The world is “on the brink of a catastrophe and moral failure – and the price of this failure will be paid with the lives and livelihoods in the world’s poorest countries,” declared WHO Director General Dr Tedros Adhanom Ghebreyesus, in his harshest rebuke to date of both countries and the pharma industry for failing to roll out out life-saving COVID-19 vaccines more equitably across the world. 

Speaking on the opening day of what is set to be a marathon session of WHO’s Executive Board, the WHO Director General noted that “more than 79 million doses of the vaccine have now been administered in at least 49 higher income countries, while just 25 doses have been given in one low income country.” 

While some WHO member states, including India’s Minister of Health Harsh Vardhan, EB Board Chair, framed the vaccine roll-outs now underway as the glass “half full” in his opening remarks – which coincided with the launch of India’s own vaccine’s campaign set to become the largest in the world, the WHO DG was not so upbeat. 

Rather Dr Tedros expressed the deep rumbles of dissatisfaction echoing among senior WHO officials over the way in which the WHO co-sponsored COVAX facility is being sidelined in the rush by countries – and even blocs of countries – to arrange their own vaccine deals. In fact that rush, which began with the United States, the European Union and other rich countries, now includes South Africa, Brazil, India, and most recently the African Union – which announced last week that it had secured pre-orders of some 270 million vaccine doses from manufacturers for its member states, outside of the COVAX framework.   Earlier this month, South Africa also announced that it had arranged for its own vaccine purchases, following on from India and Brazil. 

Countries and Companies Continue to Prioritize Bilateral Deals

“Some countries and companies continue to prioritize bilateral deals, going around COVAX, driving up prices and attempting to jump to the front of the queue,” said Dr Tedros, noting that some 44 such deals were signed last year. 

“The situation is compounded by the fact that most manufacturers have prioritized regulatory approval in rich countries where the profits are highest rather than submitting full dossiers to the WHO,” he added.  

The lack of communication from pharma producers, he warned, could also delay WHO approval of vaccines to be rolled out through COVAX: “This could delay COVAX deliveries and create exactly the scenario COVAX was designed to avoid with hoarding a chaotic market, an uncoordinated response and continued social and economic disruption.”

The WHO Director General called on countries and pharma producers to “change the rules of the game in three ways,” including by countries transparently reporting to COVAX the nature of their bilateral deals – “including on volumes, pricing and delivery dates.” 

He also called on countries with large vaccine orders to “share their own doses with COVAX, especially once they have vaccinated their own health workers and at risk populations, so that other countries can do the same.”

And, he called on pharma vaccine producers to “provide WHO full data for regulatory review in real time to accelerate approval… to prioritize supplying COVAX rather than new bilateral deals” as well as to allow countries to share any extra doses with COVAX. 

“My challenge to all member states is to ensure that by the time World Health Day arrives on the seventh of April. COVID-19 vaccines are being administered in every country, as a symbol of hope for overcoming, both the pandemic and the inequalities that lie at the root of so many global health challenges,” said Tedros. 

India’s Health Minister More Upbeat  

While the WHO Director General’s comments certainly reflect the frustrations being experienced by people in many countries who are watching vaccine distribution campaigns get underway among wealthier neighboring states, India’s Vardhan cast a more positive light on the progress seen so far in his opening remarks at the EB:

“Scientific capabilities raced against time and delivered on the promise of a vaccine in the shortest possible time in history,” declared Vardhan, who is the EB chair. “While 2020 was the year of science, 2021 shall be the year of global solidarity and survival,” he forecast optimistically.

“COVID-19 vaccines are being successfully produced across many countries, a tech investment boom is being witnessed, and digital technologies are being adopted. All of this is combining to raise the hope of a new era of progress. I want to express utmost optimism that this year the crisis caused by the COVID19 pandemic shall be mitigated and successfully reversed through committed political leadership and sustainabled global cooperation and solidarity,” said Vardhan, adding that the “COVID-19 vaccines offer a real hope – but that hope needs to reach everyone… therefore we must ensure fair and equitable distribution of the COVID vaccine.”

IFPMA – Concerns Over Speed of Access “Potentially Misleading”

Meanwhile, concerns over the lack of speedy access to coronavirus vaccines to low- and middle-income countries (LMICs) “are potentially misleading and might hinder rather than help this unprecedented effort of global collaboration and solidarity,” said the head of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), Thomas Cueni, in a lengthy response to the WHO DG’s remarks. 

“Governments around the world – in industrialized as well as developing countries – have moved overnight from concern about vaccine hesitancy to high anxiety at rolling out the distribution. The political urgency is understandably, it is important recall that the roll-out of approved COVID-19 vaccines is just weeks old. In that time, events have unfolded swiftly, with a couple of other vaccines gaining approval and more to follow. 

“While there is no room for complacency, it is important to note that this is the first global-health emergency in which new vaccines are being rolled out to LMICs at about the same time as in richer ones,” said Cueni – drawing a sharp contrast with other pandemics, where it took years for vital health products to reach poor countries.

Executive Board Packed Agenda Addresses COVID Directly and Indirectly

Much of the ten-day governing board meeting will focus on debates and a flurry of initiatives that are a product of the COVID-19 pandemic’s shockwaves. Beyond the optics and the politics, the quality of debate may be a test case for whether the 34-member EB, in its current alignment representing all six WHO member state regions equally, can regain its past lustre as a technically-focused board – or also requires more serious reform in the wake of shortcomings highlighted by the pandemic – as some critics have suggested.  

Items on the table will include, an exhaustive review of WHO’s emergency response operations in general, and its COVID-19 response more specifically. 

There is also an initiative by some 46 member states for more far-reaching reforms in WHO’s emergency powers and response capacity – looking toward a formal resolution to be submitted for approval at the May World Health Assembly.

The EB will also consider a WHO request for a nearly 20% increase in its operating budget to fill out the many performance gaps that have been uncovered in the course of the pandemic; a new framework to examine how to put WHO’s shaky finances on a more sustainable footing; and foster a more efficient Organization through a series of WHO administrative reforms. 

Along with that, there are a host of other core WHO activities, initiatives and issues, now being re-examined through a COVID “lens.” These range from topics like patient safety and medicines access – to non-communicable diseases and mental health.   

Improving WHO’s Emergency Response

Responding to the shortcoming already identified in WHO’s often delayed and wavering responses, the European Union, United States, Canada, Australia and Japan, are among the 46 countries seeking an EB mandate to develop a reform-minded WHA resolution that would sharpen WHO’s emergency response capacity. Behind the scenes, the resolution’s backers want to see much stronger enforcement mechanisms built into the legally-binding International Health Regulations that WHO administers – requiring countries that identify a new disease outbreak or pathogen risk to report on it more transparently and promptly – and enabling stronger action if they fail to do so. The proposal would be anchored in the findings of three independent investigative committees currently underway, the initiatives sponsors, led by Australia and Canada state.

The first gleanings of one such review by the Independent Panel on Pandemic Preparedness and Response will also be under the spotlight at the meeting. The review by an expert team led by the former prime ministers of New Zealand and Liberia concludes that the global pandemic alert system was “not fit for purpose” and the WHO was “underpowered” to do the job expected of it. (See related Health Policy Watch story)

NCDs, Mental Health & Patient Safety – Also Being Examined In the COVID Lens

Other items on the marathon EB agenda include a wide range of items relating to WHO’s pre-pandemic “Triple Billion” programme of work for 2019-2023, which also aims to improve the health of 3 billion people worldwide through wider access to universal health coverage as well as more action on preventive health issues, including social and environmental risks, such as poor diets, physical inactivity, and air pollution. But these items, as well, are being looked at with new eyes in light of the pandemic.   

For instance, a World Health Assembly proposal for a Global Action Plan on Patient Safety 2021-2030  states: 

“Patient safety issues such as personal protection, health worker safety, medication safety and patient engagement have become key areas of the COVID-19 response globally. Patient safety interventions must be urgently implemented in order to respond effectively to this global public health emergency of unprecedented scale. Such interventions are also needed to improve preparedness to respond to such challenges in the future.”  

The EB will also be asked to consider updating WHO’s 2013 Global Action Plan for the prevention and control of noncommunicable diseases, with one eye looking through a “COVID” lens – which saw the virus hit hardest against those with other chronic diseases. The updated action plan, which targets risks such as unhealthy diets, physical inactivity, smoking, alcohol consumption and air pollution, also would now include a stronger emphasis on mental health. It would be extended to the year 2030.

Transparency of Medicines Markets & Local Medicines Production 

The transparency of medicines markets and effective access to treatments for cancer and rare and orphan diseases, is another key topic on the EB agenda – resuming discussions over an earlier South African proposal to expand access to cancer treatments and another proposal on rare and orphan diseases by Peru, which the WHO had deferred until 2021. Linked to that, the EB willl also review the broader topic of medicines and vaccines access, in light of a WHO resolution on transparency in medicines markets, which was approved by the World Health Assembly in 2019. 

In another COVID-inspired move, some EB member states also are reportedly preparing a WHA resolution that aims to strengthen local production of medicines, vaccines and other health products, according to a Zero draft of the proposed resolution, obtained by Health Policy Watch. This has surfaced as an issue in light of the severe supply chain interruptions seen over the past year as a result of the pandemic – which left countries rich and poor facing dire shortages of basic medicines  – from antimalarials in some parts of Africa  to certain common antibiotics in Europe. 

Still other issues being considered involve WHO’s actions to address longstanding problems with fake and substandard medicines and a plan for operationalizing the new “Immunization Agenda 2030” that was approved by the World Health Assembly in August 2030. Both issues are even more important now, in light of the rollout of COVID vaccines underway, and the ongoing quest for reliable treatments. 

WHO Proposes 20% Budget Increase for 2022-2023

A proposal to sharply increase the WHO budget for 2022-23 by nearly 20% or US$447 million is also on the table, raising the two-year budget level to US$4.478 billion.

A big chunk of the added funds would go to strengthening WHO capacity at the country level. WHO also promises to use the funds to integrate the “lessons learned” from COVID into other WHO initiatives; and “mainstream” WHO polio eradication teams – which have often serviced as the “backbone” of WHO vaccine support overall for developing countries – into other functions: 

“In the past, because of limited resources, the human resources and operational infrastructure built through the polio programme has been the backbone of the WHO Secretariat’s technical and public health operational support to countries,” states the budget proposal, “this proved to be critical in WHO’s effective emergency response in immunization campaigns and in surveillance, especially in fragile, conflict-affected and vulnerable settings.”

Under the proposal, rather than staff positions being cancelled in the phase-out of polio activities, polio eradication teams would be reassigned to other functions that, de facto, they already perform anyway, supporting overall immunization goals and general primary health care provision.  

A companion proposal to the budget would establish an intergovernmental working group on Sustainable Financing for WHO. The working group would examine ways to ensure more stable contributions from member states or other sources – easing the reliance on unpredictable  voluntary contributions from member states and other donors for many core programme activities.  The reliance on such contributions is widely acknowledged as a factor leading to gaps in more strategic, long-term Organizational staffing.    

WHO Reform

The EB will also consider advancing a controversial proposal to curtail formal presentations by civil society and other non-State actors at official WHO meetings, including the EB and the World Health Assembly – while facilitating new fora for technical exchanges with WHO technical teams and WHA member states. Civil society groups have objected to the proposals – saying that the new venues for interaction will not be as fruitful since they are outside the formal channels where dialogue with member states takes place. Nonetheless, the EB proposal suggests the approach be tested at the 74th World Health Assembly in May. Other reform proposals would sunset nearly 50 WHO resolutions that are more than six years old – and which WHO argues have since been replaced by other initiatives. The sunsetting would cover resolutions as wide ranging as health responses in nuclear war to the elimination of tropical diseases – which still often entail bulky reporting requirements, WHO says. A more systematic rationale for the declaration of World Health Days is part of yet another reform proposal.

Image Credits: WHO, Independent Panel for Pandemic Preparedness – Second Progress Report. .