Ukraine’s representative speaks at the World Health Assembly ahead of the vote.

In a strong statement against the ongoing Russian aggression in Ukraine, the World Health Assembly adopted a resolution condemning the violence and calling for an immediate halt to Russian attacks on health facilities. Russia and Syria floated a resolution that made no mention of the Russian aggression, and which failed to find any support among other member states in the Assembly.

The resolution, co-sponsored by some 53 countries, including most of Europe, the United States and Australia, and Japan and the Republic of Korea, passed with 80 member states in favour and nine opposed. Another 52 member states abstained while 36 countries were absent from the vote – out of the 177 WHO member states attending WHA and eligible to vote. 

The WHA resolution, the second in as many years, notes that Russia’s aggression against Ukraine constitutes “exceptional circumstances” and is causing a serious impediment to the health of the population in Ukraine, as well as in surrounding regions. 

Prior to the vote both Russia and Ukraine engaged in a bitter war of words for the second day running, with Russia urging the WHO to not take a political stand.

“The provision of medical care should be free of politics and so should the work of the WHO. However, western countries are bringing their politics into this organization and that is undermining all our cooperation with each other and with the organization,” Russia’s delegate stated. 

The resolution also calls for an assessment of the impact of Russia’s aggression on the health sector. 

Ukraine responded strongly to Russia, calling its aggression unprovoked. “I hope that nobody in this room will be deceived by Russia’s cynical lies while its army continues shelling Ukrainian hospitals, killing our doctors and patients, denying the rights to millions of people in Ukraine and well far beyond the right to health,” Ukraine’s delegate said. 

Ukraine received strong support from Denmark which was speaking on behalf of 32 member countries in the European region. The European bloc also has demanded that the WHO European Office for the Prevention and Control of Noncommunicable Diseases based in Moscow be moved to Copenhagen.  “To host a UN office is a privilege and not a right,” 

The office is to be moved before January 2024, according to the WHO.

Panel on synergies in global health: (L-R) David Heymann, co-chair of the Commission; Masa Moshabela, Irene Agyepong, co-chair of the Commission; Francisco Songane, former minister of health of Mozambique

Changes in mindsets, decision-making, and accountability are the keys to improving synergies between the different agendas of Universal Health Coverage (UHC), health security, and health promotion, a new report shows.

Marking the 76th World Health Assembly and Geneva Health Week 2023, Professor Irene Agyepong, co-chair of the “Lancet Commission on Synergies between universal health coverage, health security, and health promotion,” spoke on the publication of the Commission’s findings.

Speaking at a panel titled “Synergies In Global Health and Why They Matter,” Agyepong stated that maximising any potential crossover between the three agendas is vital to increasing the potential for synergies to occur. 

“We suggest that the way forward requires changes in mindset and decision-making,” Agyepong said. “[We need] to help people realize that sometimes paying attention to the interests of others is the best way of advancing your self-interest, and then maximize synergies among global health actors and ensure transparency.”

Reframing goals

According to the Commission’s report, changes in mindset include the reframing of individual health goals into a single, comprehensive vision; recognizing that it is necessary to promote synergies in health rather than prioritising one particular issue; and developing shared values and principles to achieve this vision at national and international levels.

Changes in the decision-making process are also a top recommendation for the Commission. The report looks at the relationship between international organisations and individual countries, which function on many different levels, due to differing factors such as financial capabilities, the political system in place, and the overall structure of the health system in that country. 

The report states that adopting a decolonised approach and developing nationally-owned health priorities can allow global health agencies, such as WHO, to offer the flexibility for countries to adapt investments, policies, and national priority programs.  

“You cannot just build it by giving money or throwing money at the problem. It needs to enable countries and people within countries and society of local contextually-relevant innovation,” Agyepong pronounced.

This point was echoed by David Heymann, co-chair of the Commission and Professor of Infectious Disease Epidemiology at LSHTM, who stated, “It is countries that have to make the decision on what synergies they want to develop.

“It is not the donor agencies that are developing the systems. It is not the World Health Organization [WHO]. It’s countries. They need to make the decision.”

“If leadership comes from WHO where they can connect health promotion, universal health coverage, and health security in one continuing activity instead of three different silos, then it would really do a lot to help countries follow that example.”

Dr Francisco Songane, former minister of health in Mozambique, agreed that countries must take their own initiative, saying, “The crux of the matter is the leadership from the country level. 

“It is extremely important that there is clarity and coherence within the government of a particular country to devise an agenda and to sell it to the different stakeholders to make it the one-country agenda,” Songane told the panel. “I think that is the very beginning of the whole issue.”

The stakeholders’ view

In the second half of the forum, several stakeholders from different arenas sat down to discuss the Commission’s findings and recommendations for the future. 

Dr Atul Gawande, Assistant Administrator for Global Health USAID, told the panel, “It is difficult to build with intention systematized health systems because of the many different actors coming to play.

“The examples cited earlier of Ethiopia and Rwanda, I want to highlight in particular. The notion that a country would have a ‘one budget, one plan,’ that the people in the country coalesce around and the donors and other parts of the community come together – this is what made Ethiopia and Rwanda successful.”

One of the report’s conclusions was that donors also bear responsibility for fragmentation or dis-synergies in health systems.

Agnès Soucat, Director of Health and Social Protection at the French Development Agency (AFD), agreed that the “evidence is overwhelming that donors contribute to fragmentation. So despite greater public commitment to harmonization and alignment, we are moving backward, and it is because the incentives are not aligned. Something like the alliance of all the partnerships under UHC2030 is very promising.”

Justin Koonin, Co-chair of UHC2030, the international multistakeholder partnership for universal health coverage, said there were opportunities soon for the Commission’s ideas to form into a more realised vision.

“In September in New York, we have not one but three health-related high-level meetings on UHC on pandemic preparedness and tuberculosis,” Koonin said.” So I think it will be a really good test of how serious the world leaders are around actually integrating.”

The Commission’s report will attract plenty of attention for its proposals and recommendations, and it is clear that the stakeholders feel that something has to change.

“What we have been doing in the past has gotten us where we are,” Soucat told the panel. “Where we want to go will require a new approach.”

“Synergies In Global Health and Why They Matter.” was organised by the Geneva Graduate Institute, The Global Health Centre and the International Geneva Global Health Platform, The Lancet, London School of Hygiene & Tropical Medicine (LSHTM), Ghana College of Physicians and Surgeons.

 

With a political declaration on non-communicable diseases (NCDs) on the agenda of the World Health Assembly, we unpack the WHO’s  “Best Buys” that provide countries with tools to address the diseases that are responsible for three-quarters of global deaths

Professor Thifheli Luvhengo, Chief of Surgery at Charlotte Maxeke Hospital in South Africa, examines a patient who has had limbs amputated because of diabetic sepsis.

Health Policy Watch: The WHO’s “Best Buys” to prevent and control NCDs comprise 90 interventions, which can be overwhelming to countries that don’t have many resources. What are the key interventions?

Nandita Murukutla: Countries have much to gain by implementing policies aimed at preventing noncommunicable diseases (NCDs), the world’s biggest killers. WHO’s “Best Buys” are interventions that are inexpensive for governments to implement, including those that target behavioural risk factors such as tobacco use, unhealthy diets, alcohol consumption and inadequate physical activity.

These risk factors often share common policy solutions. The effectiveness of excise taxes, marketing restrictions and labelling policies, for instance, have been demonstrated to reduce the consumption of unhealthy products. Were governments to adopt the recommendations as official policies, they could, in a unified and coordinated approach, significantly reduce the proliferation of unhealthy products and make an impact on the growing trajectory of NCDs, including heart and lung disease, diabetes, and cancers.

HPW: What measures would you advise a low-income country that is facing increasing obesity and diabetes to adopt?

Murukutla: Globally, we have undergone a massive nutrition transition, with more and more ultra-processed foods in our diets. This is a disaster for health. Unhealthy diets—those high in sugar, salt and fat—are responsible for an estimated 11 million preventable deaths each year.

Most governments are failing to take advantage of proven public health interventions that can prevent today’s most common drivers of disease and death. Healthy food policies such as sugary beverage taxes, front-of-package warning labels and marketing restrictions are effective. Sugary drink taxes are a triple-win, cost-effective policy option that can improve population health, increase government revenue and reduce health care and environmental costs. The latest worldwide, systematic review, authored by Andreyeva et al. in 2022, found sugary drink taxes have been associated with significantly increased prices on targeted beverages and 15% lower sales of sugary drinks, with no negative impact on employment.

Reducing sugary drink consumption can especially benefit lower-income populations, who in many places experience obesity and other NCDs at higher rates. Taxes on sugary drinks generate significant revenue that can be used to enhance access to healthy food, health care or other public services.

 There’s hope. In countries that have taken up healthy food policies, we are seeing better diets and improved overall health as the policies reduce demand for unhealthy foods and beverages. More countries should follow.

South Africans campaigning in favour of a tax on sugary drinks in 2017

HPW: What do the “commercial determinants of health” really mean?

Murukutla: Commercial determinants of health are the systems, practices, and pathways through which commercial actors drive health and inequity.

Tobacco, alcohol and ultra-processed foods contribute to the most common NCDs. The industries that produce and market these products use their considerable resources to influence governments to reject or soften restrictions on their products.

The burden of unhealthy products falls heaviest on countries and communities that are least able to manage the effects because of historically poor access to nutritious food and weak infrastructure buckling under the demands of planetary damage. These structural inequalities perpetuate a cycle of chronic disease that shows no signs of slowing. Meanwhile, profits for commercial actors keep climbing.

The situation is urgent. The actions of multinational companies are not only going to further undermine people’s health—they’re going to undermine development and result in serious economic costs for countries.

HPW: Tobacco control is one of the global success stories. What are the key elements behind this success?

Murukutla: Tobacco control offers a clear example of how the public health community achieved huge policy wins and a strong public understanding of the consequences of consuming a dangerous product.

Since 2007, global smoking rates have fallen from 22.7% to 17.5%. Global cigarette sales have also plummeted, with 750 billion fewer cigarettes sold in 2021 compared to 2012, and 57 countries have implemented smoke-free laws.

There are several reasons for these successes: The World Health Organization’s Framework Convention on Tobacco Control brought countries together in a global treaty to reduce tobacco use. This, alongside steady and committed investments and the implementation of WHO’s technical package, MPOWER, put the focus on smoke-free policies, pack warnings on tobacco products, and media campaigns designed to change risky behaviors and build support for healthy policies.

While global smoking rates are dropping, tobacco remains a serious health threat. Tobacco taxes are still greatly underused worldwide despite being the most effective intervention to reduce purchases. In addition, the tobacco industry continues to try and expand their reach and profits by targeting countries with the weakest regulatory environments and pushing novel products in previously untapped markets.

Alcohol is linked to several cancers and other health issues.

HPW: While alcohol is widely taxed, it appears to have evaded many of the legislative measures that tobacco has faced—despite the fact that it has significant health costs, and it is a key driver of disease, car crashes and interpersonal violence, particularly in low- and middle-income countries. Is this accurate and is this changing?

Murukutla: Alcohol is a leading driver of deaths, resulting in three million deaths worldwide each year. The immense toll of death and disability makes alcohol use among the top 10 risk factors for mortality. And yet, compared to tobacco, the global effort to address the harms of alcohol is markedly subdued.

We know what works to tackle the harmful use of alcohol: Effective, evidence-based measures are available to all countries. Yet alcohol has faced fewer legislative measures compared to other commercial determinants of health, despite its significant health costs and contribution to injuries and violence.

Slower progress in the accumulation and publication of information, particularly information as outlined in the WHO’s SAFER technical package, is one issue. Policies outlined in SAFER include taxation to raise the cost of alcohol—the gold standard, as well as regulating the availability of and access to alcohol to avoid underage consumption and excess drinking. It’s also important to restrict alcohol advertising, especially when it’s aimed at youth and women.

From a global perspective, there has been little and fragmented movement and no major investment to tackle the harms of alcohol. Nonetheless, many countries have made progress, including Scotland, Ireland and Russia.

 The current alcohol environment is changing as more and more guidance has emerged. A new initiative, Vital Strategies’ RESET Alcohol, works to reduce alcohol-related harms in hard-hit countries through policy change.

Health campaigners in Mexico have consistently linked sugary drinks to diabetes.

HPW: Most countries face some economic pressure from “unhealthy” sectors – such as the ultra-processed food industry and sugar producers – not to act against them, with threats of economic consequences and job losses. What role can the WHO and others play to protect countries from corporate influence? 

Murukutla: We would argue that it is not just “some” pressure but a significant amount of it. In fact, a paper in Social Science & Medicine shows that corporate influence is among the chief reasons for the delay in the implementation of the best buys. The producers of unhealthy commodities including tobacco, alcohol, and ultra-processed foods have a direct stake in maintaining their markets and will attempt to dilute and derail WHO’s recommended policies and best buys at every step of the process.

That is why it is imperative that governments dictate policies—with the support of trusted actors such as civil society organizations—to prevent efforts by self-interested commercial entities to undercut proposed solutions to address NCDs. 

At this week’s World Health Assembly, it’s critical we recognize that even the latest iteration of the best buys leaves room for improvement. Corporate influence has been identified as key reason for the poor implementation of NCD policies in countries around the world. WHO must recognize conflict-of-interest policies as a core intervention – not just an aspirational goal. I wrote more about this in a previous op-ed for Health Policy Watch.

Global advocates must also hold the process accountable. WHO leadership must welcome this committed activism and collaboration by offering recommendations with real potential to thwart industry influence and support countries in their efforts.

Dr Nandita Murukutla is the Vice President of Global Policy and Research at Vital Strategies.

Kerry Cullinan asked the questions.

Image Credits: Medtronics, Kerry Cullinan, Taylor Brandon/ Unsplash, Vital Strategies.

NCD advocates including Clean Air Fund’s Nina Renshaw (left),Vital Strategies CEO  Jose Luis Castro (centre) and  Philippines’ Dr Razel Nikka Hao (right)

GENEVA – There needs to be stronger global action to prevent interference in health policy by industries selling products that harm people  – tobacco, alcohol, ultra-processed food and fossil fuel.

This is the call from advocates for non-communicable diseases (NCD) attending a side event at the World Health Assembly in Geneva, which is due to debate a political declaration on NCD prevention and control on Wednesday.

“The industries that produce and market these products are more interested in profit than in healthy people and healthy communities,” said José Luis Castro, President and CEO of Vital Strategies, at a WHA side event hosted by his organisation and the NCD Alliance.

“They use their considerable resources to influence governments to reject or suspend restrictions on these products,” added Castro, citing tactics such as “financial enticements, legal battles and other ways to limit the policies such as food, warning, labels, marketing restrictions, and taxes on harmful products”.

“These commercial interests are antithetical to the goals of public health policy. This alone should disqualify them from joining the table to share so-called solutions.” 

Implementing NCD plan of action

NCDs, including diabetes, heart disease and strokes, are responsible for almost three-quarters of global deaths – a staggering 40 million deaths every year. Yet no country is on track to significantly reverse this trend by 2030, one of the key health goals of the global sustainable development goals.

To help countries navigate the complexities of addressing NCDs, the World Health Organization (WHO) has come up with “Best Buys” – evidence-based strategies for countries to use, including taxing unhealthy products (officially called  Appendix 3 of the WHO Global NCD Action Plan).

WHO NCD Director Dr Bente Mikkelsen said that the “Best Buys” now consisted of 90 interventions, 28 of which are “considered to be the most cost-effective and feasible for implementation”, and that countries should select these based on “their own epidemiology”.

However, she acknowledged that the “commercial determinants” of health – industry influence – are so strong in many countries that they cannot implement some of the “Best Buys”, and that “it’s all about the country’s leadership”.

Castro believes that “Best Buys” should be modified to include “more explicit recommendations against corporate influence” because “corporate influence worldwide has been identified as the main reason why Best Buys’ implementation falls short”.

WHO NCD head Bente Mikkelsen

“For small island developing states like in the Caribbean, the best buys are the only buys,” said Dr Kenneth Connell, Vice President of the Healthy Caribbean Coalition. “The reason simply is we cannot afford treatment.”

But Connell said there were huge barriers to implementing the best buys – including that sugar and alcohol consumption had become an integral part of the Caribbean culture.

However, the Philippines is making inroads against NCDs, thanks to its system of universal health care (UHC) that is primary-care centric, and addresses prevention as well as treatment, according to Dr Razel Nikka Hao, the country’s Director of Disease Prevention and Control.

“The icing on the cake is that the tax we get from sin taxes [on tobacco, alcohol and ultra-processed food] is the one that is funding our UHC,” said Hao. “So we actually have around $2 billion a year from sin taxes, and that has triggered investments in health facilities and workforce expansions. We’re very lucky that we have very strong legislators who fight with industry leaders.”

Anna Gilmore, Nandita Murukutla, Kenneth Connell, Dr Razel Nikka Hao, and Thailand department of health’s Dr Kraisorn Tohtubtiang.

Air pollution is the elephant in the NCD room

Nina Renshaw, Head of Health at the Clean Air Fund, described the influence of air pollution on NCDs as “the elephant in the room”.

“Seven million deaths per year attributable to air pollution is a really conservative estimate,” said Renshaw.

“We know that 40% of COPD deaths are due to air pollution, over a quarter of strokes, over 20% of cardiovascular deaths… 20% of diabetes and 19% of lung cancer deaths,” added Renshaw.

“There’s emerging evidence of causality in dementia and of course with mental health. If you live in an area of poor air quality, highly polluted or an area that’s at serious risk of climate change, this is clearly going to take a toll on your mental health.”

Media campaigns help shift the social narrative

Dr Nandita Murukutla, Vital Strategies’ Vice President for Global Policy and Research, acknowledged that social and political barriers prevented the implementation of the “best buys”.

Aside from political interference, because some NCDs take a while to manifest, this undermines “the sense of urgency and the belief that the risk is real” which could lead to “apathy around implementation”, she said.

However, media and communication play an essential role in shifting social narratives, galvanising public support and putting pressure on policy-makers.

“Media campaigns and communication efforts are vital for tax implementation,” said Murukutla, adding that in some places where there had been the absence of public support, tax proposals have failed.

“Message framing on how to describe the tax is significant. Linking the tax to social benefits is a very powerful way of building public support,” she added.

For  Professor Anna Gilmore, Director of the Tobacco Control Research Group at the University of Bath, the problem is “not just a few unhealthy commodity industries and their products, its a system”. 

The commercial sector undermines the Best Buys by influencing science, said Gilmore, who also pointed to how industry players manipulate impact assessments.

“There are some minimal things we need [from policy-makers] including conflict-of-interest policies and policies on non-engagement with industry,” said Gilmore. “We need to avoid partnerships with vectors of disease and ensure that science functions in the public interest.”

WHA delegates were shown a reminder of the global toll of the COVID-19 pandemic.

GENEVA – WHO Director-General Dr Tedros Adhanom Ghebreyusus has proposed five measures to strengthen the global health infrastructure to pandemic-proof the world in his WHA report on “Strengthening the global architecture for health emergency preparedness, response and resilience”.

The pandemic accord and amendments to the International Health Regulations (IHR) are part of the measure on “international instruments”.

Meanwhile, the United Nations High-Level Meeting on Pandemic Prevention, Preparedness and Response (PPPR) scheduled for September, falls under category two: “sustained political leadership”, along with the WHO’s proposed global health threats council – being disputed by various actors who want an independent monitoring body, arguing that the WHO can’t police itself.

As a way of trying to balance national sovereignty and mutual accountability, the WHO launched a pilot “Universal Health and Preparedness Review” in November 2020 that involved countries volunteering for independent feedback on how ready they are for health emergencies.

Tedros’s report proposes that this independent monitoring “should continue to complement national-level self-assessment and peer review, with strengthened roles for existing monitoring mechanisms, such as the Global Preparedness Monitoring Board and the Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme”. 

Finances

World Bank’s Priya Basu (left), who is the executive head of the Pandemic Fund secretariat.

Money is, of course, also a key measure and a number of WHA delegates have expressed concern that the global appetite to pandemic-proof the world is already waning. 

However, the Pandemic Fund launched a year ago has mobilised $2-billion to support low-and-middle-income countries to strengthen their health systems to cope with future pandemics, according to the World Bank’s Priya Basu, who is the executive head of the Pandemic Fund secretariat.

While World Bank analysis shows that LMICs countries will collectively need to invest $30-billion a year to ensure that their health systems are fit to address health emergencies.

The Fund’s first call for funding closed last week following “very strong demand” from LMICs amounting to more than triple the funds currently available, Basu told a WHA event on Tuesday.

In addition, Tedros reports that “deliberations as part of the G20 joint health and finance track [are] beginning to forge a consensus on the scale of needs and potential mechanisms to administer surge financing for large-scale pandemic and health emergency response”. 

Health system strengthening

The final measure proposed by Tedros’s report is for member states to strengthen their health systems around “the five Cs” – collaborative surveillance; community protection; safe and scalable care; access to countermeasures; and emergency coordination.

Throughout the WHA, countries have reported on how they are taking more seriously the threat of another pandemic.

A document on “collaborative surveillance” was launched on Tuesday, according to Dr Chikwe Ihekweazu, WHO Assistant Director General for Health Emergency Intelligence and Surveillance Systems, and head of the WHO’s Hub for Pandemic and Epidemic Intelligence in Berlin.

The intention of the launch is to kick off the conversation on how member states can work together to share data to ward off health threats, Ihekweazu told a WHA event.

Pandemic
A healthcare worker wearing PPE disinfecting a street in the early days of the COVID-19 pandemic.

A new “Zero+” version of a proposed World Health Organization pandemic accord being negotiated by member states has dropped previously strong language that conditioned use of public R&D funds to private sector commitments to price transparency and tech transfer of end products, among other measuress.

However, the updated draft text, obtained by Health Policy Watch, still contains ‘optional’ language linking developing countries’ sharing of pathogen information to a guaranteed supply of drugs, vaccines and other health tools that they would access a WHO distribution scheme.

While not a formal part of this week’s World Health Assembly (WHA) proceedings, the text drafted by the “Bureau” of six member states guiding the talks is being circulated this week as they prepare for another round of  negotiations over the new accord, scheduled by the Intergovernmental Negotiating Body (INB) 12-16 June.

The latest draft of the “WHO Convention, Agreement or other International Instrument”, dubbed WHO CA+, offers a range of “options” where there are diverging opinions between member states with consensus yet to be reached.

Roland Driece, co-chair of the negotiations, highlighted equity, the sharing of pathogens, improving logistical systems, better coordination of research and development and fundraising for all of the accord’s provisions, as the key issues facing the Intergovernmental Negotiation Body (INB).

Driece, who was addressing an official WHO roundtable Monday on pandemic preparedness at the WHA, said the draft would become public during the course of the week. He added that the use of options indicated areas where there were “divergent views”.

Updated draft negotiating text for pandemic convention

Text likely to meet stiff opposition from both civil society and pharma

However, both civil society and pharma appear likely to oppose parts of the updated text – for very different reasons.

“The R&D text is much weaker,” said Suerie Moon, director of the Global Health Centre of Geneva Graduate Institute, pointing to Article 9 of the update. “We’ve lost the proposal to put conditions on public funding [of pharma R&D].

“In the old Article 9 there was this very clean and clear clause establishing conditions for publicly-funded research and development,” she said.  That text made much stronger reference to requirements for the transparent publication of prices of pharma products; data sharing and technology transfer,” in the case of products emerging from publicly-funded R&D.

In the new text, however, such provisions are more cautious and conditioned, stating for instance, that “each Party, when providing public funding for research and development for pandemic prevention, preparedness, response and recovery of health systems, shall, in accordance with national laws and as appropriate taking into account the extent of public funding,” promote transparency around R&D results, tech-sharing, and equitable dissemination of health products.

“It’s basically a huge step back from countries wielding the power of the law to regulate, and more reliance on voluntary measures,” said Moon.  “There are a lot more references to ‘as appropriate’ – I think the phrase is used some 47 times.”

Pharma object to continued link between pathogen access and benefit-sharing 

Developed countries hoarded vaccines at the onset of the COVID pandemic, while a lack of ready funding pushed low-income countries to the back of the line.

On the other side of the fence, the new text still contains references linking pharma’s access to pathogen samples or genomic data with the sharing of “benefits” from health products produced as a result.

That is something that has been hotly opposed by pharma leaders -who have said that unconditional access to pathogen data is critical to creating new drugs quickly in response to emerging threats.

While couched in the language of multiple “options”, one proposed clause also preserves a “Zero draft” reference to a 20% ‘set-aside’ of new pharma products for low-income countries, to be distributed through WHO, stating:

“The benefit sharing obligations [by manufacturers of pandemic-related products developed from the utilization of pathogens with pandemic potential] will include, but not be limited to: (i) real-time access by WHO to a minimum of 20% of the production of safe, efficacious and effective pandemic-related products, to support their equitable distribution through the WHO allocation mechanism, in particular to developing countries, [according to public health risk and need]/[that are Parties to this WHO CA+].

“The pandemic-related products shall be provided to WHO on the following basis: 10% as a donation and 10% at affordable prices to WHO; and (ii) collaboration with manufacturers from developing countries and WHO initiatives to transfer technology and know-how and strengthen capacities for the timely scale-up of production of pandemic-related products.”

Other alternative versions of the same clause, however, would rely on purely on voluntary measures to fill supply gaps in low-resource settings.

‘One size-fits-all doesn’t make sense’

Health workers in Mexico City protest the shortage of protective gear in July 2020 – shortages were felt worldwide but were particularly acute in the global south.

While countries need a new “social contract” to ensure more equity in responding to the next pandemic, establishing such a fixed set-aside formula ‘doesn’t really make sense,’ asserted Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA).

Countries need different types of products and some hotspots might need more products while others less, Cueni told Health Policy Watch at an IFPMA event innovation to prevent pandemics, convened on the sidelines of  WHA.

“Vaccines, treatments and tests are also totally different. Therefore a fixed number for vaccines, the same as tests and treatments doesn’t really make sense. A fixed number for any pandemic doesn’t make sense,” Cueni said.

He added that industry also would continue to oppose any linkage between their access to pathogen samples or genomes, and so-called “benefit sharing” of finished health products.  Such clauses, he contends, could hinder the speed at which pathogen data is shared.  

Cueni stressed, however, that a new “social contract” between countries is indeed required to ensure that vaccines, medicines and diagnostics are more equitably distributed in the next pandemic. 

The pre-purchase of COVID vaccines by North American and European countries in quantities many times the population size, left other, less developed states high and dry when initial vaccine rollout began, Cueni acknowledged, speaking at the IFPMA event.  Then, India’s export ban on COVID vaccines, which had been pre-purchased by the UN-supported COVAX facility to supply Africa, left the continent high and dry.

IFPMA Director-General Thomas Cueni (centre), at the IFPMA event on innovation and pandemic response. On left is Heulwen Philpot, Wellcome Trust with Rogerio Gaspar (right), WHO Director of Regulation and Prequalification.

“It’s obvious when you look at the experience in COVID, rollout was not fast enough,” he said. “I personally believe that we need to act on two fronts,” Cueni observed.  

“You need a signing of a kind of social contract… From the industry side, you have a commitment from CEOs from all of the major companies, and also from small biotech companies.. Committing to putting aside part of available production in real time, from rollout to demand, wherever they are. 

“But this will only work if the manufacturing countries, from the US to India, will also sign up to that commitment because if they say yes, you can have access to whatever we have, but only after you have vaccinated every signal one of our citizens, then that social contract is broken.”

The advancement of more regional manufacturing hubs for vaccines and drugs, particularly in Africa, is also critical so that developed countries – or large emerging economies like India and China – don’t monopolize supplies.   

“We need to work together on some geographic diversity of manufacturing,” Cueni added. “But I believe the only way that promises success is voluntary.“  

Pathogen spillover on farms, wild animal markets and in waste – another sticking point

Caged animals held for sale and slaughter in unsanitary conditions at Wuhan’s Huanan Seafood Market, prior to the outbreak of COVID-19, from top left: (a) King rat snake  (b) Chinese bamboo rat (c) Amur hedgehog (d) Raccoon dog (e) Marmot and (f) Hog badger.

Another obvious sticking point in the text that has received less attention refers to measures to prevent pathogen risks from emerging, as contained in Article 4.

One text option, dubbed “Option 4.B” refers explicitly to key risks that countries would commit to address.  Specifically, that text commits countries to “develop, strengthen, implement, periodically update and review comprehensive multisectoral national infection prevention and control measures, to:

  • ensure access to safe water, sanitation and hygiene;
  • ensure the implementation of infection prevention and control measures;
  • strengthen efforts to ensure the sound management of wastes from health facilities, veterinary practices, and live animal markets.

The reference to prevention in the farm sector is particularly detailed, commiting countries to: “strengthen animal disease preventive measures, including, but not limited to, on farms, transport of animals, live animal markets, trade in wild animals and in veterinary practices both for food-producing and companion animals taking into account the relevant international standards.

“Those measures include water and feed hygiene, infection prevention and control measures, farm sanitation, hygiene and biosecurity and animal welfare support measures.”

But ‘Option 4.A’  is far more succinct. And the choice between the two, in effect, illustrrates the stark choices facing member states regarding just how rigorous a pandemic accord they may decide to negotiate.

Limited to just one single sentence, Option 4.A states simply: “the Parties shall take prevention and surveillance measures that are consistent with and supportive of effective implementation of the International Health Regulations”.

Then it adds: “Article ends here.”

Options for referencing prevention of ecosystem risks – a choice between specific commitments or none at all.

Image Credits: Photo by Maksym Kaharlytskyi on Unsplash, WHO, Nana Kofi Acquah, Ricardo Castelan Cruz / Eyepix Group/Future Publishing via Getty Images, Nature .

Two residents stand in the ruins of homes in Borodianka in the Kyiv region.

Three days into the World Health Assembly (WHA), the health emergency caused by Russia’s fifteen-month invasion of Ukraine looks set to become a dominant issue at the World Health Organization’s (WHO) top decision-making body for a second consecutive year.

Over 140 Russian missiles and drones have rained down on Ukraine’s energy, civilian and medical infrastructure since the start of this month. The consequences of the onslaught continue to affect millions of civilians, jeopardizing their access to physical and mental health care and forcing nearly 10 million to flee their homes since the start of the war. 

Supply chains for essential medicines have been disrupted, hospitals destroyed, and the medical facilities that remain operational are forced to fight to keep the lights on amid regular power outages due to attacks on Ukraine’s power grid. One in five ambulances in Ukraine’s medical fleet has been damaged or destroyed. 

More than 1,256 health facilities have been damaged and 177 more reduced to rubble, Ukraine told WHA delegates on Tuesday. The World Health Organization has independently confirmed 974 attacks on medical facilities and the deaths of over 100 healthcare workers since the start of the war.

Will there be enough time to discuss other humanitarian emergencies?

The overwhelming focus on the health crisis in Ukraine by delegates in Geneva is well-founded. But amid a flurry of ongoing humanitarian crises and the re-emergence of familiar battles litigated at the WHA last year, the question of whether enough time will be left to discuss the plight of millions of civilians outside of Ukraine has grown in importance.

The World Health Organization currently counts 13 ongoing crises as “grade 3” emergencies, the UN health body’s highest internal threat level. These include the extended droughts in the Horn of Africa, the humanitarian situation in Afghanistan, and ongoing conflicts in Yemen, Syria and Ethiopia.

A deadly civil war featuring regular attacks on hospitals and civilians also recently erupted in Sudan, threatening the stability of the wider region as hundreds of thousands flee the country. 

Civilian casualties in armed conflicts increased by 53% year-on-year since 2022, according to a report presented by the Swiss Presidency of the UN Security Council on Tuesday, raising concerns that an over-focus on Ukraine could leave civilians in less represented conflicts by the wayside. Over 90% of deaths from explosive weapons detonated in populated areas documented in the report were civilians. 

The draft resolution submitted by Ukraine and its allies on Monday is near-identical – even sharing the same title – to the one passed by the WHA in 2022 which described the Ukrainian health crisis as “stemming from Russian aggression.”

Russia responded by submitting its own resolution – described by Ukraine as a “recycled” version of Russia’s 2022 proposal shot down by the WHA – calling on countries to “refrain from the politicization of global health cooperation” and to “respect their obligations under international and humanitarian rights law.”

Syria, the counter-resolution’s co-sponsor, called on WHA delegates to “avoid escalating crises” and support the Russian draft to “help further stability in Ukraine and neighbour countries.” 

North Korea, Nicaragua and Belarus are currently the only other WHO member states to voice their support for the Russian resolution.

Vote to show WHA will not stand for attacks on health infrastructure, Ukraine says

Russia
Operating theatre in a Ukrainian hospital destroyed by a Russian airstrike.

On Tuesday, the Ukrainian delegation called on the WHO’s 194 member states to support its resolution condemning Russian “aggression”. It also asked states to vote down the Russian counter-resolution, which it said is based on a “distorted, alternative reality.” 

“The Russian text is nothing short of a desperate attempt to put the aggressor on par with the victim and avoid responsibility for their attacks on the health care system in Ukraine,” its delegate said. “[Voting down the resolution] will send a clear signal that provoking a health emergency of outstanding proportions and destroying medical structures on a massive scale is not tolerated by this assembly.”

Russian diplomats, meanwhile, protested statements by Ukranian allies such as Poland and the United States condemning Russian actions in Ukraine, which its delegates argue “don’t have any relationship to the mandate of the WHO.”

Russia’s interventions have so far been shot down by WHA President Dr Christopher Fearne and other committee chairs due to the scale of the health crisis caused by the war. The Ukrainian health crisis is “clearly a health matter relevant to this assembly,” Fearne said in response to a Russian protest on Monday.

“Russia has no respect for human life,” an Estonian delegate said. “Suspend the Russian Federation from the decision-making [of WHO] until it has restored full respect to international law and human rights.”

Russia circulates document accusing Ukraine of attacking its own health care system 

Confirmed attacks on health care in Ukraine, according to the WHO.

An average of two attacks on health care a day were reported in the first year of the Russian invasion. These include strikes on hospitals, shootings of ambulances, torturing of medics and looting of medical facilities. 

This has not stopped Russia from attempting to mount a diplomatic counter-offensive. In a bid to garner support for its draft resolution, Russian diplomats circulated pamphlets in WHA accusing Ukraine of attacking its own hospitals and health care facilities. 

The delegate for the United Kingdom, referring to the move in a heated debate Tuesday afternoon, compared the Russian efforts to the “theater of the absurd.” 

“We are aware that like last year, Russia has passed around pamphlets to our fellow delegates which allege that Ukraine has been attacking its own health system,” UK diplomats told the assembly. “We are confident … delegates here today won’t be fooled by such disinformation.” 

Russia has not openly voiced such accusations in its own statements at the WHA. Its draft resolution, however, expresses “serious concern” that the WHO Surveillance System for Attacks on Health Care (SSA) – the UN health body’s database documenting attacks on medical facilities and staff – does not accurately reflect “all the incidents with attacks on health care facilities.”

It also calls on the WHO to improve its collection of “data on attacks on health care facilities, health workers, health transports and patients” – an odd request from a country accused of perpetrating nearly 1,000 attacks on Ukrainian health care. 

Human Rights Watch and other groups documented repeated “unlawful” Russian and Syrian attacks on “schools, hospitals, and other civilian objects” throughout the Syrian civil war.

Attacks on Ukranian health facilities are not the first

Attacks on hospitals, health workers and civilians by Russian forces in their intervention in Syria’s civil war have been well-documented by rights groups. Bashar al-Assad, the Syrian President and key co-sponsor of the Russian resolution, repeatedly used chemical weapons to attack civilians in his bid to retain power. 

The Russian resolution also calls for countries to “refrain from deliberately placing military objects and equipment” in the vicinity of civilians and civilian infrastructure or in “densely populated areas.” 

The language of the Russian text appears to mirror the findings of a report by Amnesty International published in August, which accused Ukrainian forces of repeatedly putting “civilians in harm’s way” by stationing soldiers nearby and staging military operations from populated areas.

Russian officials portrayed the report as a vindication of its actions in Ukraine. The Russian ambassador to the United Nations, Vasily Nebenzya, claimed the report proved Russia does not use “the tactics Ukrainian armed forces are using” such as “using civilian objects as military cover.”

An independent review of the report later found Amnesty’s claims that Ukraine had violated international law were “not sufficiently substantiated”. 

The review also called some of the language used by Amnesty “legally questionable,” particularly with respect to the report’s implication that Ukrainian forces were “primarily or equally to blame for the death of civilians” resulting from Russian attacks.

The International Criminal Court in the Hague issued a warrant for the arrest of Russian President Vladimir Putin for the war crime of abducting and deporting thousands of Ukrainian children to Russia in March.

Image Credits: Matteo Minasi/ UNOCHA, Christian Treibert.

Cholera
Floods and cyclones increase the risk of Cholera outbreaks.

As a wave of cholera outbreaks spreads around the world, Gavi, the Vaccine Alliance said it expects the global shortage of oral cholera vaccines to continue until the end of 2025.

Supply of oral cholera vaccines for preventative use could catch up to demand by 2026, but “urgent action is needed,” according to a vaccine production roadmap published by Gavi, the World Health Organization (WHO) and other global health partners on Monday.

There are currently still enough vaccine supplies to respond to emergencies, Gavi said.

“The good news is we have doses to meet all emergency demand despite the rise in outbreaks, and that is expected to continue,” said Dr Derrick Sim, head of vaccine markets and health security at Gavi, adding that the global resurgence of cholera “underscores the need to prevent outbreaks before they occur.”

The past ten years have seen a steady increase in the availability of oral cholera vaccines. Global production rose from 4 million doses in 2012 to 35 million by 2022, with a similar number of vaccines expected to be produced this year.

“Every vaccine dose delivered to a person in need today is the result of years of planning,” Sim said. “The ultimate solution to both sustainable oral cholera vaccine supply and cholera control lies in our collective ability to step-up up our efforts on prevention programmes.”

But the recent spike in cholera outbreaks driven by climate shocks, war and humanitarian crises have caused a surge in demand for the vaccines for emergency response, limiting the availability of supplies for preventative use.

Between 2021 and 2022, 48 million oral cholera vaccines were needed for emergency response, 10 million more than in the entire previous decade.

“The outlook is bleak,” WHO incident manager for the global cholera response Henry Gray said at a press briefing on Friday. “We’re not able to provide enough vaccines.” Only 8 million of 18 million doses requested by WHO have been made available so far in 2023, Gray added.

The WHO has warned that climate change is a major threat to global health, and that cholera is one of the diseases that is most likely to be affected. Extreme weather events, such as floods and droughts, increase the risk of cholera outbreaks by contaminating water supplies with sewage, waste and bacteria. People displaced by climate shocks are also less likely to have access to clean water and sanitation, increasing their risk of infection.

The ongoing cholera outbreak in Malawi, which began at the end of the cyclone season in March last year, is the deadliest in the country’s history, according to the WHO.

In response to a shortage of oral cholera vaccines last year, WHO advised countries to ration supplies during outbreaks by giving just one of the two-dose vaccine to patients. The WHO still ran out of vaccines by the end of the year.

Image Credits: World Health Organization (WHO).

climate
World Health Assembly discusses resolution on preparing for the next pandemic and emergency situations on May 23.

The messiness of the COVID-19 vaccine distribution and the growing challenge of climate change emerged as key challenges at the World Health Assembly (WHA) on Tuesday in discussions on resolutions on preparing for future pandemics in Geneva. 

Representing 47 countries in the African region, Tanzania underscored the importance of greater equity and access to technology as countries battle multiple emergencies concurrently. 

While conflict in several African countries remains an ongoing issue, climate change has worsened droughts and floods, increasing pressures on fragile health systems, the country pointed out. Tanzania stressed that even though COVID-19 is no longer an official global health emergency, many African countries are still recovering and progress has been slow. 

A small island nation, Bahamas also told the assembly that it was facing multiple challenges concurrently, with climate change posing a particular problem. 

Bangladesh, currently being battered by climate change and is at the forefront of climate adaptation, highlighted the need for public-private partnerships as various solutions are explored. 

Speaking on behalf of all countries in Southeast Asia, Bangladesh said, “Southeast Asia is of the view that during pandemics and public health emergencies, the health of the people should prevail and be prioritized over commercial interests.”

However, the needs across WHO member states are often vastly different. Bahrain, on the other hand, pointed out that it is dealing with  an influx of migrants due to conflicts in the region. 

Finland, which in recent years had adopted a feminist foreign policy approach, pointed out to the disproportionate impact on women and girls in any disaster and focussed on the need to pay attention to that. 

“Finland considers it important that people living in conflict situations in particular, women and girls and persons with disabilities are put at the center of the roadmap. They are often the ones hit the hardest in conflict situations,” the country said. 

The overwhelming majority of the countries taking part at the WHA agreed that there is a need to strengthen WHO’s presence in their region by investing in more staff at both regional and national levels. 

In the context of pandemic preparedness, Germany rued Taiwan’s exclusion from the Assembly despite the island seeking an observer status. 

“Not only, but especially in health emergencies, we must not leave any blind spots on the map and ensure inclusivity. Therefore, we also have to take into consideration and use the experience of all parties and all partners including Taiwan,” Germany said.

China, at whose behest Taiwan was excluded, promised the assembly its full cooperation and financial support in its work. 

“The Chinese government is willing to further provide the necessary human technological and financial support to who knows operations in the global health emergency response,” the country said.  

WHO Director General Dr Tedros Adhanom Ghebreyesus has urged countries to play an active role in negotiating future pandemic preparedness, and across regions countries engaged bringing in diverse perspectives. 

Tedros
Dr Tedros Adhanom Ghebreyesus speaking at the plenary session on Monday.

World Health Organization member-states greenlighted a budget of $6.83 billion for 2024-25 for the global health agency – an 11% increase over the 2022-23 budget. 

Implicit in the budget is member-state implementation of a stepwise increase in assessed contributions. 

The groundbreaking reform, which aims to have one-half of WHO’s spending financed more sustainably by fixed member state contributions by 2030, was approved in principle at the May 2022 World Health Assembly (WHA). 

But it still required a nod from member states for the increased assessments to be applied this year. And that was not a foregone conclusion until a closed door meeting last week between member states, observed former WHO chief legal counsel Gian Luca Burci at a WHA preview event on Sunday. 

The WHO budget for the previous biennium 2022-23 was $6.12 billion. 

The gradual increase in country assessments aims to correct WHO’s current over-dependence on earmarked “voluntary contributions” – money that is donated by a member state or philanthropy. 

Such voluntary contributions now make up around 84% of the WHO’s total budget. WHO Director General Dr Tedros Adhanom Ghebreyesus, along with other senior officials, have  long complained that such designated funding makes strategic planning hard to control.  

“WHO’s over-reliance on voluntary contributions, with a large proportion earmarked for specific areas of work results, in an ongoing misalignment between organizational priorities and the ability to finance them,” the WHO had mentioned in a statement during WHA 2022.

Focus shifts towards countries

Budget
Budget allocated to WHO offices this year compared to the previous allocation.

Roughly $2 billion of the 2024-25 budget will go towards furthering WHO’s goal of Universal Health Coverage, and around $1.35 billion will be channeled into a “more effective and efficient WHO”.  

The latter includes greater support to countries, including co-financing for United Nations Resident Coordinators.  While WHO will continue to maintain its own country offices in over 100 developing countries, the UN-wide Resident Coordinator system, aims to improve coordination between UN-affiliated tasks at country level.  

But the new 2024-25 budget allocation to countries and regions is, in fact, only marginally larger than the allocation of $1.25 billion from the previous 2022-23 biennium.   

Countries welcomed the gradual increase in country allocations, however modest. But , African member-states re-asserted demands that at least 75% of the budget should go to offices outside of the Geneva headquarters. 

“We wish to see the efforts to continue increasing the share of countries and regions from the program budget according to an agreed phased timeline for 2024 to 2027 with an aspiration to reach at least 75% budget allocation to countries and regions,” said the delegate from Ethiopia, speaking on behalf of the group of 47 sub-Saharan African member states.  

Of the $6.83 billion budget allocation, a little over 50% will be spent towards achieving the WHO’s triple billion targets of universal health coverage ($1.96 billion), protecting people from health emergencies ($1.21 billion). The third pillar aiming to ensure “healthier lives and well-being” for 1 billion people received the least funding with only $0.43 billion for the two years. 

Polio eradication, meanwhile, received an allocation of $0.69 billion, 23% higher than the previous biennium. Polio, which had resurfaced sporadically in Africa and North America over the past year, along with the typical Asian hotspots of Afghanistan and Pakistan, remains the only public health emergency of international concern (PHEIC) designated by the WHO as of Monday.

WHO’s Special Programmes (for Research and Training in Tropical Diseases, the Special Programme of Research, Development and Research Training in Human Reproduction, and the Pandemic Influenza Preparedness Framework) received an allocation of $0.17 billion as against the allocation of $0.19 billion the previous time. 

Main ask: flexible funding and transparency in spending

Member states, meanwhile, rallied to emphasize on the need to continue working for a flexible funding mechanism that prioritizes the causes of spending based on specific situations. 

“The lack of flexible funds remains a continued concern. We hope to witness an increase in flexible funds over the long run by steadily introducing replenishment mechanisms, which are currently being discussed,” the delegate for the Republic of Korea noted.

Calls for greater transparency in WHO spending also rang across the room. Countries ranging from the Philippines, to Namibia and Brazil demanded that WHO disclose more specific details about projects and programmes in which it is engaged at country-level. 

“Improvements in transparency, accountability and administrative measures are essential. In the absence of clear improvements in those areas, it will be impossible to adopt, let alone justify any increase in assessed contributions,” the delegate for Brazil told the floor. 

“The practice of complete disclosure of information on expenditures of member states to member states in order to ensure transparency is not only indispensable, but also something customarily adopted by the UN agencies, and it is high time the WHO follows this path.” 

Image Credits: Twitter/Dr Tedros Adhanom Ghebreyesus, WHO.