Health systems neglected by COVID-19 donors.

The Access to COVID-19 Tools Accelerator is short of billions of dollars, and the funds committed so far are skewed towards vaccines, with little for health systems. Ann Danaiya Usher reports.

Weak health systems buckling under the weight of the COVID-19 pandemic have received little support from donors in the global pandemic response. Germany, France, and Kuwait are the only countries that have earmarked parts of their contributions to the Access to COVID-19 Tools Accelerator (ACT-A) for health systems. Of the total US$5·8 billion contributed by donors to ACT-A so far, $3·9 billion have gone to support vaccine procurement and distribution in low-income and middle-income countries, while just 6% is reserved for health-care systems. ACT-A must raise at least $28 billion over the coming year to ensure that low-income and middle-income countries have the resources to fight the pandemic.

Global health experts warn that high-income countries are being short-sighted because the pandemic cannot be beaten without robust national health systems. “The irony is that health systems are most important for pandemic preparedness and response, but they get the least political attention or funding”, Lawrence Gostin (Georgetown University, Washington, DC, USA) told The Lancet. “Governments and donors...talk in strong terms about the importance of resilient health systems, but rarely, if ever, put their money where their mouth is”, he added.

Indeed, Germany is the only one of the top seven ACT-A donors—the others are the UK, Canada, Norway, the Gates Foundation, Saudi Arabia, and the European Commission—to have earmarked any of their ACT-A commitments for health systems.

The funding figures reflect only one part of the disparity, however. Health systems have been underprioritised since the launch of the ACT-A. ACT-A's first investment case, from June, 2020, had only three pillars—vaccines, therapeutics, and diagnostics—each with a price tag, but the collaboration did not include costing for support to health systems in low-income countries. It was not until the publication of the September ACT-A investment case that $9 billion were added to the health systems connector pillar. These funds are to be spent almost entirely on the procurement of two key tools: personal protective equipment (PPE) and medical oxygen. As of Dec 17, 2020, the pillar has received the least amount of funding within ACT-A—just $361 million (table ).

Table

ACT-A funding crisis

	ACT-A request	Committed	Funding gap
Vaccine pillar	11 000	3924	7076
Therapeutics pillar	7000	683	6317
Diagnostics pillar	6000	727	5273
Health systems pillar	9000	361	8639
Further health systems needs	(9700*)	..	..
Total	33 000–43 000†	5838	28 000–38 000

Data are US$ (millions). Data are from the WHO ACT-A funding commitment tracker, Dec 17, 2020. ACT-A=Access to COVID-19 Tools Accelerator.

This amount has not yet been added to the ACT-A request and is based on internal cost estimates by the Global Fund, World Bank, and WHO presented on Oct 29 for strengthening health systems in low-income and middle-income countries to cope with the pandemic.

$33 billion does not include the approximately $5 billion committed by high-income countries as self-financing contributions to COVAX for vaccines for their own populations.

Kevin Watkins (at Save the Children) and Adamu Isah have written disparagingly about the failure of ACT-A to mobilise resources for this pillar given that medical oxygen, so crucial in the treatment of patients with COVID-19, is scarce in low-income countries. “That's an outright dereliction of leadership”, they said. They pointed out that even before the onset of the pandemic the lack of access to oxygen in these countries was contributing to making pneumonia the biggest global killer of children.

Leith Greenslade, who coordinates the pneumonia coalition, Every Breath Counts, says that COVID-19 and pneumonia are a double burden in countries that face a shortage of medical oxygen. She fears that the lack of focus on access to medical oxygen by ACT-A is contributing to unnecessary deaths. “Oxygen is...at the moment the only effective COVID-19 treatment available [in low-income countries]”, she told The Lancet.

Beyond oxygen and PPE, a range of issues exist that are not covered by the $9 billion health systems request, including the cost of disposal of PPE, investments in electricity grids and pipes to make oxygen functional, the shortage of health workers, training, and the added pressure on infrastructure, such as cold chains. The costs for these have not yet been included in the ACT-A call for funds.

Modelling done in late October by WHO, the Global Fund, and the World Bank on extending ACT-A to include the cost of bolstering health systems in the poorest countries to help them manage the pandemic came to $9·7 billion. The estimate took into account the protection of front-line health workers, clinical care, in-country supply chains, and data monitoring. This would “[lay] the foundation for building stronger health systems as we emerge from this crisis”, states an internal document by the three organisations.

The additional cost of this support for health systems would bring the total ACT-A shortfall for 2021 up to almost $38 billion. But this has not been added to the funding request. The third meeting of the Facilitation Council of the ACT-A in mid-December, which expressed “grave concern” about the growing inequity of access to COVID-19 tools, referred to a $28 billion funding gap.

For the June, 2020, investment case for ACT-A see https://unitaid.org/assets/act-consolidated-investment-case-at-26-june-2020-vf.pdf

For the September, 2020, investment case for ACT-A see https://www.who.int/publications/i/item/an-economic-investment-case-financing-requirements

For Watkins and Isah's comments on oxygen supplies see https://blogs.bmj.com/bmj/2020/12/11/covid-19-has-turned-the-spotlight-on-the-uneven-provision-of-oxygen-a-stark-health-inequity/