Four Ways the UK Can Shape Global Health Post-Brexit

With a new government in majority and Brexit certainty greater, there is an opportunity for the UK to make a global mark in four areas of global health and development. A focus on these four areas would help ensure that the government’s commitment to 0.7 percent of national income for aid is spent efficiently, honouring the contributions of British taxpayers and creating shared benefits at home and abroad.

We detail four ways below that Her Majesty’s Government (HMG) can take the lead, consistent with British values and comparative advantage: (1) expanding access to pharmaceuticals by making health product markets work for the poor; (2) tackling the UK’s shortage of health professionals through a win-win global skills partnership; (3) embedding health security within the broader defense and stabilisation strategy; and (4) improving multilateral performance through the application of appropriate incentives, all while avoiding micromanagement and moving decision-making authority closer to beneficiary countries.

1. Making Health Product Markets Work for the Poor

Accelerating Private Investment and Pharmaceutical Access Through Health Technology Assessment to Inform R&D: Right now, most research and development (R&D) caters to rich countries, since companies prefer to focus their efforts on relatively lucrative and predictable high-income markets. But through a few strategic steps, HMG could help kickstart an expansion of health R&D to better address the needs of the poor—particularly those living in emerging middle-income countries (MICs), where aid is rapidly declining but private investment still lags behind.

Leveraging the UK’s own groundbreaking model of health technology assessment (HTA) and price negotiation through NICE and NHS England, the UK can help MICs identify potential health innovations that would improve health; calculate the local value that such innovations would offer through early HTA; and signal demand for health innovation to serve MICs. Many MICs, including India and China, are already adopting HTA with UK support, while emerging markets offer an important and exciting expansion opportunity for the UK pharmaceutical industry. (To this point, a recent round of procurement in China attracted high engagement from multinational companies despite very low prices; value-based pricing in this context would be significantly more lucrative for industry while still offering affordable access in emerging MICs.) We have already proposed a specific model that leverages early HTA to incentivise tuberculosis treatment development,^[1] using an intermediary development finance institution to underwrite countries’ own voluntary value-based purchase commitments. (See our recent paper introducing the Market-Driven, Value-Based Advanced Commitment [MVAC].) As we have seen with antibiotics, the commercial risk resulting from a lack of a market sometimes trumps the risk emanating from plain tough science.

Enhancing Access to Generics through Better Regulation and Enhanced Competition: Pharmaceutical markets in sub-Saharan Africa and South Asia are dominated by off-patent and/or generic drugs, which make up 90 percent of all purchases by value. In theory, these countries should benefit from a competitive, commoditised generics market that pushes price toward marginal cost. In the US, for example, generics save the healthcare system hundreds of billions of dollars each year; 90 percent of prescriptions are for nonbranded quality-assured generics, but these medicines account for just over a fifth of total pharmaceutical spend. Similarly, in the UK, 80 percent of NHS prescriptions are filled with generic medicines; these account for just 28 percent of the NHS’s total drugs budget. But in lower-middle-income countries, including India and West Africa, countries often buy expensive branded generics in uncompetitive markets. Poor consumers are subject to widely varying prices for essential medicines both within and across countries, and often pay out of pocket; some of the poorest nations pay some of the highest prices for basic commodities such as rehydration salts, metformin for diabetes, and aspirin and paracetamol. To ensure better access to basic life-saving health commodities, the UK is well placed to help poor countries improve procurement practices, attract quality-assured generic market entrants, and create greater competition, facilitated by better regulation of the marketplace^[2] and information-sharing to address asymmetries. If such measures were put in place, forthcoming CGD work suggests that many LMIC could realise procurement savings totaling between a fifth and a third of existing medicines spend.

Coupled with HTA and stronger regulation, the UK can invest in value-informed buyers’ clubs to help negotiate and secure affordable access to medicines. The buyers’ clubs could target countries graduating from aid, plus focus on the set of commodities, mostly for chronic conditions such as diabetes and cancer, which have never enjoyed global subsidies despite growing need. Further, market-shaping initiatives such as MedAccess (supported by the UK CDC) or UNITAID should endorse the principles of HTA while expanding to cover additional technologies and geographies. Wealthier nations may even be willing to pay for such a service if it is sufficiently responsive to need, affordability, and value, all determined locally and in discussion with national payers. These clubs can build on existing global purchasing cooperatives or other strategies.

2. Implement a Global Skill Partnership to Increase the Number of Healthcare Professionals in the UK and Abroad

The UK’s aging population, coupled with slight reductions in the number of working-age adults, is expected to lead to several serious skills gaps in the upcoming decades. Gaps and shortages will be particularly acute within the health sector, especially within nursing, where workforce gaps are already large and growing. There are currently an estimated 44,000 nursing vacancies across the NHS (12 percent of the total workforce); vacancies could grow to 100,000 within a decade. 

The NHS has long relied on international recruitment to staff roles on the critical shortage list, including nurses. Today, 15 percent of the NHS’s nursing workforce is foreign-trained, a number thrown into relief by the Brexit process. We are currently seeing a sharp reduction in the number of new nurses from the European Union (EU), but an increase in those from non-EU countries (Figure 1). The 2018 white paper, and the proposed “NHS visa” acknowledge the necessity of nursing migration for the sustainability of the NHS, but do not yet include concrete measures to plug skills gaps and address urgent needs.

Figure 1. Annual Number of New Nursing and Midwifery Council Registrants in the UK from EU and Non-EU Countries, 1990-2019

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Source: Nursing and Midwifery Council (NMC)/UK Central Council for Nursing, Midwifery and Health Visiting (UKCC), and authors' analysis.

The UK has a unique opportunity to promote nursing migration from non-EU countries while also promoting overseas development. A Global Skill Partnership (GSP) is a bilateral labor migration agreement between a country of origin (say, Malawi) and a country of destination (say, the UK). Malawi agrees to train people in skills specifically and immediately needed in both the country of origin and destination. Some of those trainees choose to stay and increase human capital in the country of origin (the “home” track); others migrate to a pre-specified destination country (the “away” track). The UK would finance and provide technology for the training, which would be tailored to the UK’s specific needs; the UK, in turn, would receive migrants with an optimised skills profile and the ability to quickly integrate into the UK system. This partnership model would offer a win-win for both the UK and Malawi while complying with the guidelines for responsible health worker migration set by the World Health Organization.

There are currently three active pilots of the GSP model: between Belgium and Morocco, between Germany and Kosovo, and between Australia and various Pacific countries. These pilots are new and formal evaluations are few, but existing evidence shows large potential gains to the trainees, migrants, employers in both countries, and the wider economies. The model works best with skills that can be learned relatively quickly and do not require a university degree; think construction, ICT, hospitality, tourism, and nursing.

In 2017, we scoped a model for a nursing partnership between the UK and Malawi. We found that the model would help the NHS meet urgent needs, increase the number of health workers to fill vacancies in Malawi (avoiding “brain drain”), dramatically raise nurses’ incomes, and augment their skills, boosting both Malawi’s economy and the quality and capacity of its healthcare. The partnership would need to be monitored and evaluated (by NHS England and the Department for International Development) and then scaled if desired. A conservative cost-benefit calculation suggests that the scheme offers large financial benefits and would represents highly competitive value for money for UK aid. 

3. Embed Health Security Within the Broader Defence and Stabilisation Strategy

Since the end of the Cold War, global health challenges have continued to evolve alongside human development, fragility, and conflict. Most dramatically, infectious disease threats from SARS and MERS to Ebola have had direct and indirect impacts on international security, stabilization, and economic development. But a unidimensional view of health security as “just” acute infectious disease risks overlooks other health security threats that arise from antimicrobial resistance (AMR) and broader health systems weaknesses. Today’s conflict zones, from Ukraine to endemic conflict-migration cycles across the Middle East, are major drivers and amplifies of AMR, and fragile ecosystems are major (re)incubators of new and re-emerging pathogens. Our inability to stamp out polio cannot be delinked from the conflict ecosystems where their last reservoirs are found. Climate change coupled with weak health systems, as seen now in the Sahel, can multiply existing threats. And the recent outbreak of Ebola in the Democratic Republic of the Congo—within a region of endemic conflict, insecurity, and vast political and economic complexity—has exposed serious deficits in thinking and actions around global health security.

So how is the UK to reimagine and respond to the “new” global health security world? Mark Sidwill’s Fusion Doctrine explicitly recognised the need to fuse HMG capabilities across economic, security, social and “the rest”—which we believe should explicitly include health security. Health security should not be relegated as “only” a global public good delivered through DFID and arm’s length funding such as UK Research and Innovation, but elevated as central to the UK’s development and stabilisation agenda. For example, many of the largest recipients of the UK’s Conflict, Stabilisation and Security Fund—Mali, Nigeria, Kenya, and Somalia—are also in critical need of health systems strengthening, both for local benefit but also to reduce their potential as amplification nodes in transnational health threats.

To address present or future global health security challenges, the UK should look beyond traditional aid and humanitarian policy to harness its much wider civil and military experience, expertise, and evidence. The component parts of a significant and world-leading global health security response are all there, from military assets (e.g., the Defence Medical Services and 77 Brigade) through to major civil-military research programs (e.g., the Conflict and Health Research Group at King’s College London, plus policy expertise in a variety of think tanks, such as Chatham House). Serious programming of global health security into the next iteration of Fusion Doctrine, linked to decentralised development and delivery, will create a world-leading position for the UK to address one of the most complex challenges of our time.

4. Enhancing Multilaterals’ Performance through the Right Incentives

Much of UK spending on global health is channeled through multilateral mechanisms, including the World Bank’s International Development Association (IDA); the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and Gavi, the Vaccine Alliance. Earlier this year, DFID committed £1.4 billion to the Global Fund over the next three years, making DFID the second-largest contributor after the United States; likewise, it recently committed to the IDA 19 replenishment, and the UK will host Gavi’s upcoming replenishment later this year. Yet too often, the results generated by multilaterals and the yield on their investments are unclear or based on modelling rather than empirical analysis.

The UK—with its proud tradition of emphasizing value for money and results—should lead in boosting multilateral performance and accountability. Instead of micromanaging multilaterals’ operations (and therefore encouraging multilaterals to micromanage their grantees), HMG should insist on strict, centrally established performance standards and incentives to achieve agreed goals while allowing flexible, decentralized implementation. Results should then be properly, rigorously verified to inform future funding to multilaterals­—with at least some evaluation done by independent bodies unaffiliated with implementing institutions. And allocating funding across multilaterals, HMG should carefully consider the comparative advantages of each, for example, weighing disease-specific responses (e.g., Gavi or the Global Fund) against broader country-led development efforts (World Bank IDA).

The UK will be hosting the Gavi replenishment later this year—a high-profile opportunity for HMG to articulate a new, decentralized, and evidence-based strategy for multilateral funding. We believe that only rigorous standards around evidence, results, and accountability, that in turn inform future UK aid spending through multilaterals, can reconcile increasing skepticism about multilateralism with sustained commitment to 0.7 percent. By taking the lead, the UK can change the rules of the global health multilateral game in a way that tangibly benefits the country and recipients by realigning incentives; reducing bureaucracy and micromanagement; enhancing transparency and accountability; and elevating analysis, measurement, and evidence.