A new WHO White Paper on strengthening Health Emergency Preparedness and Response supports the creation of a “Global Health Emergency Council” under WHO auspices and some “targeted amendments” to existing International Health Regulations governing emergencies.

However, the new White Paper, issued under the name of WHO Director General Dr Tedros Adhanom Ghebreyesus, also avoids taking a clear position on specific elements of reforms to the IHR rules – batting the issue back to member states.

Reform to the IHR rules, which the White Paper describes as “still too slow” to be effective in pandemics, appears to be shaping up as a key issue for debate at the upcoming World Health Assembly, which meets at the end of the month. 

The IHR reforms are seen as the most immediate answer to some of the failures of the COVID-19 pandemic – pending the negotiation and adoption of a new Pandemic treaty, convention or other legal instrument, which will take at least two years, followed by a ratification process. 

The United States is pushing for rapid adoption by the WHA of a proposal for a series of targeted IHR amendments, introducing more time-bound requirements for reporting outbreaks, and greater transparency. 

The US proposal for amended IHR rules would set tight, clear timelines for member states to report suspicious pathogen outbreaks to WHO, and for WHO to report those onwards to other member states and the public. However, it’s unlikely that China and Russia will readily agree to the US proposal – due to the threats they perceive to their sovereignty. 

United States already tabled pinpoint edits to the IHR 

Since US President Joe Biden took office, WHO’s relationship with the US administration has vastly improved, as evidenced by Tedros’ recent trip to Washington D.C., followed by the recent breakthrough agreement to increase fixed, annual member state contributions to WHO – supported by the US.

However, the Director General still must continue to balance the relationship with Washington against the countervailing pressures of other member states.  So a proposal to streamline the IHR reform process, without endorsing specific reforms, may be the best way out for him.

Similar tensions also are evident, reading between-the-lines of the zero draft report by the WHO member state Working Group on Pandemic Preparedness and response – published just a day before the White Paper.  The Working Group report suggests that tough questions on IHR reforms could still be punted down to the autumn, at least. 

The member state draft suggests that an  IHR “Review Committee” might be set up by the WHA to consider a range of member state reform proposals – implying that beyond the United States, other nations are also in the process of drafting plans for IHR reform. The Working Group would then report back by October – with a hoped-for clear set of proposals for IHR overhaul. 

Both the WGPR and DG reports are labeled as “Zero Draft” and “Consultation Draft” respectively, indicating their wide-open nature.  Both contain a much longer laundry list of reform items, ranging from thorny questions around access and equity to more action on “One Health” and global health security, suggesting that it’ll be at least several weeks until it becomes clear what shape and direction talks take at the WHA.  

Director General text proposes “streamlined process on IHR amendments”  

In terms of IHR reform, the Director General’s proposal for a streamlined process of creating amendments to the existing IHR says the following: 

“The inherent tension between the aim to protect health and the need to protect economies by avoiding travel and trade restrictions has been noted by the IHR Review Committee and the IPPPR [Independent Panel on Pandemic Preparedness and Review] as the most important factor limiting compliance with the IHR,” the Director General’s report notes, referring to two independent  reports on pandemic response, highly critical of WHO’s performance as well as of the IHR’s shortcomings, that were issued last year.

Adds the Director General’s White Paper:  

“In addition, too many countries still do not have sufficient public health capacities to protect their own populations, and to give timely warnings to WHO; the global alert system is still too slow; and the current self-reporting mechanism on the implementation of core capacities lacks incentives for compliance with the IHR. The absence of a Conference of the Parties for the IHR is an overarching limitation in their effective application and compliance.” 

“But to build further trust and strengthen global governance for health emergencies, amending certain articles of the IHR, while strengthening their implementation, is necessary. Such targeted amendments should make the instrument more agile and flexible and should facilitate compliance with its provisions,”

A related issue is the need to streamline the process to bring IHR amendments into force, which at present can take up to two years. Ensuring that the IHR can be efficiently and
effectively amended to accommodate evolving global health requirements is key to their continued relevance and effectiveness.

“A targeted amendment to achieve this streamlining has been proposed and is currently being discussed informally. The approval of this proposal at the 75th World Health Assembly will contribute substantially to ensuring that the IHR remains a foundational and relevant global health legal instrument.”

Working Group hedging bets 

The Working Group text, meanwhile, suggests a flexible time-frame for reaching consensus on IHR reforms, stating that it: “Supports the Health Assembly continuing with an inclusive Member State-led process on amending the IHR (2005)… and proposes the following approach for adoption by the Seventy-fifth World Health Assembly”: 

“(a) Decision adopted by Seventy-fifth World Health Assembly that, in overview: – adopts any amendments to the IHR ready for adoption (if any); – agrees a Member State process to convene between the Seventy-fifth and Seventy-sixth World Health Assemblies to take forward work on all proposed IHR-targeted amendments; and – invites the Director-General to convene an IHR Review Committee to make technical recommendations on the proposed amendments referred to in subparagraph (b) below, with a view to informing the work of the Member State process. 

“(b) Proposed amendments to be submitted by 30 June, 2022. All such proposed amendments will be distributed by the Director-General to all States Parties without delay. (c) An IHR Review Committee to be established by the Director-General in accordance with Article 50(1)(a) of the IHR, with particular attention to be paid to the fulfilment of the letter and spirit of Article 51(2). 

“(d) The Member State process, to be convened no later than September 2022, should be aligned with the INB process, as both the IHR and the new instrument are expected to play central roles in pandemic PPR in the future. 

(e) The IHR Review Committee to submit its report to the Director-General by October 2022, with the Director-General transmitting it without delay to the Member State process. The Director-General will also communicate the report to the Executive Board at its 152nd session, in accordance with Article 52(3) of the IHR Independent Panel review.” 

Global Health Emergency Council under WHO leadership

The proposal for a Global Health Emergency Council under WHO auspices, complemented by a World Health Assembly Emergency Committee, is another key element of the Director-General’s White Paper Plan.

It’s clearly intended to head off the creation of a similar body under the UN General Assemnly Secretariat and/or G7 auspices, as had been proposed last year by The Independent Panel report and in some other fora.  

“Several panels have proposed the establishment of a high-level council on global health emergencies, comprising heads of state and other international leaders,” states the Director General’s White Paper.  

“WHO supports this concept and proposes the establishment of a Global Health Emergency Council, linked to and aligned with the constitution and governance of WHO, rather than creating a  parallel structure, which could lead to further fragmentation of the global architecture of HEPR.” 

Unlike IHR reform, the WHO White Paper clearly “puts the WHO foot down” against the creation of other additional structures outside of the Organization that have at times been proposed, one diplomatic observer told Health Policy Watch.

The WHO White Paper does, however, support the creation of a joint WHO and World Bank-managed Financial Intermediary Fund (FIF) as a standing mechanism for funding countries’ pandemic preparedness and response needs.

A number of countries, led by French and Germany, also have supported the idea of linking the funding mechanism to a new peer-review process by member states of countries’ pandemic planning, called a “Universal Health and Preparedness Review (UHPR).

The UHPR initiative is seen as a way of reinforcing the linkage between a country’s real preparedness status and its eligibility to compete for certain types of financial support.

“It’s very interesting as an idea, but not everyone wants to have this clear linkage between reforms and funds dispersed and this peer review process,” the observer said.

Overall, however, the White Paper, “is very broad, but it has the merit that it brings together the points made by the various reform panels, for a more structured discussion of what is doable or not,” the observer added.

“Clearly some proposals are more consensual that others, but at least it’s a good point of departure.”

Image Credits: WHO/P. Virot & LoC/Carol Highsmith, WHO, UNAIDS/Twitter.