Civilian protections
Two Malian former rebel leaders, Attaye Ag Mohamed, left, and Mohamed Elmaouloud Ramadan, right, join Geneva Call’s Director General Alain Délétroz, center, at a signing ceremony in Geneva for a Deed of Commitment on Protection of Health Care in Armed Conflict

Leaders of a coalition of former Tuareg and Arab rebels in Mali signed a written pledge on civilian protections for health and medical facilities during armed conflict, reflecting global efforts to stem attacks on health facilities, transport, and patients that have became more frequent since the onset of the COVID-19 crisis.

The two leaders with the movement seeking autonomy for northern Mali signed the Deed of Commitment on Protection of Health Care in Armed Conflict at a closed ceremony organized by the Swiss-based humanitarian organization, Geneva Call, on Friday.

Geneva Call’s Director General Alain Délétroz and the two Coordination of Azawad Movements (CMA) steering committee members, Attaye Ag Mohamed and Mohamed Elmaouloud Ramadan, affirmed their pledges to enforce civilian protections through the Deed of Commitment, which marks a milestone in Geneva Call’s humanitarian dialogue with CMA over the past four years, the humanitarian organization said in a statement.

Despite its “diversity of opinion on certain social issues, the CMA could agree on a document that comprises the main themes of international humanitarian law,” Attaye Ag Mohamed said, adding that the coalition benefited from Geneva Call’s support and expertise.

“Aware of the importance of the free movement of medical missions and their access to populations targets and vice versa, the CMA can only make its modest contribution to their protection as well as to that of humanitarian convoys in Mali and more particularly in the North of the country,” said Mohamed.

“The signing of this act of commitment thus signals a new phase of collaboration,” he said. “It is up to all of us to put it into widespread use in the field through awareness-raising and training on this important topic.”

CMA pledged to respect international laws insisting on the protection of “health care personnel, facilities and medical transports, and the wounded and sick,” and to adhere to “the principles of medical ethics.”

Geneva Call works to strengthen the protection of civilians during armed conflicts in dozens of countries. The issue of protections for health care workers and facilities has become more pressing in conflicts and wars around the world, including Syria and Ukraine.

Last year, the World Health Organization (WHO) reported that more than 700 healthcare workers and patients had died, and more than 2000 were injured in attacks on health facilities across 17 emergency-affected countries and fragile settings since December 2017. Countries at risk included Ethiopia, Yemen, Syria, Mozambique, Nigeria, occupied Palestinian territory, Myanmar and the Central African Republic.

The three-year analysis ws based on data from the WHO’s Surveillance System for Attacks on Healthcare (SSA), which monitors attacks on healthcare workers, patients, facilities, and healthcare transport, the resources that they affected and their immediate impact on health workers and patients.

Working behind the scenes on protecting civilians

Geneva Call has an unusual remit, persuading armed groups and de facto authorities to respect and apply humanitarian norms and human rights.

These include the conduct of hostilities, protections for children, education, food security, health care and cultural heritage, prohibition of sexual and gender-based violence, forced displacement and humanitarian access.

The Geneva-based humanitarian organization, which has worked in around 25 countries since 2000, also boosts civilian protections by strengthening local civil society organizations and their awareness of international humanitarian norms.

As a result, it says, some armed groups have developed their own monitoring bodies for humanitarian norms and human rights, have trained their senior leadership and field commanders to effectively implement these commitments, and facilitated international access for humanitarian aid to flow.

CMA was created in 2014 as a coalition of political-military movements composed of MNLA/MAA/HCUA, present in Mali in the regions of Timbuktu, Gao, Kidal, Taoudeni, and Menaka. In 2015, CMA signed a peace and reconciliation accord in Algiers with the Malian government.

Four years of work on civilian protections in Mali

Geneva Call began working to improve civilian protections in Mali in 2018.

Since the COVID-19 pandemic began in 2020, Geneva Call says it has worked in Mali to ensure health care access and strengthen respect for humanitarian standards and military codes of conduct.

Two armed groups in Mali previously signed commitments to the Geneva-based organization to provide health care access and to try to prevent the further spread of the coronavirus.

Délétroz told the signing ceremony that attacks on hospitals, medical transport and health workers have increased in conflict zones in recent years, paralyzing emergency services and disrupting the local population – with devastating impacts on the lives of staff and patients, both civilians and wounded combatants targeted because they are among the most vulnerable.

“Unfortunately, Mali is not spared from this trend,” he said. “The deterioration of the security situation has also been reflected in increased difficulties for populations to access health care centers and health workers being targeted on a regular basis.”

The Deed of Commitment with CMA is of “paramount importance,” he said, because it “represents an important step in the humanitarian dialogue initiated four years ago by Geneva Call and the members of the Coordination of the Movements of Azawad.”

On CMA’s side, the coalition affirmed it will improve civilian protections generally and respect and protect health structures and medical missions during armed conflicts in particular. The Canton of Geneva is legal custodian of the document, the first one signed with Geneva Call in Mali since it began working there.

And on Geneva Call’s side, there’s also commitment, said Délétroz, since the organization will continue to work with CMA to stick to its pledges under a jointly developed implementation plan.

“We also hope that this signature can serve as an encouragement to all Malian stakeholders who have a role and responsibility to ensure the protection of civilians,” he said. “For Geneva Call remains concerned about the situation of populations impacted by this conflict.”

Image Credits: Geneva Call.

Malaria control in Nigeria
Health volunteers pick up supplies during a seasonal malaria chemoprevention campaign in Nigeria.

The World Health Organization (WHO) has launched a new initiative to counter the added malaria threat posed by the rapid expansion on the African continent of the mosquito Anopheles stephensi — native to parts of South Asia and the Arabian Peninsula, the organization said this week. 

The initiative comes just as the world struggles to get malaria control back on track – something that the invasive An. stephensi mosquito, which belongs to the same subgenus as  Anopheles gambiae, the primary malaria vector in Africa, expands its range.

“We are still learning about the presence of Anopheles stephensi and its role in malaria transmission in Africa,” said Dr Jan Kolaczinski, who leads the Vector Control and Insecticide Resistance unit within WHO’s Global Malaria Programme. “It is important to underscore that we still don’t know how far the mosquito species has already spread, and how much of a problem it is or could be.”

But with detections of the new vector already reported in several African countries including Djibouti, Ethiopia, Sudan, Somalia and Nigeria, WHO is sounding the alarm bell to Africa’s national malaria programmes. This is particularly the case because of the vector’s ability to thrive in urban settings – unlike An. gambiae.

Moreover, the vector has been found to be resistant to many of the insecticides used today for malaria control – thus posing an added challenge. One study projected that An. stephensi could put an additional 126 million people in Africa at risk of malaria if the mosquito vector were to spread unchecked. Another study estimated that the number of malaria cases in Ethiopia could increase by 50% if An. stephensi were to spread to all receptive areas.

Vector’s ability to spread in cities a big concern

African countries with detected spread of the An. Stephensi mosquito vector.

Of particular concern is the vector’s ability to spread in cities; as Africa undergoes rapid urbanization with 40% of people now living in cities. The WHO noted that An. stephensi is thought to have contributed to a resurgence of malaria in Djibouti City and at least one outbreak of the disease in Ethiopia —both in  2012. So while the overall contribution of An. stephensi to malaria transmission in the region today remains unclear, there is considerable potential for this highly efficient and adaptable malaria vector to undermine the gains made in reducing the burden of the disease, experts say.

For Africa then, the new WHO initiative, described in detail in a new policy brief, could be decisive in the battle to halt further spread of An. stephensi in the region, as well as determining whether it can be eliminated from areas that have already been invaded. 

Specifically, the initiative aims to: strengthen surveillance to determine the extent of the spread of An. stephensi and its role in malaria transmission; and increase collaboration across sectors and borders so as to improve information exchange on the presence of An. stephensi and the success of efforts to control it.

The initiative also will develop guidance for national malaria control programmes on appropriate ways to respond to An. stephensi, and prioritize research to evaluate the impact of interventions and tools against the mosquito vector.

Getting malaria control back on track

In 2020, malaria deaths rose by 12% as compared to the year before, as a result of pandemic-related service interruptions. Following a longstanding pattern, the vast majority of all malaria cases (95%) and malaria deaths (96%) were located in the African Region, with an estimated 80% of all malaria deaths in the region among children under the age of 5.

In June 2022, Philip Welkhoff, Director of the Malaria Program at the Bill & Melinda Gates Foundation, told Health Policy Watch that the world has lost years of progress on malaria control thanks to the COVID pandemic, with malaria mortality close to what it was almost a decade ago.

“Malaria is really unforgiving. And when there are disruptions in either access to care or some of the routine services, that malaria burden will go up. Because of COVID, we’ve gone backwards,” Welkhoff said, in an interview.

The latest, 2021 data now shows signs of recovery in malaria control programmes, according to the latest report of the Global Fund, with increased rates of testing and diagnosis in particular.

Now more than ever, however, “integrated action” that combines all available tools for vector surveillance, control, diagnosis and treatment, will be important in tackling the additional threats posed by An. stephensi to malaria control goals, said Dr Ebenezer Baba, malaria advisor for the WHO African Region.

“Integrated action will be key to success against Anopheles stephensi and other vector-borne diseases. Shifting our focus to integrated and locally adapted vector control can save both money and lives,” he said.

See the related story here:

https://healthpolicy-watch.news/tb-hiv-malaria-rebounds-pre-pandemic-level/

Image Credits: Munira Ismail_MSH, WHO .

Childhood immunisation checks in low-income countries
Doctors in Pakistan check an infant for a scar showing signs of Bacillus Calmette-Guerin (BCG) vaccination – used to protect against TB in high-burden countries. 

Routine childhood immunisation across 57 low income countries declined slightly for the second consecutive year in 2021, following massive pandemic-related interruptions in vaccine coverage in 2020, according to Gavi, the Vaccine Alliance.

Vaccine coverage stood at 77%, one percent less than in 2020. 

Preliminary data between January and May 2022, however, shows signs of improvement in childhood immunisation coverage, according to preliminary WHO data contained in Gavi’s 2021 Annual Progress Report. 

In 2021, 65 million children were immunised in the 57 Gavi-supported countries, generating economic benefits equivalent of more than $18.9 million. Gavi-supported countries also contributed $161 million in co-financing to advance national commitments to childhood immunisation, and ensure programme sustainability. 

Gavi countries also administered more than two billion Covid-19 vaccines in 2021. 

“Since 2019, we have seen the biggest sustained drop in routine immunisation in a generation, and millions of children are still missing out,” Catherine Russell, UNICEF’s executive director said. “Immunisation is one of the world’s most effective and cost-effective public health interventions.” 

This is not the first time that global health organisations have flagged this issue. In July, WHO and UNICEF sounded the alarm on the largest sustained decline in childhood vaccinations across the globe in 30 years. As per their estimate, around 25 million infants missed out on routine lifesaving vaccines due to many factors like increased conflicts that blocked immunisation access and Covid-19.

Signs of improvement in 2022

Though childhood immunisation numbers declined in 2020 and 2021 due to the Covid-19 pandemic, preliminary data from the World Health Organization (WHO) shows early signs of improvement in 2022. Data collected from January to May 2022 from 16 countries suggests a 2% increase in the basic vaccine coverage among children. 

In December 2021, Gavi also approved funding to support the world’s first malaria vaccine roll-out in sub-Saharan Africa in 2022-2025. 

Expressing disappointment over the continued decline in 2021 in childhood immunisation rates, Gavi’s CEO Dr Seth Berkley said that the early indications on the 2022 data still provides grounds for optimism. 

“There is no higher priority for the Alliance in 2022 than keeping routine immunisation progress on track,” he said. 

Focus on zero-dose children

The number of children who received no vaccine doses in the 57 low income countries increased by 570,000 in 2021, Gavi reported, pegging the total at 12.5 million children. Cumulatively, this is a 34% increase when compared with the 2019-figures – reflecting the much more massive drop in coverage that occurred in 2020, the first year of the pandemic. 

‘Zero-dose’ children are infants who have not received their first dose of the DTP1 vaccine, which protects them from diptheria, tetanus and pertussis. It is one of the first vaccines administered to infants.

In July’s report, 18 million infants out of the 25 million who missed out on lifesaving vaccines did not receive even a single dose of the DTP1 vaccine, thus increasing their risk of dangerous diseases like diptheria, tetanus and pertussis.

Prof José Manuel Barroso, chair of the Gavi Board, said that leveling out of the decline shows signs of recovery by countries’ “heroic” immunization programmes. “As we move forward, we must maintain our focus on supporting routine immunisation and reaching zero-dose children with life-saving vaccines,” he added.  

Added Russell:  “…we need to…make sure lost ground does not become lost lives.”

Image Credits: CDC Global, Public domain, via Wikimedia Commons.

Public goods
A panel discussion at the WTO’s Public Forum on “Creation and Protection of Public Goods for Health (the Experience of COVID-19)”.

At a World Trade Organization Public Forum this week, public health advocates argued for the creation of a new WTO framework to stimulate voluntary offers by countries to supply more ‘public goods’ to trading partners and the world, including investments, assets and know-how critical to protecting the world against future pandemics and other health or environmental crises.

A panel discussion at the World Trade Organization’s Public Forum on Friday took up the topic of a novel trade-based initiative that they say could help incentivize countries to share new technologies, assets and know-how more readily – not only for meeting health emergencies, but other types of health and environmental challenges.

The idea, says James Love, director of Knowledge Ecology International (KEI), is to create a new framework for recognizing ‘public goods’ within the WTO trade rules, whereby governments can make voluntary, but binding, offers to supply such goods to other WTO trading partners – including, but not limited to public health products, investments and know-how.

Examples of ‘Public Goods’ – KEI Presentation at WTO Public Forum.

The initiative on public goods is modeled on the modeled after the General Agreement on Trade in Services (GATS), a landmark deal from the Uruguay Round negotiations in 1995.

GATS is meant to provide a reliable system of international rules for trade in services, and to facilitate the progressive liberalisation of services markets.  But a unique feature of the GATS framework is the opportunity for countries to make voluntary, but binding, “offers” to liberalize domestic trade rules around services provision  – usually in exchange for another type of trade concession. For instance, a country can voluntarily pledge to drop domestic restrictions against foreign firms’ provision of any kind of services – from credit card management to hospitals administration.  But either directly or indirectly, it might obtain, in exchange, commitments from other countries for benefits or concessions – on issues ranging from agricultural subsidies to tariffs on vehicles.

Make ‘public goods’ part of the international trading environment

Excerpted from: KEI presentation at WTO Public Forum.

In a similar vein, a GATS-like framework for ‘public goods’ could allow, for instance, rich countries to pledge to share money or know-how on vaccines or medicines – in exchange for a developing countries’ pledge to reduce tariffs on electric car imports or even to conserve a biodiverse ecosystem of global significance – as part of the wheeling and dealing that anyways takes place around more conventional trade agreements.

“The idea is to make the public goods part of this trading environment,” said Love and one of the leaders in the novel effort to forge such a new WTO trading framework on such ‘public goods’.

“We’re not picking a fight with the drug companies or the energy companies or anyone else,” he added.

“The decision to supply a public good can be used to get something else you want from other countries at the WTO, or avoid something that you don’t want to do,” said Love. He says that the GATS framework has been highly successful in incentivizing trade liberalization of services precisely because it is heterogenous, but still rules-based.

“It’s not a winners versus losers situation,” Love said of his proposal. “It’s a clever hack at the WTO that has a path forward.”

Public goods debate at the World Health Organization

The question of how and if medicines, vaccines and other public health products could be redefined as ”public goods” also lies at the heart of World Health Organization talks on a proposed new pandemic accord, which began with broad agreement over the summer that a new legal instrument should complement but not repeat provisions of the existing WHO International Health Regulations, while respecting national sovereignty in terms of public health responses.

In those debates and hearings that have since followed, including a new round of public hearings on Thursday and Friday, a significant number of civil society organizations, as well as Asian, African and Latin American nations have stressed that public health responses to the pandemic and investments in R&D for countermeasures should be treated as, and accounted for as public goods- e.g. requiring more public sector investments with the resulting products then freed from profit-based constraints on pricing and distribution.

However, while the campaign to redefine essential medicines and vaccines as “public goods” has been a longstanding aim of many public health advocates – in the realities of the marketplace, it remains that private, not public investments, still drive much critical health related R&D.

Public goods
A slide shown by Antony Taubman, WTO’s director of intellectual property, government procurement and competition division, at a Public Forum discussion

Speaking at the WTO public forum panel, the French virologist Marie-Paule Kieny, a former high-ranking WHO official who now chairs the Medicines Patent Pool, argued “it is really the time to advance” the idea of public goods over “private goods and private profits.”

But making public health resources more broadly available, she said, “will need to be supported by sustainable financing.”

Against those hard realities, incentives for countries to offer up certain kinds of “public goods” in exchange for other types of trade concessions, could be an attractive proposition, panelists argued.

Antony Taubman, WTO’s director of intellectual property, government procurement and competition division, told the forum he believes “it’s a proposal that is quite fertile, in terms of making us all think.”

“More broadly it is a discussion about what it takes to deliver public goods sustainably,” he said. “But it’s also a refection … on how multilateral negotiations work.”

Taubman joked that sometimes “it’s tempting” to call WTO “the World Trade-off Organization,” because of the need to accommodate so many competing interests.

But the “concept of global public goods,” he added, “is in its own a valuable organising idea.”

–Elaine Ruth Fletcher contributed to the reporting of this story. 

Image Credits: John Heilprin, KEI .

EU

“This is really a historic meeting,” said Dr Ilona Kickbusch, co-chair of the European Health Forum at Gastein (EHFG). “Twenty years ago was the very first time there was any talk of a European global health strategy, and it took place right here at Gastein.”

“It was in 2003 that global health first became a part of the EU’s health strategy,” Kickbusch recalled. “But then it disappeared, only to come back in 2010 as the first global health strategy, and now we are working on a second one.” 

Two decades down the road, with public consultations formally closed last week, the European Union (EU) is set to release its second Global Health Strategy before Christmas this year.

“The consultations have taken us from Stockholm to Madrid, but also from Abuja to Columbia,” said Francisco Perez-Cañado, a senior expert at the EU’s Directorate-General for Health and Food Safety (DG SANTE). 

“It has been one of the widest consultations to date, not only including what our stakeholders feel in the member states, but also across the world, and in particular in the Global South.”

The EU plan aims to outline how the region will respond to future pandemics and health threats, and reflect a policy vision that embodies the bloc’s values. In light of the COVID-19 pandemic, EU officials hope to impress upon member states that ensuring more equitable global access to health products worldwide will safeguard global health.

“It is clear that no single government or institution can address this threat of future pandemics alone,” said Paul Zubeil, Deputy Director-General for European and International Health Politics at the German Ministry of Health. 

“The challenges of global health and our reality have changed dramatically since the last EU strategy plan in 2010, so it is a good sign the new European strategy is taking shape. It is absolutely necessary.”

While the draft strategy to be delivered later this year is sure to be ambitious, its  proposals will be at the mercy of the EU’s deliberative processes, and the final plan – expected sometime in the first half of next year – will reflect the views and priorities of its 27 member states.

“You will need to be very lucid that what will come out of the global health strategy will also be a composition of geopolitical agendas,” said Sandra Gallina, Director-General of DG SANTE. “My heart is with Africa, but our member states have many different geopolitical priorities.”

Nevertheless, the inclusive approach to consultation undertaken by the EU has raised hopes that the final plan will ensure that the region retains the role it assumed during the pandemic as a global health leader.

“Global leadership by the EU starts at home,” said Perez-Cañado. “The global health strategy must no longer be only about development, but a truly holistic health approach.”

North-South cooperation: partnerships, not charity 

EU
Sandra Gallina, Director-General of the EU’s DG SANTE.

While the previous EU global health strategy was crafted in European capitals, the new consultative approach has placed an emphasis on the inclusion of partners from across the Global South. 

“It’s been amazing how the EU has really consulted in a different sort of way,” said Catherine Guinard of the Wellcome Trust. “I think the values and ethos of the strategy – equity first and foremost – are so important to its salience and its ambition, and it is quite exciting to think about global health 10 years from now, where the EU has got a comprehensive, coherent roadmap for global health with this strategy as its kind of North Star.”

This inclusion of the views of stakeholders in low and middle-income countries (LMICs) in the drafting process is key to the new plan’s legitimacy, and to many, represents a watershed moment for the transition from charity dynamics to those of partnership. 

“The fact that we’re here is, in itself ,an indicator of some success,” said Dr Ayoade Alakija, member of the Africa Union’s African Vaccine Delivery Alliance and WHO Special Envoy for the Access to COVID-19 Tools Accelerator. “It’s an indicator that the world is listening, that we’re progressing from where we were, to where we should be.”

Alakija was the host of one of the consultative meetings held in the Nigerian capital of Abuja between European Commission officials and delegates from 17 African countries. 

“I remember when that invitation from the ambassador was sent out, there were gasps from some countries saying, ‘Oh my goodness, this is now fully beginning to indicate true inclusion and partnership as opposed to tokenistic participation’,” Alakija said. “Instead of inviting us to the table and saying, here’s what we made earlier, you invite us to co-create.”

Clemens Martin Auer, president of the European Health Forum at Gastein, stressed: “We must stop thinking in terms of charity, and we must begin to think in terms of empowerment.”

Health and climate

Europe’s understanding of the relationship between climate and health is key to the region’s strategic vision. 

“I would love to see the EU really step up and use this strategy as an opportunity to articulate how it will lead on climate and health,” Guinard said. “There’s real awareness across governments now that climate-health is a real issue, but I think there is a gap in leadership.”

To make progress, Guinard explained, the plan needs to push for a transdisciplinary approach in which health policy is integrated with climate, transport, energy and other associated policy areas. 

“On climate and health, this is a real chance to show how the EU can bring together its unique capabilities across policy, science, and politics to really drive effective change to populations in Europe, but also in the Global South,” she concluded.

No future without a health workforce 

Clemens Martin Auer, President of the European Health Forum at Gastein, says global health policy focus must shift from charity to empowerment.

Shortages in the health workforce are perhaps the most critical silent crisis threatening progress on global health agendas worldwide, and the EU strategy is no exception. 

For low- and middle-income economies, staff shortages in rich countries can have devastating knock-on effects for the progress of their health systems, causing medical talent to be frequently poached by high-income economies. 

“This year alone, the UK has hoovered up about 60,000 medical professionals from Nigeria – from Nigeria!” said Alakija. 

“How on earth are we going to have healthy societies in those countries? If we’re going to have a global health strategy, it has to address the difficult questions.”

“We have a lot of – I would say hoovering – of talent from Romania, from Bulgaria, that come over to Western Europe,” Gallina said. “That doesn’t work in Europe, and what we absolutely don’t want is a depletion of the health workforce in Africa.”

Furthermore, the physical and mental well-being of health workers around the world after years on the front lines of the pandemic – an oft-ignored consideration and major contributor to current and future shortages of medical staff – are reaching a crisis point. 

“The health workforce is at the end of its tether,” said Gallina. “That is the crude reality. They are very tired. There is a crisis.”

As one health worker advocate said: “We cannot magically pull a doctor out of a bag. If we are going to put an end to this endless crisis of shortage of health workforces by 2030, we have to start building the pipelines now.”

Pandemic Preparedness: “wake up”

Another essential component of the strategic vision pertains to pandemic preparedness. The status quo, Gallina remarked sharply, is far from acceptable. 

“So let me wake you all up,” she told the room. “Either our patterns change, or the next pandemic will find us in the same place that we were with COVID.

“We need to stop being in this reactive mode,” Gallina continued. “I am fed up that we in health are forced into reaction mode all the time. We wait for something to hit us in the head, and only then do we react.”

The primary mechanism the EU has selected to push for this change of posture is the World Bank’s Fund for Pandemic Prevention, a financial intermediary fund (FIF) to finance investments to strengthen pandemic preparedness and response, with a focus on low- and middle-income countries. 

With the WHO signed on as lead technical partner, the fund aims to address critical gaps in country capacities in areas such as disease surveillance, laboratory systems, and health workforce.

“Yes, we put in $450 million, and the US has put in $450 million, but the important thing will be the proof in the pudding,” Gallina said. “The World Bank must not run this as a development project. It is a health project. 

“A health project means that you listen to the health professionals that you have,” she explained. “If it becomes a development project, it’s lost. It will achieve other things, but not the things we want.”

Any successful approach to global health cooperation must also be adaptable. As crises are unpredictable, so too must world health vehicles be flexible to respond to that reality.

“At the Commission, we often don’t have real tools to push what we want to push, so sometimes we are inventing our tools [as we go],” said Gallina. “And at international level, it might have to be the same.”

Towards a better future

EU
Dr Ilona Kickbusch delivers closing remarks.

Though the final form of the new strategic plan will not be known for several months, the feeling in the room was one of optimism.

“The strategy isn’t just written for the challenges and the problems we know about now”, Guinard said. “But by embedding the science, it is also about the challenges that we don’t know about yet.”

If the plan is to succeed, global cooperation – and the interests of all stakeholders – will be critical. 

“For a collective future to be what we all want it to be, a global health strategy cannot really just be about health,” Akidja said. “We all need to begin to say ‘no!’, it’s not just health. It is education. It is the elimination of poverty. It is food insecurity. It is gender. It is about women’s rights.

“It is important if we are going to build partnerships that we talk together, because I think there is more that connects us in that which divides,” Akidja said in concluding. “Your health is my health, and your health security is my health security.”

Image Credits: Arthur Olesch, Urska Erklavec, Urska Erklavec.

A wide range of organisations and individuals took part in the second round of public hearings on future pandemic preparedness.

From bedrooms in China to boardrooms in Geneva, people offered their views on how to protect the world against future pandemics during the second round of public hearings called by the World Health Organization (WHO).

The public hearings are part of the WHO intergovernmental negotiating board (INB) process to develop a pandemic “convention, agreement or other international instrument” to “strengthen pandemic prevention, preparedness and response”, as agreed on at a special World Health Assembly in November 2021 

The call for comments elicited over 250 video submissions, some of which were aired on Thursday via the WHO’s website with the rest due to be released on Friday.

Equitable access to medicines and protective equipment, more support for health workers and an end to pandemic profiteering had wide support for inclusion in a future pandemic accord.

Meanwhile, a flotilla of conspiracy theorists also submitted the comments, condemning COVID-19 vaccines (“gene genocide”, according to one), WHO “global domination”, masks and social distancing. People from Australia, Poland and Switzerland seemed particularly agitated about these issues, as well as any notion that there could be global decision-making about how to address pandemics.

Intellectual property rights

But back to the serious commentary, all delivered in 90-second bites (and often by unnamed presenters). Equity of access to vaccines and medicines was a common theme across most presentations, a principle that member states have also agreed on at the INB.

Oxfam, supported by the People’s Vaccine Alliance, advocated for increased public investment in research and development (R&D) conditional on “sharing of intellectual property (IP) rights and know-how as well as technology transfer, especially with producers in developing countries”.

“This must be delivered by a WHO-led IP and technology pooling mechanisms and mandate governments to find regional manufacturing capacity in the Global South, which secures supplies for developing countries,” said Oxfam.

However, the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) said that the fast development of COVID-19 vaccines had been the result of many years of investment in mRNA and viral vector technologies.

“We need to make sure that the IP-based innovation ecosystem is not undermined,” IFPMA director general Thomas Cueni said.

Strong primary health systems

Rosemary Mburu, representing the community and civil society representatives at the ACT Accelerator, called for significant investment in primary health care and national health systems. 

“We need to put trained, skilled, equipped health workforce protection, recruitment and remuneration at the centre of future pandemic response,” said Mburu. “Without this, detection of new pandemics will be slower and those in the frontline responsible for testing treatments and immunisation will not be able to perform their duties.”

Bill Rodriguez of FIND, the global alliance for diagnostics, stressed that “pandemic preparedness and routine primary health care (PHC) are inseparable”. 

“Pandemic surveillance requires investment in routine PHC based testing programmes. 

If we are not testing for common conditions, we will not detect an emerging pandemic until it’s too late,” said Rodriguez, who also stressed that low and middle-income countries needed the capacity to develop their own diagnostics as pandemics disrupted global supply chains and travel.

The Pandemic Action Network wants the accord to ensure that every country has the capacity to “detect, prevent and respond to outbreaks at their source and fulfil their obligations under the International Health Regulations”. 

Legally binding

Third World Network stressed that equity in international public health response is not possible unless there are “legally binding commitments on WHO and member states to operationalize equity” and that member states should be under an international legal obligation to realise equity. 

“We firmly believe in the need for an article 19 convention which sets out what is required of countries in preparedness, response to outbreaks and management of pandemics,” said Dame Barbara Stocking from the Panel for Global Public Health Convention.

“Countries need to be held to account. There is now strong evidence that treaties without compliance measures are ineffective. We believe the best way to do this is by having an independent assessment body within the treaty structure for at arm’s length of the WHO.” 

The panel also wants to “incentivize countries to be accountable” where, for example, “non-delivery could have implications for a country’s financial stability” in terms of article four of the IMF. 

Sharing of pathogens

A number of submissions stressed the need to share information about the pathogens driving pandemics to fast-track global response.

For the IFPMA, this sharing should form part of a “social contract”.

“The world needs to show more solidarity because pandemics do not respect borders,” said Cueni. 

“The industry has committed to reserve vaccines and treatments for priority populations in lower-income countries, but this will only work if countries commit to a social contract. That means immediate sharing of pathogens and their genetic sequence data, unrestricted trade and open borders, and it also means financial support so that those most in need can have equitable access to vaccines, treatments, and tests.”

Inclusive

“Meaningfully engage civil society and communities in every aspect and structure that is set up to better protect against future pandemics,” said Mburu.

“Civil society needs to be on the governance structures of pandemic response architecture. We need to be part of the decision-making and co-creation at every stage and have a say in financing and resource mobilisation decisions. Nothing for us without us.”

AU AMA Special Representative D Michel Sidibe and AMATA moderator Kawaldip Sehmi

Africa’s most powerful countries need to ratify the African Medicines Agency (AMA) to ensure its credibility – and civil society organisations can lobby them to do so , said Dr Michel Sidibe, the African Union’s (AU) Special Representative on the AMA.

“It is important to have countries like South Africa, Nigeria, Kenya, Ethiopia, the DRC, and other countries on the continent ratifying the treaty. It is important to continue for the credibility of the AMA to drive the ratification agenda, and it is very important to not lose momentum,” Sidibe told a webinar organised by the African Medicines Agency Treaty Alliance (AMATA), a civil society network that supports AMA’s formation.

“We don’t have another way to do it except making sure that we maintain we sustained our advocacy and we mobilise political leaders,” he added, commending AMATA for its advocacy work in support of AMA.

The aim of AMA is to harmonise the regulatory system for medical products across the continent’s 55 nations to enable faster approval processes and to support local pharmaceutical production.

But its establishment has been slow, first starting back in 2009. In February 2019, the  AU adopted a treaty to establish the agency but it took until November of that year before the bare minimum of 15 member state had ratified the treaty, enabling the AU to move ahead to set it up.

In July this year, the AU selected Rwanda as the host for AMA, and Sidibe said that he was confident the process of operationalising the agency would move fast in the hands of Rwanda’s President Paul Kagame.

World Health Organization (WHO) Director General Dr Tedros Adhanom Ghebreyesus met Kagame on the sidelines of the UN General Assembly in New York last week to offer WHO’s support for AMA.

“Our continent cannot be always the second in line when we have a crisis. When I was UNAIDS Executive Director, we waited for seven years before getting the [antiretroviral] drugs to the poor people,” said Sidibe. 

“Global health security will not happen without making sure that we can provide our poor people with quality medicine that is affordable. Almost 95% of our medicines are coming from abroad when India is importing a maximum of 15% and China 5% for the same level of population.”

Sidibe has been lobbying African countries extensively himself to ensure their ratification of AMA, and so far 22 countries have done so “after intensive engagement and interaction”, he said. 

Processes to make AMA functional

Sidibe said that he expected the AMA office in Rwanda to become operational “soon”, but outlined six processes to ensure that the agency is fully functional:

  • Ensuring its ratification by all countries, particularly Africa’s largest and wealthiest countries
  • Articulate the AMA strategy and plan widely to ensure it has the support of the continent
  • Develop a funding strategy and roadmap for fundraising
  • Start to build the skeleton of the organisation, including identifying its major functions and leaders
  • Build AMA partnerships and coalitions. 
  • Identify and deliver three to five major impacts for AMA in order to establish its credibility.

Stressing that these six points were his personal views, Sidibe called for the launch of “the first replenishment for an African-based health institution” to secure money for AMA’s future.

“The ratification process has highlighted the importance of critical stakeholders – regulators, researchers, academic institutions, private industry and passionate civil society organisations,” said Sidibe.

“AMA should not be just replacing national regulatory authorities or regional harmonisation processes. I think it will be a huge mistake and it will not work. AMA will just come in complement of those and a strong AMA will depend on strong national capacities,” stressed Sidibe, appealing to academics and civil society to help strengthen ethics committees and the implementation capacity of weaker countries.

Panel members discuss innovative financing

Budgetary efficiency and innovative ways to finance health emerged as key solutions to the problems plaguing the European health systems, according to a panel at the European Health Forum in Bad Gastein on Tuesday. 

Europe’s healthcare system is faced with several bottlenecks, said panelists. The COVID-19 pandemic has exacerbated problems such as a lack of adequate workforce and increased out-of-pocket spending on healthcare for citizens of the European Union (EU). 

The need to ensure equitable healthcare, cope with inflation and muster the political will are also issues undermining the health system. 

Is lack of money the problem? 

Money is hardly the problem. The European Commission EU’s long-term budget, coupled with the NextGenerationEU (NGEU) stimulus to boost post-COVID recovery, is channeling over €2-trillion to its member states to address the most important challenges before Europe and support those in need. 

Its EU4Health programme has a €5.3 billion budget for the 2021-27 period to “build stronger, more resilient and more accessible health systems” that are better able to withstand pandemics.

In the aftermath of Russia’s aggression on Ukraine, the EU budget was mobilised to provide emergency assistance and support in Ukraine and in the EU countries, and to alleviate the humanitarian consequences of the war.

“Different needs are best when addressed at their appropriate levels. We have all painfully realised that viruses do not stop at borders. Highly communicable diseases can only be tackled at the international level,” said Nathalie Berger, the director for support to member states’ reforms at the European Commission. 

Other key messages at the session revolved around improving efficiencies and stimulating innovation.

Efficiency

Tamás Evetovits, head of Health Systems Financing at the WHO Barcelona Office, stressed the need for efficient use of funds to bolster up the healthcare system. 

He urged member state to restrict their citizens’ out-of-pocket spending on health care to no more than 15%, which would avoid “catastrophic expenditure” by households. 

According to 2019 EU data on unmet health needs, around 3.1% of the EU population aged 16 and above reported that they have unmet medical examination or treatment needs. This number varied from 0.3% of the population in Spain to 17.6% in Estonia. ‘Unmet needs’ health care needs that are not met due to reasons like cost, distance or long waiting list to access the care service. 

Innovation – now and beyond

In pursuit of universal health coverage and access, Europe should not sacrifice the quality and affordability of healthcare services, said Anca Toma, executive director of the European Patients Forum. “Equity is really important and we want to make sure that health system reform is really centred around protecting the most vulnerable.”

While the COVID-19 pandemic tested Europe’s socio-economic safety net and health systems capacity, the war in Ukraine and with that, inflation and the food and energy crisis, have worsened matters. 

“The situation is tight as we know and the money will become tighter,” said Francesca Colombo, the head of the health division of the Organisation for Economic Co-operation and Development (OECD). “There is a question of who will absorb the pressure on price increases. Is it going to be the government? Is it going to be households? Is it going to be providers?” 

Post-pandemic, money is being channelled towards sectors other than health to rebuild. However, Colombo said that “countries need to invest 1.4% of their GDP across the OECD countries in health systems, targeted at things like workforce, information systems, prevention etc.” 

Members of the audience had a few innovative solutions to finance health systems. Ricardo Leite, a Member of Parliament from Portugal said countries could ask fast food companies to fund public health as they “are taking away health from our societies”.

He added that empowering health ministers to be part of the highest decision-making body of governments could also bring in more funds to the system. 

“I don’t know any minister of health that doesn’t say I want to do better…and they are always seen as the person bringing costs to the government,” he added.

Man showing signs of workplace stress
Can flexible working arrangements help to reduce workplace stress?

Practices implemented during the COVID-19 pandemic, such as flexible working arrangements and teleworking, could help to reduce work-related mental health challenges, according to a first-ever set of Guidelines on Mental Health at Work released Wednesday by the World Health Organization (WHO).

The COVID-19 pandemic triggered a 25% increase in what was already a high percentage of people suffering from anxiety and depression worldwide, WHO has previously noted. At the same time, the pandemic accelerated the pace of transformations in the world of work, especially in remote work, e-commerce and automation – and now emerging evidence shows that more access to flexi-time and remote work arrangements have mental health benefits.

Conversely, shift work and excessively long working hours adding up to 55 hours or more a week are associated with depression, increased alcohol risk and even suicidal behaviours, the WHO Guidelines review found.

More broadly,  job insecurity as well as a lack of  “job control” also are related to higher risk of depressive symptoms and risk of suicidal behaviours, while having more authority to make decisions about your job role and performance is “protective for depressive symptoms and higher job control is associated with reduced emotional exhaustion burnout.”  A lack of “organizational justice also is associated with “subthreshhold mental health symptoms”, the WHO review found.

Work and mental health closely intertwined

Pandemic lockdowns also imposed a mental health penalty when they confined to their homes for work and socializing – but now the benefits of more flexible work schedules are being recognized in the new WHO guidelines.

Release of the detailed 135-page guidelines was accompanied by a joint WHO and International Labour Organization appeal for concrete actions to address mental health concerns amongst the working population and provided evidence-based global public health guidance on how to do so in a policy brief.

“Work and mental health are closely intertwined,” WHO and ILO wrote in their joint policy brief. “A safe and healthy working environment supports mental health, and good mental health enables people to work productively. An unsafe or unhealthy working environment can undermine mental health, and poor mental health can interfere with a person’s ability to work if left unsupported.”

“As people spend a large proportion of their lives in work – a safe and healthy working environment is critical. We need to invest to build a culture of prevention around mental health at work, reshape the work environment to stop stigma and social exclusion, and ensure employees with mental health conditions feel protected and supported,” ILO Director-General Guy Ryder said of the new advice.

The World Health Organization's guidelines on mental health at work

The WHO Guidelines, the product of a lengthy and exhaustive global review of evidence, provide guidance in the following areas: organisational interventions, manager and worker training, individual interventions for promoting positive mental health, and prevention of mental health conditions. The guidelines also include a section offering recommendations on returning to work following an absence associated with mental health conditions and how to aid people with mental health conditions to gain employment.

The guidelines meet the standards for evidence-based guidelines, although in most cases there is low or even very-low certainty of evidence given that the recommendations are based on research into highly complex psycho-social risks, as compared to randomized-controlled drug trials.

Leap in depression and anxiety

Even before COVID-19, the world of work was experiencing changes, from technological development, climate change, globalisation, and demographic shifts. The pandemic accelerated these changes and forced companies and organisations to restructure both for financial reasons and to keep workers safe.

For many employees, WHO and ILO noted, these changes created new psychosocial risks or worsened existing ones.

Before the pandemic, in 2019, around 15% of working-age adults lived with a mental disorder, WHO found in its World Mental Health Report, released in June. This included 301 million people who were living with anxiety and 280 million individuals suffering from depression.

COVID led to a 25% increase in anxiety and depression, making the situation more acute. According to the reports, 12 billion working days are lost annually due to depression and anxiety at a total loss to the global economy of $1 trillion, predominantly from lost productivity.

“It’s time to focus on the detrimental effect work can have on our mental health,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “The well-being of the individual is reason enough to act, but poor mental health can also have a debilitating impact on a person’s performance and productivity. These new guidelines can help prevent negative work situations and cultures and offer much-needed mental health protection and support for working people.”

Organisational interventions – flexible work among the many examples

Flexi-work and telework are just a few among the many examples of organisational interventions that employers can take to address psychosocial risks at work, WHO found.  Others involve  involving workers more in decisions about their jobs, and changing workloads and work schedules to enable better work-life balance.

More “participatory” organisational strategies that allow workers to have a say in their own job design, workload changes, or break schedules also have positive mental health benefits – as does better feedback on worker performance.

Additionally, improvements to the physical work environment can have a positive impact, addressing issues such as “inadequate equipment availability… lack of space, poor lighting, excessive noise.”

In all cases, there was evidence of in favour of these practices, WHO found, even if the review also classified that evidence as weak in classical terms – where randomized controlled trials of the kind used for new drugs are typically seen as the gold standard.

“The GDG [Guidelines Development Group] concluded that, despite very low certainty of the available evidence, the likely benefits of organizational interventions on reducing emotional distress and improving work-related outcomes outweighed the possible harms of implementing these interventions,” the recommendations state. “This was supported by evidence for risk factors at work which negatively affect mental health outcomes, indicating that interventions to reduce, remove or mitigate risk factors could improve these outcomes.”

Addressing mental health of people with existing conditions

On a cold winter morning these women from Raipur, India are crowded into the back of a truck on their way to work.

The WHO guidelines also include recommended measures for addressing the mental health of humanitarian and emergency workers, as well as for integrating new or returning workers with mental health conditions into the workforce.

Finally, the guidelines map out recommendations for training both employers and workers in mental health literacy – including  strengthening managers’ skills to recognise and act on mental health conditions at work, and empowering workers to seek support.

In their joint brief, WHO and ILO call for the creation of an environment with “cross-cutting actions to improve mental health at work” through seven factors they said are “critical for progress:” leadership, investment, rights, integration, participation, evidence, and compliance:

  • Leadership involves the development of a mental health plan and assigning roles based on that plan. Investment centers on allocating the financial and human resources towards implementing such plans, as well as including mental health services in any work benefits package.
  • A “‘rights” based approach calls for employers to develop and implement non-discrimination policies around mental health and take the necessary steps, such as training programs, to stop stigmas around mental health in the workplace.
  • Integration means the embedding of mental health into existing occupational safety and health strategies and participation engage workers – especially those who have lived with mental health challenges – in the decision-making process.

Walking the talk at WHO

WHO’s new headquarters in Geneva – touted architecturally for its modern design but with many staff doubling up on desks in the new atrium open-space.

Ironically, prior to the pandemic, WHO itself was the agency with some of the UN’s most restrictive policies on teleworking and flextime – until COVID which forced most of its 8,000+ workforce to abruptly begin working remotely in March 2020 – the resulting efficiencies triggered a re-evaluation of internal policies.

Until today, most the WHO workforce in its Geneva headquarters is still working off-site much or most of the time – as a massive building renovation project coinciding with the pandemic reduced office space and forced workers to double up on desks – unless they are high-level directors.

More recently, a new WHO policy calling for workers to return to the office for at least one day a week may have been met with relief among some staff happy to reconvene with colleagues again, but resistance among others who say that office work policies need to be fine-tuned in light of workers’ individual status and needs.

In particular, WHO’s new building design, chosen after painstaking review, has received complaints among from critics who say that the modern, open-plan offices reduced privacy and net desk space, leaving almost no room for consultants.  Even some of the regular staff have to double up on desks in a windowless “atrium” area, taking everything home at night.  More private office spaces, featuring windows, run along the sides of the new building, but these are largely taken up by higher-level officials.

WHO’s “atrium offices” in the new building headquarters – windowless cubicles crowded together.

Observed one senior WHO staff member who asked not to be named: “I think that days in the office should be decided upon based on the benefit that can be derived from going to the office relative to the risks/disadvantages.

“For instance, effects on work-life balance would be negative for me, since I would have to waste between 1 hour and around 2 hours of my day on commuting.

“Additionally, some 95% of my work is with people outside Geneva, not to mention that I have a great teleworking set up at home – whereas in the office I have a small desk area with ‘blinders on three sides’ in a hallway (which they euphemistically call ‘atrium’) that I would have to clear every evening since it will be used by somebody else on another day. This is not what I consider a productivity environment.”

Asked for comment, Aiysha Malik, WHO’s lead coordinator of the new guidelines from the Department of Mental Health and Substance Use said: “These first ever guidelines from WHO …mean that employers, and the people responsible for the health and wellbeing of workers, can now be assured in what works for mental health. Like all organizations, WHO will review the recommendations and ensure that this guidance forms part of its way of working.”

–Elaine Ruth Fletcher contributed to this report.

Image Credits: Ciphr Connect, Neil Moralee/flickr , World Health Organization, Prem Kumar Marni/Flickr, Geneve Internationale/WHO and BBK Architekten, Health Policy Watch .

WHO Europe Director Dr Hans Kluge pitches his “moonshot”.

European finance ministers need to recognise that the “permacrisis” of the pandemic, climate change and the war in Ukraine pose as big a danger as a nuclear threat, and double their investment in the health workforce, according to World Health Organization (WHO) Europe director Dr Hans Kluge.

This, added Kluge, was his “moonshot” for a truly European health union – the theme of the European Health Forum in Gastein that he was addressing on Tuesday.

“According to some reports, nine out of 10 nurses would like to quit their job, 80% of the nurses had psychological distress, and 40% of the medical doctors in our region are close to retirement age,” Kluge told the forum.

In addition, health workers were migrating from poorer countries to in the east to the wealthier west.

“We have medical deserts, where you have rural areas where you don’t find any doctors or nurses, and this is a big challenge,” said Kluge.

Resilience and stronger health systems

Stella Kyriakides, the European Commissioner for Health and Food Safety

Stella Kyriakides, the European Commissioner for Health and Food Safety, said that both the COVID-19 pandemic and the war in Ukraine had shown the region that it needed to focus on “resilience and stronger health systems”.

“EU Member States and other countries are supporting Ukraine with emergency assistance to a level that I believe we haven’t seen before. We’re delivering medicines, personal protective equipment, ambulances, food and shelter,” said Kyriakides, adding the EU had also set up a medical evacuation system that had enabled 1,300 patients to get special treatment outside of Ukraine.

“Wars have huge consequences at all levels and so much human suffering. But we are, as an EU, in there for the long haul to support Ukraine, and we need to be prepared for more difficult autumn and winter months,” said Kyriakides.  “We must never forget the backbone of health systems which is a health workforce.”

The European Commission’s Nathalie Berger, who is Director for Support to Member States’ Reforms, said that 17 member states were being supported to reduce their dependence on Russian fossil fuels and identify and develop renewable energy sources. 

Getting through winter

Daniels Pavluts, Minister for Health in Latvia

Government ministers from Austria and Latvia were simply and immediately focused on regional co-operation to survive the winter without gas from Russia.

Latvian Health Miniser Daniels Pavluts, outlined his two priorities: to help Ukraine win the war and second, to get through the winter. 

Latvia, Estonia and Lithuania have been “among the leading countries providing bilateral help to Ukraine”, said Pavluts, adding that his country had provided treatment and rehabilitation for Ukrainian soldiers and other victims of hostilities, and taken in about 40,000 refugees. 

“We have shared borders with Belarus and Russia and we can easily imagine ourselves being in the place of Ukraine. It is our duty to help Ukraine win this war,” said Pavluts.

Latvian health officials were travelling to Ukraine, to learn “how they operate in these conditions of war” and also how to prepare for nuclear threats, he added.

Breaking dependence on fossil fuels

Leonore Gewessler, Austria’s Minister for Climate Action, Environment and Energy,

Leonore Gewessler, Austria’s Minister for Climate Action, Environment, Energy, Mobility, Innovation and Technology, said that the multiple crises had made government officials break out of their silos.

“You have a minister of health on this panel who speaks as much about war and foreign policy as health. And you now a minister of climate action and energy who speaks as much on social effects of climate policy and health effects of the climate crisis,” said Gewessler.

She was particularly challenged by “the war in Ukraine, and its effects it has both in Ukraine and on Europe’s insecurity of energy supply and the social aspects of the price hikes that we see”.

She was also trying to help people affected by the climate crisis, including “young people who are becoming increasingly anxious about a very existential threat to their well-being”.

“The root of the problem is our dependency on fossil fuels, especially our dependency on Russian fossil fuels,” she added.

In the short-term, “I will need every kilowatt hour that I can get to make sure that I can heat homes as Vladimir Putin does  now uses gas supply as a weapon”, she said.

“In the long term, the only solution is to go renewable and as independent as we can to produce as much of our energy ourselves as much as we can. And this means from every way ,we get rid of our dependency on fossil fuels – solar panel by solar panel, by heat pumps, windmill to windmill.”