The Year of The Nurse And Midwife, 2020 will be a featured topic at the Geneva Health Forum on Monday, opening day of the conference (16-18 November). Raisa Santos discusses the dilemmas facing nurses worldwide – informed by her own experiences. 

“Why does it take a pandemic for them to suddenly recognize nurses?” says Isabelle, a Labor and Delivery nurse in New York City. “We’re on the front lines all the time.” 

Nurses celebrating Nurses Appreciation Week in May 2020 in New York City; Pictured second from right: Isabelle Santos

This is in fact my mother speaking. My mother who, just like my father, has been on the front line of the healthcare workforce since they came to the United States, back in 1994. The sacrifice my parents have made is two-pronged, for not only have they worked tireless hours on behalf of their patients, in both the night and day shifts, but they sacrificed their livelihood and everything they knew when they left the Philippines. 

Both of my parents were doctors in the Philippines, but when they immigrated to the United States took up work as nurses. “When you’re working the night shift, you have no time to study or read. I’m lucky I passed the nursing exam,” says my father Roberto, an ER nurse, who immigrated first to New York City so my mother could follow. In addition to the lack of time, they cited the numerous educational and administrative hurdles that prevented them from achieving the same medical licenses in the United States.

My parents are part of the estimated 150,000 Filipino nurses in the United States, with some regions accounting for an even larger portion of the nursing workforce. In California, nearly 20% of registered nurses are Filipino. Filipinos are one of the largest groups of internationally educated nurses in the country, and are the second largest Asian community in America. 

“It is not an exaggeration to say we literally would not have survived the COVID-19 pandemic without all of you, our Filipino brothers and sisters,” said New York City Mayor DeBlasio. “You keep our city moving forward, and you keep us progressing during one of the greatest challenges of our time.” DeBlasio honored Filipino Americans, especially those in healthcare, during Filipino American History Month, in October. Acknowledging the contributions of migrant nurses also highlights the need for active support of all nurses and healthcare workers. 

It is paradoxically fitting that the first-year dedicated to celebrating nurses coincides with the biggest pandemic that the world has seen in a century: COVID-19.

The World Health Organization (WHO) declared 2020 the International Year of the Nurse and the Midwife, in honor of the 200th anniversary of Florence Nightingale’s birth. The topic is also a featured item at the upcoming Geneva Health Forum (16-18 November), including presentations by WHO’s Elizabeth Iro and Howard Catton of the ICN, who are presenting on The Year of the Nurse and the Midwife 2020 – a catalyst for change, on Monday, 11:00 – 12:00 CET.

According to the most recent ICN data, 1,500 nurses have died from COVID-19 in 44 countries. They estimate, however, that worldwide healthcare worker fatalities from the virus could be greater than 20,000.

“Nurses and midwives have been on the frontlines of the fight against COVID-19, putting themselves in harm’s way. Many have made the ultimate sacrifice in service of humanity,” said Dr Tedros Adhanom Ghebreyesus, WHO Director General, at his opening speech for the resumed 73rd World Health Assembly last week. “Now more than ever, the world needs nurses and midwives.”

Dr Tedros Adhanom Ghebreyesus, Director-General, WHO on International Nurses Day
Applause without Action 

In fact, even before the pandemic, nurses have suffered, and continue to suffer, from long hours, risky working conditions, a gender-based pay gap, and a global shortage of nurses. 

The largest shortages of nurses are seen in some parts of Latin America, Africa, and Southeast Asia

“Applause without action is no longer acceptable recognition, without rights and proper rumination is not sufficient a resolution, without implementation is not governance,” said HRH Princess Muna al-Hussein of Jordan, in a keynote address at the resumed 73rd World Health Assembly. HRH Princess Muna is a WHO patron of nursing and midwifery in the Eastern Mediterranean Region. “We must invest in fair pay and protection of health and care workers.”

True appreciation for nurses and healthcare workers should be shown in the form of global cooperation that ensures the lives of both patient and provider are protected.

She added: “We must invest in a healthy workforce that will help the world recover. With 70% of the world’s health workers being women. We must truly invest in transformative gender equity and rights policies.”

Global Shortage of Nurses Now and Future 

According to the latest State of the World’s Nursing Report 2020, there is a 5.9 million gap in nurses worldwide – with most of the shortage, or 5.3 million (83%), concentrated in low- and middle-income countries (LMICs).

The report uses findings from analysis of National Health Workforce Account (NHWA) data provided by 191 Member States. 

Among the 28 million nurses working today, 80% are concentrated in countries that account for only half of the world’s population. And while the nursing workforce is expanding, the report projects that the shortage could reach up to 5.7 million by 2030, primarily in the African, South-East Asia, and Eastern Mediterranean regions.

Along with certain areas of Latin America, these regions are where the nursing gap is currently most strongly felt.

These are also regions that have some of the largest populations of migrant nurses.

Projected increase (to 2030) of nursing workforce, by WHO region and by country income

Dr Tedros said: “This report is a stark reminder of the unique role [nurses] play, and a wakeup call to ensure they get the support they need to keep the world healthy.”

Nursing ‘Brain Drain’ from Developing Countries to Train More Nurses 
Physicians and nurses wore adapted theatre gowns and used face shields and face masks when attending to patient during the COVID-19 pandemic, Nigeria

The migration of health professionals to high-income countries also risks worsening shortages in LMICs. The ICN warned that high-income countries must train enough nurses to become self-sufficient at a large scale.

Speaking at the World Health Assembly (WHA), it urged countries to implement a self-sufficiency indicator, presenting their reliance on foreign trained nurses as a percentage. This would give policymakers insight into the extent of dependence on international nurse supply.

Countries such as the United Kingdom have admitted dependence on health worker migration. 

Sacrifices but no Status For Migrating Nurses 

The millions of migrant nurses around the world, including many from the Philippines, also often face issues with their legal status in the very countries they are serving.

While international recruiters for nurses promise signing bonuses, referral bonuses, and relocation bonuses, the protection they are guaranteed is far less concrete.

In a review led by Kaiser Health News, some travel nursing contracts of international nurses have left a trail of wrongful termination claims, claims of discrimination, harassment or retaliation, wage claims, and claims for violation of federal, state or other laws and regulations.

These often were settled out of court, as constituents of organizations such as the Service Employees International Union, the American Nurses Association and National Nurses United were suspended or fired from traveling worker agencies for speaking to the news media, posting on social media, or otherwise voicing concerns about unfair practices.

Nurse treating a child at a medical center in Baghdad

Carey McCarthy, one of the lead authors of the State of the World’s Nursing Report, calls on countries to use this data to guide policy discussions around nurse mobility and many other problems regarding the global nursing shortage.

In a YouTube interview on World Health Day, she said: “We know that [nurse migration] is increasing. We really need better data from all countries around the world to make sure that migration is managed ethically and responsibly and that we can ensure that our migration of health workers doesn’t exacerbate, and make worse, local health challenges that already exist in terms of providing services to the population.”

Improving Nurses Working Conditions, Advancement & Leadership   

Increasing the number of nursing trainees and graduates, and retaining nurses already employed also requires improved working conditions, and avenues for advancement to ensure that veteran nurses remain motivated.

Nursing leaders and their in-country networks are crucial to this process, and their inclusion in policy dialogue that concerns them is critical, nurse advocates say.

McCarthy, who is also WHO’s Nursing and Midwifery Technical Officer, said: “We are asking governments to look at improving nursing leadership. We found chief nurse officer positions as well as leadership development programs to be highly related to improved working conditions and stronger education regulation within countries.” 

Interview with WHO Expert Carey McCarthy on The State of the World Nursing Report, broadcast 7 April 2020

Of the 191 countries who responded to the surveys informing the Nursing Report, more than 80% reported that strong government or employer regulations regarding their working conditions was one of the major drivers attracting them to job opportunities. 

This includes stronger regulation of working hours and minimum wage.

Overall, LMICs reported weaker regulatory frameworks for nurses, as compared to high-income countries. The presence of a government chief nursing officer position and the existence of a nursing leadership programme were associated with a stronger regulatory environment for nursing. 

Gender Equity in Nursing 

Approximately 90% of the nursing workforce globally is made up of women. Gender-related barriers and discrimination can constrain advancements of the nursing profession, as well as deeply impacting the well-being of female health workers and the standard of care.

Conversely, addressing gender perceptions and barriers in nursing is also important in order to empower nurses to obtain proper working conditions, receive fair pay and equal treatment, and become leaders in healthcare. 

By providing more equitable pay to a predominantly female workforce, providing adequate PPE and funding to all hospital and clinical staff, and creating gender-sensitive leadership and development opportunities for women in the nursing workforce, we can slowly ease away the inequities in healthcare and work towards attaining universal health coverage, a long-time nursing advocate has said.  

“Politicians understand the cost of educating and maintaining a professional nursing workforce, but only now are many of them recognizing their true value,” said ICN President Annette Kennedy. “Every penny invested in nursing raises the wellbeing of people and families in tangible ways that are clear for everyone to see.”

She added that The State of the World’s Nursing Report “highlights the nursing contribution and confirms that investment in the nursing profession is a benefit to society, not a cost. The world needs millions more nurses, and we are calling on governments to do the right thing, invest in this wonderful profession and watch their populations benefit from the amazing work that only nurses can do”.

HRH Princess Muna al-Hussein, keynote address to the resumed 73rd World Health Assembly

Princess Muna, in her presentation on Monday’s opening of the WHA, said: “All countries need a system that delivers public health, primary care preparedness and response, a system that delivers integrated health and care services, and a system that delivers health and well-being for all of its population.”

“The best strategies and plans will not succeed without the people to deliver them,” she added. “Invest in health. Invest in health systems. Invest in well being. Invest in people who are the world’s health and care workers.”

Raisa Santos is studying a Masters of Public Health with a global health certificate at Columbia Mailman School of Public Health. She is also an intern writing for Health Policy Watch.

Image Credits: Raisa Santos , R Santos, WHO, WHO, Community Eye Health/Flickr, International Labor Organization/Flickr, WHO, WHO.

Executive Board Room in WHO Headquarters, Geneva, during the virtual resumed session of the 73rd World Health Assembly.

The close of the World Health Assembly (WHA), Friday, saw the adoption of the first-ever resolution to eliminate meningitis by 2030 – a disease which has its biggest impacts in sub-Saharan Africa, and with a 50 percent fatality rate if left untreated. 

The closing hours of the WHA also saw the approval of a landmark roadmap for reducing the burden of neglected tropical diseases (NTDs) by 90% by 2030 – NTDs refer to some 18 parasitic, helminthic and vector-born diseases that affect over one billion of the world’s poorest people.   

Another resolution to increase treatment and control of epilepsy and other neurological disorders was also approved. 

Neurological disorders are the second leading cause of death worldwide, yet many, including epilepsy, have preventable causes. The approved resolution plans to address the current gaps and research needs to improve prevention, early detection, treatment, care, and rehabilitation. 

Dr Tedros Adhanom Ghebreyesus at the World Health Assembly’s third plenary meeting on Friday.

“You have approved a comprehensive resolution on emergency preparedness, a new road map to defeat meningitis by 2030, a new road map for neglected tropical diseases, a resolution to scale up action on epilepsy and other neurological disorders, and you declared 2021 the international year of health care workers,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, speaking to member state delegates in his concluding remarks for the 73rd WHA. 

“Each of these represents an urgent health priority that affects the lives of millions of people and which increases the demands on and expectations of WHO,” he added. 

Roadmap Aims to Reduce Neglected Tropical Diseases by 90% 

In terms of the action on NTDs, the new roadmap sets ambitious targets to be achieved by 2030. The global targets include: reducing those requiring NTD treatment by 90 percent; eliminating at least one NTD in 100 countries; eradicating dracunculiasis and yaws; and reducing the disability-adjusted life years related to NTDs by 75 percent. 

“The new road map addresses critical gaps across multiple diseases, integrates and mainstreams approaches within national health systems and coordinates action across sectors,” said Mwelecele Ntuli Malecela, Director of WHO Department of Control of Neglected Tropical Diseases, in a WHO press release.

A young girl receives a meningitis vaccine.

As for meningitis, administration of meningococcal vaccines can help prevent  the major bacterial forms of the disease among young children. The new WHA resolution aims to strengthen vaccine coverage as well as disease surveillance in order to eliminate periodic meningitis outbreaks and epidemics. 

In a discussion before the resolution was adopted, member states such as Brunei, told WHA delegates how they had succeeded in integrating meningitis vaccines into their regular basket of health services. 

“Brunei Darussalam has developed a comprehensive program which has been successful in protecting against vaccine preventable diseases, including meningitis, with a high vaccination coverage rate…ensuring high protection against childhood meningitis,” said the delegate from i on Thursday. “Accessibility to meningococcal vaccinations is now provided nationwide.”

Regarding epilepsy, Mexico echoed the resolution’s emphasis on early detection and treatment of patients with neurological disorders. Along with providing essential care, Mexico’s delegate said prevention and diagnosis would help “the fight against the marginalization of these people [with epilepsy and other neurological disorders].” 

“This [epilepsy action plan] will allow the member states to better work with international collaboration and to engage politically on this issue,” he said. 

Health Conditions In Occupied Palestinian Territories 

The Assembly also approved a decision requesting the Director-General to provide health systems support to Palestinians living in Israeli-occuped territories, including for this year’s COVID-19 pandemic. A WHO report on “Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan” is issued every year for the WHA, sparking an annual cycle of protests by Israel and its allies.  

In this year’s debate, Israel, Canada and the United States opposed the draft decision, noting once more that the Palestinian conflict was receiving special treatment – in comparison to politically charged debates over other occupied and contested territories, which the WHA typically tries to avoid.  

Said the US delegate:  “The United States believes the current draft decision does not meet our shared objective of a World Health Assembly focused purely on public health and that refrains from singling out countries on a political basis. Rather, the draft decision before us perpetuates such politicization.”

Added Israel: “Israel has strengthened its cooperation with the Palestinian Authority in order to prevent, mitigate and address the spread of the virus in the region.” 

Charged Turkey, a co-sponsor of the draft decision on Palestine, said: “12 years of inhuman blockade has had a profound effect on the health sector, as well as on underlying determinants of health. COVID-19 worsened an already dire situation and the health system continues to operate under pressure from shortages of basic supplies.”

Meanwhile, Cuba, another a co-sponsor of the draft resolution, and a member of the  Palestinian observer delegation at the WHA called upon Israel and the US to respect the recommendations by the Director-General in his report. He said Palestinians were keen for  the WHO “to continue to provide technical assistance to Palestine,” while Israel should “respect its obligations as a member of the World Health Organization.”

This year’s WHA session saw several other such disputes creep to the surface – only to be quickly suppressed in debates. Protests by member states over the WHA’s failure to include Taiwan as a observer – due to objections from China – were shut down on the floor of the Assembly – after a closed-door meeting of delegates decided that Taiwan would not be admitted.  Later, the WHA moderator also shut down comments by Armenia, when it accused Azerbaijan of  “ethnic cleansing” of Armenian nationals living in Nagorno-Karabakh – a territory inhabited by ethnic Armenians but internationally recognised as belonging to Azerbaijan, where bloody battles have occurred in recent week. Under a recent Russian-brokered peace deal, Azerbaijan will fully control of the area, forcing Armenian troops to withdraw and, along with them, many civilians.  

Image Credits: WHO, WHO, WHO.

Dr Tedros Adhanom Ghebreyesus speaks at the World Health Assembly’s closing session on Friday, 13 November.

BREAKING – World Health Organization Director-General, Dr Tedros Adhanom Ghebreyesus has proposed the creation of a Swiss-based global repository for sharing pathogen materials and clinical samples related to potential outbreak threats – allowing for the more rapid development of medical interventions. 

The COVID-19 pandemic has shown the urgent need for this kind of system, said Dr Tedros Adhanom Ghebreyesus in his closing remarks to the 73th World Health Assembly.  He alluded to the problems associated with existing WHO-sponsored frameworks for pathogen-sharing, which are based on bilateral agreements between countries, and have no centralized repository. 

“The pandemic has also shown that there is an urgent need for a globally agreed system for sharing pathological materials and clinical samples to facilitate the rapid development of medical countermeasures as global public goods. 

“It can’t be based on bilateral agreements. And it can’t take years to negotiate. 

“We are proposing a new approach that would include a repository for materials housed by WHO in secure Swiss facility; an agreement that sharing these materials in the facility is voluntary; that WHO can facilitate the transfer and use of materials; and a set of criteria under which WHO will distribute them.”

Dr Tedros said that Alain Berset, head of the Swiss Federal Office of Home Affairs [Public Health] had offered his support for the initiative, including a high-security  BSL certified laboratory (biosecurity level 4). The Health Minister of Thailand, Anutin Charnvirakul, and Italy’s Minister of Health, Roberto Speranza, have also come behind the concept, Dr Tedros said. 

Sharing of Samples is Critical to Rapid Response  – But Slow Under Current Arrangements 

Sharing of such biological samples is crucial for the rapid response to an emerging outbreak threat, leading to the faster development of diagnostic tools, medicines and eventually, vaccines. 

Current WHO-mediated arrangements are guided by bilateral Material Transfer Agreements (MTAs), a contract governing transfer of biological materials – that is relevant samples and data– between two countries or parties (e.g. laboratories).  The MTA also defines the rights of the provider and the recipient with respect to the materials and any derivatives.

The current WHO MTA formulas are part of the Organization’s broader Research and Development (R&D) Blueprint for Action to Prevent Epidemics blueprint.

WHO developed and published its first such R&D blueprint framework 2016, which was approved that year by the WHA, following the harsh experiences of the West African Ebola epidemic where a lack of such formalized frameworks hindered response. The Blueprint was updated  again in 2017, following another expert public consultation.

This Framework was scrutinized again as the COVID-19 pandemic was building steam – when WHO convened a major research meeting in Geneva in February 2020. 

The WHO-convened Global Research and Innovation Forum with scientists, researchers and public health experts followed on the heels of WHO’s initial declaration of  COVID-19 as a public health emergency at the end of January, 2020. 

The meeting, 11-12 February, yielded the first COVID-focused research and development blueprint to accelerate global research work on treatments and vaccines, which is part of the WHO’s broader global strategy and preparedness plan. 

At this meeting, the expert participants issued a set of recommendations for “immediate research actions”, saying that virus material, clinical samples and associated data should be “rapidly shared for immediate public health purposes, and that fair and equitable access to any medical products or innovations that are developed using the materials must be part of such sharing.”

Sources in Geneva told Health Policy Watch that while the Swiss Confederation has indeed agreed, in principle, to host such a repository – a more formal framework for the initiative still needs to be developed. If successful, however, such a facility could make a meaningful contribution to global health security, providing an important base for more rapid, initial investigation of emerging disease threats on neutral ground. Indeed, the concept dovetails well with the classic Swiss diplomatic positioning as a “trusted” and “neutral” partner – in the polarized world of global health diplomacy.

Image Credits: Health Policy Watch .

Limited education and employment capacity in LMICs means has encouraged health workers to move to high-income countries
Limited education and employment capacity in LMICs means has encouraged health workers to move to high-income countries. One in eight nurses globally are migrant nurses.

The migration of health professionals to high-income countries should not lead to a dearth of healthcare workers and services low- and middle-income countries (LMICs), the International Council of Nurses (ICN) has warned.

Speaking at the World Health Assembly (WHA), the council flagged that the global shortage of six million nurses, in tandem with the burden of the COVID-19 pandemic, would continue to drive health worker migration, leading nurses away from LMICs.

One in eight nurses globally are migrant nurses, according to WHO’s 2020 State of the World’s Nursing report, drawing comparison to the limited education and employment capacity in LMICs.

The global shortage of six million nurses continues to drive health worker migration
The global shortage of six million nurses continues to drive health worker migration.

To address this, the ICN said high-income countries must train enough nurses to become self-sufficient at a large scale.

It urged countries to implement a self-sufficiency indicator, presenting their reliance on foreign-trained nurses as a percentage. This would give policymakers insight into the extent of dependence on international nurse supply, it said, and would enable tracking and monitoring of their commitment to the global strategy of human resources for health.

The representative said: “The impact of COVID-19 on the nursing workforce will continue to increase the flow of nurses from low- to high-income countries. High-income countries must train enough nurses to become self-sufficient.”

UK Admits Dependence on Health Worker Migration

The United Kingdom is one of the world’s top destinations for emigrating health professionals.

Workers born abroad have constituted 50% of the increase in the country’s health and social care workforce across the last decade, according to a Nuffield Trust analysis published in December 2019. The analysis also revealed that people born outside of the UK account for nearly a quarter of all staff working in hospitals, and a fifth of all health and social care staff in the country.

The UK spokesperson at the World Health Assembly admitted that the UK’s National Health Service relies to a large extent on international health workers.

“By forging international partnerships, the UK will foster collective efforts across the world to address the global shortage of health workers and provide health workforce-related support and safeguards to countries with the most vulnerable health systems, enabling progress towards universal health coverage and sustainable development goals,” she told the assembly.

She added that in consultation with WHO, the UK has updated its code of practice for international improvement based on the latest advice, due to be published later this year.

Feeling the Weight of Health Workforce Inequality

Evidence points to a direct correlation between the size of a country’s health workforce and its health outcomes, with WHO estimating a projected global shortfall of 80 million health workers by 2030, mostly in LMICs.

A COVID-19 responder in Kenya learns how to properly equip protective gowns in Kenya. The country is experiencing a critical resource shortage during the pandemic.

COVID-19 has piled additional pressure on the healthcare systems in many countries losing health professionals to high-income countries.

This is an especially pressing issue in Kenya. In a 2016 study published in BJPsych International, researchers noted that one in five nurses trained in Kenya applies to emigrate. They also found that up to 40% of the country’s 600 medical graduates leave upon completing their internship every year.

Kenya’s spokesperson said the East African country’s healthcare system is faced with a shortage of critical human resources for health demands. Similar situations occur in many other African countries.

“We continue to experience challenges in managing human resources for health, such as severe shortages of essential workers, inability to attract and retain health workers, and even remuneration among workers,” she told the assembly.

Kenya also urged WHO to establish and regularly update the list of countries with critical health workforce challenges.

Transparency and Accountability

A representative from the United States asked WHO to put more pressure on Member States to report information on international recruitment of health professionals.

She said this would promote fair, equitable and ethical decision-making. She referred to Cuba, which had more than 30,000 doctors working in nearly 70 countries in 2019.

The US called for the investigation of any allegations by health personnel of human trafficking and slave labour conditions. If substantiated those responsible must be held accountable, she said.

Dr Jim Campbell, WHO’s Director of Health Workforce, noted that the global health body will work on the strategic directions on the code of practice, and address the implementation gap.

Image Credits: Tim Kubacki/Flick, UNICEF/Frank Dejongh, Twitter: WHOAFRO.

A scientist at Ethiopia’s National Influenza and Arbovirus Laboratory, in February, equipped to test for COVID-19.

Africa is set to establish a plan of preparedness and to compile influenza data sets with the World Health Organisation (WHO), to expand its surveillance of potential flu outbreaks.

The African region has also called for the integration of influenza surveillance into an all-inclusive infectious disease surveillance system, and for the creation of a necessary mechanism for contributory finance that can make vaccines and control measures affordable and equitable.

Dr Chikwe Ihekweazu, Director General of the Nigeria Center for Disease Control (NCDC), told the World Health Assembly (WHA): “We notice the challenges with influenza preparedness as well as the consequences that recurring pandemics have on health, economies and society – particularly on vulnerable countries with weak health systems, now exacerbated by the COVID-19 pandemic.”

Establishing a plan of preparedness with the Secretariat would “help expand and reinforce the surveillance and diagnostic capacity of the African region in case of influenza outbreaks,” he said.

He also asked WHO to continue to stockpile vaccines in anticipation of influenza outbreaks, so as to support the region’s ongoing plan to expand sentinel sites next year.

Could the Northern Hemisphere Avoid Flu Season?

In the early weeks of the COVID-19 pandemic, WHO and health stakeholders noted that COVID-19 could worsen the seasonal influenza outbreaks around the world.

“Every year, there are up to 3.5 million severe cases of seasonal influenza worldwide, and up to 650,000 respiratory-related deaths,” WHO stated. “Every hospital bed occupied by a patient with COVID-19 is a bed that is unavailable for someone else with another condition or disease, such as influenza.”

As of November, however, trends are less clear.

On the one hand, over the spring and summer, the southern hemisphere registered a sharp drop in flu cases compared to previous years – attributed to COVID-19 restrictions and guidance like social distancing and hand washing.

At the same time, given the unpredictable course of the pandemic, public health officials have warned countries in the north not to let up their guard.

“We cannot assume the same will be true in the northern hemisphere flu season,” WHO stated. “The co-circulation of influenza and COVID-19 may present challenges for health systems and health facilities, since both diseases present with many similar symptoms.”

WHO said it is working with countries to take a holistic approach to the preparedness, prevention, control and treatment of all respiratory diseases, including influenza and COVID-19.

“Many of the same measures that are effective in preventing COVID-19 are also effective for preventing influenza, including physical distancing, hand hygiene, covering coughs, ventilation and masks,” said WHO Director-General, Dr Tedros Adhanom Ghebreyesus.

WHO Must Make Sure Africa’s Record-Low Cholera Cases Are Not Undone by COVID-19

African countries, including Zambia, Nigeria and South Sudan, reported an average 59% decrease in the number of cholera cases between 2017 and 2018, as the broader African region experienced its lowest number of cases in the 21st Century. COVID-19’s impact on vaccination campaigns, however, threatens to drive cases back up.

Dr Chikwe Ihekweazu says influenza outbreaks in Africa require improved surveillance
Dr Chikwe Ihekweazu, DG of Nigeria’s NCDC, spoke on behalf of the African region at the WHA on Wednesday.

Despite the successes so far earned by global initiatives – like the Global Task Force on Cholera Control’s 2030 roadmap which aims to reduce cholera deaths by 90% using evidence-based best practices – Ihekweazu noted the urgent need for additional work to ensure these milestones are consolidated.

“We emphasize that despite a significant downward trend in cholera transmission, more effort is needed to sustain the results achieved, especially during this period of the COVID-19 pandemic,” Ihekweazu said.

He also called for support for a privatization of epidemiological and laboratory surveillance, and a multi sectoral approach to strengthening health systems: a sentiment mirrored by a separate committee at the WHA.

Dr Ibrahima Socé Fall, WHO’s Assistant Director-General for Emergencies Response, noted that there was a 64% reduction in cholera deaths between 2019 and 2018 in the African region, and he drew attention to Nigeria and Sudan’s requests for continued investment in laboratory capacity and community engagement.

He said: “We are continuing to work on this with our partners. There are still a number of challenges despite this progress that we’ve made.”

Dr Socé Fall noted that many African countries, including Cameroon, Uganda and Mozambique, are now resuming their vaccination campaigns following COVID closures, with others resuming preventive campaigns. In 2019, the region distributed 23 million oral cholera vaccines.

“We are also seeing preventive campaigns in Zambia, Tanzania and other countries,” he said. “We would encourage countries not to cancel these campaigns.

“COVID-19 measures have been implemented and it is important that we continue to do this to save lives.”

Image Credits: WHO AFRO/Otto B., WHO / WH.

A bavy is given a polio vaccine
A new oral vaccine that is expected to have a substantially lower risk of generating vaccine-derived poliovirus is expetced to roll out in Janaury.

Despite the big success this year in the eradication of wild poliovirus in the African region, the COVID-19 crisis has seen a temporary interruption of polio vaccine programmes. This has led to a rise in vaccine-derived polio cases which, are more likely to occur when vaccine coverage is weaker, WHO and African Region health officials told World Health Assembly (WHA) member states in a wide-ranging review of WHO’s massive two-decade polio eradication effort.

The prospect of a forthcoming COVID-19 vaccine, meanwhile, underlines the important role the programme can play, WHO’s Dr Michel Zaffran, director of the Polio Eradication Programme, said at the WHA session. He specified that adapting national polio eradication teams to COVID-19 prevention and eventually immunization was critical.

“Since July … polio immunization campaigns have resumed under strict infection control protocols in endemic impoverished countries,” he noted, adding that “polio staff have rapidly pivoted to support COVID-response activities, helping with disease surveillance, contact tracing, and educating communities on physical distancing and hygiene.”

Zaffran warned, however, that inadequate vaccine coverage in areas at risk of outbreak mean that “risks are high”.

A map indicating the disparity in polio immunization in Africa.

“Last week, UNICEF and WHO issued a global call,” he said, “for the international community to ensure that the financial resources needed to respond to outbreaks are made available.”

WHO’s Sylvie Briand confirmed that WHO is looking at options to ensure the continued cross-fertilizing between polio eradication and the COVID battle.

She said: “We know that innovative partnerships, mechanisms and platforms, developed through the ACT Accelerator can be leveraged for long term investment in pandemic preparedness, including the research, development and availability of innovative influenza pharmaceutical products.

“So … learning from the COVID-19 crisis, we are looking at options to ensure the continent continues cross-fertilising between programmes.”

“There is an opportunity to link the transition of polio-funded assets with COVID-19 recovery efforts to build back better,” said a representative of the UN Foundation, one of the partners in the polio eradication effort.

Integrating Polio Programmes with National Health Systems

Over the longer term, better integration of polio programmes with national health systems remains a key priority, donor states have emphasized.

“Polio programmes have become cornerstones of the national health system, including their response to COVID 19. It is essential that we progress on integration of the project assets into the national health programmes and have polio vaccines integrated,” said Germany’s WHA representative.

The wide-ranging conversation followed WHO’s presentation to member states of a progress report on its eradication effort. A parallel WHO report covers polio “transition planning” – shifting polio staff and resources into broader Ministry of Health vaccines and primary health care activities.

The Global Polio Eradication Initiative (GPEI) is one of the WHO’s and the world’s largest single global health efforts, with a separate budget of US$4.2 billion, that employs teams embedded in the national health systems of countries in Africa, the Eastern Mediterranean region, and the Western Pacific (Asia). Gavi, the Vaccine Alliance has contributed more than US$180 million to the GPEI, and has pledged an estimated US$800 million in support of inactivated polio vaccines (IPV), as part of GPEI’s Polio Endgame Strategy.

The number of polio cases has dropped significantly, but the COVID pandemic threatens this progress.
Polio Programmes: From Downsizing to Repurposing

Only a couple of years ago, the main corridor conversation inside WHO was how to dramatically downsize the polio programme – including termination or transition of polio team members to other positions – as eradication goals were progressively met.

Now, talk has pivoted to a conversation about how to repurpose those same programmes and teams to help deliver COVID-19 vaccines when these become available – a new and equally momentous task.

Along with that, donors and countries are talking about the importance of better, long-term “integration” of the vertically-designed, donor-driven polio programme into countries’ broader immunization plans and national health systems.

De facto, polio teams are already deeply involved in national health services delivery of a much broader array of vaccines – including the 3-in-1 Td/IPV vaccine (protecting against tetanus, diphtheria and polio).

But until the COVID-19 pandemic, the relevance of the polio programme to vaccine services more broadly was not well understood.

Now that COVID has made this more obvious, the challenge of supporting and funding the institutional rea-lignment of resources remains. With this support in place, national ministries and immunization programmes can staff and fully budget for tasks being fulfilled by the polio programme, as part of primary health care systems.

New Low Risk Oral Vaccine Rollout Urged

A new oral vaccine that is expected to have a substantially lower risk of generating vaccine-derived poliovirus (VDPV) cases was also announced to replace a predecessor that had been used until 2016. The new vaccine is expected to be rolled out, beginning in January 2021 and will be deployed under emergency use.

While oral polio vaccines (OPV) are generally safe and effective, on rare occasions the live poliovirus component can cause infection.

But since 2016, when the earlier OPV was withdrawn, some 49 outbreaks of a genetically distinct circulating VDPV have been reported in 21 countries, including in Africa and the Eastern Mediterranean and Western Pacific Regions.

“Unfortunately, 2020 has seen a dramatic increase in outbreaks of circulating VDPV in Africa and Asia,” said Dr Zaffran. Commenting on the deployment of the new vaccine, he added: “This must be complemented by existing tools, including efforts to strengthen routine immunisation with a second dose of IP.”

Increasing Risk of VDPVs in Migrants to Polio-Free Countries

Several countries – including those certified polio-free – reported an increased risk of polio infection in vulnerable populations, caused by COVID-impeded vaccination campaigns.

Malaysia is a country that was declared polio-free in 2000, however it warned that delays in vaccination campaigns pose a risk to newborns and migrants. The representative said that the GPEI and international organisations need to assist countries to “address the issues of highly-mobile, cross-border populations.”

A representative from Iran cited a “growing concern due to illegal immigration” with neighbouring countries. Wild polioviruses still exist in Afghanistan, which sits along Iran’s eastern border, and experienced an outbreak of VDPV type 2 earlier this year.

The Malaysia representative also said: “Undocumented migrants are at an even greater risk of missing not only routine immunisation, but also polio vaccination campaigns. Efforts to address these marginalised populations will benefit polio control.”

Image Credits: UNICEF Ethiopia/Mulugeta Ayene 2018, WHO.

A doctor checks an x-ray of the lungs of a hospitalised boy with COVID-19.

What if every household in the world could diagnose coronavirus-triggered pneumonia from their home with a cheap handheld device?

We are not at this stage yet. But the Swiss-made Pneumoscope, an intelligent stethoscope that can diagnose pneumonia in seven minutes, is bringing this dream closer to reality, says Benissa Mohamed-Rida from the Pneumoscope initiative.

The device is one among a series of new portable and low-cost innovations that will be featured at the Geneva Health Forum which opens Monday, 16-18 November.

Why is This Important?

The three-day Forum brings together Swiss and European expertise with that of researchers and practitioners from low- and middle-income countries (LMICs) to explore problems on the cutting edge of global health, as well as innovative solutions.

While an overarching theme of the first-ever virtual of the Forum will naturally be COVID-19, the conference is covering a wide range of other topics – from big picture themes such as climate change and decolonising global health to nuts-and-bolts approaches to tackling cervical cancer or neglected tropical diseases.

The event is co-sponsored by the Geneva University Hospitals and the University of Geneva, in collaboration with Geneva International, WHO, UNAIDs and UNITAR.  It is expected to draw some 1,600 participants from 80 countries worldwide.

In addition, some 120 new health technologies will be showcased at a special GHF Innovation Fair, including the Pneumoscope. People registered to the GHF will be able to visit the online “exhibit” spaces at certain times every day to meet with the innovators and chat with them about their products.

A Pneumonia Diagnosis in Just Seven Minutes

The current Pneumoscope prototype can diagnose in just seven minutes common forms of pneumonia, one of the leading causes of death for children under five in low-income countries.  Although this diagnosis isn’t sufficiently fine-tuned [yet] to identify only COVID-19, it’s a hint at the direction such new technologies are heading.

“In times of a pandemic, public health professionals are on the lookout for cost-effective strategies to promote diagnosis and disease prevention, not only in low-resource settings,” notes Mohamed-Rida, a Paris-based medical doctor who is working with the Swiss-based Pneumoscope Initiative. “If we can be precise in the laterality of pneumonia, there is no need to do an x-ray, so insurance companies will want to pay for the Pneumoscope, even in high-income countries.”

The Pneumoscope Initiative is being led by Geneva University Hospitals and the University of Geneva, in collaboration with the Swiss Ecole Polytechnique Federale Lausanne (EPFL) and Terre des Hommes, a global NGO.

The Smart Scope, an Indian invention that can detect cervical cancer in under 10 minutes.

Among the many other innovations on display will be the Indian-designed Smart Scope, an award-winning portable device that can detect cervical cancer, the second largest killer of women in India after breast cancer.

They are just two examples of the many low-cost health technologies that are emerging out of the “reverse innovation” spirit of entrepreneurs looking to turn resource scarcity into a virtue.

Such devices are potential deal breakers in LMICs, where a lack of more sophisticated x-ray and laboratory infrastructure and trained healthcare workers, means that many preventable diseases, including pneumonia and cervical cancer, slip past our radar.

How Does it Work? Think Shazam

Just like a song that can be recognised through apps like Shazam, respiratory diseases also have their own acoustic “signature”. And they can be recognised by artificial intelligence (AI), with the help of a smartphone or tablet, at a surprisingly high accuracy.

Working from this principle, the Pneumoscope can tease apart a healthy lung from a diseased one at a sensitivity of almost 100%, according to a preliminary case-control study that compared children under 5 years of age with pneumonia to healthy children.

In comparison to commonly used tools to diagnose pneumonia like the WHO/UNICEF case management algorithm, the Pneumoscope is twice as accurate, says Mohammed-Rida. Currently, the algorithm developed by UNICEF/WHO misses every second child with pneumonia, which is ‘simply not good enough’, he adds.

But there’s more. The Pneumoscope can also tease apart viral pneumonia from bacterial pneumonia almost 90% of the time.

That means that it could help address another important issue – unnecessary prescription of antibiotics. In low-income countries, given the scarcity of effective diagnostics, antibiotics are often prescribed when a child is sick with pneumonia – even though they may have a viral infection – and this contributes over time to drug resistance.

In addition, the device can potentially diagnose severe bouts of asthma, the leading chronic disease in children that affects almost 340 million people worldwide. Preliminary results are ‘quite promising’, says Mohammed-Rida, noting that the Pneumoscope picks up asthma’s acoustic signatures 90% of the time, according to preliminary trials that are still unpublished.

The device is currently being field tested in Burkina Faso, Morocco, Brazil, Cameroon and Senegal.

Not a Rolex

The Pneumoscope is designed to withstand a range of extreme conditions, including deserts with scorching temperatures as hot as 50 °C, as well as humid environments and rain.

“The Pneumoscope can’t be a Rolex,” says Mohamed-Rida. “It has to withstand extreme conditions, especially heat and humidity, as well as sand, which clogs up electronics and renders them unusable.”

Although its price remains to be determined, its cost-effectiveness ratio is likely to be “quite interesting”, says Mohammed-Rida. The group is working to manufacture it locally in LMICs through 3D printing.

Reverse Innovation

Because it doesn’t need lots of technical training to use, it’s particularly well-suited for LMICs, where pneumonia is five times more common than in rich countries.

But there may be appetite for the Pneumoscope in high-income countries as well, especially during the pandemic, says Mohammed-Rida. Precisely because such devices save time and money – and may even be more accurate – they often infiltrate upward into more affluent countries – a process some call “reverse innovation.”

Notably, since the Pneumosocope can also detect which side of the lungs is infected, more formally known as the ‘laterality of disease’. it may be able to overcome the need for pricey x-rays.

“This could save overwhelmed healthcare systems tremendous amounts of money,” says Mohammed-Rida.

Image Credits: Keystone / EPA / Emanuele Valeri, Periwinkle Technologies.

Melinda Gates tells Paris Peace Forum that broad global access to COVID-19 vaccines is criticlal to  recovery

A series of new COVID-19 drug and vaccine funding commitments worth just over US$300 million were announced on Thursday by the Gates Foundation, France and the European Commission – amidst a quickening pace of anticipation that at least one, if not two, COVID-19 vaccines may soon become available. 

Appearing at the Paris Peace Forum, Melinda Gates announced a new $US 70 million contribution by the Bill and Melinda Gates Foundation to vaccine research and the ACT Accelerator’s COVAX facility. The WHO co-sponsored ACT Accelerator aims to ensure the worldwide distribution of forthcoming COVID vaccines, along with drugs and tests, to countries that can least afford to purchase them. 

“In this pandemic there is no difference in helping yourself and helping others,” said Gates. “But its not enough to have the right values, we have to put enough money behind our values,” said Gates.

She spoke at the Paris Peace Forum shortly after WHO published an urgent appeal for US $4.579 in immediate financing to the Accelerator’s various arms of support – which aim to cover worldwide procurement of not only vaccines, but also COVID-19 tests, treatments – and required health systems capacity.  Some $US 28 billion will be needed over the course of 2021, WHO warned, in a detailed investment case, published just hours before the Paris Peace Forum event. 

‘Urgent’ finance asks for COVID-19 drugs, diagnostics, vaccines and related health system capacity, published by WHO on 12 November 2020

Gates appeared at the Paris Peace Forum high-level event along with French President Emmanuel Macron, Norwegian Prime Minister Erna Solberg, European Commission President Ursula Von der Leyen, and Dr Tedros Adhanom Ghebreyesus, head of the World Health Organization.  Both the French President and the Von der Leyen also pledged another €100 million Euros each to the Act Accelerator vaccines, tests and treatments initiative. 

Macron also called upon global leaders to adopt an “Act-A Charter” to ensure that “regulatory and policies making COVID-19 products available for all people…if part of the planet is not safe, the entire planet will remain under threat,” he said.

Added von der Leyen, “If we have a COVID19 vaccine, we should have a common approach to give a fair share to everyone so the most vulnerable groups, the frontline workers and the healthcare workers are the ones that get it first.”

Macron’s proposal for a Charter was applauded by WHO’s Dr Tedros who said: “WHO welcomes the ACT-A Charter, which outlines the core principles of equity and fair allocation that align this landmark effort to ensure vaccines, diagnostics and therapeutics are allocated fairly as ‘global public goods’ and not private commodities.”

Meanwhile, however, Norway’s Solberg stressed that, “money talks” and what is needed is $US4.5 billion immediately – as well $US28 billion over the course of 2021 in order to fully fund all four pillars of the Act Accelerator’s activities.

She was referring to the new WHO “investment case” outlining “Urgent Priorities and Financing Requirements” for the ACT Accelerator initiative.  Solberg and other panelists pointed out that the monies, while significant, are small in comparison to the economic costs of a continuing pandemic.  

The Act Accelerator’s $US 28.3 billion ask includes: $US 5.3 billion for COVID tests;  $US 6.1 billion for drugs and other therapeutics; $US 7.8 billion for vaccines; and $US 9.1 billion for upgrading health systems to make it all happen, states the investment case.

Act Accelerator Therapeutics Pillar
ACT Accelerator Vaccine Pillar
Act Accelerator Diagnostics Pillar
Act Accelerator Health Systems Pillar

The Access to COVID-19 (Act) Accelerator is a collaboration  between WHO and the GAVI Vaccine Alliance, the Global Fund, Gates Foundation, The Wellcome Trust, FIND diagnostics, Unitaid and the Oslo-based Coalition for Epidemic Preparedness Innovations (CEPI). It is acting on four pillars – that aim to ensure worldwide access to COVID drugs, vaccines, tests and health services.

“Our goal is to accelerate the development of COVID vaccines and ensure people in all countries get rapid and equitable access regardless of their ability to pay, said Seth Berkley, CEO of GAVI, also speaking about the Accelerator at the Paris Peace Forum.

Generic Drug Manufacturers Pledge To Collaborate With Medicines Patent Pool 

Meanwhile, a coalition of 18 of the world’s largest generic drug manufacturers pledged to work with the Geneva-based non-profit Medicines Patent Pool (MPP) to expedite delivery of the latest COVID-19 drug solutions, including monoclonal antibodies to low- and middle-income countries.  

“We strongly believe that collaboration is the only way we can make it past this pandemic. Each of us stands ready to contribute to the fight against COVID-19 through our technical expertise and longstanding experience in manufacturing and distribution of quality-assured medicines,” states the pledge, signed by the leading generics manufacturers such as Adcock Ingram, Celltrion, Sun Pharma, Natco and others. 

“This unprecedented cooperation from companies that are typically competitors represents a breakthrough in our efforts to level the playing field for access to drugs that will be crucial to controlling and defeating this pandemic,” said Charles Gore, Executive Director of MPP, in a press release. “These are companies with an excellent track record of working with originators to ensure generic versions of their innovations meet high standards for quality—while answering the need for more affordable, accessible therapies.”

Gore noted that collectively the 18 companies that have so far joined the  “open pledge”  have the capacity to deliver huge amounts of conventional drugs, technically known as “small molecules” in industry parlance.  They also have a growing capacity to produce cutting-edge “biologics,” or drugs based on the chemistry of living, biological compounds. Promising COVID-19 biologics include monoclonal antibodies targeting COVID-19 that are currently in clinical trials, and have shown potential for either treating or prevent viral infections such as COVID-10. However, their cost and manufacturing capacity pose substantial barriers to deploying them globally. 

Gore said he hopes the pledge by such a respected group of generic industry players to produce large volumes of high-quality COVID-19 treatments will encourage firms now developing either new or re-purposed therapies to negotiate agreements allowing rapid access to those in need. This can be either through licensing of their intellectual property, or where licences are not needed, facilitating ways to scale up manufacturing capacity to meet the high demands.

Charles Gore, Executive Director, Medicines Patent Pool

MPP was created in 2010 by the global health initiative Unitaid to negotiate license agreements for the generic manufacture of patented drug products of critical importance to health-care systems in low and middle income countries – vastly easing the process for generic drug manufacturers.  Beginning with HIV and Hepatitis C drugs, MPP’s mandate had recently expanded to include other treatments, most recently COVID-19 therapeutics. 

World Health Assembly Sees Debate on WTO Patent Waiver Proposals – Affirmation by Pharma of “Equitable Access”

In a separate statement, the International Federation of Pharmaceutical Manufacturers and Associations and the International Generic and Biosimilar Medicines Association, declared their “shared commitment to equitable acccess to COVID-19 medicines and vaccines” – adding that the pandemic has also highlighted the “importance of ensuring adequate resources are spent to build stronger, more resilient health systems that can cope with complex health challenges.”

The statement, coincided with this week’s World Health Assembly, which saw a wide-ranging discussion of the COVID-19 pandemic, including fears expressed by low- and middle-income WHO member states that their countries could be left out of the COVID-19 vaccine sweepstakes – as rich countries snap up huge pre-order supplies of those products most likely to come first to market.

To address those concerns, South Africa and India have already jointly proposed an IP “waiver” at the World Trade Organization on patents, copyrights and trade secrets for COVID-related health products – covering not only drugs, tests and vaccines, but also hospital supplies like respirator and protective gear.   The “waiver” proposal has, however, so far failed to make headway against rich countries’ objections. And the proposal was subject to considerable pushback again at this week’s WHA from high-income countries, including the United States and the United Kingdom.

Meanwhile, WHO has tried to promote a “third way” including a C-Tap initiative that would mimic the successful Medicines Patent Pool approach, but for a wider array of COVID-19 products, particularly vaccines.  So far, however, that WHO-led effort does not seem to have gained much ground. That appeared even more evident on Thursday in the news that MPP is now building an alliance with generic drug manufacturers to negotiate patent pooling deals over key COVID drugs – in a format that is more predictable and familiar to industry partners.

Overall, the trends have frustrated medicines access advocates who protest the notion that public monies will be spent to buy pharma products that were also financed, in part, by public “Lofty rhetoric on global public goods and solidarity in the COVID-19 response has not been matched by concrete action on the sharing of know-how and intellectual property rights to facilitate deep technology transfer,” said Knowledge Ecology International’s representative, Thiru Balasubramaniam, during the WHA debate. At the minimum, he said public funders of COVID-19 R&D, such as governments and philanthropies should “use their financial leverage to enable the sharing of know-how, cell lines and rights in data and patents, for COVID-19 related technologies.”

Along with tried-and-true MPP approaches, the mood at the Paris Peace Forum made it clear that European leaders are trying to cut a path forward in the marketplace to ensure universal access to whatever the world needs to recover from COVID-19.

Rather than upending the established legal order at WTO or anywhere else, the approach is to leverage huge loans and donations to buy cutting-edge vaccines, drugs and tests as they come to market – but in coordinated, large scale deals that would at least be more affordable.

And that, may be the other bottom line of the US$28 billion Ask.

 

Image Credits: Paris Peace Forum , WHO , WHO , WHOI , MPP.

WHO Financing by Regional Major Office

Despite nearly two years of internal restructuring, WHO’s budget at its Geneva headquarters is still twice the amount spent in all 54 countries of the Organization’s African Region, said the African bloc of stated at Wednesday’s World Health Assembly. 

Speaking on behalf of the African bloc, Seychelles noted that the most recent WHO financial report highlights the continued trend of disproportionate spending in its Geneva headquarters in comparison to the Organization’s six regional offices and nearly 100 country offices. 

Under a “transformation” plan announced by Director General Tedros Adhanom Ghebreyesus in 2019 WHO Regional and Country offices, which are maintained in the countries of most low- and middle-income WHO member states, are supposed to be assuming a greater leadership role – with more resources allocated to their needs. 

But as of end 2020, more of the $US3.7 million annual budget is still being spent at WHO headquarters than anywhere else — including Africa, where WHO teams desperately need more funds to tackle problems associated with the continent’s high disease burden and systemically weak national health systems. 

“Apportionment of funds to Headquarters remains higher than other regions,” said the Seychelles representative, speaking on behalf of the African bloc during a review of WHO’s 2020-21 biennial budget. “It is twice higher than apportionment to Africa which has weak health systems and burdens. There is the need to shift resources from WHO HQ to where the health issues are, and more can be achieved,” the spokesperson concluded. 

Rich Countries Call for Greater Investment in Primary Health Care and NCDs 

Meanwhile, countries ranging from Japan to China and Norway have enjoined the WHO to commit more resources to the prioritisation of universal health coverage and combating the non-communicable diseases – which are a growing problem in poor as well as rich countries today.

Japan’s delegate noted that efforts should be made towards ensuring that finance and health ministers of member countries are able to collaborate in order to ensure mutual understanding of national and global health financing priorities, especially in countries that are struggling to meet their financial commitments to the WHO.

For the WHO, Japan also urged the global health body to strengthen accountability and enshrine transparency more deeply into its operations. It also called for an independent assessment to ascertain resources were being deployed and used in the most efficient way. 

The delegate for the People’s Republic of China added that funding gaps exist in non-communicable diseases and such gaps will only be closed when member countries of the WHO pay their contributions on time.

LMIC Member States Decry Negative Impact of COVID-19 on their Ability to Contribute to WHO

Although WHO’s leadership has also called upon member states to step up to the bat with larger and more predictable funding, Member States said they are already having a hard time paying the current annual assessments to WHO – as a result of the pandemic’s economic fallout. 

Argentina cited COVID-19 as reason for its delay in paying annual assessed fees to WHO – but pledged to fulfill its commitments. 

“We are making our payment. We’ve made partial contributions for 2019 and we hope to meet pending balances,” the country’s representative said. 

Wars and civil conflicts have also compounded pandemic problems for some countries. Libya’s delegate, for instance, pointed to the suspension of oil extraction activities, the country’s major source of revenue generation. 

“Hostilities have halted oil production but we are working with Tunisia to work out an arrangement. By the end of 2020, we hope to have resumed oil production again and we are asking for global solidarity,” Libya’s representative said. 

Funding Shortfalls Constrain Operations 

Funding for the WHO has been a recurring topic at the World Health Assembly. 

In his opening remarks on Monday, Dr Tedros said that WHO’s member states need to step up to the bat. 

Dr Tedros Adhanom Ghebreyesus, WHO Director General.

Right now, regular  “assessed contributions” comprise only 20% of the organization’s budget, and that is a diminishing proportion. The bulk of the money comes from additional voluntary funding provided by countries and other donors. But ‘earmarking’ of those funds often constrains WHO’s ability to spend money according to its own defined priorities. .   

“Predictable and sustainable funding remains one of the fundamental challenges for the future success of this Organization. For WHO to do its job, we must address the shocking and expanding imbalance between assessed contributions and voluntary, largely earmarked funds,” the DG said.

Over the past decade, Dr Tedros said, the world’s expectations of WHO have grown dramatically, but the organisation’s budget has barely grown at all. Those expectations, he said, will only continue to increase in the wake of the COVID-19 pandemic.

“Our annual budget is equivalent to what the world spends on tobacco products every single day. If the world can send that much money up in smoke every day on products that maim and kill, surely it can find the funds – and the political will – to invest in promoting and protecting the health of the world’s people,” the DG added.

Too Dependent on Handful of Donors 

Tedros also has admitted that WHO is too dependent on a handful of large donors, and there is need to broaden the donor base overall. 

WHO funding by fund type and contributor

 

To that end, he last year announced the creation of the WHO Foundation. The Foundation can draw funds directly from the private sector and individual donors – something that WHO’s strict conflict-of-interest rules generally prevent.   

However less than a year after those moves were put in motion, the COVID-19 pandemic hit – vividly illustrating the shortcomings between expectations and delivery of the WHO’s emergency response in a number of arenas.  

Particularly evident was the slow scientific response to urgent issues like whether the virus was airborne or not, whether masks were useful, and whether or not travel restrictions would help curb the spreading pandemic. 

While some of the delays may have been due to the conservative nature of WHO – which simply re-issued the same kind of travel and public hygiene advice that had been a standard for other epidemics – it was also blamed on a lack of in-house scientific know-how.  

In July, an announcement by the US Administration that it would withdraw its funding – which comprises some 15% of the Organization’s operations, including a significant proportion of resources that go to the African Region and the WHO Health Emergencies Programme. 

The shock has prompted a rethinking among European donors, led by Germany, about how to improve WHO’s budget and make it more sustainable over time. 

Speaking Monday at the resumed 73rd WHA, on behalf of the European Union, German health minister Jens Spahn said the COVID-19 pandemic had highlighted “a gap between WHO‘s 194 member states’ expectations and requests vis-à-vis the organization and its de facto capacities to fulfill them.” 

Jens Spahn, Federal Minister of Health, Germany, speaking at the WHA.
Pockets of Poverty 

While there is a drive to bolster scientific staff and expertise presumably at headquarters in the wake of the pandemic, the underfunded WHO regional and country offices of the low and middle-income countries are also a big donor concern. 

At a WHA debate over the budget, extending over Tuesday and Wednesday, another German WHA delegate  acknowledged the “pockets of poverty” that are often seen in specific programmes or WHO offices. 

Each year, again and again … with a déjà vu we see pockets of poverty — so specific programs that have not received adequate funding,” the official said of the assembly. “Within the last 10 years, many options have been explored in order to change the situation but the financing challenge has not been properly addressed.” 

But another problem, said the delegate, is that information provided by WHO, which informs WHA members’ debate, is “often not adequately grounded on a thorough analysis. We are discussing earmarked versus flexible, predictable versus non-predictable funding. But we never discuss what the consequences and implications are for WHO to perform.”

As a way forward, Germany has now proposed placing an item on sustainable financing on the agenda of the January 2021 WHO Executive Board – the next meeting of WHO’s 33-member governing body. The “ask” from donors is that WHO provide a coherent account here of its  current financial state – and how it affects its capacity to deliver, and what realistic needs it has – as well as alternatives for expanding the overall pool of donors – and money.

 

Image Credits: WHO, WHO.

Hypertension, an NCD that can be prevented through monitoring and early diagnosis

Norway will contribute an additional 133 million USD (1.2 billion NOK) to reduce the burden of non-communicable diseases (NCDs) in low-income countries from 2020 to 2024, the Ministry of International Development announced today. 

The announcement comes in the wake of last year’s path-blazing strategy for how to tackle the growing NCD burden in LMICs, “Better Health, Better Life”. The strategy was the first by an  international donor country to address health risks that are an increasing factor in deaths and disease in poor countries – where poor diets and degraded, unhealthy environments combine with a lack of access to standard NCD prevention and treatments. More than 15 million people under the age of 70 die every year from NCDs, with most of those under-70 deaths in low- and middle-income countries where people have less access to treatment.

Despite the growing burden, most donor assistance to developing countries remains focused on infectious diseases, including vaccine preventable diseases. While those risks can’t be discounted either, too many health programmes are often organized “vertically” so that even basic NCD services, like cervical cancer screening, are ignored. The intricate link between NCDs and infectious diseases has also become more apparent during the COVID-19 pandemic –  where NCD conditions increase the risk of becoming seriously ill or dying from the SARS-CoV-2 virus. 

“Norway is the first donor country with a strategy focusing on NCD-action in developing countries. I hope other donor countries will follow,” said Dag-Inge Ulstein. “There is a huge need for funding. Despite the enormous death burden in low- and middle- income countries, NCD efforts only receive between one and two per cent of all global health-related development aid. The funding gap comes with a consequence, and too often the victims are the most vulnerable.” 

World Health Assembly Discussion on Healthier Lives and Wellbeing 

The announcement coincides with discussions at the World Health Assembly gathering of its member states on a third pillar of the WHO’s strategy that aims to promote – Healthier Lives and Wellbeing. 

However, those discussions covering strategies for healthy ageing, food safety and nutrition… also are at risk of being eclipsed by the highly-politicized debates over the COVID-19 pandemic response and WHO reform.  

“We applaud Norway for prioritising NCD prevention and control within its poverty alleviation and sustainable social development priorities,” says Katie Dain, CEO of the NCD Alliance, in responding to the announcement.

 “Norway is walking the talk on the Sustainable Development Goals and has recognised the urgency for action on the global tsunami of NCDs. It is setting an important precedent for other OECD countries to follow.”  

Nina Renshaw, NCD Alliance Policy and Advocacy Director also adds: “Financing has long been the Achilles heel of the NCD response. The emphasis on ensuring sustainable financing for NCD prevention and control is particularly welcome. 

“We’ve been hearing throughout this week’s World Health Assembly that countries have the will to achieve Universal Health Coverage, (UHC) but need to mobilise the means, in increasingly challenging financial circumstances. That Norway is offering countries support to develop sustainable financing models and calling on other donors to join in to act on NCDs as a major cause of poverty, is a strong signal for others to invest.”

NCDs, including heart disease and hypertension, cancers, lung disease, diabetes, and mental health disorders cause more than 70% of all deaths worldwide. This means that far more people die from non-communicable diseases than from infectious diseases such as malaria, tuberculosis, polio, HIV/AIDS, and Ebola. And in developing countries, NCDs are a large and growing proportion of the disease burden. 

‘Worldwide, 41 million people die each year as a result of respiratory disease, cancer, cardiovascular disease, diabetes, mental disorders and other non-communicable diseases. This cannot continue,” said Ulstein when the Norwegian NCD strategy was first launched a year ago in Oslo.  

A 2019 panel at the launch of Norway’s new NCD-focused development strategy. (left-right) Maria Neira, WHO; Omnia El Omrani, (IFMSA); Mamka Anyona, UNICEF; Tiy Chung, CCA Coalition; Andrea Winkler, Centre for Global Health, the University of Oslo; Katie Dain, NCD Alliance.

“The NCD crisis has been ongoing for several decades. The death toll is rising year by year. NCDs are often chronic diseases, resulting in high health costs for individuals, families and societies. As is often the case, people in vulnerable situations bear the heaviest burden,” said Ulstein. 

And moreover, 86% of “premature” NCD-related deaths occur in low- and middle-income countries, where there is lack of awareness about prevention, and lack of access to diagnosis and treatment. These deaths will cost $7 trillion in economic losses over the next two decades.

Currently about 1-2% of global health-related assistance goes towards combating NCDs, or around $US 611 million. Bilateral donors (national governments or their development agencies) are the dominant source of funding in global health, but have been relatively absent in the field of NCDs until recently. 

Between 2010-2015, non-governmental organizations (NGOs) collectively provided more than twice as much aid for NCDs than bilateral donors, and considerably more than multilateral organizations such as the World Bank and the WHO. 

LMICs have been left to respond to increasing burdens of NCDs with their own scarce resources. Large-scale global efforts have the potential to save millions of lives and contribute to healthier populations and economic growth in LMICs. 

The Norwegian assistance will help fund activities around its three-point strategy: Strengthening primary health care; prevention targeting leading risk factors for NCDs, such as air pollution, tobacco and alcohol consumption, as well as unhealthy diets; and strengthening health information systems and other global public goods for health. 

Strengthening Primary Healthcare Services 

At the primary healthcare level, many NCD interventions can be delivered effectively and affordably, benefiting patients and savings for health systems. This can include checks for hypertension, diabetes, prevention of cervical cancer with HPV vaccination, as well as capacity for prevention and early diagnosis and treatment of mental health disorders in primary health services. Norway will support strengthening health services so that primary health care services are well-equipped to support NCD prevention, early diagnosis, and treatment.

Knowing your blood pressure supports NCD prevention, diagnosis, and early treatment.
Prevention Targeting Risk Factors for NCDs

Norway will support countries requesting assistance to improve taxation and regulation and regulation of products that are harmful to health through its Tax for Development Programme (Skatt for utvikling). These measures can be effectively used to discourage consumption of health-harmful products such as tobacco, alcohol, and sugary drinks. Pollution taxes and regulations can encourage shifts to clean energy and transport. All these are key risk factors that contribute to NCDs. 

Unhealthy, unregulated food is one risk factor for NCDs

Strengthening Health Systems 

The aim is to aid countries in developing better health information systems to improve access to health data critical for early stage NCD diagnosis treatment, supporting NCD-related health norms and standards, and will improve access to medical equipment and medication, especially in areas hit by crises and conflict. 

Together, these three points support the WHO Sustainable Development Goals (SDG) of reducing premature deaths from NCDs (SDG 3.4) by one-third by 2030 and Universal Health Coverage (SDG 3.8), and includes targets of reducing deaths from air pollution, strengthening tobacco control, and preventing harmful use of alcohol. 

Image Credits: icd 10/Flickr, Stine Loe Jenssen, John Campbell/Flickr, Sven Petersen/Flickr.