Health leaders criticise limited ACT-A review
Authors: Ann Danaiya Usher
Journal: The Lancet (2021)

A review of the Access to COVID-19 Tools Accelerator will be a “mid-course correction” rather than substantive, drawing criticism from health leaders and civil society. Ann Danaiya Usher reports. An ongoing review of the Access to COVID-19 Tools Accelerator (ACT-A)—an ad-hoc coalition of global agencies and private foundations that came together to fight the COVID-19 pandemic in April, 2020—is under fire for not looking deeply enough into the causes of global inequity in access to COVID-19 tools. The review is expected to deliver a final report in early October, 2021, in time for the G20 summit at the end of that month. The terms of reference state that it will document lessons learned from ACT-A, and examine the results achieved, its strengths and weaknesses, and financing issues. The consultants’ recommendations will guide decision making on the current functioning of ACT-A and its potential role beyond the first quarter of 2022. However, the terms say that “it will not be a full evaluation of ACT Accelerator work and performance; this effort is ongoing, and it is too soon to try to quantify impact”. The WHO Special Envoy for ACT-A, former Swedish Prime Minister Carl Bildt, wants to limit the review's mandate to a “mid-course correction”. He said the “long-term philosophical questions” about how to deal with the next pandemic should be left for later. Observers such as Olusoji Adeyi, former senior adviser for human development at the World Bank and now president of the policy analysis and advisory firm Resilient Health Systems, challenge this perspective. “I think Carl Bildt's approach is inappropriate and totally misguided”, Adeyi said. “I believe [such a limited review] is politically tone deaf and it is a disservice to those in the Global South who currently are being poorly served.” ACT-A was established for the purpose of ensuring that low-income and middle-income countries (LMICs) would not be left behind in the scramble for vaccines and other health interventions required to fight COVID-19. However, as the SARS-CoV-2 Delta variant surges, inequity persists. 8 months after the UK became the first country to start using COVID-19 vaccines, Africa has received less than 2% of the 4·6 billion vaccine doses administered worldwide. The global distribution of COVID-19 diagnostic tests and therapeutics is similarly skewed in favour of high-income countries. Donors have provided US$18 billion to ACT-A over the past year, with 80% earmarked for vaccines. ACT-A still lacks $15 billion for this year's budget to pay for other COVID-19 tools such as tests, medical oxygen, and personal protective equipment for health personnel. Billions more will be needed for 2022. At the G20 Global Health Summit in May, 2021, the world's richest countries called for “a comprehensive strategic review [of ACT-A] as basis for a possible adaptation and extension of its mandate to the end of 2022”. With such general instructions, it was left to Bildt, formally one of three sponsors of the review (the other two being Sir Andrew Witty and Ngozi Okonjo-Iweala, who served as COVID-19 envoys during the first year of the pandemic), to set its precise terms. Bildt is adamant that adjustments should be made as needed, but the main focus must be on ending the pandemic. “We are in the middle of a war with a living enemy. The priority is to get the work done that ACT-A was set up to do”, said Bildt. “What we do after the pandemic to prevent a repetition of this thing, whether there will be an ACT-A or not, is a totally separate question. Let's have a discussion on the next war when we more or less believe we have won this one. We are further away from that than I think most people are aware.” ACT-A consists of ten organisations: WHO; UNICEF; the Coalition for Epidemic Preparedness Innovations; Gavi, the Vaccine Alliance; The Global Fund to Fight AIDS, Tuberculosis and Malaria; the Foundation for Innovative New Diagnostics; Unitaid; the World Bank; Wellcome Trust; and the Bill & Melinda Gates Foundation. Two major reports on the global pandemic response—by the Independent Panel for Pandemic Preparedness and Response, published in May, 2021, and the G20 High-Level Independent Panel report, published in June, 2021—have already concluded that ACT-A is seen by countries and civil society as “supply-driven and not inclusive enough”. “I don’t know what that means”, said Bildt. “[ACT-A] is of course driven by the need to have the tools available as soon as possible. In that sense, it is supply-driven. And it is inclusive in that it tries to include every relevant actor. It coordinates the operationally relevant actors. We can’t reinvent the world. These are the actors that are there.” Bruce Aylward, a senior adviser at WHO, described ACT-A as “a coalition of the willing”, a group of organisations that have been temporarily repurposed to focus on stopping a global pandemic. They have no official mandate and are accountable only to their own boards. The review will not delve into the actions of the individual agencies, but rather focus on their collective work, he said. Bildt admits that ACT-A is an unusual construct. “I have a fair amount of experience from the international community…but here we have something that doesn’t have any formal structure whatsoever. I found that rather strange in the beginning. ACT-A…isn’t an organisation. It is an informal network. This is to a certain extent the secret of the entire thing”. Commenting to The Lancet on the ACT-A review, Adeyi said, “when you are dealing with a pandemic and this level of gross inequities in access to diagnostics, vaccines, etc, and the virus is evolving, it stands to reason that a review ought to take a broad perspective with a view to enabling a far more robust response. If one opts to have a very restricted examination, it raises the question: what are you opting not to learn? And what mistakes are you opting to continue making in the process?” Adeyi was involved in consultations at the World Bank about the creation of ACT-A until his retirement in June, 2020. He said he does not question the intention of the designers of the mechanism. “However, in the fullness of hindsight, it is now eminently clear that the power structures have favoured the Global North over the Global South. These power structures crippled the functions of [ACT-A], including [COVAX].” In a recent article in Development Today, the director of the Nairobi-based African Population and Health Research Center, Catherine Kyobutungi, has argued that the moment requires a deeper questioning of the fundamental model of COVAX and ACT-A. “I think it would be a huge mistake if [this review] just tinkers on the edges.” The civil society representative for the review, Rachael Crockett, said civil society organisations also want the review to be expanded to include the perspectives of people outside of ACT-A who have been following its progress, such as those from think tanks, academia, and research. A draft inception report shows that most of the individual interviews to be carried out by Dalberg, the consulting firm who are preparing the report, are with people directly involved in ACT-A. “It feels like we’re marking our own exam paper here”, Crockett said. Other issues that civil society organisations want the review to address include the disproportionate resource allocation to vaccines; how to increase transparency, accountability of governance, and decision-making structures; and a deeper look into ACT-A's original goals, assumptions, and design. Although Bildt and Aylward argue that inclusion of LMICs in ACT-A has been assured through regular consultations with WHO member states, there remains a broad sense that the agenda and discussions have been dominated by a few agencies based in places like Geneva. Pascale Ondoa, Director of Science and New Initiatives at the African Society of Laboratory Medicine, headquartered in Addis Ababa, Ethiopia, says “the current format of the consultations could be improved to provide the right enabling environment for LMICs to bring their priorities forward and shape the agenda.” Ondoa hopes that the participation of LMICs and indigenous African health institutions becomes more prominent in the ACT-A decision process. Aylward is despondent when reflecting on the level of global inequity in access to COVID-19 tools. He insists, however, that this inequity is a fundamental problem of the multilateral system that cannot be solved by an 8 week review. He warns that trying to take on these big issues now could cause the whole construct to unravel. “We are operating in an environment where there are no rules of the game. And any rules that were put in place were flaunted”, he says. “When you look at the differential between the coverage in Africa and the coverage in [high-income countries], you have to stop and think: if you intentionally tried to restrict access, how much worse could it have looked? And when you bring the fire-power of these ten agencies working together in a collective way in this extraordinary construct that I have never seen before…to be unable to crack some of these fundamentals. I think this is just an extraordinary alarm for the world. It is just deeply disturbing.”