What COVID-19 Should Teach Us About Smart Health Spending in Developing Countries

With thanks to additional authors: Amanda Glassman (Center for Global Development), Adrian Gheorghe (Imperial College London), Francis Ruiz (Center for Global Development & Imperial College London), Tony Culyer (University of York), Ryota Nakamura (Hitotsubashi University), Yot Teerawattananon (HITAP), Edwine Barasa (KEMRI), and Mahlet Kifle Habtemariam (Africa CDC).

With a number of African countries confirming their first cases of COVID-19 and the continent bracing for major outbreaks, health system resilience and basic functionality emerge once again as the determining factor for a successful response. Since the Ebola crisis in West Africa claimed over 11,000 lives five years ago–challenging both the health systems and economies of affected countries–there have been numerous calls identifying the need to strengthen core health systems functions ahead of emergent threats to enable effective preparedness and response efforts. Yet, in the face of this new coronavirus and other outbreaks of Lassa fever, Yellow fever, cholera, and monkeypox across the continent, we have not seen the “lessons learned” from Ebola translate into the needed investments in primary health services, the health workforce, and other key capacities. Instead, we are left with a distinct feeling of “déjà vu.”

As WHO Regional Director for Africa Dr. Matshidiso Moeti noted, “the threats posed by COVID-19 have cast a spotlight on the shortcomings in health systems in the African Region.” Just last week several pieces discussed Africa’s preparedness and how it relates to stronger health systems including healthcare professionals, accessible clinics, commodities (incl. protective equipment and diagnostic assays) and working supply chains; the role of trust in domestic and global authorities and norm setting institutions; and the importance of local leaders’ ability (and willingness) to engage with well-resourced parallel systems built by development partners to target HIV or TB and run by a complex network of non-governmental organisations.

Realizing progress in these areas will require sustained and strategic investments in the health sector.

Some of us have already called out the need for special financing arrangements to support surveillance and preparedness–before, between, and during outbreaks–while underscoring the importance of incentivising the right types of capacity, including the right research and evidence generation capacity, to mount effective prevention, containment, and mitigation strategies. With billions of dollars in emergency funds now being directed toward the COVID-19 response, particularly in countries with weak health systems, it will be critical to use these resources wisely. This means:

• Investing in country-led capacities and systems functions that provide value long after the threat of COVID-19 has waned, with inputs supporting routine health services as well as future response ability as threats emerge;

• Drawing upon, sharing, and adapting global and local evidence of what works (and what doesn’t) to minimise the spread of disease and avoid inefficient spending of constrained resources;

• Engaging with low- and middle-income country (LMIC) decision-makers in national and local government, service delivery, and the universities to advance evidence-informed approaches to resource use and determine the appropriate role of domestic versus external financing; 

• Investing in LMIC regional public health institutions, such as Africa CDC, to facilitate exchange of information and lessons among countries, link fragmented efforts by multiple stakeholders, develop region- wide policies and interventions, and provide guidance on resource allocation decisions; and,

• Avoiding or mitigating the harmful diversion of resources during outbreaks that jeopardize key health gains and priorities in areas of maternal and child health, endemic infectious diseases, and non-communicable diseases and other health system strengthening efforts. 

Building capacity to combat epidemics … with evidence

Modelling and health economics for preparedness and response

In a recent Lancet piece, the Director of the Africa Centres for Disease Control and Prevention praised the use of “[m]odels that enable the continent to better allocate scarce resources to better prepare and respond to the COVID-19 epidemic…” He is referring to a modelling analysis, also published in the Lancet by a majority French and Belgian group of researchers earlier this month, assessing the preparedness and vulnerability of different African states against the risk of importing COVID-19. Given the relevance and usefulness of such analyses, we posit there is a need for the Africa CDC in Addis Ababa and its hubs across the continent to build their own capacities—not only for commissioning, interpreting, and acting on such models, but also for producing similar analyses in partnership with universities across Africa and the global North.

But such capacities are in short supply in Africa and, worse perhaps, so is the appetite of authorities, global and national, Northern and Southern, for following evidence-informed and transparent decision-making processes for making policy and resource allocation decisions when disaster strikes. Whereas routine decisions on healthcare resource allocation are increasingly relying on multidisciplinary frameworks for applying the best economic and scientific evidence for strategic health investments—with Health Technology Assessment (HTA) as a prime example, now well established across Europe, Australia, and Canada, as well as gaining traction in emerging economies and endorsed by WHO and the UN—there are few examples of such systematic thinking on the comparative clinical and public health effectiveness, let alone value-for-money, of investing in alternative preparedness interventions ahead of nor during outbreaks.

Evidence to policy translation

This is not to say there is no science underpinning the response to COVID-19, or Ebola, and SARS before it. International centres of excellence, including Imperial College London and the recently launched J-IDEA institute (one of our home institutions and a WHO Collaborating Centre), have been supplying WHO and national governments with valuable information on tackling the epidemic. However, the culture to look at evidence—especially comparative economic evidence—via open, systematic processes that acknowledge uncertainty remains lacking when it comes to informing emergency action for outbreaks and epidemics.

This is not unique to infectious disease outbreaks, and the humanitarian sector is a case in point. For example, there were fewer than 10 studies of acceptable quality looking at comparative costs and benefits of alternative humanitarian interventions published in the last 40 years, whilst global norms for prioritizing sector-specific interventions, such as sexual and reproductive health, in such settings have been described as “wishful thinking” given lack of consideration of resources and feasibility of implementation.

This lack of evidence-informed decision-making processes for dealing with emergencies— which goes further than producing epidemiological models of disease transmission and risk assessment—is also evident in wealthier countries with stronger healthcare systems and well-established priority setting institutions. All too often, even in countries with more advanced infrastructures, the evidence base is decidedly lop-sided. Quality epidemiological evidence of efficacy and effectiveness far outweighs the economic evidence—especially that which seeks to compare the productivity of interventions in terms of health gain (or disability averted) and the associated health loss from not using resources in more productive ways. Matters can be even worse. Even when the evidence is clear, decision makers can still make uninformed decisions. For example, Tamiflu was shown by NICE in the UK not to be cost-effective (with the exception of using it in localised outbreaks among high-risk groups like the elderly), and by Cochrane not to even be clinically effective. Yet the UK and other Western governments continue to purchase and stockpile it. Widely adopted containment measures such as travel bans and school closures also seem to be unbacked by evidence, although the health and negative macroeconomic consequences of such actions may be even higher than the direct impact of the outbreak itself. The infectious disease outbreaks literature is also weak, not surprisingly given the lack of policy buy-in: a Scopus (Elsevier) search for: (“health technology assessment” OR “priority-setting” AND “outbreak”, with no time restrictions and terms searched as Title, Abstract, or Keyword, produced only 30 hits—of which only three looked at setting priorities at a global level (here, here and here) and two explored priority-setting for outbreak preparedness in LMICs (Uganda and Thailand).

Where to start? Toward contextually relevant “Best Buys”

Prioritising gaps identified by the Joint External Evaluation

So, what can we do better? Take the Joint External Evaluation (JEE), “…a voluntary, collaborative, multisectoral process to assess country capacity to prevent, detect and rapidly respond to public health risks occurring naturally or due to deliberate or accidental events.” There is some evidence that JEEs help countries identify gaps in their own infrastructure and seek international support, thereby improving their chances of successfully responding to an outbreak. However, JEEs cannot, by design, assess the quality and effectiveness of the international support nor the ability of local systems to absorb it successfully. Further, JEEs, though increasingly carried out even by the poorest countries, are composed of noncomparable and qualitative indicators, rarely costed out and even more rarely adequately financed.

Making progress on shortcomings identified by the JEE will require a dose of realism. Given the limited resources available, especially amongst the poorest nations with multiple competing demands, is there a way to help countries rank the JEE fields and respective preparedness and response capacity interventions to guide their investments and allow them to make tough trade-offs? And can it be done in such a way that recognizes local contexts, including countries’ own risk profiles and priorities? Are there additional indicators (e.g. inter-departmental, inter-sectoral, and state-to-state coordination in federal states) to consider or interventions to pursue that could be identified through a systematic review of what works in terms of preparedness and mitigation (and at what cost)?

Best and worst buys

Perhaps guidance and options could be synthesized into a menu of potential “Best and Worst Buys,” akin to the recently published analysis on NCD risk factor control or to Cochrane’s EvidenceAid. A menu like this would benefit from additional, locally adaptable material on the economics of transmission for country authorities as well as resources for the press and civil society as a given response upfolds, including what to do in the worst-case scenario. Such a systematic effort could also identify interventions where there is a strong case for global financing of global public goods (or common goods for health), instead of relying on domestic investment. There may be a further role for the global community to play in supporting countries’ national efforts to set up evidence into policy mechanisms for decisions about allocating scarce healthcare resources, particularly in ways that help the public understand the complex trade-offs faced by policymakers and the reasons underlying their decisions.

Leading the charge: Africa CDC?

With the right support, Africa CDC, a respected but relatively young and under-resourced institution, would be in a strong position to lead efforts on the continent to enhance decision-making structures and develop menus of “Best Buys” that can be adapted and adopted by countries, leveraging the existing regional collaborating centres and National Public Health Institutes as well as national committees on health benefits and essential medicines. Such menus would include information on cost-effectiveness and budget impact to inform financing decisions, including which investments ought to be picked up by a preparedness fund, and which should be financed by countries’ own budgets. For example, interventions such as lab optimization or stockpiling processes (product selection, pricing, distribution choices), may be ideally suited to a cost benefit analysis for informing optimal investments across geographies which fall well within Africa CDC’s remit. International counterparts such as the UK’s PHE, Norway’s NIPH and the US CDC, themselves well connected with academic centres of excellence and with in-house capacity, are well placed to continue offering support on technical and institutional strengthening as part of such an effort and may stand to benefit their own constituencies given the dearth of standardized and openly available options’ analysis.

Some useful preparatory work has already been conducted. For example, the average investment required in LMICs to implement the national action plan for health security (estimated by the World Bank at USD 1.69 per capita based on a sample of 22 countries, though ranging from a high of USD 6.89 in Sierra Leone to USD 0.33 in Indonesia). And without more granularity on the estimates or the baseline, it is hard to understand whether this is incremental and whether it assumes linearity of investment or if it takes some account of economies of scale and scope; for that a country by country analysis as well as an intervention by intervention analysis is needed (i.e., a country specific/adaptable ‘Best Buys’ menu).

Challenges and opportunities

Developing such a menu is not going to be easy. Depending on the type of epidemic—including factors related to presentation of disease, transmission, and the existence of animal reservoirs and vectors—what is “best” will likely differ country by country. Whilst there are some general capacities (e.g. real-time surveillance, lab diagnostics, infection control measures) that will be applicable in every setting, other interventions like contact tracing may be incredibly important for outbreaks such Ebola and COVID-19, but much less so for vector-borne viruses such as Zika. From the country perspective, a list of ‘“best buys’ would likely be informed by the kinds of investments that would simultaneously promote effective management of endemic and seasonal threats while also helping prevent or respond to emerging pathogens. For instance, vector control efforts that offer cross-protection against seasonal dengue and other emergent flaviviruses or effective broad-spectrum antivirals are likely good value-for-money compared to interventions that target only a single pathogen that may never emerge.

There may also be regional “best buys” based on the presence of animal reservoirs or frequency of outbreaks for a particular disease in the area–for instance, interventions that are well-suited to countries in the Lassa belt. However, interventions comprising a list of ‘best buys’ from the country or regional perspective may not always be the ones that fill in critical gaps in the global preparedness infrastructure to safeguard against rarer, pandemic events. Health systems strengthening efforts align with country priorities and are the backbone of effective global preparedness and response efforts, but some kinds of diagnostics or medical countermeasures developed for pathogens with pandemic potential may not represent a cost-effective investment for countries with many other pressing burdens of disease—even if the global case for using them in containment efforts is compelling. The distinction between local and global best buys may help guide which investments should be prioritized for domestic resources versus where new external financing has a role to play in supporting costlier interventions that can contain the global spread of dangerous pathogens. 

With the externalities of a global outbreak yet to be fully described and quantified (e.g., the impact of the Chinese outbreak on antibiotic supply chain across high-income countries), global financing mechanisms, especially for LMICs, are likely to remain of the essence.

Beyond the Best Buys—a broader role for priority setting in global health security

Avoiding costly diversion of resources

One angle often neglected during emergencies is allocation of existing resources (e.g., professional staff, beds, respirators, medicines) across the broader population in need of “routine” and often urgent health care services. As with Ebola outbreaks before it, COVID-19 has already contributed to serious disruptions in access to maternal and neonatal care in areas of China where health facilities and staff have been re-allocated to response efforts. There have also been reports of impacts on HIV patients who struggle to get their antiretroviral drugs in areas hit hard by the virus. Priority setting processes can help compare the cost and benefits of different approaches to help direct scarce resources where they are needed most, avoid costly ineffective strategies, and assure that ongoing high-priority health needs continue to be addressed, especially when the knee-jerk reaction is to shift all resources to response efforts without attention to the costs of diverting resources.

Strategic Stockpiling

Another area where priority-setting and HTA could inform strategic investments in preparedness is in the development of stockpiles. Understanding the value-for-money of different supplies and interventions (e.g., medical countermeasures (MCM) like antivirals, monoclonal antibodies, vaccines as well as diagnostics and equipment) can help ensure adequate and rapid supply of the most effective interventions against an epidemic threat – with some of these being critical for a range of different outbreak scenarios. Strategic stockpiling may also present an opportunity to help address the currently unfavourable market incentives for development of vaccines or medical countermeasures against (re-)emerging pathogens, creating a foreseeable market for manufacturers while signalling pricing that would meet acceptable thresholds for purchase by governments and aid organizations. Our recent work on the use of early HTA to help define and guarantee a value-based market for a TB cure may be worth considering as a mechanism for crowding in private investment to boost grant funding. 

Encouraging the open use of evidence of what works and at what cost, by both local and global institutions, is likely to enhance the effectiveness of the response to a serious global threat like COVID-19. As some of us have argued elsewhere, even (or especially) in the midst of a global crisis, “…it is national policy-makers and technocrats, elected by the people or appointed by elected officials, respectively, who will be accountable for their decisions and it is probably these and other local stakeholders who can form the best judgments about what is actually feasible, sustainable and timed rightly for their particular situation.”

Amidst renewed efforts to ramp up epidemic preparedness and response capacities and the stark reality of insufficient progress since the Ebola crisis in West Africa, it is incumbent upon the public health community, political leaders, donors, and universities to lay the groundwork for strategic and evidence informed decision-making that can help combat future threats. This entails:

1. Commitments to strengthening capacity for systematically applying evidence to health policymaking in ways that mutually support ongoing progress toward Universal Health Coverage and Global Health Security;

2. Generating and using evidence that is fit-for-purpose and adaptable for local and regional contexts in the face of new epidemic or pandemic threats; and

3. Careful consideration of effectiveness, cost-effectiveness, and equity when comparing health investments and interventions—for routine healthcare provision and in combatting emergent infectious diseases—recognising that there are always opportunity costs and degrees of uncertainty in the evidence.