNAIDS and the Global Fund) or to finance and encourage innovation and access (such as UNITAID). The UK funding for these, and other organisations, has been vital for their continual functioning. In the midst of the current pandemic and its terrible impact of rolling back HIV programmes, cuts in UNAIDS and UNITAID will have a terrible impact on access to prevention and treatment not only for HIV but also for TB, malaria and HEpatitis C.
5.3. The lack of transparency and detail around massive cuts to multilateral bodies leaves hugely important questions unanswered, particularly whether the UK government is content with critical programmes being rolled back. It is also unclear how the UK split its funding towards the global COVID-19 response and the broader global health objectives via multilateral or bilateral channels.
6. The FCDO’s approach to the process of implementing in-year changes to the aid budget during the 2020-21 financial year, including its communication with stakeholders
The FCDO’s approach to setting ODA budget allocations for the 2021-22 financial year, including its communication with stakeholders
6.1. There has been a lack of clarity and communication around the process and decision-making behind these cuts and financial allocations with stakeholders. In particular there has been a dearth of information around how these updated funding allocations align with the FCDO’s strategic objectives. Stakeholders have had to suddenly close vital programmes, such as ambulances and first response, leaving many people without access to emergency care, and hundreds of millions of doses of medicines expected to go to waste after 90% cut for treating neglected tropical diseases - all no doubt resulting in mortalities, delays and reversals in achieving disease control and elimination targets, and leaving organisations scrambling to adjust. These ‘adjustments’ are largely taking the form of programme closures and/or severe and abrupt cutbacks to service delivery. Moreover, the sudden cuts to the aid budget has led to increased pressure for other funders to step in to cover these funding gaps. On the off chance that this is possible in some circumstances, this funding will need to be diverted from other programmes meaning that the price of these cuts will impact an even wider scale of programmes.
6.2. Given the sudden implementation of these cuts, we are also concerned about the lack of impact assessments being carried out to ascertain the negative impact of these cuts, both on the programmes themselves and the sudden and chaotic nature by which they have been implemented.
6.3. Given the distinct lack of consideration and assessment on the implementation of the cuts, there are concerns around the consideration and specific assessments on how, when the UK returns to 0.7, programmes will be rebuilt. Once a programme has closed or has experienced sudden and severe scalebacks, as is the case with most UK-funded programmes, the work to reinstate or rebuild will be much more challenging and costly due to the rollback of disease prevention and health services that these cuts will certainly have. The implementation of services, due to the return to 0.7%, will need to be done with care and consideration in an evidence-based way that should strengthen health systems.
7. Impact upon communities in lower income countries
7.1. Action for Global Health’s analysis, with input from a range of civil society organisations, research institutions and delivery partners, indicates that the cuts will impact every area of global health and interconnecting issues, and result in a decades-long, catastrophic rollback on a myriad of health issues, to which the UK had previously contributed so significantly and laudably.
7.2. The table below indicates the impact of the cuts that have been announced so far against Sustainable Development Goal 3 (health and wellbeing), a goal to which the UK committed in 2015. Many of these areas were on the cusp of success and now face devastating setbacks.
SDG 3 Sub goal
ODA Cut and Impact Example
3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births.
UNFPA Supplies programme
To receive approx. 85% cut. UK Gov funding amounts to 60-70% of this programme’s funding, therefore this cut will have devastating impacts on women, girls and families – esp. those living in poverty, in remote underserved communities and living through humanitarian crises. This is particularly devastating at a time we have seen a rise of maternal deaths due to the impact of COVID-19.
3.2: By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births.
Global Polio Eradication Initiative
Funding cut by 95%, from £100m to £5m, on top of cuts in 2020, which will be catastrophic in ability to eradicate polio around the world. UNICEF, Gavi and WHO previously warned that up to 80 million children under the age of 1 are at risk of missing out on routine immunisations for diseases such as measles, polio and yellow fever due to disruption of mass immunisation projects to combat COVID-19.
Analysis suggests a cut of 80% from 2019 down to just £26m on vital nutrition services this year. Within humanitarian settings, analysis suggests that nutrition-sensitive assistance could be 45% less than in 2019. Malnutrition is a key factor in around half of all child deaths. The pandemic is estimated to increase the number of malnourished children dramatically with an additional 9.3 million wasted children, 2.6 million stunted, and 165,000 child deaths. The WHO has warned nutrition services are amongst the most disrupted because of the pandemic. UK aid cuts to nutrition will cost children's lives and are entirely inconsistent with stated leadership on famine prevention.
3.3: By 2030, end the epidemics of AIDs, tuberculosis, malaria and neglected tropical diseases and combat hepatitis water-borne diseases and other communicable diseases.
Neglected Tropical Diseases (NTDs)
90% funding cut (£150 million), which will leave more than 200 million people vulnerable to NTDs. It also threatens elimination goals in 9 countries and possible disease resurgence in areas once free of these devastating diseases. In some countries, these cuts mean the removal of ‘last resort’ programmes in the fight against NTDs. The reduction of UK funding means cutting a lifeline for countries that received limited to no other donor support.
80% of funding cut from £15m to £2.5m will jeopardise the UK’s current support and effective delivery of 2021-2026 Global Aids Strategy, which it endorsed in March 2021. This will impact support for the most marginalised people affected by HIV and Aids. Such a cut in a very low cost, high impact agency that is key to driving progress on health security and tackling pandemics, on girls’ education, and which is responsible for coordinating the High-level Meeting on HIV & AIDS, undermines the UK’s own priorities.
Water, Sanitation and Hygiene (WASH)
More than 80% cuts in funding for water, sanitation and hygiene bilateral projects. As WASH is a key factor in the fight against various communicable diseases, including COVID-19, this will have devastating consequences.
3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.
SUCCEED Mental Health Programme
A further substantial cut the Support, Comprehensive Care and EmpowErment for people with psychosocial Disabilities, a sub-Saharan 6-year research program, whilst still expected to deliver a demanding set of objectives. Prior to the pandemic depression was recognized by the World Health Organization as the world’s leading cause of disability, and mental, neurological and substance use disorders contribute to significant economic output losses. COVID-19 has created an increased demand for mental health services already stressed due to chronic neglect; underscoring the need for urgent funding.
3.7: By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.
Will receive no new funding allocation in the funding cycle in 2021/2022. U.K.’s flagship WISH (Women’s Integrated Sexual Health) programme delivers life-saving contraception and sexual and reproductive health services for women and girls in some of the world’s poorest and most marginalised communities. Cuts will mean clinic closures in multiple counties and result in massive reductions in delivery of life-saving services for women and girls in some of the world’s poorest and most marginalised communities. Over the last two years, the MSI Choices (MSI) managed part of WISH programme has provided reproductive choice to 3.5m women; saving the lives of 22,000 women. And in the same period, the International Planned Parenthood Federation (IPPF) managed part of the WISH programme has provided reproductive choice to over 4.7million women, saving the lives of over 12,500 women’.
UK Aid Connect programme
Consortiums led by MSI and IPPF will now be closed. This means that many will be unable to access sexual and reproductive health services, leading to an increase in maternal mortality, unsafe abortions and will hinder girls and women’s economic advancement. If allowed to continue, this programme would have generated important learnings on how to reach the world’s most marginalised groups with comprehensive sexual and reproductive health services to help them adapt and become more resilient to climate change and humanitarian crises.
3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
Ambulance and Referral service
Ambulance and referral service in Sierra Leone has been impacted as part of 2020/21 cuts. Ambulances left without enough fuel resulted in patients with severe complications (typically 70% mothers and children) not referred to hospitals for emergency care. Over 300 referrals were not made as a result and there were no doubt fatalities.
Evidence and Collaboration for Inclusive Development (ECID)) project
100% cuts will result in closure of programmes, which develops innovative solutions to address exclusion and barriers to accessing healthcare, water, sanitation and voting for the most marginalised people in Myanmar, Zimbabwe and Nigeria. The programme had started strengthening civil society effectiveness to use data as evidence for action in addressing issues, such as gender-based violence and girls’ education. Closure of this programme will result in challenges experienced by marginalised people going unaddressed.
3.b: Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all.
Funding significantly cut, leading to a £125m budget and a £120m gap between allocations and commitments. The consequences of the decision are far-reaching for the health and wellbeing of some of the poorest, most vulnerable and marginalised members of our global community, and for the creation of the next generation of young researchers in ODA-recipient countries and in the UK - individuals whose skills are essential in finding solutions to the many challenges facing our world.
Cuts to the research agenda damages the capacities of all of us to provide evidence for tackling these complex challenges, including for those in the UK. Health risks and vulnerabilities are shared globally, as are the solutions being developed the world over to address emerging health threats.
3.c: Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States.
Health Partnership programmes
Funding cut by 100%, from over £48m to £0. NHS overseas training schemes totally £48m in funding have been cut, including the £28.5m UK Partnerships for Health Systems (UKPHS) programme. The programme would have seen NHS staff provide training to 78,000 healthcare professionals in countries including Nepal, Uganda, Ethiopia, Bangladesh and Myanmar, benefitting more than 430,000 patients. The training would have included care for children with cancer and improving maternal and neonatal care.
Mental Health GOAL project
Funding reduced by 50%. The GOAL project led by the London School of Hygiene and Tropical Medicine and partners in Lebanon seeks to support health system strengthening for mental health care for Syrian refugees and host communities in Lebanon. This ODA cut is resulting in cuts to staff and data collection. This will undermine capacity to complete crucial research on mental health care financing and governance and will have a detrimental impact on efforts to support health systems strengthening for mental health.
7.3. As indicated in the above, these cuts will undoubtedly result in the preventable deaths of women, newborns and children; increased transmission of communicable diseases such as polio, tuberculosis, malaria and neglected tropical diseases; removal of support for mental health services; reduced access for vulnerable and marginalised people to essential, quality health services, including sexual and reproductive health care services; increased risk of ill health and health-care associated infections due to lack of investment in water, sanitation and hygiene; weakened health systems globally; and severely reduced research on global health threats.
7.4. We’re already witnessing the impacts of the cuts on health services around the world – from the sudden closure of ambulance services, leaving people unable to reach emergency healthcare, to cuts of 80% to UNAIDS, jeopardising the effective delivery of the 2021-2026 Global Aids Strategy which it endorsed only two months ago.
7.5. Many health projects that were on the cusp of success now face devastating setbacks. For example, a 95% cut to the Global Polio Eradication Initiative that was so close to achieving its goal will no doubt result in a resurgence of polio. Despite being a manifesto commitment, even programmes to improve health services for mothers and children have seen huge cuts. Up to 80% of nutrition programmes have been abruptly cancelled and there has been a significant withdrawal of funding for sexual and reproductive health programmes. This will result in an increase in child deaths and maternal mortality – in direct contradiction to the government’s ambitions.
7.6. At a time when people living all around the world are struggling with the pandemic on top of other heightened challenges – from financial insecurity to social injustices – it is becoming clear that these cuts will result in the fuel of new crises. These will be in the shape of mental health crises; the resurgence of polio; or an increased risk of ill health and other infections due to reduced funding for preventative measures such as water, sanitation and hygiene.
8. Impact upon organisations implementing UK ODA programmes
8.1. There is already evidence of organisations implementing programmes seeking to commence redundancies due to the severe scale back or full closure of programmes, having impacts on mental health and local/national economies.
Action for Global Health, IDC Inquiry: The Future of Aid, May 2021
In 2019, the UK spent more than £2.2 billion on ODA to health. See combined health totals from Table A7 (bilateral aid by sector) and Table A9 (imputed multilateral share by sector) at: https://www.gov.uk/government/statistics/statistics-on-international-development-final-uk-aid-spend-2019. In his recent statement, the Foreign Secretary indicated only £1,305 million had been allocated to ‘COVID and global health’ in 2021/22: https://questions-statements.parliament.uk/written-statements/detail/2021-04-21/hcws935. However, we should note that this figure does not include the health ODA spent by other government departments outside the Foreign, Commonwealth and Development Office (data not yet available).