Hear the UK Secretary of State for International Development, Rt Hon Anne-Marie Trevelyan MP pledge support for Gavi.Our symposia were sandwiched the highly successful UK Government Global Vaccine Summit to ensure funding for Gavi.

Throughout our Symposia we heard how the response to disease outbreaks and more chronic health systems stressors in low- and middle-income countries is characterised by its flexibility, dynamism and responsiveness.

Lessons from Liberia and Sierra Leone on the response to Ebola Virus Disease are that researchers can play a key role in shaping emergency policy and implementation, collecting data in real time, providing expert advice on issues related to the health systems building blocks such as human resource management and supporting the nations recovery from shocks, particularly the psycho-social effects of epidemics.

Given the ongoing COVID-19 pandemic many of our discussions centred on how best to harness this dynamism in the creation and distribution of diagnostics, therapeutics and vaccinations. The importance of academia to the COVID-19 crisis response was very much in evidence. We heard how vaccine and diagnostics researchers in Liverpool are playing a leading role in supporting the WHO-led effort to move through the science, to trial, to manufacturing, to distribution pipeline.

Of course, speed it not everything and academics in our Symposia provided interesting reflections on the ethical implications of different types of vaccine trials and the importance of considering what practical steps should occur should we have a scientific breakthrough to ensure access to new technologies.

I want to highlight the importance of responsive and people-centred health systems.

Professor Sally Theobald, Liverpool School of Tropical Medicine

Ensuring equity in our response to global health and COVID-19 was a theme that echoed throughout the Symposia. Many people pointed to the importance of WHO-led processes to ensure the equitable distribution of a COVID-19 therapeutic or vaccine, should one become available. The UK Government representatives made strong statements in favour of a focus on the poorest when it comes to the COVID-19 response.

Others were more sceptical of the likelihood of the private sector and pharmaceutical companies working in the best interests of the poorest and most marginalised in low- and middle-income countries rather than for profit. But mechanisms to shape the pharmaceutical market such as Advance Market Commitments were put forward as a mechanism for positively skewing the market towards science that would benefit the poor. Gavi’s success over the last 20 years in vastly expanding immunization programmes and supporting primary health care was highlighted.

When considering the reality of delivering health services and vaccines we heard about the challenges that are faced by the most marginalised people living within urban informal settlements in low- and middle-income countries. These spaces are underserved by vaccine programmes. COVID-19 has highlighted existing inequities in all settings. In many low- and middle-income countries restrictions on movement are having devastating consequences for the livelihoods and coping strategies of many people, particularly those working in the informal sector. These affects can be gendered with rising rates of intimate partner violence against women, greater caring responsibilities and associated effects on mental well-being.

What needs to be highlighted is that these challenges - those experienced by the urban poor, exacerbated by the pandemic - result from political, economic and social processes and structures of exclusion, including failures of governance. We need to keep these in mind when considering interventions for these communities including the COVID-19 response.

Dr Rachel Tolhurst, Liverpool School of Tropical Medicine                  

The world of international research brings together a vast number of stakeholders who pool their collective knowledge and strength to meet the needs of the most marginalised around the world. We heard how interdisciplinary arrangements for knowledge generation and the use of a range of research methods – from participatory action research to molecular science – will be needed in the COVID-19 response. We were reminded that that Corona viruses are not new, and have been studied since the 1930s. Previous work on Severe Acute Respiratory Syndrome (SARS) and Middle-Eastern Respiratory Syndrome (MERS) could assist us in moving forward.

This mix of disciplines will be particularly important as we work on vaccines, diagnostics, therapeutics, social and behavioural dynamics and the political and economic elements of pandemic response and recovery.

We heard how partnerships with the private sector are not always plain sailing – particularly when academic and private sector incentives, ways of working and values may be out of sync – but that they can work well. Partnerships between Liverpool-based researchers and the private sector have vastly speeded up the development COVID-19 testing technology. The ACT Accelerator for COVID-19 has been an unprecedented example of public-private sector collaboration designed to leverage innovation in vaccine development and hope to ensure future equity in supply of COVID-19 vaccines. The example of Gavi was held up as a public-private partnership which has excelled in delivering global public goods in the form of vaccines and strengthened health systems.

We were challenged to think more widely about what our partnerships with the private sector might look like, particularly in low- and middle-income countries. For example, how influencers could help us overcome vaccine anxiety, hesitancy and myths and how work with the informal sector could assist in accelerating progress towards Universal Health Coverage. What is clear is the time for isolation and going it alone is long past.

We heard that in Sierra Leone Ebola Virus Disease demonstrated and exacerbated low levels of trust between the people and the health system which negatively affected the efficacy of the response. The use of community health workers and Traditional Leaders as mediators between communities and services was key to rebuilding collaboration.

In Liberia community dialogues helped to mend some of the rifts that had occurred due to Ebola-related stigma and lack of trust more generally. Structural and longer-term interventions to tackle governance and accountability weaknesses also helped to build trust between citizens and decision-makers. Approaches to Ebola Virus Disease in West Africa contain many lessons that can inform our approach to the COVID-19 response.

We heard how community engagement is key to designing policies and programmes that are fit for purpose and not ‘one-size fits all’. For example, the design of social protection schemes should include representatives of affected communities and civil society organisations. This approach increases utility – it is more likely to lead to an effective response – but can also help strengthen accountability mechanisms and the realisation of human rights.

Cross-sectoral government engagement is also necessary for vaccine development, action on the social determinants of health and the delivery of complex health interventions. We heard from Malawi how the typhoid vaccine trials were delivered mainly through schools, pointing to the importance of partnership with Ministries of Education. Learning from interventions for Neglected Tropical Diseases pointed to the importance of working with Ministries with a responsibility for gender and the family. Researchers should look for partners and champions across governments alongside Ministries of Health.

Through collaborations and new relationships, built on mutual respect and trust we can ensure inclusivity in who participates in health-related decision-making and that it is led by those with the greatest knowledge of context.

More specifically the symposia contained some critique of models of ‘white saviourism’ and many calls for global solidarity. The COVID-19 pandemic has very clearly shown that fragile health systems are not only found in low- and middle-income counties and that a high GDP is not as protective as was once imagined when it comes to disease outbreaks.

In responding to COVID-19 in low- and middle-income countries global solidarity will have to be informed by context specific granularity of knowledge. We heard a call for more context-specific research led by local experts which takes issues of equity, gender sensitivity and inclusivity as a starting point. It was suggested that this should be coupled with the creation of knowledge sharing platforms to share evidence from the South to the North and build capacity.

“I think in general the South-North learning still appears novel to most. So, when there are conferences and other opportunities for sharing these represent times to think more broadly and in more diverse ways about how to cross fertilize our ideas. I also think that small countries like Liberia and Sierra Leone are rarely privileged in global meetings to share lessons learned not only on ‘novel’ disease outbreaks but on general issues that they confront in primary care delivery in resource-poor/constrained settings.” 

Dr Janice Cooper, Carter Centre, Liberia