Dr Patrick Amoth, Chair of the Executive Board,

As the 150th Executive Board Meeting of the WHO closed Saturday, attention focused on the inability of the WHO governing board to reach consensus on critical issues that it had debated – including a more sustainable financing framework as well as a clear way forward on a proposed new pandemic legal accord, reforms of global pandemic response and related WHO emergency operations. 

Despite six days of hours-long discussions, EB agreement to increase WHO member states´  assessed contributions to 50% of the budget by 2028-29, remained elusive. Nor could EB members even agree on a way forward for changing the format for voluntary contributions – using newer, and more innovative fundraising models, such as the ¨replenishment drives¨ that have made other non-profit global health organizations like Gavi and The Global Fund even more financially robust than WHO. 

Decision to extend mandate of Sustainable Finance working group keeps hopes alive

WHO Director General Dr Tedros Adhanom Ghebreyesus on Saturday, the closing day of the EB´s 150th session

In his closing remarks, Dr Tedros Adhanom Ghebreyesus, Director-General of the WHO, noted that while a conclusion on funding for WHO, which is a crucial issue, could not be reached at the meeting, the decision to extend the mandate of the working group on sustainable financing until the World Health Assembly demonstrated optimism.

“I sincerely hope that by working together, we can make substantive progress on this issue,” the DG said.

In advance of this year’s World Health Assembly, Tedros said that the WHO Secretariat also will further develop proposals, in consultation with Member States, on strengthening the global health architecture for emergency preparedness, response and resilience.

“In doing so, we will take into consideration the preliminary findings of the Working Group on strengthening WHO Preparedness and Response to Health Emergencies, and recommendations of recent review panels and committees,” he said.

However, that Working Group, as well, failed to reach agreement on key reforms, such as bolstering WHO´s mandate to make visits early on to sites of suspected pathogen outbreaks. 

Long, unwieldy agenda proves frustrating  

Dr Clemens Martin Auer, Austria´s EB representative and vice-chair

Before officially declaring the meeting closed, Dr Patrick Amoth, Chair of the Executive Board, also stressed the need for discussions on how to improve the efficiency of WHO’s Executive Board meetings, and other member state fora, in order to ensure that member states can help WHO to perform more effectively.

In all, the board reviewed over 55 agenda items and sub items.  That, Amoth admitted, was ambitious, given the number of days available.

“This resulted in longer sessions than we anticipated,” the chair added. 

While he also described the sessions as ´rich and engaging´ other member states were more blunt about the fruits of hours, upon hours of rhetorical statements by member states  – which obscured real debate and discussions about key decision points.  

EB Vice Chair, Dr Clemens Martin Auer, Austria´s Special Envoy for Health, said that the Executive Board´s inability to come to any real conclusions not only harms WHO´s ability to perform, but leaves it in a ¨critical¨ situation.

“We have reached the situation where we still don’t act accordingly to what we are supposed to do. We are still not living up to what we have to do, colleagues. We have to be aware that we haven’t concluded on anything and that we are leaving this organization in a critical situation,” he said.

Auer warned that failure of governance, not by the WHO Secretariat, but by member states failing to get their act together on how to implement better governance — could make the organization progressively less relevant – and create a vacuum into which other global actors such as the G-20 would step.

“We are contributing to further fragmentation when it comes to global health issues and also emergency issues and we pay the price of non-inclusivity and that’s a high price. Don’t talk, act. Don’t say, show. Don’t promise proof,” Auer told member states.

Hours and hours talking 

Last June, a G-20 High Level Panel proposed the creation of a ¨Global Health Threats Board¨ including health and finance representatives of the world´s major economies, working in conjuction with the WHO and another proposed body, a Global Health Threats Council, that would be overseen by the UN Secretary General´s office. 

During the EB, a US State Department spokesperson said that President Joe Biden wants to support the creation of such a new financing mechanism, housed at the World Bank, to ensure a reliable source of investments for helping countries increase their own global health emergency preparedness – rather than remaining so dependent on donor aid. 

The US and other supporters have stressed that such initiatives should not detract from the central role of WHO´s global health support to countries and emergency response. 

And indeed, as if to underline the central role the WHO will continue to play, US Secretary of State Anthony Blinken also announced an additional $280 million more in fuding to the agency in late December.  

If that funding were to be added to the $ 365 million annually Washington provided last year, it might even put the US ahead of Germany once again as the WHO´s top donor for 2022. That, despite a statement by WHO Director General Tedros, on the opening day of last week´s EB session, to the effect that Germany is now WHO´s biggest donor. 

Greater efficiences a challenge both inside WHO and within its governing board

But money aside, the struggle for greater efficiencies remains a challenge – both inside WHO and among the member states’ own governing board. 

Dr Ahmed Mohammed Al Saidi, Oman’s Minister of Health corroborated Auer´s call on the board members to actively seek more efficient ways of doing things in order to achieve desired results.

“We need to find a more efficient way of doing things and implementing them. We spent hours and hours talking, but let’s find a way where we can do things more efficiently. It can be by limiting the interventions and making it easier for the Executive Board members via retreats during which we have free time to talk about issues that matter to health care, not in our countries, but worldwide,” he concluded.

Other EB members also complained that even certain tactical procedures, such as the bundling together of numerous reports, action plans, and updates into the same EB document, made it more difficult to wade through the various background documents.

In an age in which written presentations to busy executive boards typically rely heavily on indexing, infographics, bullet points, graphics and other visual aids, EB documents continue to be drafted like the text-heavy academic theses of the mid-20th century style –  which makes it almost impossible to quickly read and seize key messages, issues of debate, decision and action points.

Similarly, EB member state statements remain heavy on rhetorical flourish – but lacking slides, visuals or even, in many cases, a written text, to support better understanding.

The old-fashioned, and very indirect, style of the deliberations certainly also serves certain diplomatic goals – allowing countries to voice criticism in nuanced, coded language that is inscrutable for most outsiders, preserves decorum and avoids out-and-out conflict.

Still, the formulas of presentation are often as obscure as the countries´ commentaries on them.

Notably, some items, such as the NCD agenda, covered over a dozen different issues, from healthy foods to mental health, wrapped up into one long run-on document followed by annexes – with nary even a table of contents.

As the US EB representative Loyce Pace observed at one point such bundling together of so many action plans and statements into one document, made it all the more difficult for EB members to weed through, and consider all of the important issues being raised. 

National health systems are needed in tackling global health threats.

As the world enters the third year of the COVID-19 pandemic, an increasing number of important efforts are underway to strengthen global health security.  However, it is vital that, while strengthening our global health architecture, we do not lose sight of the fundamental role played by national level health systems in tackling global health threats.

Throughout this and previous pandemics, the strength of countries’ national health systems has been a critical success factor against pathogens. For example, even many countries with well-organised, well-financed and well-staffed health systems suffered throughout COVID-19. Viewed through these lenses, global health security may exist only as the sum total of the performance of all national health systems of all countries, rather than as a standalone and separate entity.

Since the onset of the pandemic, we have seen a plethora of new institutions and new ideas for improving global health governance. These include the Access to COVID-19 Tools (ACT) Accelerator and the COVAX Facility in April 2020, the Independent Panel on Pandemic Preparedness and Response proposal in May 2021 for a Global Health Threats Council and the World Health Assembly (WHA) agreement in December 2021 to proceed with the negotiation and drafting of a new international instrument to strengthen pandemic prevention, preparedness and response.

It is hoped that these new international institutions and platforms will support better pandemic governance and financing at the global level. However, although a strong global focus is essential for ensuring equitable distribution of those goods that are necessary for fighting COVID-19 and future pandemics, national efforts must be equally prioritised. 

In other words, global leaders must resist two great temptations: the desire to build new institutions instead of strengthening existing ones such as the WHO and the International Health Regulations, and the tendency to ‘securitize’ health at the global level instead of implementing strong public health measures at the national level.

Three functions to achieve resilient health systems

global health security
One interlocking function needed is resilient healthcare systems.

Global health security demands strong and resilient health systems that can prevent, detect and respond to infectious disease threats, wherever they occur in the world.  Therefore, we propose a new understanding that approaches this goal through the lens of three interlocking functions at the national level. 

The first key function is building resilient national healthcare systems. It is critical that they have built-in surge capacity (including for primary healthcare) to manage patients who have been infected and require care, while at the same time continuing and sustaining routine health services for those who have not been affected.  In addition to deaths from infection during the COVID-19 pandemic, there have been an excess of deaths of non-infected persons over what would be expected, likely due to the fact that they were not able to access routine health care, especially that which required frequent attention.  The same occurred in West Africa during outbreaks of Ebola in 2014 – health facilities could not accommodate most of the patients with Ebola infection resulting in a high level of death from Ebola virus diseases, and also, the number of deaths from children who could not get care for malaria and other childhood diseases because of the lack of resilience in the health system was documented as being higher than the number of deaths from Ebola virus disease.   

The second key function is developing strong core public health capacities that meet the WHO’s International Health Regulations. Countries with early detection surveillance systems that identified outbreaks rapidly at the start of the pandemic, and those that had strong response mechanisms including outbreak responses – especially Singapore, Japan, and South Korea – showed the importance of strong public health core capacities to manage pandemics.  And rather than using blunt lockdowns of the entire economies, they were able to save lives by outbreak investigation, identification of sources of infection and then shutting them down with precision, rather than blunt lockdowns.    

Thirdly, countries need to invest in broader supportive environments that enable the health and wellbeing of their populations. Infection with SAR CoV2, as with many other viral and bacterial infections, resulted in more serious illness and death among the elderly and those with comorbidities such as diabetes, cardiac disease and obesity.  By using smart regulations and other healthy-lifestyle-enabling measures, governments can ensure populations are healthier and more resistant to serious illness after infection, decreasing morbidity and mortality in an outbreak and/or pandemic. Healthy populations also require adequate health financing, strong health literacy and health-seeking behaviours, and improving the social determinants of health, like education, housing and working conditions.

Synergistic approach as opposed to mutually exclusive strategies

This synergistic approach to universal health coverage, health security, and health promotion is necessary to prepare for future pandemics. Currently, many countries seem to assume that public health, universal health coverage and creating the enabling environment for healthy populations are mutually exclusive strategies.  This can be due to limited resources and/or donor funding pushing governments towards “false choices”. 

Such false distinctions are further enhanced by the “global nature” of global health security with accountability towards the international community, contrasted with the domestic nature of universal health coverage and health promotion, with accountability towards local voters, taxpayers and citizens. 

A strategy focused on the three interlocking functions provides countries with a middle way – an integrated approach that equally prioritises national and global health security. Each of the functions has a strong conceptual framework and large body of evidence to support its positive impact on global health security.  Each is closely aligned with well-established and highly-visible health frameworks. 

 It will take political and health leaders with courage, vision and ambition to rethink some of the many vertical (albeit well-meaning) global implementation and funding streams to ensure that they serve to strengthen these three functions and not bypass or weaken them. They will need understanding and support from the global health community.

If implemented correctly, the three interlocking functions would be mutually synergistic, with progress in one function accelerating or enhancing progress in another. Taken together, they represent a more balanced approach to global health security and reduce the risk of over-globalizing, over-engineering or over-securitizing health. By better linking these three functions within WHO, and within its guidelines for epidemic and pandemic preparedness, WHO technical support to countries could provide better preparedness and response capacity for the next major outbreak or pandemic.

Biographies

Professor David Heymann is professor of infectious disease epidemiology, London School of Hygiene & Tropical Medicine.

Professor Ilona Kickbusch is the Founder of the Global Health Centre at the Graduate Institute in Geneva.

Chikwe Ihekweazu is the WHO assistant Director General of health emergency intelligence, the former Director General of the Nigeria Centre for Disease Control (NCDC) and was previously the Acting Director of the West Africa Regional Centre for Disease Control.

Doctor Swee Kheng Khor is a physician specializing in health systems & policies and global health, focusing on south-east Asia.

 

 

Image Credits: Nigeria Centre for Disease Control , Flickr: Maxim Malov/CDC.

17 January 2019 – Beni, North Kivu region, Democratic Republic of Congo.
Families go the Ebola Treatment Center to visit a family member who is held in quarantine in the centre.

WHO needs to reform lines of authority and responsibility across all aspects of its emergencies response operations in order to effectively prevent, report, and take measures against sexual exploitation and harrassment.  

Those were the highlights of a final report by an Independent Oversight Advisory Committee (IOAC) of the WHO Health Emergencies Programme, examining the claims of sexual exploitation and harrassment that first emerged in connection with WHO’s 2018-2020 Ebola response in the Democratic Republic of Congo. 

The report, presented in a Friday afternoon session of the WHO Executive Board, marked another milestone in the follow-up to reports of sexual exploitation and abuse claims by some 75 Congolese women against 25 WHO workers deployed to the Democratic Republic of Congo’s 2018-2020 Ebola response – which was first reported by the New Humanitarian in 2020. 

Following the reports, WHO initiated an independent investigation, as well as initial internal reforms to improve staff training in the prevention of sexual exploitation and harrassment (PRSEH); deployment of more training staff; and new recruitment standards that also consider any exploitation and abuse issues in a candidate’s background, the IOAC report states.

But there remains “ deep, lingering frustration expressed by Member States and staff about the lack of transparency, delays in responding to incidents and holding perpetrators accountable, and the defensiveness with which the Organization has dealt with SEAH in the past,” states the report, presented to the EB. 

response to drc claims
Felicity Harvey, co-chair IOAC

And more comprehensive cultural and structural changes need to occur across WHO to reduce the risks of abuse from ever occurring in the first place, said Felicity Harvey, co-chair of the IOAC committee, in her presentation of the report to the WHO Executive Board on Friday. 

“The second edition of The WHO Emergency Response framework should be further revised to provide greater clarity on the accountabilities and lines of authority across offices, regional offices and headquarters with explicit roles and responsibilities given to each player and updated procedures for all hazards emergency risk management,” she said. 

The IOAC report outlines five priority areas where more action is needed. Those include: 

  • Clarifying the lines of responsibility and delegation of authority across the three levels of the organization; Strengthening the accountability framework for emergency response and other field teams; 
  • Reform the organization’s PRSEH management structure, and accelerate  organizational capacity to implement a “victim survivor-centered” approach to PRSEH; 
  • Financial investment in PRSEH programmes as an essential WHO function – and particularly in field operations, where WHO is currently responding to some 80 emergencies around the world; 
  • Periodic assessments of PRSEH in acute emergency response settings, including a mapping of community and local resources; identification of trusted local partners for PRSEH incident management; ensuring that field operations include a balance of  experienced male and female personnel. 
  • Building a culture of equity, diversity and transparency 

“WHO needs to promote or advocate for institutionalized culture change to strengthen PRSEH,  including greater gender and racial diversity, improved performance management, and a renewed commitment to WHO values – to build a culture of equity, diversity and transparency,” said Harvey, a former director-general of international health in the United Kingdom Department of Health.  

DG Proposal – separate line of investigation for sex abuse complaints

WHO Director General Dr Tedros Adhanom Ghebreyesus

Responding to the IOAC report, WHO Director General Dr Tedros Adhanom Ghebreyesus noted that WHO has recently engaged an external investigator to follow up on further on the abuse allegations – and their perpetrators.

“This is the first time a UN Organization has installed an independent investigation, opening up to an external investigator,” he noted.  

“One of the things that our member states emphasized is transparency; we are doing that, and we will continue to do more. We will continue to build on this, because more should be done,” Tedros said. 

Tedros also asked the EB to approve a draft decision that would create a separate line of authority to the investigator heading up the Organization’s investigations of sexual exploitation and abuse allegations – and reporting directly to the Director General.  

All sexual exploitation and abuse allegations would thus be treated separately from other WHO internal justice investigations, at least temporarily, according to the draft WHO proposal. 

The WHO DG also noted that in the last two weeks, the Organization had received three new complaints of alleged sexual harrassment and exploitation from the Central African Republic, DR Brazzavile, and the Democratic Republic of Congo (DRC) – the latter where Tedros also said that WHO was creating a model for rehabilitation and support to victims, helping them access livelihoods as well as other means of support. 

“We support zero tolerance and we will do everything to build a better culture,” he said. 

The DG’s proposal to create a separate chain of authority for sexual exploitation and harrassment cases churned up some initial resistance among some EB members – who said that it should have been discussed even before the EB convened, at a meeting of member states’ Planning and Budget Advisory Committee (PBAC).  

Harvey, however, said that the IOAC would “strongly endorse the decision to keep the PRSEH Investigation Unit separate from general investigations,” att least for the moment until progress has been made on the investigations still ongoing in the DR Congo and elsewhere.  

The EB members deferred debate on the draft WHO decision until Saturday morning.

Country responses commend WHO and emphasize survivor-centered approach and ‘zero tolerance’ policy

WHO Representative of France

Representatives across Member States otherwise commended the WHO for its efforts towards prevention of sexual exploitation, abuse, and harrassment, with some emphasing the need to adopt a survivor-centered approach in responding to the allegations. 

“It is important that we create an environment conducive to effectively preventing sexual exploitation and abuse, and that means asking ourselves hard questions about responsibility,” said Tunisia, on behalf of the WHO Eastern Meditterean Region. 

Tunisia, and many other Member States noted that a zero tolerance policy is needed, and proposed that a common UN database be created. The database would be consulted before staff recruitment, ensuring that the necessary checks can be made. 

“We need to do this, making effective and efficient use of the resources we have available on gender equality.”

France, on behalf of the European Union, echoed these sentiments, and also reiterated the need for “accountable culture within the organization.”

“We think it is better to have people providing the information because peace is being swept under the carpet.”

Concern and clarification needed on transparency and accountability 

Bathsheba Nell Crocker, US Ambassador to the United Nations

However, some representatives continued to express their concern regarding the WHO’s work on sexual exploitation and abuse, including China and the United States. 

China noted the need for clarification from the WHO on the interim report and “transparency and accountability of the related work.”

“We hope that WHO will further clarify on how it will communicate on concrete action taken both within and outside of the organization.” 

The US representative, Bathsheba Nell Crocker, acknowledged the recent progress of the WHO, but added that “broader organization reforms are needed, as well as the dedicated effort now required to translate division laid out for WHO’s work in this area into concrete results on the ground.”

She also pointed out that WHO’s efforts to increase awareness, conduct training, and fill capacity are “essential but insufficient.” 

“[There is] absence of investment in evidence-driven survivor centered prevention, risk mitigation, and response protocols.”  

Crocker noted that WHO must encourage prompt reporting and delivery of survivor centered services. 

“Organizational change starts at the top with leadership. We call on WHO to ensure that roles and expectations are clear and to enforce whistleblower protections.”

Image Credits: Flickr: World Bank / Vincent Tremeau, WHO EB 150.

lassa fever
Nigeria has set up an emergency response centre to deal with outbreaks of the deadly Lassa fever in parts of the country.

Following reports of an unusually large number of cases in January 2022 across some 12 states, Nigeria is stepping up its surveillance of Lassa fever, the deadly viral hemorrhagic illness transmitted by infected rodents, or through other infected people or tainted food. 

This year marks the fourth year in a row in which large outbreaks of the  disease are being reported by Africa’s most populous state..   

According to the Nigeria Center for Disease Control (NCDC), there have been a total of 759 suspected cases, 170 confirmed cases and 32 confirmed deaths in January – following the emergence of the first cluster of new LF cases in December.

In a worrisome trend,  January’s cases were reported from 37 local government areas (LGAs) spread across 12 states. 

That is about twice the number of LGAs and states where cases of Lassa fever were reported within the same period in 2021 (17 and 6 respectively).

While the number of cases and states so far affected by the 2022 Lassa fever outbreak are higher, the case fatality rate of 18.8% remains lower than that of the  2021 outbreak where one out of four confirmed cases resulted in death (CFR — 25%).

Notably, is also about 16 times higher than the CFR for COVID-19 in Nigeria (1.2%), Nigerian health authorities underline.

Although cases have been reported from 12 states, three states (Edo, Ondo and Bauchi) are the epicenters for the outbreak, accounting for 74% of all confirmed cases.

Expanding range nationally and global health threats

This year mark’s the fourth in a row when large clusters of cases have been reported in Nigeria, “raising concerns about an ongoing, systematic emergence of LF nationally,” according to a recent Nature Communications review of the disease’s gradual expansion country-wide.

In 2019, there were 833 confirmed cases of Lassa fever in Nigeria with 174 deaths (CFR — 20.9%). In 2020, Nigeria recorded a total of 1181 confirmed cases of Lassa fever and 244 deaths (a CFR of 20.7%) but the following year (2021), the number of confirmed cases reduced to 510 with 102 deaths among confirmed cases (CFR - 20%). 

In addition to the national and regional risks, Lassa Fever is a “WHO-listed priority pathogen and a major focus of international vaccine development funding3 and, although often framed as a global health threat.”

Lassa fever is an acute viral illness and a viral haemorrhagic fever that is associated with high morbidity and mortality, and it thus has both economic and health security consequences.

Some cases, however, can be mild and thus go undetected or be confused with other common febrile conditions, like malaria - underlining the need for surveillance and vigilance to stop its spread. 

First reported in Nigeria’s state of Borno in 1969 when two missionary nurses died from an unusual febrile illness, Lassa fever cases and outbreaks continue to be reported in Nigeria and the diseases is increasingly recognised to be endemic in many parts of West Africa, including Nigeria, Benin, Ghana, Mali and the Mano River region (Sierra Leone, Liberia and Guinea).

The disease has typically been characterised as having two main endemic foci in West Africa, one centered around Sierra Leone and Liberia, and the other in Nigeria, but in recent years, Nigeria, in particular, has continued to record a trend of increasing numbers of cases - although most countries in the region have reported regular or sporadic cases, researchers report.


Response measures

In a statement this week, NCDC said it has activated the country’s national multi-sectoral and multi-disciplinary Lassa fever Emergency Operations Centre (EOC) in response to the Lassa fever outbreak in some parts of the country. 

“This became necessary given the increase in the number of confirmed Lassa fever cases across the country and a joint risk assessment with partners and sister agencies,” the center said in the statement.

It described the reports in weeks 1 and 2 as the highest number of confirmed cases recorded in Nigeria in the last four years for the same period. It however reassured Nigerians of its preparedness which hinged on the center’s experience in responding to Lassa fever outbreaks. 

“Since 2016, NCDC has worked hard to improve diagnostic capacity for the disease. Currently, seven laboratories can conduct confirmatory tests for Lassa fever in Nigeria and are coordinated by the NCDC National Reference Laboratory (NRL). This has improved active case detection for the disease,” NCDC stated. 

In the same vein, care for affected individuals has improved. NCDC said it is providing support to states including the provision of emergency medical and laboratory supplies as well as oral and intravenous Ribavirin for preventive and curative treatment to treatment centres across the country. 

“In addition, Nigeria through NCDC is participating in the largest-ever Lassa fever study that aims to provide an accurate assessment of the incidence of the disease in West Africa. This will also accelerate the development of vaccines and therapeutics for Lassa fever,” NCDC added.

It has also commenced training for healthcare workers in Nigeria’s tertiary health institutions on Lassa fever case management and infection prevention control.

Risk factors for exposure 

Contact with the rodent Mastomys natalensis is thought to be the reason for Lassa fever.

According to a research report published in Nature Communications in October, 2021, the significant majority of observed LF cases—including those from recent years in Nigeria—are thought to arise directly from contact with the rodent rodent Mastomys natalensis, the main viral reservoir host and a common agricultural pest. Other cases have occured, however, via hospital-acquired infections and potentially, in other small clusters of human-to-human transmission.

Risk factors for spillover of the virus, while not well understood, are thought to include factors that increase direct and indirect contact between rodents and people through poor food storage and housing quality, as well as certain crop processing practices.

Correlations between human case surges and seasonal rainfall patterns “suggests that LF is a climate-sensitive disease whose incidence may be increasing with regional climatic change,” according to the Nature Communications study, led by David Redding of University College London and and Chikwe Ihekweazu, of the Nigerian Centre for Disease Control (NCDC). 

Image Credits: Channel Africa/Twitter, Sahara Reporters/Nigeria.

Neglected Tropical Diseases remain stagnant in their funding

Despite the strains of COVID-19, global funding for poverty-related infectious diseases, such as HIV/AIDS, TB, and malaria, remains virtually unchanged at US $3.937 billion, with investment dropping only 4% in 2020, according to the fourteenth annual G-FINDER Report.

The report, released by Australia-based Policy Cures Research group on Thursday, showed a drop of only US $172 million from 2019. This year’s funding remains the third highest ever seen by the group for neglected diseases. 

Funding for neglected diseases declined only 4% in 2020

But though the decline may be a marginal one, funding for neglected tropical diseases (NTDs) continued a decade of relative stagnation, with only snakebite envenoming seeing an increased investment in 2020. 

Resilient funding may be impacted by COVID-19 in the future 

Nick Chapman, CEO of Policy Cures Research

The G-FINDER report is a comprehensive analysis of global investment of R&D for poverty-related neglected diseases. It is widely used by national governments, industry, civil society, and the World Health Organization to identify gaps in progress and areas where investments would be needed.

Reactions to the report were cautiously optimistic regarding the sustained investment in global R&D, with concerns that COVID-19 still could shift the direction of funding. 

“These figures are reassuring for the neglected disease research and development community as they indicate continued commitment to advancing health innovations for some of the world’s most vulnerable populations,” said Nick Chapman, CEO of Policy Cures Research.

“However, we can’t assume that resilient funding in the first year of the pandemic means that we are safe from impacts on funding in the future.”

Paul Barnsley, senior analyst at Policy Cures Research, also expressed his concerns during the Thursday launch event of the report. 

“We’re still worried that a focus on COVID might capture some of the attention and resources of traditional funders, and that the cost of stimulus during the pandemic will lead to future reductions in overall government spending flowing through to neglected disease R&D,” he said. 

Funding for top three infectious diseases declines 

The top three infectious diseases – HIV/AIDS, tuberculosis, and malaria – received the largest shares of funding, as they have every year, accounting for more than two-thirds of reported global investment. 

However, funding for all three of these diseases fell in 2020, taking their share of global funding to 68% to the usual annual average of 75%. 

In the case of HIV/AIDS, the vast majority of the decline was attributed to decreased investment from the US National Institutes of Health (NIH), the Gates Foundation, and industry. 

Tuberculosis also experienced a decrease in funding from the NIH, but recond-high funding from the European Commission, a result of new funding for the European Regimen Accelerator for Tuberculosis, an initiative dedicated to new treatments for TB. 

Disruptions in clinical trials due to pandemic 

While investments in neglected disease R&D stayed near their historic highs, despite the turbulent first year of the COVID-19 pandemic, the pandemic hindered product developers’ ability to conduct clinical trials in 2020. 

Barnsley anticipates these disruptions to have continued into 2021. 

In line with this trend, multinational pharmaceutical companies’ (MNC) investments in clinical development decreased for the second consecutive year in 2020. 

The previous G-FINDER report attributed this to normal fluctuations and the conclusion of late-stage trials in treatments. However, the report does warn that “another year of decreases in MNC funding could signal a trend.”

“Although the 2020 decline is most likely due to pandemic-disrupted trials, it could indicate that half a decade of soaring MNC funding is coming to an end.”  

Philanthropic funding increases

funding
Philanthropies such as Wellcome Trust and Open Philanthropy have increased their infectious disease R&D

Contributions from public and private sectors both dropped slightly in 2020 but funding from philanthropies saw record high levels of funding, an increase of US $28 million over the previous year.

Both established and new philanthropies such as Wellcome Trust and Open Philanthropy, were the primary reason for this new increase, with Open Philanthropy nearly tripling its funding for neglected disease R&D between 2017 and 2020. 

Increased investment in platform technologies 

Funding for platform technologies continues to increase

A key reason that overall funding to infectious diseases remained relatively stable, despite cuts to clinical development, was the US $33 million increase in total funding in platform technologies.

The Bill and Melinda Gates Foundation was the largest funder of platform technologies, providing 40% of investment, followed by US government agencies, the US NIH and the US Department of defense. 

Though the increase predates the pandemic, a number of grants for platform technologies in fact cite COVID-19 as the reason for accelerated interest. 

“In light of that, we predict that the already hastened pace of investment in platform technologies we saw in 2019 and 2020 will continue in the neglected disease R&D space, at least in the immediate years to come,” said Chapman. 

Funding cannot rely on ‘coattails of the pandemic’ 

Though the response to COVID-19 has demonstrated the potential for new funding mechanisms, strategies, and technologies, the report does note that this is a “stark reminder that neglected diseases persist because of insufficient funding and momentum”. 

“The next challenge for global health stakeholders will be to ensure that neglected diseases benefit from opportunities and innovations that have emerged from the pandemic.” 

Barnsley pointed out how it “may be tempting to ride on the coattails of the pandemic” in order to increase investment, and instead addressed the need to craft a message of genuine self-interest in eliminating neglected diseases. 

“We need to be able to defend neglected disease funding during periods of austerity.”

Image Credits: Policy Cures Research, Policy Cures Research.

Botswana’s representative, Dr Edwin Dikolo, at the WHO Executive Board Thursday – fighting COVID has pushed aside the battle against NCDs in Africa and beyond.

In a long and winding discussion Thursday at The World Health Organization’s Executive Board, low- and middle-income countries (LMICs) pledged to redouble their efforts against noncommunicable diseases (NCDs), such as diabetes and obesity, which are having increasing impacts on health and well-being – in addition to infectious diseases that have been at the forefront of health sector efforts for most of the past half century. 

Some 70% of premature deaths worldwide are now due to NCDs.  And two-thirds of deaths annually in low- and middle-income countries are NCD-related, according to the NCD Alliance. 

Risks of dying young from cancer, diabetes, a heart attack or another chronic diseases are higher in most developing countries, because health systems still don’t offer basic primary prevention measures like cervical cancer screening, diabetes diagnosis or insulin treatment – not to mention more costly and high-tech treatments for conditions like cancer.  

The Thursday session focused on action plans to implement a 2018 political declaration of UN General Assembly on the prevention and control of noncommunicable diseases (NCDs), a cross section of African countries noted that the ongoing COVID-19 pandemic has made it even more difficult for them to combat both diseases and other NCDs.

Among the NCD risk factors, obesity stands as one of the largest – and growing risks. Worldwide obesity has tripled since 2021 and more than 1.9 billion people over the age of 18 are obese today, according to WHO.

Africa – COVID pandemic has sapped resources from NCD prevention and treatment

As with other NCDs, death rates from obesity in parts of Africa, the Middle East and South-East Asia are among the highest in the world – even though there are just as many or more obese adults, per capita, in the United States and other parts of the Americas. That is just one more example of the lack of preventive and other treatment services in LMICs.

Dr Edwin Dikolo from Botswana, speaking on behalf of the African region, noted that resources and manpower that could have been channeled toward tackling the diseases have been repurposed for the COVID-19 pandemic response in member states. 

According to him, there is the need for investments in LMICs to facilitate the emergence and availability of context-specific medical devices and technologies that are more attuned to countries’ health systems capacity and disease responses.

The region also asked for international and regional collaboration, and support for research and measures to promote more transparency in the licensing of Intellectual Property rights. 

“Another demand is improved access to WHO’s pre-qualification list, and support for member states in improving access and affordability of medicines for NCDs,” the statement concluded.

Last October, WHO’s Essential Medicines List (EML) Expert Committee recommended that the Agency establish a pricing committee, as an adjunct team to provide “advice to WHO on policies and actions to make highly priced essential medicines more affordable and accessible” – incorporating pricing issues more directly into the WHO review and recommendations on new “essential medicines.”

But WHO’s senior leadership has been foot dragging on making such a formal recommendation, civil society sources in Geneva have suggested.  

Kenya’s representative, meanwhile, noted that while there are commendable regional efforts to improve access to diabetes care at the primary health care level, and many countries in the region, including Kenya, have integrated diabetes into the universal health coverage packages, diabetes services remain unequitable. 

“Insulin and associated interventions required in the management of diabetes remain unaffordable in many low and middle income countries and out-of-reach for many patients,” the representative from Kenya stated.

Kenya’s representative speaking at the WHO Executive Board in Geneva, Thursday.

Addressing obesity

Mother and son in Usolanga, Tanzania. Childhood fat is traditionally seen as a sign of abundance, but it can lead to adult obesity, and related diseases later in life.

According to the WHO, a major risk factor for diabetes is obesity. Moreover, obesity is believed to account for 80-85% of the risk of developing type 2 diabetes, while obese people are up to 80 times more likely to develop type 2 diabetes than those with a body mass index (BMI) of less than 22.  People with a BMI greater than 25 are considered overweight, according to WHO.  Childhood obseity is another growing problem, increasing risks of chronic disease later in life. 

A WHO target set in 2016 called for halting the global increase in obesity in children, adolescents and adults altogether by 2025 .

But countries are far off course in reaching that goal.  As things stand now, one in five adults worldwide will be obese by 2025, with LMICs experiencing the greatest obesity surges, according to the World Obesity Federation.

As a result, WHO has now proposed shifting the target of halting the rise in obesity to 2030.

At the same time, it has etched out more modest “intermediate” targets that countries could aspire to reach.  Those include reducing intakes of free sugars to less than 10% of total energy intake and reducing physical inactivity by 15% by 2030.  Other “process targets” would include increasing primary health care coverage of obesity prevention, diagnosis and treatment, increased regulation of corporate food marketing of unhealthy foods and drinks to children, and national physical education campaigns.

WHO’s interim proposed targets for obesity reduction – very far from the ambitious 2016 goals of halting the rise in obesity altogether by 2025.

At Thursday’s session,  the United Kingdom said it would support the WHO-proposed intermediate targets.   The UK government delegate, however, stressed that countries need to do more on their own as well as bolstering  global collaborations addressing obesity.

“Action to date has been insufficient, and we would therefore like to call on member states for further joint action to address the global burden of obesity and achieve better health worldwide,” the UK  representative said. Sharing the UK experience at today’s session, the representative described how the UK has put in place a policy package that includes front-of-package labeling, taxes on sugary drinks and salt, sugar and calorie reformulation programs. 

“This year we are going further and we’ll be introducing new regulations on advertising, promotions and calorie labeling in the out-of-home sector,” the representative said.  

The UK also is leading WHO/European Region Sugar and Calorie Reduction Network that will be launched next April. 

“The network will provide a forum for countries to share lessons learned, identify and address barriers to sugar and calorie reduction and assist industries in their efforts to make food and drink healthier. We will also be working on addressing the data gaps and increasing transparency and accountability,” the UK stated.

Concerns from China and Thailand that targets are too ambitious 

Diets rich in fresh fruits and vegetables combat obesity – but these are being overtaken by fast and processed foods in developing as well as developed countries. Portrayed here a market in Tamil Nadu, India

Delegations from China and Thailand however expressed concerns that the interim targets for obesity reduction and related programmes remain too high and too difficult to achieve. 

China recommended that the WHO Secretariat should organize in-depth discussions on this issue, building on the development trend in recent years and the indicators “so as to scientifically predict and set the coverage targets to ensure that they are achievable.” 

Addressing the concerns, Dr Francesco Branca, Director of WHO’s Department of Nutrition and Food Safety, said the WHO will support the adoption of healthier dietary and food policies, through development of policy guidelines for: marketing food to children, fiscal policies, and school food offerings, as well as guidelines on the management of obesity in children and adolescents accompanied by practical How to Guides. 

“We’re also developing a service delivery framework for prevention and management. And looking at diagnostic criteria additional to the body mass index. WHO [also] plans to establish benchmarks for the reduction of sugars based on the experience of member states. Nutrition professionals are those trained to pursue a professional career in nutrition [and] are described in most countries as dietician or nutritionist,” Branca said.

Bente Mikkelsen, Director of WHO’s Department for NCDs told China and Thailand that the WHO took national health systems’ contexts and capacities into consideration when developing its policies and in setting the global targets.

“We have developed the targets based on the data from the member states and with the methodology that is developed in the technical paper. The targets seem ambitious but are achievable,” Mikkelsen added.

She added that the NCDs global action plan on tobacco, alcohol health, healthy diet and physical activity also contain similar targets that will “remain and will complement the targets on coverage and treatment”.

Image Credits: Jen Wen Luoh, Paul Adepoju , Political declaration of the third high-level meeting of the General Assembly on the prevention and control of noncommunicable diseases, @veerajayanth03.

Dr Christopher Murray, director of the Institute of Health Metrics and Evaluation at the University of Washington

Despite a severe lack of COVID test and serological data in Africa, most people on the continent have probably already been exposed to SARS-CoV2, said the director of the influential Institute for Health Metrics and Evaluation on Thursday. 

And in light of that, and the fact that COVID vaccines do not prevent infection, but rather only serious cases, more investment should probably be placed into testing and anti-viral treatment for older, more vulnerable people, said Dr Chris Murray, whose Seattle-based Institute collaborates closely with the World Health Organization on many of its key global data studies. 

Murray stressed that, “regardless of whether people have got some protection from past infection there’s a strong moral arguments about making more vaccine supply available in Africa – everybody who wants a vaccine should certainly be able to get one as a matter of fairness and equity.”

But he also included a provocative caveat, adding that: “if you are a government in Africa, there are a bunch of questions” that still arise about investment priorities.

He spoke Thursday at an IHME briefing webinar on the latest trends in Omicron infection – and what that means for the pandemic and policymakers going forward.  

IHME data shows vaccine hesitancy in Africa to be among the highest in the world – along with Eastern Europe – with less than 50% of people in some countries saying that they would like to be vaccinated,” Murray said, without elaborating on what that data is. Follow-up questions by Health Policy Watch, submitted by email, failed to yield a reply by publication time. 

“But as vaccine supply becomes available, you’re going to hit that limit to people who want to be vaccinated,” he warned. 

In addition, there is currently no solid “adult vaccination platform in many sub-Saharan African countries.”  

How to prioritize ?

Pfizer’s Paxlovid, an oral antiviral approved by the US FDA in December, has shown 90% efficacy in preventing mortality among those who take it in the first few days of infection.

“So the other very real policy question is  should there be more focus on getting the testing capability and access to antivirals in high-risk, older adults in Africa, and would that strategy have a bigger health benefit. 

“There’s a lot to be figured out for countries in Sub Saharan Africa about what  should be the focus, in addition to vaccination, making it available in terms of reducing harm in the future. 

Throughout most of the pandemic “one of the great gaps” in global data on prior exposure to SARS-CoV2 has been Africa.

“There is a lack of population based seroprevalence data in many parts of sub-Saharan Africa – it’s been something I’ve been asking people to fund since May of 2020. 

“But now that there are more studies coming – we’ve heard of early results. The studies from sub-Saharan Africa suggest that 70-80% of populations in Africa pre-Omicron, have already been infected.  

He cited studies from South Africa in early December 2021, which suggested that people coming for treatment at antenatal clinics and other health settings had a 30% prior infection rate – even before Omicron hit with full force there. 

“So we think the vast majority of Africa has actually had Omicron,” he concluded, based on that and other data available. He did not elaborate on the other data.  And as of publication time, IHME had not responded to follow up questions from Health Policy Watch. 

But he said that the worldwide nature of current Omicron exposures raise new questions about how to prioritize resources going forward.  Pushing aggressively for access to treatments for those who do become ill may now be more important than ever.

“Do you put your energy into securing access and ability to deliver in a timely way the Paxlovid or other antivirals that are coming – which can reduce the fatality rate by 90%, which is a pretty dramatic reduction?” 

Omicron as the ‘great equalizer’ 

People vaccinated & infected (red line) have the strongest immune response against SARS-CoV2, seconded by those who were infected (and survived). Those who are were never exposed, vaccinated or not, are the most at risk. But by March 2022, those groups will comprise less than 5% of the world’s population.

People Vaccinated and Infected Have the Best Immunity 

At the same time, people who have been both vaccinated and infected with COVID appear to have the best immunity today – and thus are likely to be better protected against future SARS-CoV2 variants going forward, added Murray.   

“ Who has the greatest protection?- the red line does – people who are vaccinated and infected. The next category is probably green, previously infected.  And the people in the highest risk categories [blue and yellow] are vanishingly few,” said Murray, pointing to a line graph estimating prevalence of the four groups over the course of the pandemic.

“In some ways, Omicron was the great equalizer… We now know that infection-acquired immunity is as good or better than vaccination – although you run the risk of dying with the former. 

But if you are in the fortunate 99%, or now with Omicron, 99.9% to not die, then you end up with pretty good immunity, and what’s what the studies now seem to suggest. 

“And it (infection derived immunity) may even wane more slowly. There are people who are arguing that you get more diverse immunity because it’s not just the spike protein,” the element used in most vaccines to prompt immunity – “and that may put you in a better place for new variants in the future.” 

His statements echoed emerging findings of other recent research, including a study published this week in the journal Science Immunology, by a team of researchers based at the Oregon Health and Science University. The study’s conclusions, as it’s title declares, is: “Vaccination before or after SARS-CoV-2 infection leads to robust humoral response and antibodies that effectively neutralize variants.”  The study was undertaken before Omicron emerged, but it’s likely the results would be the same for the new variant, one lead co-author, Fikadu Tafesse, was quoted as saying.

Currently available vaccines don’t stop infections – only serious cases 

The dilemmas of investment priorities are all the more striking in light of the fact that the world’s currently available COVID vaccines don’t really to much any more to prevent infection – and never were designed for that in the first place, Murray added.   

And while two jabs still continue to give protection against serious cases – the returns on that score also have diminished significantly over time – even in the best vaccines.  That has bolstered the argument for a third booser jab – recently recommended by the World Health Organization.”  But even that has proved to be of limited value over time. 

As for a fourth dose – since Israel this week extended its approval for any healthy adult to get a fourth Pfizer jab “we shall see” soon how effective that may be. 

“But there is a bit  of a debate amongst the vaccinologists about whether the data supports an every six month dosing against the or every periodic dosing,” he cautioned. 

“You know that the argument against that is that once you start, you never stop.” 

Vaccines as ‘harm reduction’ 

He pointed out that “many governments misinterpreted” the initial results from much trumpeted vaccine clinical trials – confusing results that showed 93% or more protection against symptomatic disease in the Moderna and Pfizer vaccines, per se, as as infection protection. 

“They thought that vaccination was a way to control infection.. But in fact the data was never there,” he said, noting that infection prevention was typically not even measured in the clinical trial data.  

“Some of the immunologists who were involved in setting up the trails, argued strenuously that we should have had infection as an outcome of the trials It didn’t happen.

“Now you have data post vaccination in Israel, UK, Canada and elsewhere that have given us insights that depending on the variant they (vaccines) provide some protection but not enough to think of vaccination as an infection control strategy. 

“So as long as we think about vaccination as harm reduction, we’ll be able to figure out the timing to keep protection up, against hospitalization or death.” 

Asked by email in another follow-up question whether vaccination can nonetheless blunt the emergence of new variants, Murray did not reply by publication time.

Murray is a former WHO director, who pioneered the Organization’s initial health metrics research over two decades ago, leaving to found IHME, which is funded by the Gates Foundation.

While sometimes considered a rival to WHO’s own standing, the Geneva-based global health agency has become increasingly more dependent on IHME for data, modelling and analyses – which it lacks the capacity to do internally.

Image Credits: Pfizer , Science Immunology – Vaccination before or after SARS-CoV2 immune response.

Zsuzsanna Jakab

Only 14 countries are on track to achieve the Sustainable Development Goals to reduce premature mortality from non-communicable diseases (NCDs) by one third by 2030, the World Health Organization (WHO) revealed at its executive board meeting on Wednesday.

After listening for over three hours to countries’ views on the WHO roadmap 2023–2030 to prevent and control NCDs, WHO Deputy Director-General Dr Zsuzsanna Jakab, warned that countries had less than 10 years to meet targets.

The agenda item on NCDs was especially onerous as member countries had to consider a political declaration, that included the roadmap, plus 11 annexures – including one on curbing alcohol consumption.

Alcohol lobby exerted undue influence on WHO draft global action plan – critics charge

Last week, the Foundation for Alcohol and Research Education (Fare) accused the WHO of watering down proposals to contain alcohol consumption despite two years of negotiations.

The WHO’s draft Action Plan to Reduce the Harmful Use of Alcohol (2022-2030) has been revised in response to lobbying by alcohol companies to water down key provisions, according to the Fare analysis.

The analysis compared the first WHO working document with the final draft of the global action plan being presented to the EB this week.

Critical changes introduced include reduced emphasis on policies that target the pricing, availability and promotion of alcohol products to moderate consumption – all reflecting the fingerprints of alcohol industry influence, Fare charged.

Last week, another Fare-commissioned report prepared by the Centre for Alcohol Policy Research at La Trobe University, Australia, described how alcohol companies had worked to undermine the draft action plan, in the two year period since the WHO’s Executive Board first recommended accelerated action” against alcohol harm.   

Unhealthy environments

Aside from the focus on alcohol, a number of member states and NGOs made calls for countries to step up action on “unhealthy environments” that are the norm in many polluted, traffic clogged cities, as well as “commercial” risk factors, like the proliferation of junk food and tobacco promotion, which together contribute to unhealthy lifestyles and the development of NCDs. 

Such risks are highlighted in a draft WHO Road Map (2023-2030) for implementing a Global Action Plan for Prevention and Control of Noncommunicable diseases, under consideration by the EB. 

A new WHO “implementation framework” for improving the health and well-being of 1 billion people by 2030 also targets a wide range of risks and prevention opportunities – from promoting clean and active transport to healthier and more sustainable food systems – which in turn can blunt rising antimicrobial resistance (AMR) as well as food safety risks associated with the emergence of new pathogens and pandemics. 

Slovenia’s Kerstin Petrič

Slovenia’s Kerstin Petrič lamented the lack of member state investment in primary NCD prevention, addressing key risk factors. 

“More cost-effective measures such as rising taxes, bans on advertising and limiting access to for example tobacco, alcohol, transfats and sugar are difficult to adopt due to aggressive lobbying of industry and despite the bulk of evidence that these measures work, particularly in the most vulnerable population,” Petrič noted.

“This is the case in my country, and I believe in many other countries. Many lives could be saved if there would not be constant wavering in our member states between business opportunities and health,” she added, appealing to the WHO to “provide appropriate recommendations, including economic calculations, to generate support for public measures in political discussions”. 

Latin American countries, many of which have made substantial progress in addressing junk food consumption that is fueling NCDs including diabetes and cardiovascular disease.

Argentina told board members about its “healthy environments programme” that included  establishing smoke-free workplaces, and raising awareness of the dangers of alcohol, safe water and the importance of healthy eating and physical activity. 

Argentina has implemented front-of-package labelling on ultra-processed food that contain excessive sugars and saturated fats. 

Conflict-of-interest guidelines

Colombia also stressed health promotion strategies, including collaboration with civil society and academics, as “a vital aspect of prevention of NCDs”,  which should also include addressing  unhealthy environments that in turn create obstacles to healthy lifestyles. 

Meanwhile, Uruguay welcomed the proposed specific targets to respond to diabetes in the prevention and treatment of obesity. 

“We would once again ask the secretariat to give member state clear guidelines on the prevention of conflict of interest in the development of public policies and carry out all necessary efforts to support countries, particularly low and middle-income countries to get the necessary resources for NCD control and monitoring systems,” said Uruguay.

Meanwhile, the US appealed for stronger clauses to address air pollution.

“We would like to see the roadmap provide a more robust response related to air pollution,” said US delegate Loyce Pace. She added that mental health should also receive greater focus: 

“As other delegates have said, the COVID-19 pandemic continues to have a profound effect on availability of mental health services, including for pregnant women, children and adolescents. Greater focus is needed in expanding coverage of mental health and substance use disorders, services delivered via telehealth and similar mechanisms to help mitigate the impacts of COVID-19.” said Pace.

The Executive Board will continue to discuss NCDs on Thursday, as it struggles to catch up with its backlogged agenda.

EB chairperson Dr Patrick Amoth

While three independent review panels concur that the response of the World Health Organization (WHO) to COVID-19 was inadequate, member states made slow progress in charting better alternatives at the executive board meeting on Wednesday.

WHO members are considering three main proposals to improve the global body’s future pandemic preparedness: 

Amid the repetitive hot air that characterised much of Wednesday’s pandemic discussion, US representative Loyce Pace’s clarity and brevity made a welcome change.

“All of the review panels recognise the slow response globally in the early days of this pandemic, and establishing a standing committee is in our view, a commonsense way for the executive board to be more prepared for both current and future health emergencies,” said Pace.

She identified four priorities to prepare the WHO for future pandemics: first, targeted IHR amendments; second, a review of recommendations made by the Working Group on Pandemic Response (WGPR); third, setting up the intergovernmental negotiating body to develop an instrument on pandemic preparedness and finally improving WHO governance “starting with an informal group and then establishing a task team of Member States to work with the Secretariat”. 

“We call upon all member states to dedicate time, resources and efforts to improve WHO governance issues,” she added.

Standing Committee is Stalled

Australia’s Travis Power

The proposed standing committee, reporting to the board, would kick in automatically as soon as the Director-General declared a health emergency, and it could facilitate the immediate transfer of information between the Secretariat and member states, said Austria’s Dr Clemens Martin Auer.

Australia stressed that the standing committee “should focus on governance for the health emergencies programme, allowing for in-depth discussion and reporting to the EB” and it “should not encroach on the technical advisory and leadership roles of the Director-General and the IHR Emergency Committee”.

In response, Director-General Dr Tedros Adhanom Ghebreyesus said that such a committee would be helpful, particularly as the board only meets twice a year. However, a handful of countries indicated that they weren’t yet ready to support the resolution so it was stalled.

Agreement to amend International Health Regulations

The Working Ground on Pandemic Response (WGPR), chaired by the US and Indonesia, has been charged with overseeing the process of discussing targeted amendments to the IHR. IHR amendments are expected to address equity, technology governance other gaps.

“The US led an exclude inclusive and transparent process to develop this decision as we are mindful that updating and modernising the IHR is critical to ensuring the world is better prepared for and can respond to the next pandemic,” said Pace.

“The United States formally transmitted its proposals for targeted amendments to the IHS last updated in 2005 to the Director General consistent with IHR article 55 for circulation to states parties at least four months in advance of the World Health Assembly.”

While supporting IHR amendments, Russia’s delegate, Mikhail Murashko, said that these “should not undermine the sovereignty of countries or regions in ensuring health and or biological security”. 

“We reject any proposals which could be used as grounds for interfering in the international affairs of nations, including the holding of international investigations on the basis of rumours and information unconfirmed by states,” said Russia, a reiteration of China’s concerns.

Russia wants IHR amendments to address “improving the priority infrastructure, developing regional and global networks, increasing cooperation between countries on implementing the rules and ensuring free movement of medical staff and technology to fight infections”.

Russia also called for member states to “work harder to fight the distribution of false and unreliable information because this prevents effective scientifically based measures being taken to fight epidemic outbreaks and it undermines international cooperation.” Ironically, Russia has been identified as a key source of COVID-19 misinformation aimed at undermining “Western” vaccines.

Reality check from civil society

KEI’s Thiru Balasubramaniam

The key discussions on an effective pandemic instrument will take place in the intergovernmental negotiating body, which is in the process of being set up. The EU announced that a Dutch official would lead its region, while South Africa indicated it had been nominated for this task by the Africa region.

A wide range of civil society groups breathed some reality into Wednesday’s discussions, reminding delegates that the world was still in the grips of a pandemic and that citizens of the world had been failed by inadequate sharing of rights and know-how on government-funded technologies; bottlenecks in vaccine delivery; and more broadly by health services that have been unable to deliver sexual and reproductive health services and ongoing treatment for people with non-communicable diseases.

“The WHO negotiations on a pandemic treaty are not a quick fix to the current pandemic, but they offer a much more comprehensive and potentially useful response going forward, including for the next pandemics,” said Knowledge Ecology International’s Thiru Balasubramaniam.

He called for delegates to “address policy failures that have accompanied the current pandemic response, and create a better global framework for cooperation”, including “sharing of rights and know-how from government-funded technologies, mandatory intellectual property exceptions, global norms for financing R&D in both the preparatory and crisis stages, and concrete obligations for transparency”.

KEI also called for reforms to the funding and management of clinical trials “so that the public has transparent and unbiased information on the relative effectiveness and safety of countermeasures”.

Pharma leaders, from their side, acknowledged: “society needs to do more and go further, urgently addressing the bottlenecks in vaccine administration while, reflecting on how to achieve ore equitable allocation faster in the future. Manufacturers, governments, academia, NGOs and other global health institutions have a collective responsibility to ensure that no one is left behind in this pandemic and the next outbreak.”

But the statement by the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) stressed that private sector collaborations had been critical to the rapid development of new vaccines and treatments, adding that the world should “enhance not hinder the thriving innovation eco-system while building a resilient, sufficiently-resourced, health infrastructure.”

Loyce Pace, Assistant Secretary for Global Affairs at US Health and Human Services

Despite earlier disruption from Ethiopia, Dr Tedros Adhanom Ghebreyesus received overwhelming support for his nomination for a second term as World Health Organization (WHO) Director-General from the body’s executive board on Tuesday.

As the only nominee, Tedros is guaranteed to be re-elected at the next World Health Assembly in May.

All WHO regions expressed their support for is nomination, including the African region which commended the global body for its clear nomination process – the message delivered by a representative from Burkino Faso, a country in limbo since a military coup on Sunday night.

 

As part of the nomination process, Tedros gave an address to the board and answered a number of questions.

During his address, he appealed for “assessed member state contributions” to cover at least half of the WHO’s roughly $3.5 billion a year budget. At present, assessed contributions (fees based on countries’ GDP) account for less than 20% of the budget, with the remainder from voluntary contributions which are usually earmarked for particular issues, preventing flexibility and equitable regional distribution, said Tedros.

WHO funding 2021

Financing dominated the second day of the board meeting, with Germany’s Bjorn Kummel, chair of the Working Group on Sustainable Financing (WGSF) describing the global body’s finances as “rotten and unsustainable for the future”.

In the run-up to the board meeting, Kummel’s group had failed to reach consensus on the proposal that at least half of the WHO’s budget should come from assessed contributions. The board agreed on Tuesday to extend the group’s mandate until May in the hope that a contribution formula can be agreed on.

The US and Japan are holdouts on increased member contributions unless the WHO guarantees to improve its financial governance.

During afternoon proceedings, US representative Loyce Pace called for a “holistic package of measures” to ensure WHO sustainable finance, that included improved governance and transparency on “current funding mechanisms, prioritisation, budget processes, improved cost efficiency and early member state inclusion in the decision-making processes”.

When Japan asked Tedros how he was going to reform WHO’s financing, particularly  “accountability and transparency and financial discipline”, he asked for the country’s support to increase members assessed contributions.

He explained that under his leadership voluntary contributions had risen from around $14m in 2017 to almost $260m – but no progress had been made on increasing assessed contributions.

However, Tedros later assured members that he was committed to increased accountability and transparency, and would deliver this.

Bjorn Kummel, chair of the Working Group on Sustainable Financing.

Transformation plan – where has it led? 

Shortly after taking office, Tedros undertook a massive transformation plan for WHO, aimed at making the organization more transparent and responsive to the needs of member states, and with more “leadership” in developing regions and countries. 

However, COVID-19 forced the WHO to shift focus from internal reforms to responding to an immediate crisis, while a temporary halt in US funding under former US President Donald Trump sparked a short-term financial crisis. 

A key element in the transformation plan, to move more funding and positions to WHO’s six regional and 152 country offices was stymied by the COVID-19 crisis. 

The pandemic also cut short a new WHO system of more regular rotations of staff in and out of headquarters to regions – along the lines of diplomatic missions – to which there was already considerable staff opposition pre-pandemic.

As a result, WHO is falling short of what has been a decades-long target for a 75%-25% split of its budget between regions and headquarters with over 30% of the total budget being spent in headquarters today.

This goal was surpassed in 2016/7, the last budget cycle before Tedros took office, when 84% of the budget was spent in regions, and only 16% at headquarters.  

The net result is the persistent under-financing of African and South-East Asian regions – which generally host the biggest disease burdens in the world. The African Region only gets 22% of WHO funding – although that is supplemented by direct bilateral support from the US and other donors through channels like PEPFAR – the US HIV/AIDS relief plan which has been a backbone of HIV/AIDs battle since 2003 – funnelling some $10.8 billion into AIDS programmes – and hybrid AIDS/COVID efforts in 2021. 

The Western Pacific (including China, Pacific Island States, Australia and Japan) receives only 4.28% of funding. The South-East Asia Region only gets 6% – about the same as the European Region – whose budget is also self-financed by EU member state contributions. In contrast, the conflict-wracked Eastern Mediterranean gets 26% of the WHO programme budget. 

The Americas region gets the least, less than 3% – although WHO support is is massively supplement by the US and other North American donors that fund the powerful Pan American Health Agency (PAHO), as a semi-autonomous agency.  

Not without reason, however, responding to health emergencies has also consumed a huge portion of WHO’s recent budget – some 41 % of resources in 2021.

UN Foundation Vice President of Global Health, Kate Dodson, sent a letter to the Board on behalf of a wide group of health organisations appealing for increased funding, which was read out on Tuesday 

The letter calls for member states to “agree to increase the share of assessed contributions to the WHO base budget to 50% by 2029”, noting that only a “sustainably financed WHO that is not subject to the political influence of its donors or the whims of funding flows can fulfill its role as the leading technical and normative international body”.

Over-dependence on short-term consultants 

Meanwhile, as things stand now, WHO insiders say that the body is overly dependent on short-term consultants that it parachutes into jobs. Approximately a quarter of WHO staff are on short-term contracts, according to insiders. 

The net result is an organisation that lacks a stable backbone of fixed-term professional staff – from entry to senior levels –  that can dare to question conventional wisdom and take unpopular positions in a large bureaucracy. 

That, along with a weak internal justice system, which was the focus of WHO Staff Association complaints at last May’s World Health Assembly, have reinforced what some WHO insiders describe as “authoritarian” tendencies in the DG’s office and Tedros’ leadership style. This, in turn, also diminishes the independent authority of his Assistant Director Generals – who are anyway all politically appointed. See Related Story: 

WHO Internal Justice Needs Reforms; Staff On “Unequal Footing” With Administration