Last month, the World Health Organization reported that for the first time in 15 years the number of people who have died from tuberculosis has increased. Worldwide, in 2020, more than 1.5 million deaths were attributed to tuberculosis; the first year-on-year increase since 2005. Multiple reasons have been cited, one of which is diversion of resources due to the Covid-19 pandemic.
And, tuberculosis is not the only diseasethat has been impacted, with disproportionately severe health burdens on the world’s poorest populations.
Since the spring of 2020, there has been acute disruption of activities, such as neglected tropical disease (NTD) control and elimination programs. Across the globe, for example, mass drug administration campaigns targeting NTDs have been postponed. NTDs are a heterogeneous group of infections which are common in developing regions of Africa, Asia, and the Americas. These diseases – caused by a variety of pathogens, including viruses, bacteria, protozoa, and parasites – include, among others, onchocerciasis (river blindness), African trypanosomiasis, leishmaniasis, cholera, Chagas disease, and Dengue fever. Diseases are said to be neglected if they are (often) overlooked and therefore underfunded by drug developers, owing to a lack of commercial prospects.
And, while tuberculosis has also suffered from neglect, it belongs to the so-called “big three infectious diseases” – HIV/AIDS, tuberculosis,and malaria – which have generally received more media attention and research and development funding than the NTDs.
The WHO had developed an NTD roadmap that was meant to officially launch in June 2020. The roadmap included specific disease targets to control and eliminate NTDs by 2030. Not only did the Covid-19 pandemic postpone the launch of the work plan, many NTD activities that had been ongoing were suspended to prevent the risk of additional transmission of the coronavirus.
In fact, interruptions in NTD program work were experienced in at least 44% of low and middle income countries: Specifically, suspension of mass administration campaigns of vaccines and treatments, case detection, and vector control. In addition, there was disruption to supply chains and reduction in the manufacturing of active pharmaceutical ingredients. In brief, there was diversion of financial resources, which effectively meant a reassignment of NTD personnel to the Covid-19 response .
It’s not all been bad news, as a month ago the WHO endorsed the first malaria vaccine (a recombinant, protein-based agent) for use among children in at-risk areas. Malaria is a preventable disease that kills around 500,000 people a year; mostly African children.
It should be noted, however, that most of the clinical development of the malaria vaccine occurred prior to the Covid-19 pandemic. Furthermore, the vaccine – called Mosquirix – has modest efficacy, as it reduces the number of severe malaria cases by approximately 30%.
To save the most lives, African countries must continue to scale up teams of local health workers to identify and respond to cases, and increase access to mosquito nets and antimalarial drugs, such as the fixed dose combination Coartem (artemether/lumefantrine). Yet, it’s precisely in these areas that the pandemic has been the most disruptive.
One of the core tenets of economics is that resource allocation decisions invariably involve trade-offs. As an illustration, there is an opportunity cost of allocating large amounts of resources towards the Covid-19 response. The dollars spent on combating the coronavirus can’t be used to address other diseases. Unless the overall amount of healthcare resources is expanded, there will be forgone alternatives left unfunded. And, government budgetary constraints often prevent expansion of healthcare budgets from happening. Alternatively, it is difficult to draw down budgets in other sectors, such as defense, in order to fund healthcare sector expansion, whether domestically or for the purposes of international health aid projects.
Budget impact analyses lay bare the individuals or groups who lose out; in other words, those who bear the opportunity cost of spending resources in one area, say, Covid-19, rather than another.
This doesn’t mean that a substantial amount of resources shouldn’t have been spent (or continue to be expended) on developing and paying for coronavirus vaccines or Covid-19 treatments. It does, however, imply that policymakers be made aware of forgone alternative uses of resources, account for the extent to which society can afford to crowd out non-Covid-19 resources, and fill in the budgetary gaps where necessary.
At multiple levels – local, state, federal, and global – when a healthcare system or international program with a relatively fixed budget “overpays” in one area, it must extract resources from elsewhere in the budget, or enlarge the budget.
Early in the pandemic, it was clear that federal regulators in the U.S. were aware of the issue of opportunity cost. In reallocating resources to address the novel coronavirus, the Food and Drug Administration (FDA) stated that new drug and biologics programs were being impacted by “considerable increases in Covid-19 related work.” As a result, the agency said “it’s possible that we will not be able to sustain our current performance level in meeting goal dates.”
Of course, this wasn’t just an issue at the FDA. Other government regulators, as well as global agencies such as WHO, were faced with similar sets of problems.
With government deficits running at record levels, it’ll be extraordinarily difficult to expand budgets to sustain non-Covid-19 related work at the desired levels. But, moving forward, such expansion will have to occur in order to meet the needs of underserved populations worldwide.