The ACT Accelerator: heading in the right direction?

April 24, 2021, marks 1 year since the formation of the Access to COVID-19 Tools Accelerator (ACT-A) partnership. Its mission is to accelerate the development, production, and equitable access to COVID-19 tests, treatments, and vaccines, which is central to ending the acute phase of the COVID-19 pandemic. With the pandemic still raging, has ACT-A been successful so far? And what does the future hold?

ACT-A coordinates the strategy and work of several global health partners under four pillars: diagnostics, therapeutics, vaccines (COVAX), and health systems. Much of the attention has been focused on vaccines. COVAX plans to deliver 2 billion doses of COVID-19 vaccine by the end of the year, but its mission has been hamstrung by political realities and a lack of ambition.

The diagnostics pillar, led by the Foundation for Innovative New Diagnostics (FIND) and the Global Fund, aimed to develop new, affordable, high-quality tests, and to support the procurement and deployment of 500 million tests for low-income and middle-income countries (LMICs). In September, 2020, FIND announced that 120 million rapid diagnostic tests had been made available through ACT-A at a set price for LMICs. But large discrepancies exist in testing rates between high-income countries (620 tests per 100 000 people per day) versus low-income countries (6·5 tests per 100 000 people per day, with a high positivity rate of 13·3%). As with vaccines, individual rich countries can buy up tests directly from manufacturers. Countries with no resources to buy tests are left without. A lack of laboratory facilities for RT-PCR tests and the paucity of trained laboratory specialists leave many LMICs disadvantaged in reaching full testing capacity.

The therapeutics pillar, co-convened by Unitaid and the Wellcome Trust, is tasked with finding effective therapies and their large-scale, equitable distribution. Many potential treatments have unfortunately been found to be ineffective in clinical studies. The RECOVERY trial, co-funded by ACT-A partners, established dexamethasone as the first life-saving therapy for patients admitted to hospital with COVID-19, and ACT-A secured 2·9 million treatment courses for LMICs through advanced purchases. However, this figure is only a fraction of the pillar's aim to deliver 245 million doses of therapeutics to LMICs. Strict patent and technology transfer regulations have hampered the scale-up of much needed vaccine manufacturing, and the same barriers will likely apply to new treatments such as monoclonal antibodies. ACT-A was also slow to take up the issue of medical oxygen, and other essential medicines for patients with COVID-19 remain in short supply.

The health systems pillar of ACT-A is narrow in scope, largely focused on the effective deployment of COVID-19 vaccines, treatments, and diagnostics and ensuring health-care workers in LMICs have sufficient personal protective equipment. These are unambitious goals. As David Hipgrave points out in a Correspondence, ACT-A neglects to ensure quality primary care and essential public health functions.

ACT-A was a necessary response to an emergency. It was quick to bring together partners and stimulate research and development of new technologies for COVID-19. But ACT-A is, in many ways, a traditional global health entity. Funding follows an international aid model, depending on the benevolence of rich donors. The result is a funding shortfall and a system not based on solidarity but rather one that reinforces inequities. This set-up must be rethought. Thomas Piketty, for example, has proposed a wealth tax of 2% to finance global public health goods. The partners of ACT-A are receiving huge amounts of public money in a global emergency. The minimum to expect in return is transparent and fair pricing, and the sharing of intellectual property, technology, and knowledge.

Furthermore, ACT-A is a vertical programme and heavily focused on technical solutions. Diagnostics, treatments, and vaccines are essential, but too little attention is given to health systems strengthening and systemic drivers of epidemics. The broader implications for ensuring social welfare and cohesion within countries and globally are profound. Any inequities will only prolong the pandemic.

On May 21, at the Global Health Summit in Rome, countries and organisations will discuss financing for the global COVID-19 response. ACT-A may be large in scale, but it suffers from the same shortcomings as countless previous global health initiatives. If ACT-A is to deliver on its goals, these weaknesses need to be confronted and overcome. Only then might it find a worthwhile place in the global health architecture, for this pandemic and beyond.

For more on COVID-19 testing rates see https://www.finddx.org/covid-19/test-tracker/

For more on dexamethasone see N Engl J Med 2021; 384: 693–704

For more on a wealth tax for global public goods see https://www.lemonde.fr/blog/piketty/2021/04/13/rights-for-poor-countries/

For more on the Global Health Summit https://global-health-summit.europa.eu/index_en