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Countries expressed concern at an uptick in polio cases last year and discussed ways to double down on routine immunizations – interrupted by the pandemic and conflicts – at Thursday’s World Health Assembly. Polio is currently the only official global public health emergency. 

Afghanistan and Pakistan are the last two remaining countries where the virus is endemic, WHO has said. In 2022, Afghanistan reported two new cases while Pakistan reported 20. Pakistan which has also reported a new case in 2023, said it, “continues to make consistent progress towards stopping the transmission of poliovirus.”

The virus has been found to be in circulation across 31 countries in three regions, threatening to roll back hard fought for gains over several decades.

“We are only safe once everyone is safe,” Germany said, as it highlighted the need for global cooperation. The United Kingdom asked countries to guarantee the safety of teams conducting routine immunisation, an issue in both countries where poliovirus remains endemic. 

Australia commended the work of the Global Polio Eradication Initiative (GPEI) in Afghanistan for operating under challenging conditions as the ruling Taliban continues to make it near impossible for women to work. 

“We commend GPEI in Afghanistan despite increasingly stringent bans on women working for NGOs and UN agencies. Ensuring the safety of all frontline polio workers should continue to be a high priority. The risk that women may no longer be able to perform house-to-house campaigns must be mitigated to sustain high coverage and reach zero dose children,” Australia said. 

The scarcity of women healthcare workers in some areas of Pakistan has also affected routine immunisation, leaving blind spots. 

“The Mehsud belt in southern Khyber Pakhtunkhwa remains a persistent challenge as no polio campaign has been conducted in debates since last months,” Pakistan said. To counter this issue the country said it is focusing on entry and exit points to the belt as well as areas around it where security remains a concern. 

Iran, which borders Afghanistan flagged concerns about the influx of migrants in recent years due to the conflict in the country and called it a challenging situation. Iran also said that it continues to face barriers when accessing vaccines, and asked for greater WHO support for its national laboratories. 

Canada assured its financial support to the polio campaign and highlighted the need to focus not just on countries where polio is endemic but also other countries that might need support. “We fear that other vulnerable countries that do not have the resources to organize effective campaigns are further exposed to outbreaks and the risk of outbreaks,” the country said.

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

GENEVA – The World Health Assembly is poised to decide on an “investment round” in late 2024 to boost the World Health Organization’s (WHO) finances  – but not the establishment of a  “replenishment fund”. 

 Member states and donors will be able to continue to provide funds to the WHO earmarked for specific health programmes – something that the WHO’s Working Group on Sustainable Financing advised that the organisation moves away from as this skews the work of the global body.

This is according to a copy of the draft text leaked to Health Policy Watch, based on member state discussions late on Wednesday. The US is widely believed to have pushed for the continued inclusion of earmarked funds as a condition of its support for the resolution.

The formation of a WHO Investor Forum has also been mooted ahead of the investment round, according to those close to discussions.

Members’ fees to cover 20% of budget

The text also urges member states to pay their membership fees – which the assembly earlier resolved would now cover 20% of the budget (up from an estimated 14%).

While the text proposes that the WHO should continue to accept, “alongside unearmarked voluntary contributions, voluntary contributions that are earmarked and/or single-year contributions from member states and other donors” it urges an increase in “transparency of reporting on voluntary earmarked contributions and on their impact and allocation”.

In the lead-up to planning the investment round in the last quarter of 2024, the WHO is directed to provide member states with regular updates and to provide the Executive Board with “a full plan that includes modalities and anticipated costs”  for approval.

Various efforts to improve the financial viability of the WHO have hammered on the importance of the organisation having access to flexible funds – rather than funds donated by philanthropies and wealthier member states that are tied to programmes that might not be top global health priorities. 

Civil society condemnation

Four civil society organisations condemned the new text, describing it as “nothing but the institutionalisation of the earmarked contribution that has led to the dismal functioning of the WHO at various levels,  including the increasing penetration of the private philanthropic sector in the organisation”.

“The draft decision goes against the very objective of the recommendation of the Working Group,” said Lauren Paremoer of the People’s Health Movement.

“As per the approved budget of $6834.1 million for the 2024-25 biennium, $5685.8 million is to be funded through voluntary contributions. The institutionalisation of earmarked funding would further stabilise donor-driven priorities and compromise the credibility, independence and integrity of WHO.” 

Nicoletta Dentico of Society for International Development (SID) condemned “the multilateral development community’s fixation with leveraging the private sector in healthcare, using public money to de-risk investments”. 

Third World Network’s KM Gopakumar condemned the idea of a WHO Investors’ Forum, saying it would “seriously undermine the role of the vast majority of Member states in WHO’s governance”. 

“The  Forum participants, consisting of a rather impenetrable network of philanthropic foundations and the private sector, would de facto control WHO’s priorities,” he added.

Image Credits: Twitter/Dr Tedros Adhanom Ghebreyesus.

More lives are being lost to climate change every year than in the Holocaust and World War II, warned US Special Climate Envoy in an address before World Health Assembly delegates

In a precedent-setting move, the UN’s annual Climate Conference of Parties (COP28) scheduled for 30 November – 12 December in Dubai will have a formal day in its calendar dedicated to health and climate change. The summit will also host a first-ever climate and health ministerial, WHO’s Director General Dr Tedros Adhanom Ghebreyesus said on Wednesday.

“The climate crisis is a health crisis, fueling outbreaks contributing to higher rates of non-communicable diseases and threatening to overwhelm our health workforce and health infrastructure,” Tedros said, speaking at a climate and health technical briefing event on the sidelines of the World Health Assembly, also attended by the Chief Executive of COP28, Adnan Z. Amin as well as by US Climate Envoy John Kerry, who appeared virtually. 

There have been worries among some health and climate activists that the United Arab Emirates which is hosting this year’s COP, and is a major fossil fuel producing country, could use health as a fig leaf to obscure the lack of progress on real reductions in climate emissions.   

‘Massive course correction’ is needed says COP28 CEO

However, the lead advisor to the COP28 President, CEO Adnan Z Amin, came out sounding bullish about the level of ambition for the event being planned.

The Kenyan diplomat and former director-general of the International Renewable Energy Agency (IRENA), told the WHA delegates that a “massive course correction” will be required by countries at the annual meeting to rein in fossil fuel emissions sufficiently to meet the 2015 Paris Agreement limiting global temperature rise to 1.5 degrees Celsius, Adnan Z Amin, the CEO of COP 28, told the several hundred WHA delegates gathered for the briefing Wednesday.

“With the recent IPCC report, we have had very troubling news that there is a scientific consensus that we are way off track on meeting virtually every goal,” Amin said. “If we are to course correct, if we are to meet the ambition that [US Climate Envoy] John Kerry laid out, of meeting the Paris Agreement ambitions, we are going to have a massive correction and that course correction needs to happen at COP28. 

 “We will need to decarbonize, we will need to reduce emissions by 43% by 2030. This is the decade of action,” Amin said.

He added that the focus of COP28 will be on potential solutions ranging from finance to technology. “This COP must be a COP of solutions. Not a COP of wishful thinking,” Amin said.

Kerry – ‘make no mistake it is a battle’ 

Speaking on video, John Kerry, US’ special Presidential envoy on Climate Change told the group that “ignorance” and avoidance of facts – along with a shortage of funds for climate investments – continue to be the main barriers to climate progress. 

 “Make no mistake, folks. It is a battle,” he declared. “I’ve been involved in public life for more than 50 years …. and I’ve never seen people so willing to wrap their arms around ignorance… and be unwilling to do what the facts are screaming at us.

 “There’s really no polite way to put it, the climate crisis is killing people,” added Kerry. 

“Methane emissions, CO2 emissions, nitrous oxide and other emissions are escaping into the atmosphere, fed by the way in which we continue to choose to fuel our vehicles, propel our vehicles, heat our homes, light our factories and so forth. 

 “Those emissions result in disgraceful, polluted air quality, extreme heat, loss of water, loss of crops, loss of ecosystems. And at every stage, the loss of life. 

 More lives lost to Climate Change every year than in the Holocaust 

The consequent health impacts are not something for the future, but happening here and now. 

“We’re losing many more lives every year [to climate change] than we lost in the Holocaust and World War II, maybe three to four times as many lives – now that extreme heat is now increasing around the world” he said, referring to trends that experts say will also make large swathes of the earth uninhabitable within decades. 

“There are millions of people who are sleeping outdoors in India right now, because they can’t find relief because even at nighttime, it’s 30 degrees centigrade,” he observed.

Private sector still turning a blind eye 

“And the truth is that responsible people, particularly economists, and people who make  enormous decisions about trillions of dollars and its allocation to the building of capital and investment around the world, ignore the real costs.

 “The cost of coal is not the cost of mine to burning. It’s the cost of black lung disease. It’s the cost of increases in emphysema, heart disease, all the other downstream causes and the ash that is filling up lakes and rivers. 

 “It’s the warming of the ocean –  90% of the heat on the planet goes into the ocean. And that heat is changing the chemistry of the ocean… in dangerous ways as we’re witnessing, not the least of which is the possible tipping point we may have reached with respect to the Arctic,  and the Antarctic, and the coral reefs and the Bering Sea, and of course permafrost which is thawing around the world, which releases massive amounts of methane. 

 “So if the consequences of what I’ve just described don’t don’t underscore a health crisis. I don’t know what will. And what adds insult to injury is that everything we are talking about is preventable. 

 US climate commitments aim to slash climate emissions by nearly half

On the positive side, some 20 nations, representing 76% of the world’s climate emissions, have committed to meaningful reductions, he said. That includes new US commitments to reduce its emissions by 45%, or more, by 2030. 

“But we have a lot of other countries in the world that continue to build coal fired power plants, and continue to burn that coal fired power,” he added. 

More finance is key to climate progress

To push the curve further, more finance is needed, he stressed, saying that “this finance gap,  it’s really the greatest stumbling block of all.”

The US recently announced that it would invest $1 billion into the Green Climate Fund – which has suffered from a lack of resources to effectively finance a clean energy transition in developing countries. 

But the private sector needs to be mobilized more aggressively too, he said. 

“We are working on releasing tens and hundreds of billions of dollars from the private sector by bringing them to the table, creating blended finance mechanisms and other ways of investing solutions.  

“We now have more venture capital money moving into green hydrogen, battery storage, direct air carbon capture, carbon capture storage and utilization. The possibilities of new energy coming from sources that we’ve never been able to tap like fusion, small modular nuclear reactors,” he said.

“It’s really hard. It’s being made harder by the day by all of this new gas and oil and fossil fuel burning that is taking place despite the realities that we face. 

“But we can change this,” he concluded.

Health sector also needs to decarbonize

The health sector, which is responsible for about 5% of annual global carbon emissions, also needs to shoulder its share, said Dr Maria Neira, director of WHO’s Department of Climate, Environment and Health, and moderator of the panel discussion. 

She added that while most of the emissions come from high-income countries, solarizing  health services in low and middle income countries also help improve healthcare access in rural areas along with putting them on a green trajectory. 

 The cost of solar and wind energy has dropped by 85% when compared to 2010 prices – making small-scale solar more affordable. 

 And insofar as a considerable share of air pollution is caused by fossil fuel burning, reducing global carbon emissions will lead to reduction in the estimated 7 million premature deaths a year from unsafe air, she added.

Palestine
A wall near the Erez Crossing separates Israel from the Gaza Strip.

In what has become an annual ritual, the World Health Assembly adopted a decision on Wednesday decrying the health conditions in the occupied Palestinian territories, and calling on WHO to monitor progress in recommendations for reform by both Israel and the Palestinian Authority.

The decision was approved by 76 votes to 13, with 35 abstentions and 53 countries absent. The decision was a virtual carbon copy of one passed last year, with the exception of two new clauses – which reflect in some sense the recent escalation of conflcit on the ground.

Those new clauses call on Israel “to ensure unhindered and safe passage for Palestinian ambulances as well as respect and protection of medical personnel, in compliance with international humanitarian law and to facilitate the access of Palestinian patients and medical staff to the Palestinian health institutions in occupied east Jerusalem and abroad.”

A second new clause called for WHO to “identify the impact of barriers to health access in the occupied Palestinian territory including east Jerusalem, as a result of movement restrictions and territorial fragmentation, aswell as progress made in the implementation of the recommendations contained in the WHO reports on the occupied Palestinian territory including east Jerusalem.”

The Palestinian-led resolution also asks the UN health agency to assist in improving its health system, ensuring procurement of vaccines, medicine and medical equipment, and ensuring non-discriminatory and equitable access to health in the occupied territories.

United States, UK and Canada led dissenting group

This year’s decision was supported by the majority of Arab and African nations and, notably, a handful of European countries including Belgium, Ireland, Switzerland and Spain.

The United States, United Kingdom, Canada, Australia, Germany and Israel led the group voting in dissent.

Following the vote, Israel said the countries that supported the resolution had chosen to “turn away from logic and reality,” calling the motion “a politicized resolution that has not helped a single Palestinian.”

“It is a tool just like Palestinians use in nearly every multilateral arena to target my country,” said Meirav Eilon Shahar, Israeli Ambassador to the UN in Geneva. “It is devoid of reality.”

The Palestinian delegate, meanwhile, said the language referred directly to United Nations resolutions and terminology that have been accepted in multiple fora in the past.

“This draft decision is procedural and technical in nature,” its delegate said ahead of the vote. “It uses words based on consensus wording of UN and WHO instruments and draws from the outcomes and recommendations of the Director-General’s report.”

Remove “arbitrary” barriers to health for civilians, Tedros tells Israel

The Palestinian-led resolution follows upon the publication of WHO’s annual report on health conditions in the occupied Palestinian Territories by WHO Director-General Dr Tedros Adhanom Ghebreyesus.

The report documented 191 Palestinian deaths and over 10,000 casualties as a result of “occupation-related” violence, with the number of Palestinians killed in the West Bank (154), the highest since 2005, according to the report.  Some 24% of the casualities were related to settler violence, the report stated.

The report also documented some 187 attacks on health care responders, mostly coinciding with peaks in the escalation of Israeli-Palestinian violence.

The report also documents the physical barriers that Palestinians face in accessing routine health care services due to the geographic fragmentation of the West Bank, Gaza and east Jerusalem, as well as particular problems encountered due to the military closure of Gazan entry points into Israel and closures around certain West Bank areas during periods of violence and tension.

The decision requests that the WHO ensure “unhindered” passage for Palestinian ambulances, which Israel does not allow beyond checkpoints on the border of the OPT.

Appeals to Israel to ease barriers and to the Palestinian Authority to improve health care coverage

The report calls on Israel to “end the arbitrary delay and denial of access for Palestinian patients and their companions, and promote unhindered movement for Palestinians throughout the occupied Palestinian territory, including east Jerusalem and between the West Bank and Gaza Strip,” for specialized treatment as well as for more routine care.

The report also calls upon Israel to end “arbitrary delays” of ambulances at checkpoints and facilititate entry of medicines and medical supplies to the Palestinian territories.

Palestinians must also apply for permits to visit hospitals outside the occupied territories, and the “arbitrariness” and unpredictability of approvals costs people their lives, the report states. Cancer patients initially delayed or denied permits to access chemotherapy or radiotherapy were 1.5 times less likely to survive, the report said. The consequences of denying people permits to receive treatment are also evident in individual cases.

Fatma Al-Misri, a 19-month-old girl living in the occupied territories, was twice denied a permit to travel for treatment of an artrial septal defect, which is a treatable condition. She died awaiting the outcome of her third permit application.

The Director General’s report also calls on the Palestinian Authority to assign greater priority to health care expenditures, ensure more “continuity” of essential health care services, and reform “revenue raising and risk pooling mechanisms to strengthen the social protection of Palestinian households against catastrophic health expenditure and impoverishment.”

The lack of comprehensive health care coverage is a factor throwing families into poverty, forcing many families to pay for medical care and medicines out of their own pockets.

The Palestinian Authority also needs to “simplify and streamline the referrals system” including through “identifying and promoting understanding and awareness of patient
entitlements to essential health care services,” the report stated.

Life expectancy is lower in the occupied Palestinian territories

In 2022, the average life expectancy in the West Bank and Gaza was 75.4 years for females and 73.2 years for males. In comparison, Israeli life expectancy wsas 85.1 years for females and 81.8 years for males. In east Jerusalem, where Palestinians have more freedom of movement and can also access Israeli health care systems, life expectancy is much closer to the Israeli averages of 81.9 for females and 78.1 for males.

Israel has one of the world’s best health care systems, ranking alongside countries like Italy and South Korea. In metropolitan areas. The average response time of emergency services in its major cities can be as low as 90 seconds.

In the occupied Palestinian territories, the average response time for ambulances is 59 minutes, the WHO report found.

People living in the occupied Palestinian territories were three times as likely to die from noncommunicable diseases between the ages of 30 and 70 than their Israeli counterparts in 2021, the report added.

A survey of infant mortality rates found Palestinians were four times more likely to die before their first birthday than Israelis – five if the child was born in a refugee camp.

Tedros also criticized Israel’s obstruction of deliveries of key medical supplies, equipment and staff, saying bureaucratic obstacles had caused long delays in the WHO supply chain.

“Dual-use” restrictions put in place by Israel to stop the entry of devices that could be repurposed for military use are also applied too broadly, slowing or blocking the arrival of basic medical equipment like x-ray machines, oxygen cylinders and MRI devices, Tedros said.

“Access to health is limited because of the Israeli occupation and the military administration,” the Palestinian delegate said. “We must ensure the rule of law and logic prevail. We are the ones suffering.”

Politicizing the Assembly

Israel and its allies have long opposed the annual report and vote on Palestinian health conditions, stating that it singles out the Israeli-Palestinian conflict in a way no other regional conflict is highlighted by WHA.

“There is not a public health emergency or crises that this item is addressing,” the US delegate said. “We cannot support an agenda item that does not meet our shared objective of a World Health Assembly focused on public health.”

Canada reiterated its commitment to support efforts towards “a lasting peace” but said that a “technical health body is not the place for political discussions.”

At the same time, as the vote on Ukraine earlier in the same day illustrated, the “politicization” of WHA appears to be an increasingly inevitable consequence of a world beset by regional conflicts – with major powers shifting sides rhetorically, depending on their immediate interests and alliances.

Russia, for instance, whose ongoing invasion of Ukraine has caused a health crisis affecting millions of civilians, called on Israel to stop its “illegal military activities” and attacks on Palestinian “buildings and homes.”

After three days of demanding the assembly “talk about health” and “stop politicizing” the health crisis in Ukraine, its delegate made no such interventions relating to the Palestinian resolution.

Image Credits: Levi Meir Clancy.

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 .