COVID-19, Humanitarian Crises and UK Response

              Written Evidence to the International Development Select Committee             

Kalipso Chalkidou; Carleigh Krubiner; Patrick Saez; Ian Mitchell

Center for Global Development

8th May 2020

This note sets out a brief assessment of COVID-19 in the developing world, highlights the UK’s strengths, successes, and mandate in the global response and identifies four areas where the UK should be building on this leadership.

COVID-19 and its development and humanitarian impact

The COVID-19 pandemic presents developing countries with incredibly difficult policy choices. Modelling by Imperial College and London School of Hygiene and Tropical Medicine (LSHTM) predict that many countries could see over 90% of their population affected, and hundreds of thousands of deaths in the course of a few months, unless they act decisively. Many countries have decided to act. Unprecedented lockdowns are currently in force in over 115 countries. Meanwhile, a nutrition and economic crisis is looming, with developing countries now experiencing unprecedented economic slowdown due to policy decisions taken by their own governments, and due to shut downs carried out by wealthy countries in response to the virus. In Africa, the economic crisis preceded the COVID-19 healthcare crisis. International agencies have warned that 49 million Africans may be pushed into extreme poverty, a quarter of a billion people could face starvation (see below) and that routine services have already been interrupted, resulting in an estimated 13.5m children will miss vital vaccinations.

Fragile and conflict-affected countries, from Yemen to South-Sudan, where the most vulnerable already rely on humanitarian assistance to survive, face particular difficulties with health systems weakened by conflict and crisis and populations with pre-existing vulnerabilities. Camps and informal settlements for refugees, migrants and internally displaced persons are some of the most densely populated areas in the world, making them particularly at risk. The UN has warned that the number of people at risk of starvation could double to 265 million as a result. Tensions arising from the imposition of containment measures could exacerbate violent conflict, although the fight against the pandemic could also offer opportunities to negotiate ceasefires.

UK as a leader on global health

The UK has a strong track record of supporting international health—it was a founding member of the Global Fund (to end AIDS, tuberculosis and malaria as epidemics) and a founding member of Gavi (on direct grants but also for Advance Market Commitments (AMC) and the International Finance Facility for Immunisation (IFFIm)—which increasingly have a role in Gavi’s approach to address COVID-19. The UK is also the only one of the World Health Organisation’s top 10 supporting countries to provide voluntary core funding which enables the organisation to fund its priorities and respond flexibly. The UK also played an important role in responding to Ebola which was praised by the Independent Commission for Aid Impact (ICAI).

UK response and the role of vaccines

Internationally, the UK has responded well⁠—suspending debt, funding and acting multilaterally, and supporting the trade system. It has also pledged £250 million, the biggest donation by any country, to the Coalition for Epidemic Preparedness Innovations (CEPI) for vaccine development, as well as launching a Vaccine Taskforce.

The tremendous investments in COVID-19 therapies and vaccines offer promise for more effective tools to combat this pandemic threat and a potential pathway out of the pandemic. This is particularly important as many extreme distancing measures are infeasible or inadvisable in lower income settings—like those in Malawi—due to the severe harms they impose for those without adequate access to food, water and sanitation, education, and essential health care amidst strict lockdowns 

Despite verbal commitments to promote equitable access to COVID-19 vaccines and therapeutics, without innovative financing mechanisms and globally coordinated efforts, the limited supply of vaccines and therapeutics will go disproportionately to high-income settings, leaving poorer nations with delayed, insufficient, or suboptimal products for those who may face even greater risk of disease and death. While Gavi has expressed interest in an Advance Market Commitment, with a cost-plus strategy and establishing a stockpile, there remain many questions about how decisions will be made regarding the selection of products, allocation criteria, and governance. Additionally, while Gavi may be able to sufficiently support lower income countries that traditionally fall under their eligibility criteria, additional strategies may be required to enable market access for middle-income countries.

Given these challenges, we identify four areas where the UK can do more.

1) Lead the way on “equitable access” to vaccines and therapeutics

The UK should lead the way in shaping how Gavi and other global efforts leverage strategies to promote appropriate, equitable, and efficient global stewardship of epidemic vaccines and therapeutics⁠—with attention to global procurement and financing mechanisms as well as appropriate allocation criteria and governance structures. This would involve:

-          Promoting access, affordability, and value across settings ⁠— The UK can support strategic spending on novel COVID drugs and vaccines, using the experience of the National Institute for Health Research and National Institute for Clinical Excellent (NICE) to develop a prototype for assessing the value of forthcoming interventions in different contexts. For vaccines, these value assessments can form the basis for innovative demand-side incentives, specifically a value-based advance market commitment approach that simultaneously promotes market access for lower and middle income countries through value-based pricing, while proactively signalling demand to attract the significant private investment needed to bring these products to market⁠—all without requiring national government to commit large sums in advance. Using early health technology assessment (HTA), already piloted for therapeutics, to understand how helpful a vaccine would be in different country contexts, and to assess each country’s ability to pay would ensure neither the NHS nor much poorer nations have to pay prohibitively high prices, paving the way for countries across different income levels to secure vaccines for their populations that are both affordable and good value-for-money. 

-          Allocation and oversight of global supplies of vaccines and testing ⁠—there are a number of issues the UK should consider now in relation to vaccines and access, in particular: the UK should convene, perhaps using a platform such as the Royal Society, a multicountry multidisciplinary platform for addressing the following: (1) institutional arrangements for the management and governance of global stockpiles; (2) financing of medical countermeasures; (3) decision criteria and evidence around the volume and mix products that compose global stockpiles; and (4) norms and criteria for allocation of vaccines and therapeutics, across and within different populations and country contexts. We set out a framework for doing so here. With deep commitments to bringing forth effective countermeasures and ensuring equitable global access, the UK government should, together with partners such as the Wellcome Trust, support much-needed research to guide appropriate stewardship of these critical resources.

2) Strengthen global health institutions and core capacities for Global Health Security

-          Make the global health architecture more effective and agile ⁠— The UK should continue to support the WHO and be ready to address funding gaps. But a wider review will be needed of global health security infrastructure when, at the appropriate moment, the experience of the pandemic can provide a learning opportunity to examine and address inefficiencies and shortcomings of WHO processes, but perhaps more importantly the limitations of the International Health Regulations which dictate reporting access are set and agreed by countries. Changes can build on progress made following the West African Ebola Crisis. This includes empowering the Global Preparedness Monitoring Board with a stronger mandate and ability to monitor progress and promote accountability for action.

-          Establish a Global Health Security Challenge Fund ⁠— with an estimated $4.5 billion annual financing gap for preparedness, especially among LICs and LMICs, there is a clear need for a new global financing platform to align and mobilize additional resources in support of country preparedness plans. The Fund would complement the WHO’s Contingency Fund for Emergencies and existing emergency response and preparedness funding available through the UN and the World Bank by strengthening countries’ long-term preparedness capacity and ensuring that preparedness remains a political and budget priority. Specific recommendations for the G7 and G20 members to operationalise the fund are detailed here.

-          Strengthen health information systems and surveillance capacity at country level ⁠— reliable disease surveillance systems, routine health information systems, and civil registration and vital statistics remain some of the most critical data sources for protecting and promoting health and welfare, with tremendous value during and between epidemics. Vital statistics systems alone provide data to monitor 12 of the 17 SDGs and 67 of the 232 SDG indicators, yet over 110 lower middle income countries do not have functioning systems. As discussed here and here, donor support to countries should focus on building the essential data and research infrastructure to make evidence-informed decisions for health, in service of universal health coverage and health security. The UK can lead the way in calling for a data compact with a focus on disease surveillance data and better vital statistics. Initiatives such as this are working to strengthen national Offices of National Statistics but more is needed to incentivise countries to collect and share data and support them in doing so. CGD and the African Population and Health Research Center called for a data compact. Now is the time to invest in traditional epi systems alongside high tech digital solutions so that during the next outbreak countries do not rely solely on modelled estimates of infection rates imported from the global North.

3) Address deficiencies in the humanitarian system

The response to this crisis will need to be fundamentally different to other humanitarian emergencies because of its global nature and the restrictions on international humanitarian personnel; the UK should champion a new approach.

The pandemic has shone a light on the long-standing deficiencies of the international humanitarian business model. This uses a ‘begging-bowl’ approach that relies on voluntary contributions from individual donor governments. The UN-led humanitarian system has appealed for $2bn to mount an emergency response. As of today, the appeal has only been 59% funded. Critically, the crisis and governments’ response to it challenges a model based on surging international aid workers and other resources to a single country or region. The ability of international humanitarian agencies to stay in-country⁠—let alone surge additional personnel⁠—needs to be balanced with duty-of-care. Some governments and non-state armed groups are also using the pandemic to justify additional constraints

on the entry and movement of foreign aid workers. While the UN response plan includes a vast logistics effort to fly in resources and staff to compensate for the lack of commercial flights, and regional field hospitals to treat aid workers with COVID-19, this is unlikely to be sufficient to circumvent access and movement constraints. Supporting national and local ownership of the response should be an immediate priority. Yet the UN appeal only pays lip service to this: 95% of the funding it seeks is for the UN agencies themselves.

As a long-time proponent of humanitarian reform, DFID should champion a new way to plan, coordinate and finance the response to COVID-19 with other like-minded donors in the G7 and G20 and in coordination with the UN and the international financial institutions.  This would include:

-          A common surveillance and early warning mechanism to better anticipate the primary and secondary impacts of the pandemics in fragile countries, act early to mitigate those impacts, while we still can (according to the UN the peak of outbreaks in these countries is expected to occur in 3-6 months) and adapt to future changes;

-          A common approach that prioritizes support to national systems and local frontline responders rather than creating a parallel international response on the ground. For instance: upskilling national healthcare workers and equipping local healthcare structures with supplies such as PPE, and supporting nation-wide surveillance and testing. On the income protection front: supporting cash transfers through adapted national social safety nets or civil society organisations. The role of international humanitarian organizations should focus on enabling the national response - for example by setting norms and monitoring the quality of the local response and providing much needed financing, logistics and procurement capacity. They would only deliver directly where national and local systems are inexistent or unwilling to help certain population groups (e.g. refugees, migrants, minority ethnic or religious groups);

-          A common financing strategy at the country level: frontloading resources for early action and adaptation according to forecasts, layering different sources of finance according to the agreed response model for each country and establishing platforms to finance local civil society groups;

-          Real-time evaluation and lesson-learning, which would inform future reforms of the international crisis response architecture.

4) UK government support on aid levels; Brexit and COVID-19 operations

There are a number of other non-health and humanitarian areas where the UK will also need to take action. Specifically:

-          Exceeding 0.7% ⁠— As the economy shrinks, the government’s aid spend will need to exceed the 0.7% target to meet needs. The 0.7% target is a minimum, not a maximum and “doing what it takes” with unprecedented fiscal expansion must surely apply to the poorest too. Within the aid budget it will need to ensure funding is focussed on need, pausing lower urgency and priority areas of spend in line with evidence

-          No deal Brexit trade risk ⁠— a number of countries ⁠— Ghana, Cote D'ivoire, Cameroon, Algeria face a further risk of new UK-imposed trade barriers in January 2021 as their EU trade agreements have not been rolled over. This is particularly acute for Kenya, who are also facing a locust plague

-          Operations challenges ⁠— DFID will need to meet the challenge of operating with significantly fewer in-country staff, and avoid the risks that non-COVID priorities and programmes suffer