WRITTEN EVIDENCE BY RESULTS UK TO THE INTERNATIONAL DEVELOPMENT COMMITTEE INQUIRY ON HUMANITARIAN CRISES MONITORING: IMPACT OF CORONAVIRUS

About RESULTS UK

RESULTS UK seeks to mobilise the public and political will to end extreme poverty. We undertake strategic policy, parliamentary and grassroots advocacy on three key determinants of poverty: economic opportunities, health and education, with a particular focus on child vaccinations, tuberculosis (TB), education and nutrition.

This submission will explore the following points, as outlined in the inquiry’s Terms of Reference:
 

●        The longer term impacts of the pandemic on developing countries

●        The longer term impact of the pandemic on the Department for International Development’s (DFID) operations

●        The impact of the pandemic on UK aid funding in the longer term

This submission will highlight the potential longer term impact of COVID-19 on: 1) international development finance; 2) the UK’s Official Development Assistance (ODA) budget; 3) programmes; 4) research and development (R&D), and innovation; 4). As a member of both Bond and Action for Global Health, RESULTS UK endorses their submissions to this inquiry.

How will COVID-19 affect international development finance?

1. Existing institutions and multilaterals are well placed to respond to COVID-19. For example, the World Health Organisation (WHO) can lead in global health coordination, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund) and Gavi, the Vaccine Alliance, are able to rapidly channel resources to support the most vulnerable, the Coalition for Epidemic Preparedness Innovations (CEPI) and Unitaid will be crucial to develop new tools, and the Global Polio Eradication Initiative (GPEI) is experienced in surveillance. However, international funding for global health is already being affected by the COVID-19 pandemic.

2. The Global Fund is the largest multilateral financing mechanism for health systems strengthening. It invests over US$1 billion per year in its programmes which include training health workers, improving supply chain and laboratory capacity, and strengthening surveillance. This has enabled the Global Fund to take swift action in response to COVID-19, alongside WHO and other global health partners. In response to COVID-19, the fund has made available up to US$1 billion through grant flexibilities and the COVID-19 Response Mechanism[1].
    
3. Whilst this reprogramming is important for the global COVID-19 response and will help protect programmes for the three diseases during the pandemic, it will result in less Global Fund financing in the longer term for TB programmes. Prior to the pandemic, TB programmes would typically receive 30% of the Global Fund’s unspent or unallocated pot, called Portfolio Optimisation money, which is now part of the grant flexibilities pot for the Global Fund’s COVID-19 response.

4. The financial requirements for global efforts to eradicate polio are also likely to rise. The pausing of polio immunisation activities in response to the COVID-19 pandemic, will almost certainly increase the number of polio cases in the short-term. In the longer term, this will likely postpone the certification of global polio eradication, therefore requiring GPEI to exist beyond its intended wind-down date of 2023. In doing so, this will necessitate further financial commitments beyond those outlined in the 2019-2023 GPEI Investment Case.
    
5. The COVID-19 pandemic has postponed many replenishment moments where DFID would often make multi-year financial and policy pledges. Uncertainties about the size of the future ODA budget, as well as staff and resources within DFID being redeployed to address COVID-19, make it more challenging to devise business cases and receive ministerial sign-off for commitments.

6. An area of DFID spending of particular concern is nutrition. There is currently no DFID money allocated for nutrition from the start of 2021. DFID had been expected to renew its commitment to nutrition at the Nutrition for Growth (N4G) summit, which would have been in Tokyo in December 2020, with a pre-summit event in July. Both events have been postponed with no decision made on when they will take place. It is unlikely that there will be an in-person event in 2020. DFID is a global leader in nutrition as the UK hosted the first ever N4G summit in 2013. Prior to COVID-19, RESULTS UK had been advocating for DFID to use its influence and pledge early in order to leverage other donors and domestic resources. To avoid a cliff edge in nutrition financing, DFID could either rollover existing commitments for nutrition into 2021 or make a multi-year financial N4G commitment in 2020. RESULTS UK strongly recommends the latter because:

7. DFID financing for nutrition has fluctuated considerably in recent years. It is unclear how the rollover figure would be calculated or what it would be. Additionally, certainty about future financing is invaluable in the current context, when economic uncertainty is making it difficult for many DFID partner governments to make long term domestic resource commitments.

8. COVID-19 is reversing years of progress on nutrition, with every percentage point contraction in global Gross Domestic Product (GDP) as a result of COVID-19 likely to increase the number of stunted children by 4 million and raise the number of people vulnerable to infectious diseases like TB. In order to mitigate the long term effects of COVID-19 on nutrition, there is an urgent need to increase resources and reform policies to ensure maximum reach and effectiveness. Rolling over existing finances is a stop gap solution that will not accelerate meaningful progress in the same way as a renewed multi-year commitment.

9. COVID-19 will interrupt progress on many internationally agreed health targets. In 2015, world leaders committed to ending TB by 2030 as part of the Sustainable Development Goals, a target that under current projections is unlikely to be achieved for 100 years. To address this, the UN convened a High-Level Meeting on TB in 2018, where countries committed to a series of steps to accelerate national and international responses to the disease, and agreed to meet targets by 2022. The implication of COVID-19 on TB services will be significant and efforts will need to be made to develop new roadmaps and action plans to meet targets.

10. Immunisation funding is already seeing huge paradigm shifts in the way that donors approach the funding of R&D and delivery programmes. The UK’s recent commitment to Gavi is welcomed, as it will be an effective mechanism for the delivery of any COVID-19 vaccine to the world’s poorest countries.
     

RECOMMENDATIONS:

●        The UK should channel a portion of COVID-19 response funds through additional, targeted support through the Global Fund. This will enable a rapid, highly effective response on a scale that will be difficult to replicate through bilateral spending.
 

●        In addition to programmatic investments, the UK should support the Global Fund in providing technical assistance to countries managing COVID-19 and to ensure the continuation of current TB, HIV, malaria, community, rights and gender, and health systems strengthening programming, both at country and secretariat level.  
 

●        The UK is a key donor to GPEI. DFID’s commitment will need to be sustained until global polio eradication is achieved. This should include continued engagement with GPEI’s work to improve its governance and integration between polio eradication and wider essential immunisation activities.
 

●        Where appropriate, the UK should continue to encourage pledges from other countries to GPEI to meet financial gaps.

●        DFID must not allow the lack of pledging moments to cause cliff edges in financing for any part of its human development portfolio, especially nutrition. Where possible, DFID should make multi-year financial commitments and not simply rollover existing commitments by another year.
 

●        The UK should leverage other donors to make ambitious pledges to Gavi ahead of the June 2020 Global Vaccine Summit to ensure a fully-funded Gavi can implement the Gavi 5.0 strategy.

How will the economic effects of COVID-19 affect ODA availability?

1. The International Monetary Fund (IMF) predicts that the world economy will shrink by 3% in 2020 due to COVID-19, with a “substantial” risk of a more protracted recession[2]. This global downturn will have a devastating effect on many of the world’s poorest people. In addition to job losses, government debt is predicted to rise and there will be less domestic resources for governments to invest in health, education and social protection.

2. Equally, there is likely to be less ODA available globally. Under the IMF’s baseline scenario, global ODA is set to decrease by $10bn to $143bn in 2020[3]. If a more protracted recession occurs, global ODA could continue to fall throughout 2021 by up to $25bn[4].

3. The Office for Budget Responsibility has predicted a 13% decline in UK GDP in 2020[5]. As the International Development Act sets the ODA budget at 0.7% of Gross National Income, we can expect to see a commensurate reduction in UK ODA. Current predictions forecast a worst-case scenario of up to a $2.2bn reduction between 2019-2021[6].

4. The reduction in ODA, when many of the world’s poorest countries are already suffering economically, will have severe long-term consequences for the health and economic wellbeing of the most vulnerable.  

5. The UK Government has committed to spending more ODA through other government departments (OGDs)[7]. The UK Government has also declared that all OGDs spending ODA should be ranked as ‘Good’ or ‘Very Good’ in the International Aid Transparency Index.

6. In 2018, 25% of ODA was spent by OGDs[8]. Currently only DFID, and the departments of health and social care, and business energy and industrial strategy, scored ‘Good’ or ‘Very Good’ in the UK Aid Transparency Review[9]. Those three departments are responsible for 82% of ODA, meaning that 18% is spent by departments scoring ‘Fair,’ ‘Poor’ or ‘Very Poor.’

RECOMMENDATIONS:

●        Given the predicted reduction in ODA at a time when demands on ODA will be higher than ever, the Government should revise their policy of spending more ODA through OGDs and should instead seek to protect or increase DFID’s share of ODA.

●        The Government should only spend ODA on programmes that are proven to be high impact.

●        Mitigating the secondary impacts of COVID-19 will require an increased focus on health, education, economic development and social protection. The Government should protect or increase ODA spending in these areas.

What will COVID-19’s impact be on programming? 
 

1.      Developing countries’ programming for TB, nutrition and immunisations are already being affected by COVID-19, a trend likely to worsen as the pandemic develops. Lessons must be learnt from previous epidemics such as the 2014-15 Ebola epidemic, where there was a 53% decrease in the diagnosis of TB and a doubling of the TB mortality rate in Guinea.

2.      COVID-19  is causing various disruptions to TB programmes, including the following: repurposing GeneXpert machines for COVID-19 testing; personal protective equipment for health workers being used for COVID-19 leaving a shortage for TB workers, repurposing of national TB budgets; conversion of drug-resistant TB wards to COVID-19 wards and disruptions to supplies of essential TB medical commodities. Latest estimates show that a 3-month lockdown and protracted 10-month restoration could lead to an additional 6.3 million cases of TB and an additional 1.4 million TB deaths between 2020 and 2025[10]. This means that global TB incidence and deaths in 2021 would increase to levels last seen in 2013 and 2016 respectively.

3.      Like COVID-19, better prevention, diagnosis and treatment of TB requires strong health systems for case detection and screening, laboratory capacity, supply chain capacity and trained health workers. Prior to the pandemic, an average of 30% of new TB cases were undiagnosed or unreported each year, but in low-resource high burden countries the TB infrastructure is unparalleled in terms of respiratory specialist staff, diagnostic networks which include contact tracing, specimen transport, laboratories, and the tens of thousands of GeneXpert diagnostic machines. This makes it well placed to respond to new emergencies, including COVID-19. Additionally, the US Food and Drug Administration has approved a COVID-19 cartridge that can be run on GeneXpert machines, which are closer to point-of-care than any other COVID-19 test currently available.

4.      However, Cepheid, the manufacturer of both diagnostic modules, has stated its intention to repurpose existing manufacturing plants to meet demand for COVID-19 cartridges, which will likely impact global TB cartridge availability. This repurposing of TB infrastructure must not be at the expense of TB service provision, which should receive increased investment to provide additional capacity for COVID-19. Failing to do so will be at the detriment of the COVID-19 response and see increases in TB infection rates, mortality and drug-resistance. 10-15 additional TB infections are transmitted per person with untreated TB per year. Mortality rates for untreated drug-susceptible and drug-resistant TB are 23% and 30% respectively.

5.      The COVID-19 pandemic greatly increases the risks and likelihood of disrupted supply chains, resulting in treatment interruptions. As global transport networks are reduced, national stockpiling efforts affect usual procurement patterns, and as countries involved in TB medication manufacturing are affected, there may be delays and stock outs in the procurement chain. As the majority of TB drugs are manufactured in India, with minimal competition, the implications of the Indian lockdown are likely to be considerable, with most Indian suppliers operating at 25% production capacity or less. If health systems are overwhelmed or there are staff shortages, stock management may be de-prioritised or rendered impossible. The Global Drug Facility (GDF), which has been an effective mechanism for the supply of affordable, quality-assured TB drugs to countries in need over the last two decades, will be key to mitigating supply chain disruption.

6.      Trade restrictions are significantly disrupting vaccine supply chains,[11] whilst travel restrictions at national and international levels are impeding the delivery of vaccinations. The disruption to immunisation means many children will miss out of routine vaccinations during the pandemic. It is, therefore, vital that all necessary measures are taken to intensify vaccine and essential medicines delivery. Rapidly addressing disruption to vaccine frontline delivery, supply chains and international transportation will be critical to reaching those at risk of, or currently, being missed.

 

7.      Communities play a key role in strengthening TB responses through outreach, education and prevention activities. Such interventions will be crucial in strengthening and sustaining responses to COVID-19. This is especially important for neglected, marginalised, vulnerable or criminalised populations, and for breaking down human rights and stigma-related barriers to accessing healthcare.
 

8.      As outlined, polio eradication efforts have been paused until at least the second half of 2020. These efforts will need to restart stronger than ever, as soon as possible, and should include strengthening routine immunisation systems. To ensure that the world does not see a resurgence of polio beyond what is caused by the current pause in immunisation activities, continued financial, programmatic and political support is required.
 

9.      COVID-19 has significantly impacted the ability of healthcare workers to deliver routine immunisation services. A recent assessment of the Africa region by WHO estimates that 46% of countries have partially or fully halted outreach services, and 67% of countries have delayed supplementary immunisation activities.[12] Gavi has also seen its immunisation services reduced in 21 countries. Due to lockdowns, people have been unable or unwilling to travel to health centres for immunisations.
 

10.  To date, 14 Gavi supported vaccination campaigns against diseases like measles, polio, cholera and HPV have been postponed.[13] Additionally, four national vaccination introduction programmes have been postponed, impacting countries’ ability to vaccinate against other diseases. Gavi is also increasingly diverting their health system strengthening budget (crucial for developing resilience to health crises and building sustainable health systems) towards COVID-19.

RECOMMENDATIONS:

●        The UK should issue guidance to, and funding for, DFID country programmes on adapting and sustaining TB programmes alongside COVID-19 responses. For example, on adapting TB services to ensure people with TB continue to receive their medication, and to address the need for surge support for TB programmes that reflect the unique intersections of both responses and vulnerabilities of people with TB.
 

●        The UK should provide flexible funding support to the GDF to support supply and procurement systems, and facilitate a quick and flexible response to urgently address stock outs of TB commodities globally.
 

●        RESULTS UK welcomes the UK’s recent commitment to Gavi of £1.65 billion between 2021-2025[14]. The UK should leverage its position as a leading donor and member of the Gavi board to ensure that the Gavi 5.0 strategy (2021-2025) includes improved and tangible commitments to equity and access, to ensure universal access to COVID-19 vaccines once available, alongside other WHO recommended vaccines.
 

●        The UK should work with all relevant development partners to intensify the delivery of routine immunisation programmes and overcome trade and transportation restrictions. This should include vaccination at country levels, enabling an adequate supply chain and moving rapidly to ensure the transportation of routine vaccines internationally and domestically. 
 

What Impact will COVID-19 have on R&D, and innovation?

1. There is a significant risk of delays to vital global health R&D as research infrastructure, professionals and funding are repurposed for COVID-19 innovation. It is expected that there will be widespread delays to clinical trials for TB and other disease research.
    
2. New COVID-19 innovations need to be accessible and affordable to all in order to avoid exacerbating inequalities between and within countries, regardless of ability to pay. The UK and other countries should ensure access conditions are attached to publicly-funded innovations, which applies evenly between high-income, low-income and conflict-affected countries.

RECOMMENDATIONS

●        The UK should endorse: the proposal by the Costa Rican Government to pool all COVID-19 intellectual property rights for COVID-19 vaccines, treatments and diagnostics at a WHO-level to ensure equitable access; that the COVID-19 vaccine becomes a part of routine immunisation delivery; that the UK Government convened taskforce[15] ensures that pharmaceutical companies such as GSK and Sanofi Pasteur[16] continue to operate effectively in partnership to deliver the R&D and manufacturing needed to produce enough vaccines quickly.
 

●        RESULTS UK welcomes the UK’s recent funding commitment to CEPI[17], which will be essential in developing a COVID-19 vaccine. The UK should impose public interest conditions on all funding committed to develop COVID-19 vaccines, treatments and diagnostics. These should ensure that the final product is affordable, accessible and available to everyone who needs it, whether in the UK or developing countries.
 

●        Conditions should include full transparency in all stages of R&D, including registration and public reporting of clinical trial data, R&D costs, manufacturing costs and product prices. Any contracts agreed with companies and partners using public funds should also be made publicly available