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What Role Can Spanish Cooperation Play in the Response to COVID-19 and the Prevention of Future Crises?

Series | COVID-19 & response strategy

Authors: Gonzalo Fanjul, Leire Pajín and Virginia Rodríguez (ISGlobal)*

[ This document is one of a series of discussion notes addressing fundamental questions about the COVID-19 crisis and response strategies. These documents are based on the best scientific information available and may be updated as new information comes to light. ]

12 June 2020 Cover photo: Jeyaratnam Caniceus / Pixabay

The worldwide spread of the SARS-CoV-2 virus has triggered a health and economic crisis without precedent in our recent history, which is currently straining the limits of the global system for human protection, governance and security. While the final story of this pandemic has not yet been written, some of the lessons learned have started to emerge more clearly. The first of these is that, more than ever before, the well-being and safety of every person in the world depends on the well-being and safety of all the others. The second is that this mutual dependence underscores the importance of joint responses and international aid and confirms the position of global health as a strategic component of every country’s national security policy and an investment rather than an expense. These lessons are absolutely in line with the logic and road map set out in the United Nations 2030 Agenda. In this scenario, few tools will be more useful than international development

cooperation, a modest mechanism for the global redistribution of wealth, but one with enormous potential for promoting innovation, consolidating good practices and leveraging other sources of finance. In the context of the COVID-19 response and, in particular, the prevention of future pandemics, development aid policies can play a strategic role in the early detection of threats, the generation of rapid and effective responses, joint interventions involving both public and private actors, and the financing of the entire process. To achieve this, however, we will need to rethink some of the assumptions that have underpinned our work to date and implement reforms that will adapt the current system of cooperation to the new situation. This transformation is already underway in the field of global health and is happening with surprising speed. Spain is in a position to play an important role in this process and has a responsibility to do so

* All three authors work at ISGlobal: Gonzalo Fanjul is Director of Policy; Leire Pajín is Director of Global Development; and Virginia Rodríguez is an Advocacy Officer.

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1. “The direct impact of COVID-19 on the poorest countries in the world could be considerable, although the final outcome remains to be seen.”

What Has Been the Response of International Cooperation So Far?

By early May this year, the response from multilateral organisations and regional institutions had reached almost $400 billion—far more than twice the amount of all global aid in 2019; this sum was further incremented by around $5.6 billion pledged by bilateral agencies and a further $2.8 billion from private philanthropists1. Planned interventions include programmes designed to reinforce social and economic structures, strengthen health care systems and to provide external debt relief. The crucial question is whether these interventions will prove to have sufficient scope and the right mix of components to overcome the challenges involved in strengthening health systems and programmes and reinforcing other social infrastructures that fulfil the basic needs of the world’s most vulnerable populations, in addition to supporting the development, production and equitable distribution of COVID-19 diagnostic tools, treatments and vaccines. The current needs of low- and middle-income countries can be grouped into three categories:

• Health and social infrastructures. From the lack of access to safe drinking water and sanitation in most homes to the impossibility of social distancing and safe lockdown in large areas of urban sprawl, where contagion is accelerated by substandard housing and overcrowded con-

ditions. In many countries, the fragility of health systems lacking the capacity to meet the demand for hospital care or to implement even the most basic prevention measures in rural areas is further exacerbated by unreliable stocks of essential drugs, staff shortages and frequent power outages.

• Materials for prevention, health care, and epidemiologic monitoring. These include gloves and masks for the population and personal protection equipment for health personnel, all of which are required to reduce the spread of the disease and attrition of personnel. Another cause for concern is the lack of respirators and tests, even for patients hospitalised with severe symptoms. These problems are compounded by the lack of capacity to produce or purchase these materials or quality treatments that could limit the infection. • Existing vulnerabilities and the many health priorities that could intensify the direct and indirect impact of COVID-19. Food insecurity and malnutrition, socio-economic vulnerability and the disruption of routine medical services such as immunisation could lead to a rapid increase in rates of infant and maternal morbidity and mortality. In Africa alone, five preventable diseases caused more than three million premature deaths in 2016, a number that could increase substantially as a result of the pandemic.

Box 1. Main Causes of Death in Africa before the COVID-19 Epidemic. Cause of Death

Number of Deaths

Share of Total Deaths

Lower respiratory tract infections

916,851

10.4%

HIV/Aids

718.800

8,1%

Diarrhoeal diseases

652.791

7,4%

Malaria

408.125

4,6%

Tuberculosis

405.496

4,6%

Source: WHO. Data from 2016, the most recent comparable year. 1

Data compiled and updated by the Overseas Development Institute (https://set.odi.org/coronavirus-economic-vulnerability-economic-impact-and-economic-policy-responsetracker/), accessed 8 June 2020.

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Taken together, these factors suggest that the direct impact of COVID-19 on the poorest countries in the world could be considerable, although the final outcome remains to be seen. The map of the pandemic, updated by the World Health Organisation (WHO), shows that the disease has now reached almost every country in the world, although its incidence in the more developed countries remains disproportionately high. The number of COVID-19 cases reported in Africa in mid-June 2020 was only 7% per cent of those reported in the United States of America2. This suggests two things: first, that the effect of the virus may vary across different environmental and demographic settings; second, and more importantly, that the information available on the impact of the novel coronavirus in certain countries is dangerously deficient.

bility of governments to provide the most basic safety nets during lockdown, could make social distancing and the adaptation of other health strategies useless. This would be a problem for all of us. National plans drawn up and implemented by developing countries should incorporate de escalation strategies tailored to their particular circumstances and adequately supported by the international community through technical and economic assistance. The only way to address these risks is to envisage a comprehensive road map that goes beyond an emergency response and takes into account the social, economic, scientific and institutional determinants of global health. What is needed is a two-speed road map that can reconcile the needs of an urgent response in the short term with the transformation required in the medium term. And that is precisely where cooperation can help

In the worst scenario, economic pressure on families and communities, and the ina-

“The COVID-19 pandemic will inevitably raise the profile of global health on the list of international priorities, altering traditional models of governance and the strategies States use to influence them.”

What Solutions Can Cooperation Offer in a Post-coronavirus World?

The COVID-19 pandemic will inevitably raise the profile of global health on the list of international priorities, altering traditional models of governance and the strategies States use to influence them. For Spain, this new scenario represents an opportunity to optimise resources, capitalise on past investments, and position itself prominently with respect to other actors. While a response that can rise to this challenge is beyond the scope of cooperation policy, cooperation can play a strategic role in a much broader and more ambitious framework: international cooperation as the main axis of a global security and welfare structure based on shared interests. The current situation offers us an opportunity to actually achieve a coherent policy and to lead an effort capable of involving all the nec-

essary actors in line with the aspiration formulated in the 2030 Agenda. In a post-COVID-19 world, the global health strategy of a country like Spain should at least comprise the following elements: a) A work agenda based on the SDG3+ concept. The United Nations 2030 Agenda, which provides a precise and agreed road map for achieving the world we aspire to, has become more relevant than ever. One of the core components of this agenda is the set of health-related targets and goals, formulated principally—but not exclusively—in Sustainable Development Goal 3 (SDG 3). Ultimately, maternal and child health, pandemic prevention and control, universal health coverage and all of the other targets in SDG3 depend

WHO Coronavirus Disease (COVID-19) Dashboard (https://covid19.who.int/).

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on the environmental, socioeconomic and financial targets addressed by the other SDGs. ISGlobal has coined the concept of SDG3+ to refer to the whole set of goals and targets in the 2030 Agenda that directly or indirectly determine health indicators. b) A participatory strategy funded and implemented by various branches of the government and civil service. International cooperation must play a critical role in the response to the challenge. However, other players who are crucial to the implementation of this effort must also be fully represented and involved in drafting and managing the strategy. These will include the following: public and private bodies involved in the management and production of science, research and innovation; the departments and agencies responsible for Spain’s health systems and international economic policy; other foreign relations actors who can secure the highest degree of influence in the European Union; and other decision-makers, including those in autonomous communities and municipalities. The strategy should be informed by expert advice from academic, business and civil society organisations. At present, venues for this type of consultation and participation either do not exist or are organised in a fragmented way and not interconnected3. It will be essential to step up innovative efforts to increase participation and to promote initiatives that combine and complement the strengths of all the actors involved. c) Innovative financial mechanisms—our own and in collaboration with others—will be key to ensuring the sustainability of these initiatives. In 2019, Spain’s Official Development Assistance (ODA) was equivalent to just 0.21% of its gross national income. This contribution was 30% below the target for the Organization for Economic Cooperation and Development (OECD) donor countries and less than half the average for the European Union4. Development assistance for health, in particular, fell from 10% to 2% of total ODA between 2008 and 2018, eliminating Spanish Cooperation from most of the countries, agencies and initiatives it had previously supported. 3 4 5

The contribution an agency makes is the yardstick of the importance it attaches to the strategy. This means that we must identify innovative financing instruments that can enable us to meet the commitments of our global health strategy and leverage the complementary efforts of other actors, such as the private sector. Fortunately, health has been one of the most productive areas in terms of financial support. According to a review published in 2017 in The Lancet5, between 2002 and 2015 innovative financial instruments mobilised almost $9 billion for development assistance for health, most of which was channelled through GAVI, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The list of the top ten instruments included the International Finance Facility for Immunisation (IFFIm), advance market commitments, mechanisms for exchanging debt relief for health investments (Debt2Health) and the Airline Solidarity Levy. The success of GAVI’s recent pledging conference, which raised over $8.8 billion ($1.4 billion over its target) is an indicator of the potential of these new instruments. d) Incentives to bring together the capacities of private, academic, scientific and civil society actors. In addition to funding, the challenges facing global health require other capacities from non-governmental actors. Knowledge generation processes, for example, often flow between universities and the companies that market innovations. These companies contribute part of the financing for this research. Philanthropic foundations act as catalysts, capturing the best of each of these capacities and scaling up certain projects to make them viable. One of the areas in which this type of collaboration is essential—which may need to be reconsidered in light of the COVID-19 experience—is humanitarian assistance and health-related emergency aid, including models that include the management of environmental and personal risks. New scientific disciplines, such as planetary health, offer a stimulating field of analysis related to these approaches. e) A proposal for effective global health governance. Over the past two decades we have witnessed the construction, by default,

One of the most innovative exceptions The Day After Will Be, a community platform that has organised very stimulating debates. OECD Development Aid Committee (DAC). Innovative financing instruments for global health 2002–15: a systematic analysis: https://www.thelancet.com/action/showPdf?pii=S2214-109X%2817%2930198-5.

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of a system of global health governance. In theory, the WHO (and its regional offices, such as the Pan American Health Organization) provide international leadership and focus on developing evidence-based public health policies and guidelines for disease control and response, promoting epidemiological surveillance and providing members countries technical support and emergency response assistance. However, the organisation’s mandate and financial resources come from its member states and it is, therefore, subject to the priorities imposed by these countries. The limitations of this model have become evident during the response to COVID-19.

f) A model of pharmaceutical innovation and access to medicines that can guarantee the availability of treatments, diagnostic tools and vaccines of public interest, ensuring coverage for all affected populations. The current model of innovation and access to medicines favours research into diseases that affect the wealthiest populations and gives rise to pricing policies that deprive the poorest consumers of access. Even though public institutions and funding play a key role in the early stages of research and take considerable risks, they receive a disproportionately low economic return, even in terms of their influence on the use of the innovations generated.

Global health priorities before and after COVID-19—including a pandemic prevention and response plan—require representative and effective governance capable of aligning the resources, capacities and policies of all countries around the common goals established by the 2030 Agenda and any additional goals arising from the experience of the pandemic. As explained in the twelfth document in this series, a new model that is leading the way—ACT Accelerator—reframes the way this work has been done to date and consolidates the shift towards an ecosystem of public-private initiatives and organisations aimed at addressing some of the major challenges facing global health, including universal immunisation and the fight against HIV/Aids, malaria and tuberculosis. The WHO’s contribution to the creation of operational research models tailored to the needs of the poorest countries has been of incalculable value.

The ethical and practical limitations of this model have even had a negative effect on the powerful public health systems of wealthy countries, as we saw in the case of hepatitis C and may see again with the novel coronavirus. In the race to develop the most effective treatments and vaccines against COVID-19, there is a risk that innovations will fall into the hands of countries or companies that are unwilling to treat them as global public goods. This would not only jeopardize the access of low- and middle-income countries— and vulnerable populations in affluent countries—but would also threaten the global strategy for containing the spread of the disease

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3. “Spain’s response to the international coronavirus crisis must be leveraged to further the reform of its official cooperation and adapt it to the needs and opportunities of the new context”

Spanish Cooperation as a Pillar of Global Health and Security: Recommendations for a COVID-19 Response Strategy

Before the start of the crisis caused by the COVID-19 pandemic, the Government of Spain had already announced some of the principal lines of its foreign policy: a more multilateralist approach, the central role of cooperation and humanitarian policy as a global projection of Spain’s commitment to the 2030 Agenda, and a return to a leadership role commensurate with its scientific and economic contributions in the field of global health. The current crisis—in which Spain has been one of earliest and most severely affected countries in the world— has only served to reinforce this logic. There is no exit strategy from this crisis for individual countries, a reality recently emphasised on several occasions by the President of our government. In this new phase, Spanish cooperation must recommit to the solidarity goals declared in the past, and then take the next step. It is time to integrate this policy into a multilateral plan for the welfare and security of all based on cooperation and global public goods rather than the isolationist and unilateral approach advocated by some powers. Spain—like the European Union—aspires to a model of shared prosperity aligned with the 2030 Agenda, but neither its policies nor its budgets, as yet, to live up to this rhetoric. Spain’s response to the international coronavirus crisis must be leveraged to further the reform of its official cooperation and adapt it to the needs and opportunities of the new context. The following are ISGlobal’s recommendations.

On the immediate response to COVID-19 1. Spanish Cooperation should be aligned with and contribute conscientiously to the WHO strategic plan, the UN humanitarian response and other important multiwww.isglobal.org

lateral initiatives. Specifically, it should take part in the following: the multilateral humanitarian response and external debt relief initiatives; the effort to strengthen health systems; and the support for crisis response and de-escalation strategies in countries that require assistance, working actively to ensure gender equality and to prevent this effort from jeopardising other health priorities. 2. In the case of its bilateral aid programme, Spain should share the knowledge it has acquired during the response to the pandemic with its partner countries and mobilise available health resources. This will result in the creation of knowledge exchange platforms that will be of use to everyone. 3. Spain has a responsibility to do everything it can to support the development of diagnostic tools, treatments and vaccines against COVID-19 and to ensure that these are accessible and affordable to all populations. This support must be expressed publicly in Europe Union debates and the replenishment forums of the various bodies, as well as in the discussions of the G20 between now and its meeting in November. 4. Our country has the opportunity to become a guarantor of the interests of middle-income countries in the global response strategy and in the debate on access to treatments and vaccines. This means paying particular attention to the approval of mechanisms to guarantee affordable prices in regions, such as Latin America, that are excluded from GAVI vaccine distribution programmes.

On global health policies 5. Spain needs to draw up and promote a Global Health Strategy driven by development aid, but in combination with other policies. Following the road map 6

set out in the 2030 Agenda, this strategy should incorporate objectives and strategies in each of the six priority areas listed in section 2 of this document. 6. Spanish cooperation should help to support plans to strengthen health systems, and to strengthen networks and tools for the prevention and early detection of new infectious outbreaks in the world’s most vulnerable regions and the capacity to respond rapidly to such events.

This work should include the promotion of universal health coverage and epidemiological surveillance mechanisms. 7. Spain ought to adapt cooperation instruments and programmes to foster multi-actor alliances capable of achieving innovative and high-impact transformations and thereby creating a culture of collaboration between scientific, academic, private, public and non-governmental actors.

TO LEARN MORE • COVID-19, the challenge of immunisation and Spain’s contribution. ISGlobal, April 2020. • What are the barriers to achieving universal immunisation against COVID-19? Series | COVID-19 and response strategy # 12, ISGlobal. June 2020. • Coronavirus Policy and Donor Tracker. ISGlobal. June 2020. • Los riesgos y oportunidades del COVID-19 para el desarrollo de los países pobres. Gonzalo Fanjul and Rafael Vilasanjuan (ISGlobal). Análisis del Real Instituto Elcano 71/2020.