ICAI follow-up of: The UK aid response to global health threats

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Executive summary

ICAI’s follow-up review is an important element in the scrutiny process for UK aid. It provides the International Development Committee and the public with an account of how well the government has responded to ICAI’s recommendations to improve spending. It is also an opportunity for ICAI to identify issues and challenges facing the UK aid programme now and in the future, which in turn helps to inform subsequent reviews.

This document is a summary which focused only on the results of our follow up of The UK aid response to global health threats. The full Follow Up report of all our 2017-18 reviews, including overall conclusions from the process and details of our methodology, can be found on our website.

Findings

The UK aid response to global health threats

The UK’s aid response to the growing risk of global health threats is led by DHSC, but with strong involvement from DFID and a wide range of government departments. ICAI’s review, published in January 2018, covered the totality of the UK aid response to global health threats from 2014. It found that the UK government responded rapidly to address weaknesses in the international response system exposed by the Ebola crisis in West Africa, establishing a portfolio of relevant and often pioneering programmes and influencing activities. ICAI made four recommendations, summarised below, to help the government build on this good foundation.

Subject of recommendation	Government response
The UK government should refresh its global health security strategy, with emphasis on health systems, research and mechanisms for collaboration	Accepted
The Department of Health and Social Care and DFID should strengthen and formalise cross-government partnership and coordination mechanisms for global health threats, including regular cross-government simulations	Partially accepted
Ensure that DFID has sufficient capacity in place to coordinate UK global health security programmes and influencing activities in priority countries, including on strengthening national health systems	Accepted
DFID and the Department of Health and Social Care should work together to prioritise learning on global health threats across government	Accepted

Table 1: Summary of recommendations and the government’s response

The UK government should refresh its global health security strategy, with emphasis on health systems, research and mechanisms for collaboration

The ICAI review found good programming on global health threats within both DHSC and DFID, but urged the government to refresh and improve its overall ‘Stronger, Smarter, Swifter’ strategic framework. There are significant improvements under way in response to this recommendation. DHSC and DFID are in the process of refreshing the strategic framework and have committed to sharing it externally when completed. The work has been delayed due to capacity constraints caused in particular by the Ebola outbreak in the Democratic Republic of the Congo (DRC), but descriptions of the work done indicate that the concerns raised in the ICAI review are being addressed. A range of stakeholders have been included in the process of finalising the strategic theory of change. The framework is being adapted to follow more closely the internationally recognised terminology of ‘Prevent, Detect, Respond’. This will facilitate coordination with other donors and country partners, as well as engagement with the private sector.

Box 1: The response to the current Ebola outbreak in the DRC

In August 2018, the DRC declared a new outbreak of Ebola (the country’s tenth Ebola outbreak since the disease was first identified in 1976), only a week after the previous outbreak in Equateur province had been declared over. The outbreak is located in North Kivu province (and to a lesser extent in neighbouring Ituri province), which is in the midst of a protracted and complex conflict. The collapse of government authority has led to political turmoil, ethnic rivalries and clashes between militia groups. The conflict has created severe difficulties for Ebola responders, with armed groups targeting the response and access being impaired due to security concerns.

All actors in the response have had to adapt their approach to the difficult security context. For the UK and others, the security situation has made it much more difficult to have personnel ‘on the ground’ in the immediate outbreak area. It will be important in due course to learn lessons from the approach pursued through mechanisms such as the After Action Review. The deployment of personnel from the UK’s Public Health Rapid Support Team (UK-PHRST), established after the Ebola outbreak in West Africa, has been a key part of the UK’s contribution to the response. UK-PHRST is a partnership between Public Health England and the London School of Hygiene and Tropical Medicine, and has provided epidemiological and logistical support as well as continued research.

The Ebola epidemic in the DRC is an example of how weak health systems can exacerbate the devastation of a disease, and DFID and DHSC continue to make the strengthening of health systems a clear priority. UK aid is contributing to funding an experimental vaccine for frontline workers and those who have come into contact with infected people, with more than 49,000 people receiving the vaccination so far. The UK is also helping to fund efforts to develop new therapeutic drugs for Ebola.

The epidemic in the DRC is getting worse, with the number of fatalities reaching 1,000 by the beginning of May 2019. Attacks on health workers and Ebola facilities continue. Yet the UK’s response demonstrates a strengthening capability to work within fragile and conflict-affected states, building effective local capacity alongside other international actors. The UK’s work on the ground in the DRC has been complemented by wider regional preparedness work in neighbouring countries to enable them to better detect and respond to potential outbreaks of Ebola. The detection of Ebola cases in the Kasese district of Uganda in June 2019 underscores the importance of this regional approach.

The refreshed framework reportedly presents the government’s rationale for embedding global health security work within a health systems strengthening approach, making explicit links to the World Health Organization (WHO)’s work and internationally recognised terminology, such as health systems building blocks. We also saw signs of a practical shift in programming away from vertical interventions into particular health issues and towards health systems strengthening and capacity-building programmes.

These improvements have taken place at the same time as the UK’s close involvement in the international response to the outbreak of Ebola in the DRC (see Box 1 below). Drawing on the experience of this outbreak, lessons on the importance of having effective systems and capacity to respond to outbreaks in fragile and conflict-affected settings and ways of achieving this are being incorporated in the government’s new strategic framework. These include a focus on the knowledge and mechanisms needed to facilitate and coordinate deployment of a range of international actors (UK and others) and to keep response systems going for long periods in challenging contexts.

The Department of Health and Social Care and DFID should strengthen and formalise cross-government partnership and coordination mechanisms for global health threats, including regular cross-government simulations

The ICAI review found detailed evidence of effective cross-government mechanisms to share intelligence on disease outbreaks but noted that cross-government coordination at the strategic level and between programmes could have been improved. The Global Health Oversight Group (GHOG) was overly focused on programme monitoring, leaving gaps in strategic leadership and coordination, and there was not always a shared vision between DFID and DHSC – particularly on health systems strengthening.

The government only partially accepted ICAI’s recommendation on cross-government coordination, arguing that government departments and agencies were already working closely together. However, improvements have taken place since the publication of our review. GHOG has expanded its membership to include all government departments and agencies involved in delivering the government’s objectives for global health security, and a range of relevant government actors are holding regular coordination meetings and discussion forums. There has been a strong emphasis on close cross-government collaboration to deal with Ebola outbreaks in the DRC. These add up to significant improvements, although currently GHOG does not meet often enough to be fully able to spearhead cross-government cooperation and provide strategic leadership.

We also saw evidence of improved collaboration taking place at country level, including the development of common theories of change and monitoring and evaluation indicators by DFID and Public Health England (PHE). We found strong collaborative efforts in Sierra Leone, with weekly meetings between the international community and Sierra Leone’s Ministry of Health. After severe floods in 2017, the Ministry of Health reacted quickly, with support from the UK government, using existing data to mobilise effectively and averting serious disease outbreaks. A similar positive relationship was described in Burma, where DFID health advisers now work closely with PHE and Burma’s Ministry of Health to ensure that preparedness strategies are in place.

Ensure that DFID has sufficient capacity in place to coordinate UK global health security programmes and influencing activities in priority countries, including on strengthening national health systems

The ICAI review suggested that there was room for improving coordination of global health threats programming at country level, to maximise the collective impact of UK programming in areas such as WHO reform, International Health Regulation (IHR) compliance and health systems strengthening. DFID health advisers and other personnel are key to fulfilling this, but they are often overstretched. We recommended that the government should ensure that DFID has sufficient capacity in place to coordinate UK global health security programmes and influencing activities in its priority countries, including on strengthening national health systems.

The government accepted this recommendation. An increase in PHE activities has contributed to closer collaboration at country level, with DFID and PHE working together in countries where the IHR Strengthening programme has current or planned presence: Burma, Ethiopia, Nigeria, Sierra Leone, Pakistan and Zambia. The Fleming Fund, a UK aid programme aimed at helping low- and middle-income countries combat antimicrobial resistance (AMR)¹, has led on establishing coordination mechanisms and cross-department working on AMR detection, with crucial help from DFID health advisers. All stakeholders we talked to reported that the role of DFID health advisers is central to collaboration efforts. However, across DFID, and particularly in Burma, health advisers continue to be overstretched, navigating the complex political landscape of their country. DFID informed us that the UK government is recruiting seven more staff members to work on health security in Africa, which will be very helpful. However, by the end of May 2019, the recruitment process had not yet been completed.

DFID and the Department of Health and Social Care should work together to prioritise learning on global health threats across government

The government accepted ICAI’s recommendation that DFID and DHSC should work together to prioritise learning on global health threats across government. ICAI recommended that the two departments jointly oversee the development of a broad evaluation and learning framework, conduct regular reviews of what works (and represents good value for money) across the portfolio, and put in place a shared approach to the training and development of health advisers.

The new strategic framework and theory of change will facilitate cross-departmental coordination and give strategic direction to evaluation and learning. As the framework has not yet been published, we do not know whether it will include sufficient mechanisms to share learning at a strategic level and to ensure a broad programme of evaluations. However, the government’s response to the ICAI review, and a flurry of recent learning and evaluation activities among the main government global health security stakeholders, show that the need to prioritise learning is understood. We believe GHOG could take a strategic lead on this work, particularly with developing mechanisms to ensure that learning is disseminated across government and shared with external partners.

Conclusion

There have been positive developments in response to all four of ICAI’s recommendations. Although we have not seen the refreshed strategic framework, we understand that it will highlight health systems strengthening work and will facilitate wider external engagement by adopting the ‘Prevent, Detect, Respond’ terminology. We have seen clear improvements in cross-government working and learning in support of the government’s global health security objectives.

Summary of findings

Subject of recommendation	Recent developments	ICAI’s assessment of progress
Refresh the government’s global health security strategy, with emphasis on health systems, research and mechanisms for collaboration. Government response: Accepted	The Department of Health and Social Care (DHSC) and DFID are refreshing the strategic framework and are committed to sharing it externally. The UK has been closely involved in the international response to the outbreak of Ebola in the Democratic Republic of the Congo (DRC), building on its experience in Sierra Leone, and is feeding learning from this latest outbreak into its new strategy. The refreshed framework employs the internationally recognised ‘Prevent, Detect, Respond’ terminology which will facilitate coordination with donors and partner countries and engagement with the private sector	There is a shift towards stronger emphasis on health systems strengthening, in line with ICAI’s recommendation Important learning is taking place on how to adapt global health threat responses to fragile and conflict-affected settings.
Strengthen and formalise cross-government partnership and coordination mechanisms, including regular simulations. Government response: Partially accepted	The government argued that relevant branches already coordinate and collaborate closely. It has nevertheless expanded the membership of the cross-government Global Health Oversight Group (GHOG) to include all relevant government actors. DFID and Public Health England (PHE) are working more closely together at country level.	The strengthening of GHOG, together with a range of other cross-government coordination meetings and discussion forums, constitutes a significant improvement. Cross-government collaboration has been strong during the Ebola outbreak in the DRC.
Ensure that DFID has sufficient capacity to coordinate programmes and influencing activities in priority countries. Government response: Accepted	Recruitment is under way for seven new UK government posts focusing on global health security in the Africa region. PHE is increasing its in-country activities, and DFID and PHE now work closely together in countries where both organisations have a presence.	The new staff will bring additional capacity to enhance the UK’s engagement on global health security within the Africa region. However, the recruitment process has been lengthy.
DFID and DHSC should work together to prioritise learning on global health threats across government. Government response: Accepted	There has been a flurry of learning and evaluation activities. We do not yet know how learning will be incorporated in the new Prevent, Detect, Respond framework.	The significant learning and evaluation activities that have taken place since the publication of the ICAI review are a good response to our recommendation. The new framework and theory of change, once completed, will facilitate cross-departmental coordination and give strategic direction to learning activities.

Footnotes

¹ More information on the Fleming Fund can be found here.