UN Deputy Secretary-General Amina Mohammed holds back tears after revealing that her father died from tuberculosis.

An emotional Amina Mohammed, Deputy Secretary-General of the United Nations (UN), revealed that her father had died of tuberculosis (TB) as she thanked advocates for their work to secure the adoption of the UN political declaration on TB at the high-level meeting (HLM) on Friday.

Urging UN member states to devote the necessary resources to ending one of the world’s oldest and deadliest infectious diseases, Mohammed said that her commitment to ending TB was personal.

“My commitment is my personal story: losing my father to TB at 50, 37 years ago this week,” said Mohammed, blinking away tears. 

“Today we have the tools to diagnose and treat TB, and what we need right now is a vaccine. Let’s end TB now. It is possible.”

Earlier, she described TB as “a major cause of global antibiotic resistance” and “a global health security threat” aggravated by” armed conflicts, economic upheavals and climate disasters”. 

“We must work to address the main drivers of TB: poverty, undernutrition, a lack of access to health services, the prevalence of HIV infections, diabetes, mental health and smoking,” said Mohammed.

Dr Tedros Adhanom Ghebreyesus, World Health Organization (WHO) Director General, joined TB activists chanting “Stop TB” before addressing the HLM.

None of the targets set by the previous HLM on TB in 2018 have been met, largely due to the COVID-19 pandemic, said Tedros.

Member states committed to treating 40 million people for TB between 2018 and 2022, but only 34 million people were reached (84% of target), said Tedros.

However, the biggest failure involves the target of treating 1.5 million people for multidrug or rifampicin-resistant TB  – with slightly over half this target reached (55%). 

While we have new and powerful tools we didn’t have five years ago including a rapid TB test that gives results in two hours and effective treatment “one important thing that we do not have is a new vaccine”, said Tedros.

The BCG vaccine given to infants was developed over 100 years ago and is inadequate for protecting adults and teens.

“That is why the WHO has established the TB Vaccine Accelerator Council to develop, licence and ensure equitable use of a vaccine,” said Tedros, adding that the council had met for the first time this week.

Tedros addressing the UN HLM on TB on Friday

Some new wins for TB

“This declaration contains clear targets for the fight against TB. The TB community should be proud of their amazing work done to secure these targets. However, we know commitments alone aren’t enough and declarations will gather dust without further action,” said Lucica Ditiu, executive director of the Stop TB Partnership.

“In 2018 member states promised to provide $13 billion a year in annual TB funding by 2022, yet they’re providing less than half that amount – who is accountable for the failure to follow through on this promise?”,

The declaration offers a number of new wins for patients, notably “specific, measurable and time-bound targets to find, diagnose, and treat people with TB with the latest WHO recommended tools, as well as time-bound and specific targets for funding the TB response and R&D,” according to a civil society analysis of the TB declaration,

Another big win for the TB community is stronger language around a commitment “to strengthen financial and social protections for people affected by TB and alleviate the health and non-health related financial burden of TB experienced by affected people and their families” and to ensure that by 2027 100% of people with TB “have access to a health and social benefits package so they do not have to endure financial hardship because of their illness”.

There is also the explicit recognition that it is a human right to enjoy the benefits of scientific progress.

But some key targets have also been watered down, such as the erosion of language around gender and human rights with  none of the key asks related to ensuring that all national TB responses are “equitable, inclusive, gender-sensitive, rights-based and people-centred” being secured.

The Stop TB Partnership said that it was working on translating the global targets and commitments to national level commitments,  and ensuring that civil society and TB communities have the resources and tools to ensure leaders follow through on their commitments.”

Future disruptions?

The three political declarations on health adopted this week – on pandemics, universal health coverage and tuberculosis – will be referred to the UN General Assembly for formal ratification, said UNGA president Dennis Francis. It is possible that the 11 member states including Russia, Syria and Venezuela that disputed consensus had been reached on these declarations in a letter sent to the UN Secretary General earlier this week will object then.

“Our delegations oppose any attempt to pretend to formally adopt any of the draft outcome documents in question, during the meetings scheduled for 18, 20, 21 and 22 September 2023, respectively,” the 11 warned.

“In addition, we reserve the right to take appropriate action upon the formal consideration of these four draft outcome documents in the coming weeks, after the conclusion of the High-Level Segment of the 78th Session of the General Assembly, when they must all be considered by the General Assembly in accordance with its rules of procedures.”

However, none of the 11 contested the adoption of the declarations in the HLMs despite some of them speaking during the proceedings.

Activists rally outside the European Union Mission in New York shortly before the HLM, calling on the EU to stop aiding Uganda after it passed its Anti-Homosexuality Act outlawing LGBTQ people.

NEW YORK – While the United Nations (UN) high-level meeting (HLM) on universal health coverage (UHC) adopted a political declaration on Thursday committing member states to accelerate health for all, this will remain a paper promise unless governments invest in primary healthcare.

This was the challenge issued to member states by World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus at the start of the HLM.

“Ultimately, UHC is a political choice. The political declaration you have approved today is a strong signal that you are making that choice, but the choice is not just made on paper,” said Tedros.

“Most of all, it’s made by investing in primary health care, which is the most inclusive, equitable, cost-effective and efficient path to universal health coverage. In particular, investing in primary health care means investing in the people who deliver it: the healthcare workers who are the backbone of every health system.”

Tedros then made three requests of member states: make UHC “the central policy priority for your government”; increase domestic investments in primary health care, health workers and financial protection starting with the most vulnerable; and address the drivers of poor health in “the food people eat, the air they breathe and the conditions in which they live and work”.

Dr Tedros challenges to UN member states to invest in primary healthcare.

Going backwards?

In 2019, the UN adopted a similar political declaration on UHC aimed at ensuring all people have access to health services when and where they need it, irrespective of their financial position. 

But progress towards UHC has stalled since then, primarily due to the COVID-19 pandemic. By 2021 over half the world’s population – at least 4.5 billion people – were not fully covered by essential health services. About a billion spent over 10% of their income on health expenses.

Rebecca Akufo-Addo, Ghana’s First Lady and a UHC champion, told the HLM that “geography, income, education, gender and age continue to exclude many from basic health services” while “a further threat is the rise of non-communicable diseases.”

“We cannot continue to push people into poverty because of illness. We must develop insurance schemes that cover our people,” urged Akufo-Addo.

US activists protesting outside the EU Mission in New York on Thursday against what they describe as EU collusion with the anti-LGBTQ Uganda.

Expanding access to healthcare is also constrained by religious and cultural bias. The EU has not halted aid to Uganda despite that country passing an Anti-Homosexuality Act in May that criminalises LGBTQ people, even compelling health workers to report “suspected” LGBTQ people to the police. Kenya, Tanzania and Ghana are considering similar legislation.

Shortly before the HLM began, activists held a protest outside the EU Mission in New York to protest its ongoing aid to Uganda, holding posters calling for UHC to apply to everyone.

Addressing the HLM, the US and Norway explicitly called for UHC to be inclusive of all marginalised people.

“We must take bold action to include historically marginalised populations and ensure sexual and reproductive health and rights for all,” said Xavier Becerra, US Secretary of Health and Human Services.

“We must include the voices of women, the underrepresented, and LGBTQIA+ populations in our decision-making, and we must meaningfully include all people in all their diversity and reject policies that hinder their access to care because of bias, discrimination, or stigma.”

EU Commissioner Ylva Johansson

EU Commissioner Ylva Johansson said that governments “need to address the determinants of health as well as inequality and gender equality, including sexual and reproductive health, as a prerequisite for equitable, sustainable health systems and UHC”. 

Sexual and reproductive health services are dismal in many parts of the world. At an event earlier in the week, philanthropist Melinda French Gates said that almost half of women in sub-Saharan Africa who wanted contraception could not get it. Meanwhile, access to abortion – even when a woman’s health is in danger – is getting far more difficult in many parts of the world, including the US.

Africa’s ask, EU and Japan’s response

Tunisia’s foreign affairs minister, Nabil Ammar

Tunisia’s foreign minister, Nabil Ammar, speaking for the Africa group, called for “sufficient, predictable and sustainable financing to support national efforts by developing countries [to achieve UHC] through bilateral and multilateral financing, including innovative financing mechanisms and concessional financing”. 

He also called for international financing to support the local and regional manufacturing of medical countermeasures to ensure Africans are protected during health emergencies and pandemics.”

Both Japan and the European Union have invested heavily in UHC. Japanese Prime Minister Fumio Kishida said that his country had made contributions totalling more than $7.5 billion dollars to assist with this.

He also said that G7 leaders had also endorsed the Impact Investment Initiative for global health to pursue expansion of private investment in UHC.

EU Commissioner Johansson said that between 2021 and 2027, EU institutions alone will contribute over €4.4 billion to health system strengthening in countries that most need UHC.

She emphasized strengthening primary health care “as the first line to protect people’s health and defend against infectious disease outbreaks”. 

“We must foster digitalization as a fundamental enabler and exploit the potential of voluntary technology transfers based on mutually agreed terms fully in line with international intellectual property rules,” she said

Image Credits: Kerry Cullinan.

United Nations Secretary-General António Guterres sent a clear message to the world’s largest polluters when he excluded them from his Climate Ambition Summit. But will they listen?

The United Nations Secretary-General, António Guterres, explicitly excluded the world’s five largest emitters of greenhouse gasses – China, the United States, Russia, India and Japan – from his Climate Ambition Summit, held Wednesday on the sidelines of the UN General Assembly.

The United Kingdom, another major polluter, was notably absent from the summit, amid reports that Prime Minister Rishi Sunak had avoided the UN General Assembly after being warned he would be excluded from the climate discussions.

The summit, announced by Guterres in December 2022, was intended to be a “no-nonsense” showcase of the “first movers and doers” fighting to keep alive the increasingly unrealistic goal of limiting global warming to 1.5°C.

By excluding the world’s largest emitters, Guterres sent a clear message to their leaders: you are not taking the climate threat seriously.

“Humanity has opened the gates of hell,” Guterres said. “We must make up time lost to foot-dragging, arm-twisting, and the naked greed of entrenched interests raking in billions from fossil fuels.”

The United Nations kept the final list of world leaders invited to speak at the climate summit under wraps until the eve of the meeting on Tuesday.

In the months leading up to the summit, Secretary-General António Guterres made clear that only countries that had taken significant steps to address climate change would be invited. Invited countries were also required to send a high-level leader to the summit.

Several G20 countries made the final cut, including Brazil, Canada, South Africa, and nine European Union countries, among them Germany, France, and Spain.

“To all those working, marching and championing real climate action, I want you to know that you are on the right side of history and that I am with you,” Guterres told the General Assembly on Tuesday. 

“One summit will not change the world, but today can be a powerful moment to generate momentum,” Guterres said. “We can and we must turn up the tempo.” 

Excluded leaders show few signs of caring 

Rishi Sunak announced a U-turn on net zero targets from London during the Climate Ambition Summit on Wednesday.

The lineup at the climate summit on Wednesday stood in sharp contrast to the two previous UN climate action summits in 2014 and 2019.

In 2014, then-UN Secretary-General Ban Ki-Moon hailed the gathering of a record number of heads of state, business leaders and civil society as “a great day for climate action”.  In 2019, 65 countries made pledges to cut carbon emissions, and heads of state from every major nation attended, including Indian Prime Minister Narendra Modi and former US President Donald Trump.

But this year, the climate summit convened by the UN Secretary-General had not even concluded by the time Guterres received a stark sign that major polluters were not listening.

As the Climate Ambition Summit got underway at UN headquarters in New York, British Prime Minister Rishi Sunak — the first prime minister to skip the U.N. General Assembly in a decade — announced plans to renege on many of the UK’s existing climate commitments, including ones made by his Conservative predecessors, such as former Prime Minister Boris Johnson, who hosted the COP26 Conference in Glasgow in 2021.

The move follows Sunak’s vow to “max out” U.K. fossil fuel reserves in the North Sea in August. Infosys, a six-trillion-dollar company founded by Sunak’s father-in-law, signed a $1.5 billion deal with British Petroleum just two months before Sunak announced the new oil and gas drilling licenses.

Shell CEO Wael Sawan, who called the phase-out of fossil fuels “dangerous and irresponsible” on July 6, 2023, the hottest day ever recorded in human history at the time, is a member of British Prime Minister Rishi Sunak’s business council.

Guterres’s message to the world’s largest polluters at the Climate Ambition Summit was further undermined by the fact that most of the key leaders he barred from the summit — Chinese President Xi Jinping, Russian President Vladimir Putin, and Indian Prime Minister Narendra Modi — chose not to attend the UN General Assembly in the first place.

Brazil makes ambitious commitment to halve emissions by 2030

Brazilian minister for the environment, Marina Silva, announced at the climate summit that her country aims to cut its carbon emissions by 48% by 2025, and 53% by 2030. Silva made the announcement in place of President Luiz Ignacio Lula da Silva, who missed the summit due to illness.

The ambitious goals mark a significant shift in Brazil’s climate policy under Lula, who has vowed to reverse the environmental damage done by his predecessor Jair Bolsonaro.

Bolsonaro presided over a period of mass deforestation in the Amazon and denied the existence of climate change.

European Union on track to surpass its 55% reduction goal

European Commission President Ursula von der Leyen told the summit the EU is on track to surpass its goal to reduce greenhouse gas emissions by 55% by 2030. The EU will also continue to contribute its “fair share” of $27 billion to the global climate finance fund, she said. 

Her counterpart, European Council President Charles Michel, told the General Assembly on Tuesday that the EU is committed to ensuring that concessional finance is available to countries that need it.

Michel compared the current global financial architecture to “an old house, built in another time, for another time”. 

“We need to make sure everyone has fair access to financing,” Michel said. “It costs eight times more for African economies to borrow than it does the rest of the world.”

“That is simply unfair,” he said.

Only 17 Countries call for a global “phase-out” of fossil fuels 

Carbon capture and storage technologies will play a minimal role in mitigating global emissions, according to Climate Action Tracker.

The heads-of-state of 17 countries, including Kenya, Colombia, a group of small island states, and EU countries such as France, Belgium, Denmark, and Spain, published a letter ahead of the Climate Ambition Summit calling for a global phase-out of fossil fuels.

“There can be no more pretence that anything other than staying within 1.5 degrees is an acceptable limit to pursue,” the letter warned.

The statement by the 17 countries explicitly denounced the idea that carbon capture technologies can be a solution to the climate crisis.

“[Carbon] abatement technologies have a role to play in reducing emissions, but that role in the decarbonization of energy systems is minimal,” the letter said. “Systemic transformations are needed across all economic sectors, driven by a global phase-out of fossil fuels.”

The statement by the 17 countries directly contradicted the position of the United Arab Emirates, host of this year’s upcoming UN Climate Conference COP28, which aims to focus on reducing emissions rather than phasing out fossil fuels.

Critics say that the UAE’s stance, shared by other petrostates such as Saudi Arabia, would place untested carbon capture technologies at the center of global mitigation efforts and disincentivize critical investments in renewable alternatives to fossil fuels.

Fossil fuels are currently currently subsidized at a rate of $7 trillion every year, according to the International Monetary Fund.

Most climate scientists agree that carbon capture and storage technologies can play only a minimal role in decarbonising the economy. A recent report by Carbon Action Tracker found that such technologies will play, “at best, a minor role” in helping the world reach the 1.5°C target set in the 2015 Paris Agreement. 

“The direction for all fossil gas, whether equipped with carbon capture and storage or without, is the same: It’s one of swift decline,” Neil Grant, one of the Carbon Action Tracker report’s authors, told Semafor.

The high-ambition position statement also called for trillions of dollars in climate financing and financial system reforms to address the climate crisis.

“The mobilization of finance for climate action must reach the trillions, and we must put in place financial system reforms to be responsive to the multitude of crises the world faces today,” the statement said.

“No country should have to choose between fighting poverty and fighting for our planet.”

Money, justice, and global finance reform 

Mia Mottley, Prime Minsiter of Barbados, began campaigning for the Bridgetown Initiative at climate talks in Glasgow in 2021.

Guterres has made climate change the cornerstone of his tenure, and the agenda of the Climate Ambition Summit reflected his flagship issues.

Top of the list is a call for reforms to the global financial system and multilateral banks – which Guterres calls a “new Bretton Woods moment” – and securing climate justice through a surge in climate finance.

Mia Mottley, the prime minister of Barbados and a leader of the movement to reshape the global financial architecture to help countries such as her own adapt to climate change, described the lack of climate finance as “almost a crime of humanity” at the Climate Ambition Summit.

UN Secretary-General António Guterres also called on world leaders to fully operationalize the Climate Loss and Damage Fund, which was agreed to at COP27 in Sharm el-Sheikh in December 2022 after years of resistance by major polluters.

The fund is supposed to support climate adaptation and mitigation in poor nations, which emit a tiny fraction of the world’s greenhouse gases but are suffering a large brunt of climate impacts. However, the mechanisms for financing the fund, prioritising countries’ needs, and delivering money remain poorly defined.

“Make no mistake, the storm is gaining strength,” Samoan Prime Minister Fiame Mata’afa told the summit in a statement on behalf of the Alliance of Small Island States, which face an imminent and existential threat from climate change. 

“The pursuit of profit over the well-being is not right – it is unjust,” Mata’afa said. “Our contribution to greenhouse gas emissions is less than 1%. The G20 is responsible for 80% of the emissions.”

Civil society’s hopes for climate justice now rest on the outcome of the UN Climate Summit set to take place in Dubai in November.

“We the people of the global south are not asking for aid or assistance,” said Lidy Nacpil, coordinator of the Asian People’s Movement on Debt and Development. “Climate finance is an obligation, and part of reparations for the historical and continuing harms and injustice.” 

“We have a right not just to survive, but to build a better home and future for our children,” Nacpil said. 

Image Credits: UK Foreign Office, Climate Action Tracker, UNCTAD.

Plenary panel of the High Level Meeting on Pandemic Prevention, Preparedness and Response, Wednesday 20 September.

NEW YORK – A long-awaited political declaration by United Nations (UN) member states on more effective pandemic preparedness and response was approved at a High-Level Meeting (HLM) on Wednesday – without the anticipated political objections raised by 11 member states including Russia in a letter to the global body earlier in the week.

The declaration is a milestone insofar as it signals recognition by the world’s heads of state that pandemic threats are existential threats, much more than simply health emergencies, said Carolyn Reynolds, co-founder of the Pandemic Action Network, which has pushed for a broader approach to pandemic preparedness and response since the onset of the COVID pandemic: 

“Pandemic prevention, preparedness and response is so much more than a national health issue; it is a national and global security and economic issue. Like climate change, pandemics are a global systemic risk and existential threat to humanity, and we need to treat them as such.”

No real commitments

At the same time, the declaration has been bitterly criticised as a text that is largely rhetorical and devoid of real commitments, beyond the pledge to convene another high-level meeting in 2026. During the member state comments following the plenary, heads of state from the world’s leading countries were noticeably absent, with most of the interventions led by ministers of health. 

At least for the upcoming year, the ball is now back in the court of World Health Organization (WHO) member states, which must come to agreement on an effective pandemic accord that places equity at the center of the global response, said former New Zealand Prime Minister Helen Clark, co-chair of the Independent Panel, the WHO-appointed body that issued a scathing report on shortcomings in global pandemic response in 2021.  

WHO member states also must agree to revisions in WHO’s International Health Regulations (IHR) that empower the Organization to “sound the alarm rapidly with evidence and without bureaucracy,” Clark said.

“The Geneva processes, they must be ambitious,” Clark told the HLM. “A new pandemic accord can commit countries to strengthen national health systems surveillance, solidarity and equity. This is the world’s next opportunity. Please don’t miss it in Geneva.”

Helen Clark, former prime minister of New Zealand and former co-chair of The Independent Panel on Pandemic Prevention, Preparedness and Response

Governance: who leads?

Critics have also expressed misgivings about the ability of WHO, representing politically weak health ministries, to oversee and enforce the kinds of tough, binding commitments that would be needed for effective pandemic response.  Those concerns have been behind the push to make UN fora platforms for pandemic debate and decisions.

Advocates for more UN-centred action have proposed the creation of an independent pandemic governance mechanism in the office of the UN Secretary-General, and/or a UN Global Threats Council, to oversee the implementation of any pandemic accord approved by WHO member states.

“I continue to believe that action at the head of state and government level is so needed to help break the cycle of panic and neglect, which sets in around pandemics and to sustain political momentum around preparedness and response,” said Clark, who has called for the creation of a UN-hosted Global Threats Council. 

“And then on accountability. independent monitoring of country preparedness is needed to guarantee our mutual assurance, compliance and accountability with international agreements.” See related story.

Leaders Suggest UN May Be More Appropriate to Lead Pandemic Response Than WHO

R&D and tech transfer 

And a pandemic accord is only the beginning. There need to be much broader reforms in mechanisms to finance improvements in developing country health systems, as well as ensure R&D and technology transfer, HLM speakers  emphasized.  

“There has to be a pre-negotiated and financed end-to-end ecosystem for medical countermeasures,” Clark said.”Every region on earth needs the technology, the knowledge and the local capacity to stop outbreaks when and where they occur, and essential supplies to safeguard human life must be accessible. No country should be at the mercy of global markets to protect their citizens. 

Drowning in debt

Amina Mohammed, deputy UN Secretary-General

As for finance, while some $2 billion has been gathered for a new World Bank managed Pandemic Fund, that is woefully inadequate in comparison to the sums required for debt-burdened countries to improve their health systems and prepare hospitals, data systems and laboratory facilities to meet future threats, critics have said.  

An SDG “stimulus” package including “deep” reforms to the international financial architecture is needed to empower countries, UN Deputy Secretary-General Amina Mohammed stressed. 

“Many developing countries are drowning in debt,” Mohammed told the high level meeting, echoing remarks at a SDG Summit on Monday. 

“Today Africa spends more on debt service costs than on health care and education. We need a finance boost so that countries can invest in universal, resilient health care; their populations have a right to [access]. 

“We’re calling on countries to support the stimulus to scale up affordable long-term financing by at least $500 billion per year, and to support the development of an effective debt-relief mechanism that supports payments, suspensions, longer lending terms and lower rates for developing countries that are drowning in debt – and create the fiscal space to spend on the health that people have a right to [enjoy].”

Strong signal, but not binding 

WHO Director General Dr Tedros Adhanom Ghebreyesus at a press briefing on the High Level declaration on pandemics.

The declaration is a strong signal that countries are committed to learning the lesson of the COVID pandemic.and strengthening the world’s defenses against pandemics, said WHO Director General Dr Tedros Adhanom Ghebreyesus.  

“For too long, the world has operated on a cycle of panic and neglect. When an epidemic or pandemic strikes, response is in crisis mode and when it passes, they move onto the next crisis and fail to learn the lessons that could prevent or mitigate the next epidemic or pandemic,”  said Tedros, speaking at a press briefing shortly after the declaration’s approval. 

The WHO Intergovernmental Negotiating Body (INB) will resume meetings on the Geneva pandemic accord text and discussions on the text in November, with further meetings scheduled for December and January, said Dr Jaouad Mahjour, head of the WHO Secretariat supporting member state negotiations in the INB and in a parallel body for revisions to the IHR. 

Key divisions have emerged between developing and developed countries over Pandemic Accord language around equity and access to the diagnostics, treatments and vaccines that would be needed to counter any future pandemic. 

At the same time, there are geopolitical divides over the process by which new pathogen threats might be reported more rapidly and effective action taken, with fears that such commitments could somehow erode national sovereignty.  

“The process is a bit slow and there are contentious issues that have to be addressed,” said Tedros of the Geneva negotiations. “But the good news is that the areas are now identified and member states are going to get into real negotiations on the issues that are dividing them, and I hope that they will have a way to address these differences and find common ground.”

“Today’s agreement is very historic and we hope it will give energy, it will give negotiation energy and push it forward.”  

NEW YORK – Despite the weaknesses of the political declaration on Pandemic Prevention, Preparedness, and Response (PPPR) expected to be adopted by the United Nations (UN) High-Level Meeting (HLM) on Wednesday, some world leaders believe that the UN is a more appropriate forum to thrash out the global pandemic response than the World Health Organization (WHO).

Juan Manuel Santos, former President of Colombia and a member of The Elders, believes that the UN may be the better forum as “pandemic preparedness encompasses far more than health”.

Santos told a UN side meeting on Tuesday hosted by the Pandemic Action Network (PAN) that if the pandemic accord negotiations are still “mired in confusion” by the time the WHO Intergovernmental Negotiating Body (INB) meets for the seventh time later this year,  “someone has to say, enough, we need to shift it back to New York.”

Mary Robinson, former Irish President and Chair of The Elders, supported Santos’s view that pandemic negotiations should be at the UN. 

“We do need to strengthen the WHO, but we need to realise pandemics affect the whole economy. It has an incredibly devastating impact that drives countries into debt,” said Robinson.

“The world is dismally prepared for the next pandemic, which is definitely coming,” warned Joy Phumaphi, chair of the Global Preparedness Monitoring Board, adding that her body’s report on global readiness would be released in six week’s time.

Next steps?

Alejandro Solano Ortiz, Costa Rica’s Vice Minister for Multilateral Affairs, said that while he was optimistic that the declaration would be passed, “what are the next steps?

“This is a non-binding declaration. It’s just a political declaration, and we need concrete steps in this process to complement the Geneva [WHO] process.”

WHO member states are currently involved in two pandemic negotiations: strengthening the International Health Regulations (IHR), the only legally binding global rules governing health emergencies, and negotiating a pandemic accord to address gaps that emerged during COVID-19, particularly equitable access to vaccines and medicines.

Winnie Byanyima, Executive Director of UNAIDS, said that any future pandemic response needed to be based on technology-sharing to enable more equitable access to medical products.

Byanyima also said that many countries were unable to invest properly in health and pandemic preparedness as they were servicing debts that were bigger than their health budgets.

But Dr Magda Robalo, president of The Institute for Global Health and Development, said that “there is no way we are going to prevent, prepare and respond to pandemics if we don’t address the critical issue of the healthcare workforce.”

However, she too stressed that countries with massive debt repayments were unable to invest in their health systems and health workforce.

Global Threats Council

Helen Clark

Meanwhile, Helen Clark, former Prime Minister of New Zealand and former co-chair of The Independent Panel on PPPR, repeated the panel’s call for the establishment of a “high-level Global Threats Council” as a UN standing committee. 

It would be tasked with “really keeping everyone on their toes about the need for preparedness, and also support the mobilisation of finance to support […] the capacity of low and middle-income countries,” she said.

The Independent Panel had uncovered 16 previous reports about how unprepared the world was to address pandemics, as well as a previous call for a Global Threats Council to be set up following the Ebola outbreak.

“We have to break the cycle of panic and neglect. As we’ve seen with the COVID pandemic, which really isn’t over, we’ve been through the panic phase, and we’re well into the neglect phase. To break that, you need sustained political attention on the importance of preparedness and response because otherwise we will be doomed to repeat the painful lessons of history,” said Clark, reminding the audience that excess mortality during the COVID-19 pandemic was in excess of 24 million people.

Climate and health

Robinson also called for closer collaboration between the climate and health sectors, and for health to follow the lead of the climate sector, which is “trying to have the broadest climate justice movement possible”.

In the face of a massive fossil fuel lobby, climate activists are “trying to gather all the forces” and “the health space needs to widen the circle as much as possible. Health is everybody’s business [and we need] the same kind of connected movements.”

Mary Robinson, chairperson of The Elders

Most of the speakers at the PAN event expressed frustration that the declaration did not commit member states to any action. 

Zeid Ra’ad Al Hussein, former UN High Commissioner for Human Rights and also a member of The Elders, said that weaknesses in the UN system itself needed to be addressed.

“Some parts are highly developed and mature, where the mechanisms are layered and there’s a measure of surrender of sovereignty, which is acceptable. Then parts of the UN system are highly underdeveloped, almost primitive, and it’s staggeringly slow getting anything done. Health is one such sector. The other is climate,” said Hussein.

“In human rights, you have an interesting array of different incentives and disincentives to get governments to do things. That doesn’t exist where you have only a voluntary system and that is where we are with health.”

Glimpse of Bharat Mandapam in Pragati Maidan ahead of the G20 Summit, in New Delhi on September 06, 2023.

Health systems in Africa are under considerable strain: rapid demographic change, rising non-communicable diseases, and emerging and re-emerging threats such as COVID-19 and Ebola are increasing demands on limited health services.

Africa, however, faces a challenging period in health financing to meet these increasing needs. Health spending in most countries remains far short of what is needed to achieve universal health coverage, and in several countries, high debt service has outpaced domestic spending on health and education.

There is no indication from donors that development assistance for health will increase to meet these needs, which means that domestic financing will have to close these critical gaps.

These challenges need an integrated national, regional, and global response. Yet, the global development and health financing architecture has, historically, excluded Africa’s voice from important decisions. 

G20 countries have begun to collectively shape the post-COVID health financing agenda. The group has created a Joint Health and Finance Task Force, and launched the G20 High-Level Independent Panel on the best way to finance pandemic preparedness going forward. 

The African Union’s (AU) admission to the G20 therefore provides an opportunity for Africa to be recognized as a true strategic partner in development; for the continent to make critical inputs to decisions on its development, including health financing reforms; and has the potential to reinvigorate Africa’s resolve to reform domestic issues that hold back the potential for sustainable domestic financing of health. 

But questions remain about what kind of opportunity this presents: would the G20 membership provide true co-ownership? Would it present equal partnership to engage in meaningful and respectful partnership that would bring true and lasting change to Africa’s development? 

An opportunity for Africa’s voice to be heard and acted upon

A COVAX vaccine delivery to Africa in April 2021.

Historically, Africa has often been excluded from discussions and decisions that impact development and health on the continent. Two recent initiatives with little room for Africa’s voice and participation include the design of COVAX and the design and operation of the Pandemic Fund. 

A recent evaluation of the COVAX facility showed that the design of this important initiative had insufficient inputs from beneficiary countries, including those in Africa. Yet, this facility was intended to make substantial inputs into how the COVID-19 financing and response was implemented in Africa. 

“The original design process was driven by a small subset of stakeholders, notably donors and industry of the Global North, without the meaningful engagement of beneficiary countries,” the evaluation noted.

Similarly, the Pandemic Fund—a creation of the G20, sought to have game-changing impacts on the financing of pandemic preparedness and response globally. Yet, the Africa Centers for Disease Control and Prevention (Africa CDC), Africa’s foremost continental health agency with the mandate to lead public health policy and action in Africa, has yet to be accredited as an implementing partner of the Fund. 

Instead, the Africa CDC is represented as an Observer on the Pandemic Fund’s Governing board, denying it a full seat at the table where crucial decisions are made and preventing it from designing a coordinated regional response.

This limits the meaningful participation of the continent in the activities that seek to impact the pandemic preparedness and response landscape in Africa. As a result, in the first allocation of funds by the Pandemic Fund, Africa is the only continent without a funded regional proposal. 

Going forward, the AU can use its voice within the G20 to ensure that this doesn’t happen again and that it has a seat at the table on all future global health decisions that affect its development: this might include international trade practices, the impacts of climate change, and the growing threat of antimicrobial resistance. 

Africa can now contribute its voice on these issues at the G20 in unison.

Two key health financing concerns for the G20 to consider: debt relief and reforming global health aid

Interest payments in Africa have increased by 132% over the past decade, according to the UN Conference on Trade and Development (UNCTAD).

The G20 membership presents an opportunity for Africa to boldly confront two key global issues that hold it back from achieving its health financing goals. 

Firstly, about 23 African countries are in or at high risk of debt distress. Debt service has clearly outpaced spending on health and education, with consequences on other sectors of the economy. With many of Africa’s creditors in the G20, Africa has an opportunity to make the case for debt relief to assist it with rebuilding its health systems. The G20 has done this before—at the height of the COVID-19 pandemic, it suspended  $12.9 billion in debt service payments. 

Secondly, the AU could press the G20 to revisit prior agreements on aid effectiveness to ensure that foreign aid is properly monitored and aligned with national and regional priorities.

This is timely as many stakeholders are now calling for substantial reforms of the global health architecture, including major institutions such as the Global Fund and Gavi, to increase country ownership and strengthen country capacity in a sustainable manner, while charting a clear path to ending dependence on these institutions. 

Africa can therefore use the G20 as a means through which to establish a new compact for donor and domestic financing of health services that puts African governments back in charge of setting health priorities and funding core services, with aid restored to its place as a supplementary health financing stream.

An opportunity for a coordinated African domestic policy response

The G20 membership also has the potential to spur African countries to act on areas where there has been little progress in the past. Despite skepticism about the potential for domestic resource mobilization for health in Africa given the ongoing economic challenges, there are opportunities to boost domestic financing by introducing non-traditional or innovative financing mechanisms. 

Taxes on alcohol, tobacco, and sugar-sweetened beverages are lower in Africa than in all other regions. By “soft-earmarking” these funds for health, they can mobilize popular support, raise finance, and combat the growing burden of non-communicable diseases.

In addition, to mitigate the devastation of the COVID-19 pandemic on economies in Africa, countries should explore other forms of raising (for example through airline levies, import and other duties) and channel domestic resources to strengthen national and regional health systems and public health functions. 

Furthermore, the time is right for African countries to strengthen their public financial management systems and introduce the use of evidence-informed priority-setting mechanisms to improve efficiency in health system decision-making to ensure that resources are channeled to the most effective and cost-effective health interventions.

Concluding Reflections

The admission of AU into the G20 is timely and welcome.

It presents an opportunity to reflect on Africa’s role in ongoing global development and health financing conversations. It gives Africa a voice and a long-overdue seat at the table of global health financing reforms. 

It enables Africa to renegotiate debts to spur investment in health systems, to input into reforms of the global health architecture, and to establish a new compact for donor and domestic financing of health services that puts African governments back in charge of setting health priorities.

Finally, it gives Africa an opportunity to overhaul its financing systems to appropriately prioritize health in its spending through national budgets. 

Now is the time to move from agenda to action.

Authors

Justice Nonvignon is Acting Head, Health Economics and Financing Programme, Africa CDC. He is also a Professor of Health Economics at the University of Ghana, and Non-Resident Fellow of CGD.

Boima S. Kamara is the Health Financing Advisor at the Health Economics and Financing Programme, Africa CDC. He is a former Minister of Finance and Economic Planning, Republic of Liberia and former Deputy Governor (Research and Monetary Policy) of the Central Bank of Liberia.

Pete Baker is a Policy Fellow and Deputy Director of Global Health Policy, Center for Global Development.

Javier Guzman is a Senior Policy Fellow and Director of Global Health Policy, Center for Global Development.

Jean Kaseya is Director General of the Africa Centres for Disease Control and Prevention, African Union.

Image Credits: India Ministry of Culture, WHO.

Testing for hypertension

NEW YORK CITY – A leading killer, hypertension, receives barely a nod in many of the world’s health systems – even though it’s the key contributor to deaths from cardiovascular disease, which claims about 17.9 million lives annually and is the single largest cause of deaths in the world today.  Addressing this systemic neglect is critical to advancing universal health coverage, says the World Health Organization. 

WHO’s first-ever Global Hypertension Report, released Tuesday, calls for the dramatic scale up of prevention, treatment and diagnosis of a condition that affects one in three adults worldwide, but is adequately treated only in about one in every five cases.  

The report was one of two WHO publications released just in advance of a critical UN High Level Meeting on Universal Health Coverage, set for Thursday, 21 September. 

A second publication, the Global Monitoring Report co-authored with the World Bank, underlines the huge gap that still exists between the vision of UHC and the reality. Half of the world’s population lacks access to essential health services and 2 billion people face severe financial hardship due to out-of-pocket healthcare expenses. That reality is far short of the 2030 Sustainable Development Goal (SDG) of coverage for all.  

Without more attention to hypertension and other noncommunicable diseases, which today represent some 74% of premature mortality worldwide, progress on UHC will remain stalled, WHO officials have warned.

Dr Tedros Adhanom Ghebreyesus at the launch of the WHO Global Hypertension report, Tuesday 19 September, in New York City.

“Uncontrolled hypertension can lead to heart attack, stroke and premature death,” said WHO Director General Dr Tedros Adhanom Ghebreyesusm, speaking Tuesday at the launch of the report . “The loss of families and communities is not only personal, it also affects economies and development. In the Sustainable Development Goals, countries have committed to reducing premature mortality from noncommunicable diaseases by one-third by 2030. To get anywhere near that target, all countries must take urgent action on hypertension as part of their journey towards universal health coverage.”

Number of people living with hypertension has doubled

Hypertension diagnosis and treatment by region – a snapshot.

The number of people living with high blood pressure doubled between 1990 and 2019, from 650 million to 1.3 billion, the global hypertension report notes. But nearly one-half of people are entirely unaware of their condition, and only one out of five people actually receive adequate treatment. 

Moreover, the condition that was traditionally associated with the rich diets and sedentary lifestyles of high-income countries is making big inroads in developing regions – along with the encroachment of salt-laden processed foods on traditional diets and other lifestyle changes. 

In fact, more than three-quarters of adults with hypertension today are living in low- and middle-income countries, the report stated. 

Bente Mikkelsen, WHO director of NCDs, at Tuesday’s launch of the report: most hypertension cases go undetected and untreated, particularly in low- and middle-income countries.

“One in three people worldwide has hypertension, only one in two knows that they have it and only one in five globally are under control [of their condition],” said Bente Mikkelsen, director of WHO’s Department of Noncommunicable Diseases at a press briefing on Monday, just ahead of the report’s release.

Increased diagnosis and treatment could prevent 76 million premature deaths by 2050

Tom Frieden, head of Resolve to Save Lives

Technically, the condition is defined as having a blood pressure measurement of more than 140/90 mmHG [millimeters of mercury] or taking hypertension medication, said Mikkelsen. 

However whenever blood pressure levels rise above 120/75 mmHG, risks begin to increase sharply, warned Tom Frieden, head of the US-based nonprofit Resolve to Save Lives, which has long supported WHO’s work on hypertension and cardiovascular disease.  

“Hypertension is the world’s leading killer,” he declared at the WHO briefing. “And in fact risks double with every 10 mmHG increase in blood pressure.”

Additionally, although the 1.3 billion estimate of people with the condition spans the ages of 30-79, it can occur at younger ages as well, he said.

Detecting and treating people at levels achieved in “high-performing” countries could prevent some 76 million premature deaths by 2050, along with 120 million strokes and nearly 100 million cases of heart attack and heart failure, the report concluded. 

Scenarios for scale-up of hypertension treatment – which could save tens of millions of lives by 2050.

Solutions are cheap and simple – or should be

Digital blood pressure monitoring devices have now become widely available.

But while diagnosis and effective medications are both simple and inexpensive, in principle, neither are routine services in primary health care systems in many low and middle income countries, the health experts noted. 

“The most deadly condition is also the most neglected,” declared Frieden.

He noted that the technology to detect hypertension, a simple handheld sphygmomanometer, is hardly new. More recently, battery-powered devices have made measurement even easier for lay people. 

“There is no excuse for any country not to measure blood pressure,” Frieden declared. “This is not an innovation that just happened, it’s an innovation that happened many years ago.” 

And he described it as “unethical” that many generic medications, which are inherently inexpensive, are subject to markups and price gouging in many developing countries – and thus unavailable to many people. 

“It’s an immoral fact that we have off-patent medicines that are unavailable,” said Frieden, who revealed that he, himself, uses an inexpensive, generic blood pressure medication known as amlodipine. 

“I have hypertension. I am on it.  It’s not second rate in any way.

“But we have to put on record that, as of today, there is a huge access problem,” he observed, for drugs just like the one he is using. “It is almost catastrophic. These are very cheap molecules. But if you look at countries, you have markups, you have little regulation. And until medicines are free, the most vulnerable may have to choose between food and medicines.” 

Essential to UHC core package

Countries that have implemented HEARTS-based programmes for hypertension control.

Mikkelsen declared that “an essential package for hypertension should be core to any universal health coverage,” referring to the WHO HEARTS technical package for guidance. 

She pointed to the examples such as Canada, India and the Philippines, which have made hypertension diagnosis and treatment a standard procedure in primary health care. 

“We want to make it clear that it is possible for any country, low-income or high income country, to change the situation,” she added. 

In India and the Philippines, community-based and team based care has made all the difference, she said. 

“India has the largest HEARTS-based programme in the world,” added Frieden. “I’ve never seen anything as exciting and as important as the Indian health and wellness centers, which have very effective hypertension treatment.”

Yet while such Asian countries are making big progress, in Africa, hypertension treatment lags far behind.

“If in Canada six out of every 10 people with hypertension are very well treated, in Africa it’s only five or six people out of 100,” noted Mikkelsen. 

Even so, money is not the secret to success. The United States, which outspends most countries on healthcare, has far lower hypertension detection and treatment rates than its neighbor to the north, Mikkelsen and Frieden noted.  

Unhealthy diets, physical inactivity and air pollution 

Air pollution in New Delhi, India, one of the most heavily polluted cities in the world. Policy change is essential to reduce such hypertension and health risks.

Incorporating hypertension treatment into the traditional national and donor-supported programmes for HIV/AIDS ,TB, malaria and maternal health is one way to mainstream diagnosis and treatment, the experts noted. 

Collaborations with organizations such as The Global Fund have expanded along with the recognition that people living with diseases like HIV/AIDS also are at increased risk of hypertension – particularly as they age.  

Prevention of hypertension through diet, lifestyles and environmental factors is another key message, however, of the new WHO report and initiative. 

Levels of hypertension roughly correlate with salt and potassium intake, Frieden said – with salt increasing risks and potassium reducing them. 

However, barely 6% of countries have policies in place to combat excessive use of sodium in food products, he pointed out.  Excessive use of alcohol and tobacco are other factors – also still poorly regulated in many countries. 

‘We have imported an alien way of life’

(Left) Terrence Deyaisingh, Minister of Health, Republic of Trinidad and Tobago. (Right) Kwaku Agyemang-Manu, Minister of Health, Republic of Ghana, at the launch of the Global Hypertension Report

Urbanization and the onslaught of cheap processed and ultra-processed foods marketed by global food chains  are changing diets and lifestyles in many low- and middle-income countries, increasing hypertension risks, noted Terrence Deyaisingh, Minister of Health, Republic of Trinidad and Tobago, at Tuesday’s launch event.

“We have, unfortunately, imported an alien way of life in what we eat. When we try to walk around, it’s like New York City. In the adoption of technology, children no longer play [outdoors],” he lamented. The country implemented a HEARTS-based programme of outreach to increase diagnosis and control, and is committeed to have 50% of people living with hypertension under treatment by 2050.

Lesser known is the fact that exposure to air pollution increases hypertension risks, as well.  The fine particles of pollutants absorbed into the bloodstream inflame and constrict the blood vessels, as well as increasing blood clotting, which can lead to a stroke. WHO estimates that 99% of people worldwide are exposed to unhealthy levels of air pollution. 

And overall, addressing such issues require a wider approach, beyond the individual and the health care system, Frieden noted.

“Encouraging people to have healthier diets is fine,” he said. “But it’s not really effective. You have to make the physical environment more conducive, so that you are more likely to walk or bicycle.”

Added Mikkelsen. “We don’t believe that we can totally delete the problem by prevention – rather we are looking into modifying the trajectory of hypertension. So I have to say that we need to continue to focus on treatment and control.” 

Image Credits: WHO Global Report on Hypertension/Natalie Naccache, E. Fletcher/HPW, WHO Global Hypertension Report, 2023, E. Fletcher/Health Policy Watch, WHO Global Hypertension report, Marco Verch/Flickr , WHO Global Hypertension Report , Jean-Etienne Minh-Duy.

NEW YORK CITY – World leaders issued a political declaration Monday warning that the world is nowhere close to achieving the Sustainable Development Goals (SDGs) it set in 2015. The declaration, adopted at the first UN high-level political forum on the SDGs since 2019, comes at a time when progress on the goals has been slowed by the COVID-19 pandemic, the war in Ukraine, and other crises.

UN Secretary-General Antonio Guterres billed the Sustainable Development Goals summit as a chance to agree on a “global rescue plan” to save the SDGs. Failure to achieve the SDG targets will leave millions of people around the world without access to education, quality healthcare, food, and routes out of poverty, Guterres told world leaders gathered at UN headquarters in New York City. 

“You made a solemn promise, a promise to build a world of health, progress and opportunity for all, a promise to leave no one behind, and the promise to pay for it,” Guterres told world leaders at the summit’s opening ceremony. “This was not a promise made to one another, as diplomats, from the comfort of these chambers. It was always a promise to people.

“Instead of leaving no one behind, we risk leaving the SDGs behind,” said Guterres. “The SDGs need a global rescue plan.”

Politics over people

Since the start of his invasion of Ukraine, Russian President Vladimir Putin has leveraged the importance of the Black Sea corridor to global food security to obtain concessions from the international community.

The political declaration was approved by world leaders without objection on Monday morning. However, a coalition of 11 authoritarian countries, led by North Korea, Russia, Iran, Venezuela, Syria and Belarus, also published a 17 September letter to UN General Assembly President Dennis Francis in which they stated that they did not consider today’s decision binding. 

The countries said that their objections to language in the declaration had been ignored and they “reserve the right to take appropriate action upon the formal consideration” of the documents in the UN General Assembly later in this autumn’s session.

The countries are reportedly upset over the deletion of a clause in the declarations calling on countries to refrain from “unilateral” trade and economic sanctions. But the rift also goes to the heart of the world’s major geopolitical battles, and the political and social conservatism of the countries involved (see related story). 

The first in-person appearance of Ukrainian President Volodymyr Zelensky at the UN General Assembly has heightened political tensions. At a critical juncture for the SDGs that are supposed to help the world’s poorest people, experts worry the week could be derailed by politics. 

“Rising authoritarianism, democratic backsliding, but also geostrategic competition and economic distress: those are likely to overshadow other fundamental issues related to climate change and global development,” Noam Unger, a development expert at the Center for Strategic and International Studies told AFP.

At half-time, the world is not close to SDGs

The world is set to miss its 2030 hunger eradication target by 600 million people.

The SDG targets were set in 2015, and the deadline was fixed for 2030. At halftime, the score is depressing: just 15% of the 17 targets to transform the world are on track to be achieved by 2030, and eight are going backwards.

Half a billion people are on course to remain in poverty in 2030, while nearly 100 million children will be out of school. Last year, 735 million people faced acute hunger.  

“Can we accept these numbers? Or because they make us uncomfortable, should we pretend they do not exist and carry on with business as usual?” said UN General Assembly President Dennis Francis.  

Poverty eradication, gender equality, education and hunger have all faced setbacks amid several crises, including the COVID-19 pandemic, Russia’s invasion of Ukraine, a food and energy crisis and climate shocks.

Finance is “fuel”

The success of Guterres’ rescue plan hinges on several key financial provisions that all have one thing in common: more money.

The provisions in the draft declaration include a call to recapitalise the multilateral development banks – the International Monetary Fund and the World Bank – and rework the “international financial architecture” that forces developing countries to pay more to borrow money and blocks foreign investment.

“Instead of leaving no one behind, we risk leaving the SDGs behind,” said Guterres. “This can be a game changer … [we] need to reform the international financial architecture that I consider outdated, dysfunctional and unfair.”

Financing is the lifeblood of the Sustainable Development Goals (SDGs), but developing countries are falling short on the trillions of dollars they need to achieve them, Guterres warned. 

“I accept that there may not be enough public money, and to that extent, how do we mobilise money?” said Barbados Prime Minister Mia Mottley, a leading figure in the fight for global financial reform. “The major multinational corporations have balance sheets that dwarf and miniaturise the majority of countries in this room.

 “We have to find a way of them contributing to the financing of global public goods,” said Mottley.

 In some regions of the world, the deadly interplay between conflict, climate and poverty means money is just one part of the solution. Conflict hits women, children and other vulnerable groups the hardest. 

“[We] need to recognise the intertwined nature of the challenges that we are facing with climate, with pandemics, with fragility, with war, and with food insecurity,” said World Bank President Ajay Banga. “We cannot solve one without having a holistic view of the total.

Hunger: missing SDGs leaves people behind

Global hunger took centre stage as a stirring example of the lives changed by missing the SDGs.

The world is currently set to fall 600 million people short of its goal of ensuring not a single person goes hungry. Some 2.4 billion people, 30% of the global population, did not have constant access to food in 2022.

“In our world of plenty, hunger is a shocking stain on humanity and an epic human rights violation,” said Guterres. “It is an indictment that millions of people are starving in this day and age.

“The SDGs aren’t just a list of goals. They carry the hopes, dreams, rights and expectations of people everywhere,” said Guterres.

Image Credits: Mohammed Omer Mukhier/Twitter , UNCTAD.

Eleven conservative countries have declared that they will not support the adoption of the political declarations on the Sustainable Development Goals (SDG), pandemic prevention, preparedness and response (PPPR), universal health coverage (UHC), and tuberculosis (TB) on the United Nations agenda this week.

Although the countries did not raise their objections during Monday’s SDG Summit, the first in this week’s series of high level meetings, they declared in a letter to the UN General Assembly President that they “reserve the right to take appropriate action” during the subsequent UN General Assembly debate and formal vote on the declarations, which must follow the HLM convocations.

“Our delegations oppose any attempt to pretend to formally adopt any of the draft outcome documents in question, during the meetings scheduled for 18, 20, 21 and 22 September 2023, respectively. In addition, we reserve the right to take appropriate action upon the formal consideration of these four (04) draft outcome documents in the coming weeks, after the conclusion of the High-Level Segment of the
78th Session of the General Assembly, when they must all be considered by the General Assembly in accordance with its rules of procedures.”

It was unclear what the practical implications of their reservations would be. Typically, the UNGA formalizes the declarations of high level political meetings in a vote on the Assembly floor after the meetings are over. The letter opens the door for further debate and deliberations, however, before the close of the 78th GA session, now scheduled for 26 September – along with the possibility that the declarations may have to be approved by a vote count, rather than unanimously, as has been the tradition.

Oppose the removal of language on unilateral sanctions

In their letter to UN president Dennis Francis, dated Sunday 17 September, Belarus, Bolivia, Cuba, North Korea, Eritrea, Iran, Nicaragua, Russia, Syria, Venezuela, and Zimbabwe alluded to a “political stalemate” relating to “unilateral coercive measures (UCMs)” as the motive for the reservations.  The claimed that their objections had been ignored or set aside at various stages in the development of the declarations, contrary to UN procedural rules. 

According to the UN Office of the High Commissioner of Human Rights Commission (OHRHC), UCMs “usually refers to economic measures taken by one state to compel a change in the policy of another state”, including trade sanctions,  embargoes, asset freezing and travel bans.

One of the issues that has apparently angered the 11 countries is that earlier drafts of the health and sustainable development declarations initially had language calling on countries to refrain “from promulgating and applying any unilateral, economic, financial or trade measures not in accordance with international law”. However, this has been removed from the final drafts.

the United States, Europe and its allies have slapped a range of trade and economic sanctions on Russia as a result of the Ukraine war; Iran has faced a variety of US-led sanctions since 1979 and more recently, as a result of its nuclear programme, and Latin American countries such as Cuba have faced a US trade blockade for even longer.

However, Lucica Ditiu, Executive Director of the Stop TB Partnership (STBP), told a webinar last week that long-held health rights had also been contested during the negotiations on all three political declarations on health.

“I was in the room and I could hear with my own ears and see with my own eyes Member States literally saying ‘we don’t want to see any language around gender’; ‘can you remove everything that is about the rights of the key and vulnerable populations’. Bodily autonomy and integrity is like up there in the sky,” said Ditiu.

“Even as weak, as watered down as these declarations are, as far as I understand, none of them is actually fully endorsed.” 

Four grievances

In the Letter to UNGA 17 September 2023, sent on a letterhead from the Venezuelan Representative to the UN, the countries outline four key grievances.

First, a small group of developed countries were unwilling to “engage in meaningful negotiations to find compromises, forcing unfair practices which pretend to impose a kind of ‘veto’ on certain issues, and pretending to even prevent their discussion within the framework of intergovernmental negotiations”.

Second, “negotiations were not conducted in a truly inclusive, fair and balanced way”, including the draft outcome of the SDGs Summit being “reopened with the purpose of exclusively accommodating the priorities of a few delegations from developed countries” while “nothing was done to reflect and accommodate the legitimate concerns of delegations from developing countries that, in addition, had broken silence repeatedly, including the Group of 77 and China”.

Third, there were attempts to “ignore formal communications of delegations from developing countries, including from the Group of 77 and China, on behalf of its 134 Member States, indicating strong reservations and objections.”

Finally, the letter claims that the UNGA president had attempted to “force consensus” when it is” evident that no consensus has been reached on any of these processes”.

The delegations conclude by saying that they will “oppose any attempt to pretend to formally adopt any of the draft outcome documents in question, during the meetings scheduled for 18, 20, 21 and 22 September 2023, respectively”. 

Despite the formal objections, the Political Declaration on the SDGs was adopted at Monday’s SDG Summit.  See related story.

Global Leaders Sound Alarm on Sustainable Development Goals at UN SDG Summit

Numerous health challenges face the SEARO region, particularly in regard to women’s health.

Election fever is sweeping through the World Health Organization (WHO) in three of its six regions – Eastern Mediterranean (EMRO), South-East Asia (SEARO), and Western Pacific (WPRO). It matters who becomes their regional directors because they have considerable decentralised authority to influence the health chances of billions.

Its regions also make or break WHO globally.  Close squeaks, as with Ebola and COVID-19, show that a divided WHO can be catastrophic. Conversely, a united WHO is a vital defence against borderless health threats yet to come.

Take SEARO – the focus of this article, after we earlier considered EMRO. The South-East Asia Region is special in WHO annals as it is the first regional office that opened – in 1948 in New Delhi where it is still based.

SEARO’s 11 members are home to two billion people – a quarter of humanity. They range from mighty India (1.4 billion) to the tiny Maldives (0.5 million), with Indonesia, Bangladesh, Thailand, Myanmar, Nepal, the Democratic People’s Republic of Korea (DPRK), Sri Lanka, Timor-Leste, and Bhutan in between.

Remarkable progress

WHO was a household name during my childhood.  I got my immunisations at its centres and treasured the stickers I received as a reward.  We did not know what the WHO acronym meant but felt its goodness.

Global health’s biggest battles were waged in SEARO with notable successes including the eradication of smallpox, wild poliovirus, and maternal and neonatal tetanus. Several countries have vanquished other conditions: Nepal eradicated trachoma, Maldives eliminated lymphatic filariasis while yaws went from India, rubella from Timor-Leste, measles from Bhutan, and malaria from Sri Lanka. 

The region’s people live better with all countries approaching and four exceeding global healthy life expectancy (63.7 years). World Health Statistics indicate that SEARO has posted the fastest decline (57%) in maternal mortality ratio since the millennium and reduced its under-five mortality by 78%. New HIV infections have declined by 50%.

That is not all. The region has hot-housed crucial service innovations such as community health workers and financing, essential drug kits, integration of traditional healthcare systems,  malnutrition management, reproductive health outreach, small-scale water and sanitation technologies, and mass health education, among many examples.

To be accurate – these advances did not come from WHO but from increasing prosperity. All  SEARO countries except DPRK are now middle-income with Thailand and Indonesia in the upper-middle-income category. 

There are also hordes of well-qualified professionals, passionate health advocates and civil society groups in the region. WHO wisely partnered with them to build significant national capacities. That is how WHO accompanied South-East Asia’s post-decolonisation to help countries stand on their feet. It also eased the birth pains of newer nations emerging from bloody civil wars: Bangladesh and Timor-Leste.

Where next for SEARO? 

With increased geopolitical interest in health, WHO punches above its weight more than other technical  agencies as seen by its participation in political fora such as the G20 whose latest summit was in India.  Where does SEARO go next?  

It has plenty of unfinished business. COVID-19 was a reality check causing six million indirect excess deaths – the largest among all regions.  Service disruptions meant that immunisation rates dipped, and tuberculosis treatment declined. SEARO will catch up but remains ill-prepared for the next pandemic with a low 68% score for self-reported International Health Regulations capacities.  

Women’s health struggles with 47% anaemia prevalence, the world’s highest. Child stunting rates of 30% with its most severe ‘wasting’ form contribute an embarrassing eight million of the 13 million children afflicted worldwide.  Water and sanitation coverage lags dismally, contributing 40% of preventable global deaths. With urbanisation edging 40-50% across SEARO, record levels of particulate air pollution and road crashes take years off lifespans.

 Storm clouds on the horizon include rapidly increasing anti-microbial resistance. That is on top of climate change causing changes in vector and pathogen behaviours, risking the re-emergence of defeated conditions or increased virulence of familiar infections.  Meanwhile, richer lifestyles fuel non communicable diseases risks such as rising blood pressures and obesity across the region.

How will SEARO health systems respond? A prospering but grossly unequal region is pushing 100 million into catastrophic poverty through the world’s highest out-of-pocket healthcare costs. Ironically, the region is a mecca for medical tourism – valued at S$7.5 billion in India alone and projected to rise to $42 billion this decade.

 SEARO’s fast-digitising population has high expectations that won’t be satisfied by community health workers. They expect hospital-centered technology-dependent specialist attention.  However, SEARO is short of around seven million health workers with only DPRK and Maldives above the WHO threshold of 44.5 per 10, 000 population. That is not for lack of training. India has the most medical schools in the world and exports thousands of doctors and allied personnel to OECD and Gulf countries.

Contradictory trends mean that SEARO’s Universal Health Coverage (UHC) index has crawled to a disappointing 61 (on a 100-point scale). There is no chance of reaching the SDG target of 80 by 2030 by following WHO’s standard prescription. Where are the new ideas?

Expectations from the new regional director

In short, SEARO has already plucked the low-hanging fruit, and residual and new challenges are not amenable to quick fixes.  What is to be expected from the new SEARO regional director elected on 30 October – 2 November by 10 voting states (Myanmar’s military regime is disenfranchised under UN sanctions)?

The new leader must be humble to understand that whereas WHO was once indispensable to advancing health in the SEARO region, that is no longer the case. As ever-stronger nations grip their own destinies, and their populations’ health is dictated by externalities that only they can manage, SEARO (and wider WHO) must recalibrate its role.

The region has a cornucopia of strategies, frameworks, goals and targets bestowed by global and regional governance bodies or special interest lobbies. The incoming regional director needs political courage and clarity of purpose to cut through them to define the few essential works that SEARO is best placed to do.

Change at the regional level means more than moving into its smart new premises, a $30 million gift from the Indian government. It requires re-setting the bloated Delhi regional office with its wasteful, initiative-sapping rituals and regulations that have left staff at their lowest morale. A more collegiate leadership style and greater diversity of appointments from around Southeast Asia should reduce a stultifying atmosphere more reminiscent of the British Indian Raj than modern corporate management.

 A murky election

Who can do this? Astonishingly, Southeast Asia’s vast reservoir of talent has turned up only two candidates (compared to six in EMRO and five in WPRO elections). The SEARO contenders are from Bangladesh and Nepal.

 Bangladesh’s nominee, Saima Wazed, also holds Canadian citizenship. She has a Master’s degree in psychology and specialises in autism. Her passion for this neglected aspect of mental health is admirable. Her pitch emphasises the continuity of SEARO flagship programmes while promoting partnerships and inclusion of marginalised groups.

Unfortunately, her own capability statement does not reveal the “strong technical and public health background and extensive experience in global health”, required by the official criteria for the role. Or the mandatory substantive track record in public health leadership and significant competencies in organisational management. 

Her rival is Nepal’s Dr Shambhu Prasad Acharya with a public health doctorate and Masters qualifications in business administration and sociology. He has 30 years of substantive leadership and management experience at WHO headquarters, SEARO, and at country-level organising practical programmes in many places. 

Born in a rural farming community, he appears committed to diversity and sensitive to social disadvantage concerns. His future vision seeks population well-being, accelerated Universal Health Coverage, strengthened future pandemic and emergency preparedness, innovating  to bridge inequities, and championing an inter-connected WHO.

It is banal to say that the best candidate should get the job in a fair competition. But the SEARO election is no ordinary process.  Wazed is the daughter of the Bangladesh Prime Minister. Of course, that should not he held against her as even the offspring of a privileged public figure has the right to make their own career.

But being introduced by her mother at recent high-level summits such as BRICS, ASEAN, G20 and the UN General Assembly to craft deals in exchange for votes may be seen as crossing the fine line between a government’s legitimate lobbying for its candidate and craven nepotism.

Earlier, intense political pressure from Bangladesh appears to have dissuaded good competitors from within Bangladesh and other countries. Nepal is now under intensified pressure to withdraw its nominee and allow Wazed to be anointed unopposed.

The waters are further muddied by a complaint to WHO legal authorities alleging that  Wazed may have faked her academic credentials and lacks the constitutionally required qualifications and experience. The requested investigation cites the dismissal of the previous Western Pacific Regional Director as an example of the Organization’s ‘zero tolerance’ policy towards lack of integrity.  But it is unlikely that Geneva will wade in and future investigations – if any – will be long after the event.

Such shenanigans in SEARO plumb a new low in multilateral ethics and standards.  They undermine the WHO when we need global health cooperation more than ever.  Whether raw politics or principled professionalism will decide the election of the next regional director remains to be seen while, regrettably, the health of Southeast Asians is just an afterthought.

Mukesh Kapila is a physician and public health specialist who has worked in 120 countries, including as a former United Nations (UN) Resident and Humanitarian Coordinator in Sudan and a UN Special Adviser in Afghanistan.

 

 

 

 

Image Credits: UN Photo/Kibae Park/Flickr, Yogendra Singh/ Unsplash.