A global health crisis: responding to the International Development Committee’s inquiry on longer term issues, implications and lessons to be learned from Covid-19

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.

AfGH submitted a detailed briefing and recommendations on the immediate risks and threats presented by Covid-19 within the first submission deadline. This second submission provides further learning and evidence which has emerged since then, and is intended to be additive to our first submission.

1. The emergence, incidence and spread of coronavirus virus infections and the Covid-19 disease in developing countries

1.1 The spread and impact of Covid-19 amongst older people and those with underlying chronic conditions in developing countries, especially in humanitarian contexts, is of particular concern. We know that people living with underlying chronic conditions/Non-Communicable Diseases (NCDs), such as cardiovascular disease -heart disease and stroke, diabetes, chronic lung disease and cancer, and older people are at higher risk of more severe illness or dying from Covid-19, and in some cases appear to be more susceptible to contracting Covid-19. Recent data shows that 16% of the population of Africa is at increased risk from Covid-19 due to being older or having underlying conditions.[1]

1.2 People with disabilities are also experiencing greater risk to Covid-19 as many of the preventative measures required to keep the coronavirus at bay are often inaccessible, including hand basins, sinks and communal water pumps. Physical distancing and self-isolation are impossible for many people with disabilities who rely on daily access to care, assistance or rehabilitation, and people with complex needs who require ongoing support.

1.3 The risk of spread and impact of Covid-19 in humanitarian settings such as refugee camps (with the huge challenges of social distancing or regular handwashing), particularly where there is a high NCD burden, will likely mean even higher incidence than other low and resource poor settings.

1.4 There is a strong need for disaggregated data (by gender, age, disability, ethnicity etc.) to understand who is being infected (and impacted) to ensure an effective, targeted and inclusive response.

2. The direct and indirect impacts of the outbreak on developing countries, and specific risks and threats

2.1 The spread of the Covid-19 pandemic will exacerbate existing inequalities and have huge direct and indirect impacts on developing countries. We must respond to ensure now, more than ever, no one is left behind.

2.2 There is a need to protect whistleblowers during health emergencies, so they feel empowered to report unethical or corrupt practices that may endanger the quality and effectiveness of the government response.

2.3 Impact on health workers

2.3.1 There is an increased impact of Covid-19 on health workers, in terms of increased risk of catching COVID-19 (and reduced workforce available because they are sick) and lack of personal protective equipment. These impacts will be exacerbated in humanitarian settings, low-resource settings and settings where they are already overburdened with the impact of chronic and other diseases.

2.4 Impact on other essential health services

2.4.1 Non-communicable diseases

2.4.1.1 Access to chronic disease screening and treatments/medication is reduced or stopped. In some cases, even in the most equipped and strong (UHC) health systems, people living with NCDs like cancer, dementia and stroke, are finding it more difficult to access the regular screening, treatment and care, including palliative care, that they need due to isolation/lockdown, and the strain on health systems. In developing countries - and especially in humanitarian settings - access to treatment and care for non-communicable diseases is already stretched.[2]

2.4.1.2 We need to look for new ways to ensure medicine supply during lockdown - for example, insulin to be taken home for 3 or 6 months, so that people living with NCDs do not have to leave their homes to access their medication. We should also look at how regulatory barriers to access to morphine can be addressed given the importance of morphine to address severe breathlessness.

2.4.1.3 Negative impact on mental health of the pandemic itself and the measures being taken to address it – especially so for those more vulnerable or who have lived through situations that are already very challenging to mental health (eg conflict or being displaced). Additionally, the impact on mental health relating to people not being able to see/say goodbye to their relatives, traumatic end of life experiences due to Covid-19, without good palliative care and access to crucial medications (e.g. morphine). In addition, a focus on hygiene and social distancing in communities where there simply isn’t the means to follow general guidance can greatly increase stress and anxiety, meaning messaging must be tailored for the most disadvantaged settings.

2.4.1.4 Covid-19 may undermine any gains made through governments’ increasing focus on public health and laws/policies that help prevent NCDs.

2.4.1.5 Coping mechanisms for Covid-19 (eg. increase in alcohol or tobacco consumption) have a negative impact on health and an increase or worsening of chronic conditions.

              2.4.2 Communicable diseases

2.4.2.1 Impact on countries and communities with high prevalence rates of existing infectious diseases, including HIV. HIV prevention, treatment and care services are likely to be interrupted by COVID-19 related lockdowns and the closure or scaling back of health facilities. This could lead to higher rates of HIV acquisition if communities are unable to access prevention tools and could also lead to illness if people living with HIV are unable to access their medication.  People living with HIV are being advised to stock up on medication for at least a three month period but this may not be possible for all, and there are already reports of stock-outs which will likely continue.

2.4.2.2 Modeling by the Imperial College COVID-19 response team suggests that “disruptions in services for HIV, TB and malaria in high burden low- and middle-income countries could lead to additional loss of life. In high burden settings, HIV, TB and malaria related deaths over 5 years may be increased by up to 10%, 20% and 36%, respectively, compared to if there were no COVID-19 epidemic.”[3]

2.3.3 Nutrition/impact on availability of healthier food

2.3.3.1 The Covid-19 pandemic is already disrupting global food supplies, especially in already vulnerable areas.[4] There is a risk of increased food insecurity and of reduced access to healthy diets that are essential for maintaining immune functions. Malnutrition in all its forms can then cause additional vulnerabilities and poor health. This is true in many resource poor settings but especially so in humanitarian settings such as refugee camps. We must also consider commercial determinants of health - inappropriate marketing or even donations of very unhealthy foods at a time when good nutrition is as important as ever. The Access to Nutrition Initiative (with support from DFID) is working on mapping how the private sector is influencing nutrition in developing countries - an example of how this is an international development issue.

2.4 Humanitarian settings

2.4.1 Over a million people fled from Myanmar to camps in Cox’s Bazar in Bangladesh. 33% of people living in these camps do not own soap and lack water, making regularly handwashing difficult. Their cramped conditions and paltry access to basic infrastructure also impede safe distancing and hygiene measures. Fake news and rumours, such as “Allah will save us from the virus”, put lives at risk. With partners, Christian Aid has developed a fake news tracking sheet and shared this with doctors working in health facilities to help combat rumours and reduce panic surrounding the pandemic. 

2.4.2 In Syria, the humanitarian crisis is now in its tenth year. There are 11 million people in need of humanitarian assistance and more than 6 million people internally displaced.[5] Since December 2019, more than 1 million were displaced towards the Turkish border due to the aerial bombing of towns and villages by the regime and its allies. This extreme crisis is now exacerbated further by the onset of Covid-19, which is occurring in a country in severe economic crisis with a health sector decimated by more than 9 years of war and displacement. For those who are living in displacement camps, the options to socially distance and to wash hands regularly are moot. The issues of access to aid are deepened by cross-border access points having been decreased from four to two since January 2020. In addition to this, the WHO’s mandate of working through the Ministry of Health faces immediate issues when there is no assurance that this ministry will ensure aid reaches all parts of Syria, in particular areas under opposition control.

2.4.3 In Iraq also, the humanitarian displacement crisis, with more than four million in need of humanitarian assistance is now exacerbated. Concerns have been raised that the real number of those who have contracted the virus is far greater than official statistics. Receiving only 2.5% of the annual budget, the public health sector in Iraq is dismally under-resourced, and not prepared to tackle a crisis of this magnitude, particularly once the virus reaches into the communities of the internally displaced (of which there are 1.4 million) who live in unsanitary crowded conditions, whether in camps or outside camps in temporary shelters.

2.4.4 Impact on already existing challenges and tensions between host communities and IDPs in humanitarian settings (seeing refugee communities as a burden on already overburdened health systems and other resources).

3. The UK’s response, bilaterally and with the international community, to the spread of coronavirus to developing countries

3.1 Humanitarian response

3.1.1 The WHS’ Grand Bargain commitment to channel 25% of funds “as directly as possible” to local and national actors is far from being met. While there is some discussion about what constitutes “as directly as possible”, there is a massive gap between the aspiration that this sets and total “direct” funds to national and local NGOs. In 2018, 3.1 % of humanitarian funding was disbursed directly to local and national actors. However the proportion to local and national NGOs fell from 17% in 2017 to 15% in 2018. Overall, local and national NGOs received only 0.5% of international humanitarian assistance in 2018 (Global Humanitarian Assistance report, 2019). Yet learning from the Ebola response is that these actors, and especially faith-based organisations, are at the frontline of this response. While the UK has recently committed a further £200 million to the response, only 9% of this, £18 million, was set aside for NGOs for 15 countries, and only those with pre-approved partnerships with DFID. This is woefully inadequate. While DFID requires that its partners declare the amount of funding reaching frontline partners, and that overheads should be shared equally with partners, this is welcome but only a first step towards funding local and national NGOs “as directly as possible” since 2016.

3.1.2 To meet its World Humanitarian Summit commitments, and in line with the Inter-Agency Standing Committee Principals’ acknowledgement of the role of local partners in the coronavirus response, (“our local partners who are critical enablers in the overall response”), DFID should invest in an acceleration in localisation efforts, ensuring that frontline responders in communities, including faith-based organisations, receive direct funds for operational costs, cash interventions which enhance social protection, and for disaster preparedness and resilience measures, all in line with the Core Humanitarian Standard.

3.1.3 Past experience has shown that health-related humanitarian operations have the potential to be securitized, politicized and to lead to mistrust and stigmatization if not conducted in a manner that is understanding of local context and culture. Local and national NGOs will often be best placed to bridge this gap, including understanding local community perspectives. Local actors may be best placed not only to understand the implications of the health emergency for the communities they serve, but also to ensure that communities themselves are able to drive humanitarian decision-making and response adaptation. The potentially serious health risk associated with the COVID-19 response adds to the need to ensure that local and national partners are appropriately supplied and supported to effectively respond while caring for the health, safety and security of their staff. This is a compelling argument for all donors to urgently and comprehensively increase the level of unrestricted core funding support to local and national actors. Currently, when local partners are recipients of humanitarian funding their allowable indirect costs are typically limited. This impedes the ability of local partners to develop the necessary systems to improve staff capacity, ensure accountability, and provide for staff care and safety.

3.1.4 In line with the recent Inter-Agency Standing Committee guidance on the flexibility of funding during the COVID-19 response, DFID should demonstrate flexibility within existing grant budgets and allow a timely reprogramming of funds, expedite new grants and ensure that funding mechanisms are more accessible to frontline responders by simplifying due diligence and risk management processes, and to enable full cost recovery and adequate indirect cost rates.

3.2 Access to palliative care

3.2.1 Access to palliative care is hugely inequitable and the mainstreaming of palliative care within health systems has not happened in most settings. In most low and middle income countries, people with Covid-19 do not have access to palliative care including medications such as morphine which are crucial for severe breathlessness.

3.2.2 Health care workers are not trained in essential palliative care (including end of life care) and there are serious concerns for the consequences on their own mental health as well as the care of people with Covid-19 and their family.

3.2.3 Essential palliative care medicines (in line with WHO’s essential medicines list) are not available and accessible in most low and middle income health and community care settings.

3.2.4 Hospice and palliative care services often sit outside mainstream health services meaning health care workers and community carers are not provided with PPE, despite caring for those who are some of the most vulnerable and potentially with the highest viral load.

3.2.5 This is a gap in the international response. The UK government is the home of palliative care and has integrated palliative care in its own Covid-19 response in the UK, including taking measures such as banning parallel exports of essential palliative care medicines such as morphine.[6] The UK government must ensure palliative care is part of any Covid-19 international response, not as a luxury but as a necessity, alongside prevention and treatment. The UK Government must work to ensure a longer term shift to strengthen health systems through UHC which fully integrates palliative care, ensuring the best possible quality of life for people of all ages and their family members/carers, whatever the serious illness.

3.2.6 Funding must include a focus on those most at risk from the impacts of Covid-19 (ie older people and those with underlying chronic conditions) and must take a rights-based approach (non-discrimination).

3.2.7 The UK government must ensure that palliative care is mainstreamed into Covid-19 responses including the training of health care workers at all levels and access to palliative medications including morphine. Palliative care is not a luxury add-on, it is a necessity both for many people with Covid-19 and for those with NCDs that require palliative care.

3.4 Access to medicines

3.4.1 Challenges include: pharmaceutical monopolies, including intellectual property; a lack of public return on taxpayer investments in research and development; a lack of transparency; weak international coordination for the sharing of rights; inadequate production capacities to meet global supply; skewed incentives for health innovation; substandard and falsified medicines; embezzlement of medicines.

3.4.2 Recommendations for access to Covid-19 technologies include:

i. Attach conditions to public funding for R&D – these should ensure affordability, transparency, etc but also an open innovation approach, through the mandatory sharing of know-how, clinical trial data and health technologies.

ii. Make intellectual property rules work for public health – examples of governments adopting legalisation to make it easier to use compulsory licenses for COVID-19 are here.

iii. UK and other public funders should mandate companies to share concerned technologies, data and knowledge with a global pool of rights for open innovation, mass production and equitable access. This pool must include:

1. All needed technologies, knowledge and data (cannot rely on companies to deliver for public health on their own and must not rely on pharmaceutical companies to voluntarily and selectively decide which information or technologies they will pool)
2. Ensure rights for all to use and produce, by not allowing monopolies
3. Ensure full transparency of stakeholder negotiations, production, prices and stockpiling
4. Serve all countries
5. Make the above conditional to receiving public funds

iv. Ensure global and transparent coordination of production and distribution of COVID-19 technologies.

v. Introduce transparency and accountability measures/regulations to ensure the quality and availability of medicines.

vi. There must be global coordination of production and distribution led by WHO but also every effort must be made to overcome pharma monopolies that may limit the support of COVID-19 technologies and lead to scarcity.

vii. The UK should support, fund and expand delinkage models. Pharmaceutical companies do not invest heavily in emerging infectious diseases or areas that do not offer sufficient financial incentives. This article shows how research into a coronavirus vaccine a few years ago dried up because of lack of investment interest. Need to invest in de-linkage models that do not rely on IP and are driven by public health needs.

3.4.3 The Access to COVID-19 tools Accelerator, which the UK and other countries committed to, and the EU Resolution to the World Health Assembly are two ways to drive these solutions forward at the global level. However, the Accelerator will not have a new governance structure. We are therefore concerned about the ability for donors to be held to account on their financial pledges and commitments to equitable access. The new funding (from the pledges conference) will be driven through existing mechanisms, such as CEPI or GAVI.

4. Lessons identified and learned/applied from previous experience with infectious diseases

4.1 Learning from Ebola: community-based interventions

4.1.1 The confidence that initially existed in a purely medical approach to the Ebola virus disease outbreak was misplaced; health facilities, treatment units and case management were important. But they missed an essential element: to mobilise communities to change behaviour. In many cases neither health staff nor government could do this. Instead, the local community itself was best placed to effect change, and faith leaders, as trusted and respected members of communities, played an important role as agents of social change.

4.1.2 One of the most important lessons from the Ebola response is the importance of going beyond traditional response models for non-traditional crises. Ebola could not be addressed by the secular humanitarian system and neither could it be brought under control as a consequence of the actions of faith communities alone; it was both of these, plus traditional leaders, working together, that offered potential to improve the situation. A key lesson was that future responses must involve faith communities and invest in the response of faith-based organisations very early in the response in order to save lives.

4.1.3 In Sierra Leone, Christian and Muslim faith leaders established an important ground rule: to focus on issues that united them against the virus. This led to conversation on how to address the Ebola outbreak and to find similarities in their religious texts in how to promote behaviour change. The coherence in messaging of the two major religions and the unity of message delivery was a key platform for change.

4.1.4 Lessons from the HIV response identified to address the Ebola crisis included: rapid, point of care testing, addressing stigma and fear, screening those exposed and protecting health care workers.[7] The Global Network of People Living with HIV has also highlighted the experience in the HIV sector of using community systems to deliver care which eases pressure on health facilities.[8]

5. The implications for DFID’s policy on a global health strategy

5.1 The UK needs a cross-government global health strategy

              5.1.1 The UK government does not have a dedicated, public strategy – or any current comprehensive document - guiding its work in global health. If the 2015 UK aid strategy is now outdated, then the last strategies issued by the UK Government focused on global health are even more so. Health Is Global – A UK Government Strategy 2008-13 is the last complete strategy document which covered the UK’s global health work, and was widely considered to be an innovative model of cross-departmental collaboration. Since this strategy expired in 2013, the UK government (including DFID) have stated repeatedly that they do not plan to publish a new global health strategy, despite calls from the International Development Committee for the government to develop a global health strategy as long ago as 2014.[9] The call for a global health strategy is supported by other notable individuals, such as the former Chief Medical Officer Sally Davies in her final report, where her first recommendation to the UK government was that they ‘publish a set of shared global health objectives as soon as possible and publish a renewed shared global health strategy by the end of 2019’.[10]

5.1.2 In light of Covid-19, the need for a cross-government global health strategy is more apparent than ever. We believe that it is essential that the UK government has a coordinated and targeted approach to global health, and that this is best articulated through a global health strategy.

5.1.3 Additionally, it is also worth noting that the need for a global health strategy is further accentuated by the delays in other significant documentation around the UK’s role in global health. A Health Systems Strengthening Position Paper has been under preparation for over four years, but no date for publication is as yet confirmed. DFID had additionally recently begun work on a new Ending Preventable Deaths Action Plan but the publication was postponed due to Covid-19 with no clear timeframe of when the Action Plan will be made operational or commitment to publish.

5.1.4 All of these plans and a global health strategy could have been essential in providing a framework within which to guide the UK government’s international response to Covid-19 (and in holding the UK government accountable), as well as in assessing the impact of Covid-19 on the UK’s other global health priorities.

6. The impact of the outbreak on UK aid funding in the longer term

6.1 Building back better

6.1.1 Covid-19 emphasises the need to focus on ‘building back better’, with a real focus on equitable Universal Health Coverage (UHC). This must include a trained and supported health workforce.

6.1.2 Building back better must also include much broader issues that impact on global health, such as air pollution, focus on reduction in climate change, introducing anti-corruption measures into aid funding/programming, combating malnutrition in all its forms (including obesity), physical activity and the commercial determinants of health.

6.2 Impact on amount of ODA

6.2.1 Due to the broader economic context meaning the aid budget is likely to be reduced, and the additional expense of Covid-19 (alongside the current UK aid portfolio), cuts to existing programming are likely to have to be made in the long-term.

7. The impact of the outbreak on DFID’s operations (staff absences or reassignments, the impact of travel restrictions and other risk mitigation measures)

7.1 We would urge DFID to start to gather lessons now from its country offices about how in the future their funding mechanisms can be activated quickly to adequately fund local and national frontline NGOs and faith-based actors from the outset, when it is already clear that they will need to deliver the bulk of the response and remote management will not be adequate.