HIV-positive children can grow up healthy, thanks to the pioneering treatment interventions funded by PEPFAR and partners.

The failure of the US Congress to reauthorise a five-year budget for the world’s largest aid programme for global health, the US President’s Emergency Plan for AIDS Relief (PEPFAR), by its 30 September deadline doesn’t mean that it will automatically end – but without broad bipartisan support, it limps into an uncertain future. 

“In the short term, PEPFAR will be able to continue providing the lifesaving prevention, care, and treatment services in partnership with PEPFAR-supported countries,” said US State Department spokesperson Matthew Miller this week. 

“However, the fact that Congress did not reauthorize the program sends a message to partners around the world, especially in Africa, that we are backing down from our leadership in ending HIV/AIDS as a public health threat.”

Miller added while the Biden administration supported a five-year, “clean” PEPFAR reauthorization, the authorisation of certain programs has expired. 

“We’re still figuring out exactly what that means. There are some appropriations that have continued, so we’re going to work through it.  But the program can continue for now,” Miller told a press briefing.

As long as funds for PEPFAR are appropriated annually by Congress, the programme could continue without formal authorisation, according to Kaiser Family Foundation (KFF).

But this means that grantees would have to submit annual budgets rather than the more sustainable five-year programmes.

“Some requirements would ‘sunset’ if a reauthorisation bill is not passed,” according to KFF, which has identified seven requirements that would end after the 2023 financial year, and one that would end after the 2024 financial year.

A casualty of anti-abortion campaigning

PEPFAR was started by Republican president George W. Bush in 2003 and has enjoyed bipartisan support from both Republicans and Democrats until recently.

But in the past few months, there has been a concerted campaign to link PEPFAR grantees with the promotion and provision of abortion, despite US legislation making it unlawful for PEPFAR to fund or support abortion, and abortion being illegal in most African countries where it operates.

In May, a group of US influential right-wing groups claimed in a letter sent to Senate and Congress leaders that PEPFAR grantees “are using taxpayer funds to promote a radical sexual and reproductive health agenda”. Signatories include the Center for Family and Human Rights (C-FAM), the influential rightwing think-tank Heritage Foundation and the Dr James Dobson Family Institute.

A similar letter was sent on 6 June to the same US politicians by a group of conservative African politicians and religious leaders, mainly Catholics, claiming that PEPFAR “is supporting so-called family planning and reproductive health principles and practices, including abortion, that violate our core beliefs concerning life, family, and religion”.

Amongst the signatories were 10 Kenyan Members of Parliament, but last week the Speaker of Kenya’s Parliament distanced his institution from them, stating that the letter “is not the official position of the National Assembly”.

US Representative Chris Smith, who co-sponsored PEPFAR’s refinancing in 2018, has also joined its critics, claiming that the programme is being used to “promote abortion on demand”. 

Instead of reauthorising PEPFAR for five years, Smith proposed a one-year reauthorization of PEPFAR in the State, Foreign Operations, and Related Programs Appropriations Bill that was narrowly passed by the House of Representatives last Thursday night. 

The Bill adds strict anti-abortion clauses, slashes the foreign aid budget and is unlikely to be passed by the Democrat-dominated Senate.

US Congressional Representative Barbara Lee and PEPFAR head John Nkengasong.

‘Greatest act of humanity’

Dr John Nkengasong, who heads PEPFAR as the US Global AIDS Coordinator in the State Department’s Bureau for Global Health Security and Diplomacy, described PEPFAR as “the greatest act of humanity in the history of infectious diseases that has transformed the ugly face of HIV/ AIDS in Africa from hopelessness and helplessness to hopefulness”.

PEPFAR is estimated to have saved the lives of 25 million people since it was set up 20 years ago. According to UNAIDS, new HIV infections are almost 60% lower than their peak in 1995, while AIDS-related deaths are almost 70% lower since the peak in 2004 – and PEPFAR has played a major role in achieving this.

Around 30 million people now have access to antiretroviral treatment, while nine million still need access. In some African countries, over 90% of people living with HIV depend on PEPFAR funding for their treatment.

Nkengasong has also stated categorically that  “PEPFAR has never, will not ever, use that platform in supporting abortion”.

Dr Uche Ralph-Opara, Deputy Chief Health Officer for Project HOPE, an international organisation addressing global health crises, said that “lives are hanging in the balance”.

“As a public health expert and clinician who has witnessed the transformative power of PEPFAR on the ground, I can attest that without its continued authorization, we risk losing our hard-won gains in the fight against HIV/AIDS,” Ralph-Opara warned.

“From the global health perspective, PEPFAR is not just a program, it’s a lifeline for millions. Its absence would result in increased mortality rates, strained health systems, and certainly a setback in our collective efforts to achieve health for all.”

South African hospice Sister Vicky Sikhosana with a patient with AIDS in South Africa in 2007, before ARVs were available in Africa – a full decade after they were available in Western countries because of high costs.

Nkengasong also warned that PEPFAR’s gains are fragile

 “As a virologist, I will tell you this: if the 30 million people that are receiving [antiretroviral treatment] today stopped, within five weeks the virus will come back and within a couple of years they will start dying,” Nkengasong told the Annual Legislative Conference of the Congressional Black Caucus last week.

“Within a couple of years, [HIV] transmission becomes a global effect,  not just limited to Africa, and we will be all back again to 20 years ago. So the hundreds of billions we’ve invested in HIV goes into the drain and humanity suffers,” he added.

‘Not about abortion’

“PEPFAR is not about abortion but they’re trying to make it about abortion,” House of Representatives member Barbara Lee, the main negotiator for the five-year reauthorisation for the Democrats, told the Congressional Black Caucus conference.

Back in 2002, Lee was part of a group of Congressional Black Caucus members who approached Bush and urged him to address HIV and has been a PEPFAR champion since its inception a year later. 

She admitted that she had almost voted against PEPFAR initially because of some problematic elements including those related to abortion, but that ultimately the Democrats had resolved that they could work with it.

However, Lee said while working to ensure bipartisan support for PEPFAR’s current reauthorisation for another five years, “I have found pushback on the other side [amongst Republicans] big time in terms of, not only the money but also ‘why’ and for me that’s the moral disgrace of where we are right now”. 

She appealed to the faith community to galvanise support for PEPFAR: “We have to get back to some kind of sensible bipartisanship so that we can move forward and end HIV and AIDS by 2030”.

Power: ‘Manufactured controversy’

Meanwhile, USAID Administrator Samantha Power told the conference that “the manufactured controversy is making it difficult to get this clean reauthorization”, quoting a recent article in support of PEPFAR’s reauthorisation written by Bush, saying: “No programme is more pro-life than one that has saved more than 25 million lives”. 

“It’s more rare now to have things happen in a bipartisan way, but to have something stably, bipartisan for 20 years is a signal to all the countries in which we are working, that PEPFAR is here to stay,” Power added. 

She added that USAID staff had been able to go into health ministries of partner countries, confident that “bipartisanship puts [PEPFAR] on such a stable foundation that you can look beyond the next budget cycle.”

PEPFAR has invested some $110 billion in HIV prevention, treatment and care, which has had a huge impact on grantee countries’ health systems, including by increasing disease surveillance capacity, strengthening health services, and improving drug supply management. 

“I’m not sure there’s broad awareness of how much we relied on the PEPFAR infrastructure to tackle COVID-19,” added Power. 

“The PEPFAR tracing and the surveillance systems are ones that are being used for infectious diseases like Ebola and Marburg, or if there is a new COVID variant. The same individuals who transport HIV testing samples are the ones who transported COVID-19 samples. We used some of the same testing machines, some of the same laboratory capacities. When it came to the vaccination drive, it was our PEPFAR platform that was able to rapidly stand up… in getting those shots in arms.”

Goals almost within reach

UNAIDS Director Winnie Byanyima

“In many of the HIV high burden countries, which are in Africa, up to 95% of the funding for putting people on treatment and prevention is paid for by this programme,” according to Winnie Byanyima, head of UNAIDS, the United Nations agency on HIV/AIDS.

“These are countries that are so highly indebted that just the interest on their debt is four to five times as much as they are putting into their whole health systems, let alone for HIV,” Byanyima told a meeting organised by the Clinton Foundation on the sidelines of the UN General Assembly two weeks ago.

“This is not the time to stop PEPFAR. This is the time for the leadership in America to continue doing what it has done right and continue supporting countries to keep their people alive.”

Byanyima said that while the global goal of ending HIV by 2030 was achievable, “we have to have strong political leadership.”.

“It’s failing. We are in a world where the geopolitics have gone crazy and it’s hard to get leaders to stay committed to what they committed to long ago. 

“We need to follow the science to address the real epidemic in each country, not the epidemic they want to think they have, but to follow the scientific evidence,” she added, urging special attention to be paid to eliminating HIV transmission in most at-risk groups in Africa – women and girls, gay men and transgender women.

“Most people in Africa do not understand what we mean by reauthorisation and appropriation,” said Nkengasong. “These people say: ‘Well, it doesn’t mean that you will not get funding’. No, but it sends a signal and weakens our own foreign policy and diplomacy weakens our commitment to humanitarian efforts. Fighting HIV is not just a health issue for Africa. It’s a developmental issue and it’s a security issue.”

Image Credits: The Global Alliance to end AIDS in children, Kerry Cullinan.

Dr Hala Khudari, WHO Libya representative

The World Health Organization’s (WHO) Eastern Mediterranean region (EMRO) is struggling to address “an unprecedented number of health emergencies” driven by state fragility and conflict, climate-change-related extreme weather events, mass displacement and economic disparities”, regional director Dr Ahmed Al-Mandhari told a media briefing on Wednesday.

The most pressing immediate problems involve assisting Libya after its recent floods and addressing the humanitarian needs of people caught in the armed conflict in Sudan.

Dr Hala Khudari, an official from WHO’s Libya office, reported that 4,333 deaths had been recorded but that about 8,500 persons were still unaccounted for. Meanwhile, 101 health workers had died, including 25 specialists.

“The corpses are found in many places. Even yesterday and two days ago, there were corpses found about 250 kilometres off the beach, which shows the magnitude of this disaster,” said Khudari.

Even before Storm Daniel struck the country, a decade of conflict had taken its toll on Libya’s health system, with acute shortages of staff, medicines, equipment and medical technologies, according to the WHO.

Al-Mandhari said that “protracted armed conflicts have ravaged nine of the region’s 22 countries and territories, resulting in increased trauma, displacement and attacks on health care”, and 55% of world’s refugee population lived in the region.

“Nearly six months after the outbreak of war in Sudan, 70% of the country’s hospitals are not functional and malnutrition levels are soaring,” he added.

Next week, the EMRO region holds its regional conference where it will discuss the multiple crises and elect new leaders. 

Six candidates have made themselves available for election. Iraq has nominated pharmacologist Najim Abbas Jabir Al-Awwadi and Morocco has proposed former health minister Anass Doukkali. Pakistan has suggested health systems expert Abdul Ghaffar and Iran has put forward health policy professor Ali Akbari Sari.

Sudan has nominated its goodwill health ambassador Ahmed Farah Shadoul and Saudi Arabia has proposed the sole woman, clinical and public health specialist Hanan Hassan Balkhy.  If elected, she would be EMRO’s first-ever female regional director.

WGIHR co-chairs New Zealand’s Dr Ashley Bloomfield and Saudi Arabia’s Dr Abdullah M Assiri.

It’s likely to be a mad sprint to submit amendments to the International Health Regulations (IHR) by the World Health Assembly (WHA) next May, according to the working group overseeing this process, which is meeting for the fifth time this week.

Meanwhile, the Intergovernmental Negotiating Body (INB) is expected to release a new draft of the pandemic accord within the next few weeks following a flurry of meetings in September.  The new draft will be sent to member states ahead of the seventh meeting of the INB, which is set for 6-10 November, and resuming on 4-6 December 2023.

“When the 2005 International Health Regulations were negotiated and agreed, the final meeting finished on the weekend before the WHA started – at 4 am on a Saturday morning,” Dr Ashley Bloomfield, co-chair of the WGIHR, told the meeting on Monday.

While he hastened to add that the working group was “not intending to do that”, Bloomfield assured member states that they did not have to finish deliberations by January as they were not obliged to report to the World Health Organization’s (WHO) executive committee.

This followed an assurance by the WHO’s Principal Legal Officer, Steven Solomon, that there were no legal impediments to the WGIHR continuing negotiations up until the eve of the WHA, despite December being their last scheduled meeting.

The WGIHR could simply give the WHO DG a progress report by January, while a final text was still being negotiated, added Solomon.

Prioritise equity, Africa urges

The IHR are the only global rules that set down compulsory actions for countries once the WHO Director-General has declared that a disease outbreak is a “public health emergency of international concern (PHEIC)” – particularly in terms of reporting, surveillance and the domestic implementation of the IHR’s procedures.

However, the IHR failed to contain COVID-19, according to a damning report from the Independent Panel on Pandemic Preparedness and Response, which found that the IHR’s alert system “does not operate with sufficient speed when faced with a fast-moving respiratory pathogen” and the regulations are “a conservative instrument as currently constructed and serve to constrain rather than facilitate rapid action”.

As a result, the 2022 WHA resolved that the IHR should be amended. This resulted in a flood of over 300 proposed amendments from member states, which the WGIHR has been picking through, and has drawn up a compilation text.  Bloomfield, former Director General of Health in New Zealand, highlighted that equity, financing the response to health emergencies, and pathogen benefit-sharing are the most challenging areas.

Since the last WGIHR meeting in July, there have been briefings on the alert system for declaring a PHEIC, as well as pandemic financing together with INB members.

Kenya urges progress on equity clauses.

Kenya, on behalf of the 47 members of WHO’s Africa region, urged the working group to ensure “tangible progress on equity-related amendment proposals put forward by state parties to prevent escalation of PHEICs to pandemics by building the necessary capacities in countries”.

However, the Kenyan delegate noted that it appeared from the recent briefing on the system of declaring a PHEIC that “while the current alert system has been functioning well under the IHR, what was problematic during COVID-19 was the response, in particular actions related to equitable access to the health products and supplies.

“The PHEIC determination does not currently trigger a mechanism for the development, procurement and distribution of risk response measures such as diagnostics, medicines or vaccines.”

Meanwhile, South Africa called for equity clauses to be discussed first – while Saudi Arabia urged that clauses where there was agreement to be dealt with rapidly first.

Taking stock of progress

The meeting will take stock of progress on IHR articles previously considered. In the past week, the co-chairs have sent out new text proposals on Articles 4 (responsible authorities), 5 (surveillance), 9 (other reports), 10 (verification) and 48 and 49 (the Emergency Committee).

It will also consider Annex 2, which covers the “decision instrument for the assessment and notification of events”. Meanwhile,  informal consultations on Article 8 (consultation) and Article 11 (exchange of information) will also be considered in the WGIHR closed drafting session, which ends on Friday.

Meanwhile, the new draft of the pandemic accord comes following a series of informal meetings of the INB’s drafting group in September. These focused on some of the more contentious articles in the current Bureau text, namely  Articles 4 (pandemic prevention and public health surveillance),  5 (One Health), 9 (research and development), 11 (technology transfer) 12 (access and benefit-sharing) and 13 (supply chain and logistics). 

WHO Director Dr Tedros Adhanom Ghebreyesus announces the approval of a second malaria vaccine Monday.

The WHO has officially recommended a second malaria vaccine for children, the R21/Matrix-M, co-developed by researchers at Oxford University and the Serum Institute of India. Global rollout could greatly improve access to immnization against a disease that kills over 600,000 people a year, 96% in Africa.  But experts stress that vaccines can complement — but not replace — other malaria control strategies.

Nearly two years after the World Health Organisation (WHO) officially recommended the RTS,S malaria vaccine, the global health body on Monday approved a second vaccine, the R21/Matrix-M – whose clinical trial results have shown a high degree of efficacy in preventing serious malaria cases and deaths amongst children at risk. 

The WHO decision paves the way for a global rollout of a vaccine that could make a significant dent in the burden of malaria today – which mostly kills African children under the age of 5.

“The R21/Matrix-M malaria vaccine is an easily deployable vaccine that can be manufactured at mass scale and modest cost, enabling as many as hundreds of millions of doses to be supplied to countries which are suffering a significant malaria burden,” said the University of Oxford in press release. The Serum Institute of India has “already established production capacity for 100 million doses per annum, which will be doubled over the next two years.”

Speaking at a WHO press briefing, Dr Tedros Adhanom Ghebreyesus, WHO Director-General, noted that just as COVID-19 vaccines played important roles in getting the pandemic under control, RTS,S and R21/Matrix-M vaccines — which he described as safe and effective — are also giving the world new hope of bringing malaria, which is one of the oldest diseases known to humanity, under control.

The global health organisation’s recommendation was based on advice from two expert groups — the Strategic Advisory Group of Experts on immunisation (SAGE) and the Malaria Policy Advisory Group.

Phase III clinical trials of the R21 vaccination involved some 4,800 children in Burkina Faso, Kenya, Mali and Tanzania.

“Both groups reviewed evidence from the trials of the R21/Matrix-M vaccine, which showed that in areas with seasonal transmission, it reduced intermittent cases of malaria by 75% in the 12 months following a three-dose series of the vaccine; a fourth dose given a year after the third was shown to maintain protection,” the WHO Director General said.

When used in real-life settings in peak malaria season, both R21/Matrix-M and the RTS,S appear to perform similarly, he added, saying “It’s comparable with other recommended malaria interventions.”

While the Phase 3 clinical trials have shown the vaccine to be safe, safety monitoring will continue as the vaccine is rolled out on a wider said.

At a cost of between two and four US dollars a dose, the cost of the new vaccine is similar to that of the RTS,S. 

Reshaping the fight against malaria

R21 malaria vaccination clinical trial site in Kiwangwa, Tanzania – one of four African countries which hosted Phase 3 trials.

Welcoming the development, Gavi, The Vaccine Alliance said the vaccine can help reshape the fight against malaria, a disease that killed 619,000 people globally in 2021 with 96% of those deaths being in the Africa region, thus making the disease one of Africa’s biggest killers.

David Marlow, CEO of Gavi, described the announcement as another major step towards our goal of creating a malaria-free life for every child. The vaccine, along with the existing RTS,S vaccine, “will be an effective complement to existing malaria interventions.

The vaccine can “play a key role in meeting the high demand we are seeing in endemic countries,” Marlow added. 

Since 2000, malaria deaths have fallen by more than half, and the disease has been successfully eliminated from many parts of the world. But globally, progress has stalled with nearly half the world’s population remaining at risk of malaria. In 2021, there were an estimated 247 million cases of malaria, and 619,000 deaths with 95% of cases and deaths being in Africa — and mostly among children under five. 

Demand for the RTS,S vaccine far exceeds supply thus making the R21/Matrix-M vaccine a particularly important additional tool to protect more children faster, and to bring the world closer to the WHO’s vision of a “malaria-free world”, noted Tedros at the press briefing. 

Already being licensed in West Africa

Pre-immunisation interview for R21 malaria vaccine clinical trial candidate

The R21/Matrix-M malaria vaccine has already been licensed for use in Ghana, Nigeria and Burkina Faso – which opted to go ahead with deployment even before the formal WHO greenlight based on previously reported clinical trial results. 

“The R21/Matrix-M malaria vaccine has been shown to be safe and highly effective across multiple clinical studies and is now approved as WHO policy for widespread use. The vaccine is easily deployable, cost effective and affordable, ready for distribution in areas where it is needed most, with the potential to save hundreds of thousands of lives a year,” said Sir Adrian Hill, Director of Oxford’s Jenner Institute, where the vaccine was developed.

According to the institute, the vaccine recently reached the primary one-year endpoint in a pivotal large-scale Phase III clinical trial that included 4,800 children across Burkina Faso, Kenya, Mali and Tanzania. 

“The Phase III trial results are under peer review before publication,” the institute stated in its press release coinciding with the WHO announcement.

While the vaccine had a 75% efficacy when given just before high transmission season, WHO said, it had some waning of efficacy over the first year of follow-up at both seasonal and perennial transmission sites. But a booster dose restored efficacy at the seasonal sites with a vaccine efficacy over 18 months of 74%. 

An earlier Phase IIb clinical trial conducted in Burkina Faso also reported two-year efficacy and showed that a booster dose of the vaccine maintained high efficacy against malaria, meeting WHO’s Malaria Vaccine Technology Roadmap goal of a vaccine with at least 75% efficacy.

There has been some speculation over whether the new Oxford vaccine could ultimately be more effective than its predecessor.  However WHO said that experience to date shows similar performance in settings with high seasonal malaria transmission:

“The two WHO-recommended vaccines, R21 and RTS,S, have not been tested in a head-to-head trial,” WHO notedin a press release.  “There is no evidence to date showing one vaccine performs better than the other. The choice of product to be used in a country should be based on programmatic characteristics, vaccine supply, and vaccine affordability.”

Closing the gap between supply and demand

Dr Hanna Nohynek, Chair of SAGE

Speaking at the briefing, Dr Hanna Nohynek, Chair of SAGE, said malaria vaccines introduced widely have the potential to save tens of thousands of young lives each year. She added that the introduction of the vaccine should be done in the context of comprehensive malaria control efforts, and the vaccine can be used following a seasonal or age-based schedule as already described for RTS,S. 

“The availability of a second malaria vaccine is expected to close the gap between supply and demand, enabling broader and possibly unconstrained access,” the chair said.

Meanwhile, Serum Institute of India  said its doses are ready for wider roll-out almost immediately, with an expected production capacity of over 180 million doses per year. SII also confirmed it is collaborating with DEK Vaccines in Ghana to develop capacity to undertake fill-finish manufacturing in the country.

“The WHO recommendation and approval of the R21/Matrix-M vaccine marks a huge milestone on our journey to combat this life-threatening disease, showing what exactly can be achieved when the public and private sector, scientists and researchers, all work together towards a shared goal,” said Adar Poonawalla, CEO of the Serum Institute of India.

No silver bullet to end malaria

While commending the addition of the new vaccine to available malaria-control tools, there is no silver bullet to end the disease, Dr Michael Charles, CEO of the Roll Back Malaria Partnership noted.

“While this announcement is a step in the right direction, there are still major hurdles to overcome,” he said. “In the face of significant funding shortfalls and the growing threats of insecticide and drug resistance, and climate change – further investment must be urgently mobilised to scale-up, manufacture and roll-out malaria vaccines to ensure they are readily accessible to countries that decide to use them.” .

With countries facing different challenges, health ministries will need to determine how the two vaccines can complement their existing malaria control strategies. 

“This new vaccine will be highly effective to fight malaria, but must be used in tandem with other tools such as insecticide-treated nets, indoor residual spraying and preventive medicines to have the greatest impact,” Charles added.

Image Credits: Tom Wilkinson,/Oxford University, University of Oxford/Tom Wilkinson.

WHO is rushing emergency health supplies to refugees from Nagorno-Karabakh who have fled over the border to Armenia

WHO said it is racing emergency health supplies to Armenia, struggling to cope with over 100,000 refugees who have poured over the border from the ethnic Armenian enclave of Nagorno-Karabakh over the past 10 days. 

The enclave, controlled by an ethnic Armenian separatist group since 1994, was retaken by Azerbaijan in a lightning-style military campaign that began on 19 September and lasted about 24 hours.  

The Armenian government said Monday that 100,514 of the region’s estimated 120,000 residents have crossed into Armenia. Eyewitnesses said that the regions capital city, Stepanakert, was virtually deserted. 

In a press release, WHO said that it was rushing emergency health supplies to the Armenian Ministry of Health – to cope with the refugees’ arrival. It is the second such mass exodus event to be witnessed in Europe recently, following Russia’s invasion of Ukraine in February 2022. 

“WHO had already pre-positioned trauma supplies to Armenia,” said WHO’s Regional Director for Europe, Hans Kluge.  

“Following the dramatic explosion of a fuel depot along the route taken by those entering Armenia, WHO is dispatching burns kits to support the advanced care needed for severe burns patients,” Kluge said. He was referring to the massive fuel depot explosion on September 25 amid the exodus. The blast killed at least 170 people and injured 200 more.

“We’ve activated our emergency systems and will be sending experts to the country across a range of disciplines including mental health, burns management, essential health services, and emergency coordination following a full assessment of the needs. 

“To support the general health needs of the displaced population, WHO is also sending medicines for non-communicable diseases, that will cover 3 months of treatments for up to 50,000 persons,” Kluge added, saying “The challenges are truly enormous, and we’re there to do all we can.”

A WHO special envoy, Robb Butler, has also been dispatched to Armenia to assess more long term needs. 

“At the first major town the refugees are fleeing to, I saw an immense outpouring of solidarity from the local Armenian community and volunteers, who are doing all they can to provide food, water and shelter,” said Butler.

“But you see the despair on many of the faces of the displaced. They have left everything behind, their homes, their belongings, the graves of their loved ones. There are children, the elderly, women and girls with specific sexual and reproductive health needs. It’s clear that the mental and emotional scars the refugees carry will take time to heal. But it’s also obvious that the staggering speed with which this crisis is unfolding requires all hands on-deck – WHO, our UN partners, civil society organizations – to complement and support the government’s efforts. 

Image Credits: WHO/Nazik Armenakyan .

Germany’s Health Minister, Karl Lauterbach, and Minister for Economic Cooperation and Development, Svenja Schulze.

German Ministers urge more investment in the Pandemic Fund and universal health coverage at a high-level pandemic preparedness meeting 

Even if vaccines and medicines are developed at record speed to address the next ominous global pathogen, they cannot prevent a pandemic without strong health systems to deliver them, stressed politicians and health leaders at a meeting convened by Germany’s ministries of health and economic development.

Primary health care is the “basis” of all responses to disease outbreaks and crises, stressed Dr Mike Ryan, the World Health Organization’s (WHO) head of health emergencies at the Berlin meeting on pandemic preparedness on 28 September.

“The simple availability of a countermeasure is in no way a guarantee that they will be delivered to the people who need them,” said Ryan, pointing out that there were vaccines for many of the current global disease outbreaks – from measles to diphtheria.

Karl Lauterbach, Germany’s Federal Minister of Health, said that the annual cost of rolling out universal health coverage (UHC) was estimated to be $350 billion.

“Now everyone will think: ‘$350 billion, that’s enormous. Who’s going to pay for that?’ But on the other hand, we spend more than $7000 billion dollars for subsidies for fossil energy, which is only contributing toward climate change,” said Lauterbach.

“Wouldn’t it be a much better world if we cut a lot of our fossil energy subsidies and spend some of that money on universal health coverage? It would be definitely a more equitable world it would be a more just world and it would clearly also be safer,” he added.

Meanwhile, WHO Chief Scientist Jeremy Farrar, warned that “the pandemic will fade from memory, and if governments don’t find utility and value in what they’re investing in every Monday, every Tuesday, every September and October, then they won’t continue to invest in it. 

“So invest in the basic science, invest in people, invest in institutions, and make sure we build trust in institutions and make sure that they are part of our culture rather than something done in ivory towers by people in white coats,” Farrar urged the meeting, which was convened partly to take stock of what is needed to address future pandemics.

WHO Chief Scientist Jeremy Farrar.

Need for pandemic treaty to set mandatory rules

Lauterbach said that we may soon be  “living in the era of pandemics”, as warned by Farrar. This is being driven by biodiversity loss, which makes it increasingly possible for the “10,000 viruses harboured in animals” to infect people, and the “exponential increase in migration”, he explained.

To address the growing threats, the pandemic agreement currently being negotiated at the WHO needs to “have clearly defined responsibilities that are also mandatory” to maximise the “golden gap” between outbreaks and a pandemic, he urged.

He also expressed support for a “pathogen access benefit-sharing system”, one of the potential sticking points of the pandemic accord. African countries, in particular, want to be compensated for sharing information about pathogens while the pharmaceutical sector says this will slow the response to international outbreaks.

“Across the globe, people have come to realise that no one is safe until everybody is safe. But this is not only true for pandemic times. Health is literally a global public good that must be accessible to all people worldwide,” said Svenja Schulze, German Federal Minister for Economic Cooperation and Development, who co-hosted the meeting.

For Schulze, the pandemic treaty would provide “an international framework for communication and action, which creates trust and sets the rules”. 

“This will lay the ground for a swift exchange of data and a fair distribution of vaccines and medicines, and I hope that the agreement will be concluded as soon as next year because pandemic prevention will either work globally or not at all,” she said.

Pointing to outbreaks of dengue fever in parts of Europe as the world warmed up, Schulze, said that “as a result of climate change and globalisation, diseases are spreading to world regions that were previously unaffected”.

However, Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA), urged pandemic treaty negotiators to protect innovation and factor in pharma’s offer (in its Berlin Declaration) to make a percentage of pandemic goods to low-income countries in real-time.

IFPMA Director-General Thomas Cueni.

“Few people talk about the risk of failing,” added Cueni. “When you look at the vaccine situation pre-pandemic, three of the world’s largest vaccine manufacturers flopped…. We were lucky to have a pretty much unknown biotech company in Germany and another one in the US coming up with the mRNA vaccine, and the collaboration between Oxford University and AstraZeneca and also the Johnson and Johnson vaccine. 

“Eighty-five percent of the vaccines used by COVAX for the low-income countries in 2021 came from four innovative companies, which means when I look at the pandemic treaty negotiations, we really need to make sure that what worked – the innovation ecosystem,  which went back more than 20 years – is not compromised.”

Pointing out that low and middle-income countries were unable to get vaccines because the Indian government prevented the Serum Institute of India (SII) from exporting its generic vaccines, Cueni added that a joint partnership including the private sector needs to “focus on how can we improve diversity of vaccine manufacturing geographically”.

Germany ups emergency support, appeals for more Pandemic Fund resources 

Germany agreed last week to contribute a further €40 million to WHO’s work in health emergencies and also signed a long-term agreement to support the new Berlin-based WHO Hub for Pandemic and Epidemic Intelligence. With the new contribution, Germany has provided €53.5 million this year to support WHO’s response to more than 50 active health emergencies.

Meanwhile, Schulze said that the health sector could not build stronger health systems alone: “Development banks need to do their bit and that is why I have joined with other shareholders to initiate a reform of the World Bank. It must step up investments in global public goods, including in the health sector. Other development banks should do the same.”

She also appealed for stronger cooperation with the private sector, pointing out that Germany “is providing more than €550 million under the framework of a European national initiative to support efforts to develop [vaccine] production capacities in Africa, especially in Ghana, Rwanda, Senegal and South Africa”.

Schulze also appealed for other countries to support the Pandemic Fund, currently hosted by the World Bank. Germany is one of the biggest contributors to the fund.

Pandemic Action Network (PAN) co-founder Carolyn Reynolds described the Pandemic Fund as “one of the bright spots that have come out of the past three years in terms of global action”, but added that  $2 billion has been committed so far while $10.5 billion is needed a year to address gaps in pandemic preparedness.

“We can get there but it’s all about political results and leadership,” said Reynolds.

WHO’s Ryan pointed out that, before the pandemic, “106 countries had national action plans for public health security”. 

“They had gone through joint external evaluation they had done after action reviews, they had carried out exercises and simulations to test their system. They had identified the weaknesses in their system. Can you hazard a guess about how many of those plans got funding from the international community of the 106? Three,” said Ryan.

“Therein lies the seeds of the pandemic impact. Countries knew what was wrong. They knew what was missing. But we simply did not have the governance and financial architecture to change the dial. And we didn’t have the capacity to deliver the systems that were needed to make good on the needs of those plans.”

Mike Ryan (left) and Svenja Schulze, German Minister for Economic Cooperation and Development.

WHO officials welcome UN pandemic declaration

While Reynolds was disappointed by the lack of ​​”political resolve and call to action” at the recent United Nations (UN) High-Level Meeting on Pandemic Prevention, Preparedness and Response, Farrar and Ryan expressed support for the Political Declaration adopted by the meeting.

“Political declarations do matter,” said Farrar. “Try and achieve something global health without political support. You can’t. Does political support translate into action? No, not necessarily. And that’s why pushing the political class is so important.”

It’s the first time in the history of the United Nations that all member states came together and said anything about this, so I’ll take it,” said Ryan.

“World leaders came together. They’ve agreed to recognise the impact of the pandemic. They agreed to say: ‘We can never let this happen again.’ They’ve identified a number of areas in which we need to make progress. 

“Now, the ball is back with us. We’ve got the negotiations on the [pandemic] treaty, we’ve got the revision of the International Health Regulations. We’ve got the Pandemic Fund. We’ve got various initiatives through the G7,” said Ryan.

“I do think that next May [at the World Health Assembly], the countries of the world will come together, I hope, and there will be a solemn agreement between states that says in vernacular terms to the people of the world: ‘Never again’.”

European Union health ministers have not met to discuss the health workforce crisis since 2010.

BAD HOFGASTEIN, Austria — Belgium, which takes over the presidency of the Council of the European Union in January 2024, plans to make the healthcare workforce crisis a central item on its agenda, the first time the issue will be prioritized at the highest level of EU policymaking in over a decade.

“We are actively considering the health workforce and all the challenges around health workforces to be one of the main priorities of the Belgian presidency,” Lieven De Raedt, a strategic advisor on the international unit of the Belgian Federal Ministry of Health, told the European Health Forum in Gastein, Austria, on Thursday.

De Raedt stressed that the Belgian presidency’s agenda is not yet finalized, but confirmed to Health Policy Watch that Belgium will push for an ambitious approach to the future direction of EU health policy.

The Belgian presidency will aim to make the health workforce crisis “one of the main priorities at the EU level for the upcoming years and the next Commission”, De Raedt told the conference. 

Internal dialogues held by Belgian delegations with EU health ministers to determine the priorities of the country’s presidency of the Council of the European Union found that the health workforce crisis is the “main headache for basically all health ministers in the EU and in the WHO European region,” De Raedt said. 

“It is obvious that this is the main challenge in health policy,” he added. 

The clock is ticking on Europe’s health workforce crisis

De Raedt said Belgium aims to make the health workforce crisis a priority of its EU Council presidency.

A rapidly ageing population is putting increasing pressure on European health systems, as the bloc struggles to retain its current health workforce. Alarming numbers of health workers are fleeing to other sectors due to poor working conditions, low pay, and threats to their physical and mental health exacerbated by the strains of the COVID-19 pandemic.

The World Health Organization (WHO) has warned that Europe’s health workforce crisis is a “ticking time bomb”.

Countries in the WHO’s European region, which stretches from the United Kingdom to the plains of Kyrgyzstan and Tajikistan in Central Asia, currently face a shortfall of 1.8 million health workers, and that number is expected to double to 4 million by 2030.

Europe Is Struggling to Keep its Health Systems Afloat

“The number one problem is the health worker crisis we have here in Europe because there is no health without the health workforce,” Dr Hans Kluge, WHO regional director for Europe said on Wednesday. 

Young doctors on the frontlines of the crisis say the numbers bear out a stark reality on the ground facing healthcare workers who want to stay in the health workforce.

“The most important part for us is to retain our workforce,” Alvaro Cerame, chairperson for the Medical Workforce Committee of the European Junior Doctors Association (EJD), told Health Policy Watch. “Our generation does not only have to take care of our children, but because of the demographic changes, we also have to take care of our elders – and with fewer social support structures.”

A meeting of EU health ministers in 2010 saw the crisis coming

Header of the outcome document from 2010 meeting of European health ministers.

Thirteen years after a meeting of European Union health ministers warned of an impending crisis in the bloc’s health workforce, the situation has worsened as EU governments failed to act on the warning signs. 

The outcome document of a 2010 ministerial meeting – titled “Investing in Europe’s health workforce of tomorrow” – called on the bloc’s member states to “invest in sufficient, motivated and well-skilled health professionals in order to protect the viability and accessibility of health systems.”

EU health ministers have not convened to discuss the health workforce crisis since 2010, when Belgium last held the presidency of the EU Council.

While the EU has held consultations and launched projects on health worker migration, skills, empowerment, and workforce planning and forecasting in the years since that meeting, the bloc’s health workforce remains chronically underfunded.

The EU’s 2021 health budget, EU4Health, was the largest ever allocated to the sector, at €5.3 billion. But over half, €2.8 billion, is earmarked for DG HERA, the European Commission’s health emergency preparedness and response unit created to combat COVID-19. Most of this money has been spent on medical countermeasures against the virus such as vaccines.

A modest €2.5 billion is left for non-crisis health spending, with almost none of it going to the health workforce.

“The EU4Health program is €5.3 billion, and so far, only about €10 million has been spent on the health workforce, which is somewhere between 0.1% and 0.2%,” said De Raedt. He emphasized that his calculations are preliminary and do not reflect the official stance of the Belgian government.

Bulgaria produces the 15th most medical doctors in the WHO European region. The country ranks 31st in medical doctors per capita in the region.

EU underinvestment in health workforces stems from their long-held status as a national-level issue, rather than one for EU decision-makers in Brussels. This has left EU countries without a coordinated response to the health workforce crisis.

“Anytime we try to discuss this, at least from my experience, it always devolves into ‘this is a national competence’,” Sara Cerdas, a Portuguese medical doctor and MEP for the European Socialist party, told Health Policy Watch.

“Whereas, as I see it, we should have an EU approach on this because we cannot see 27 health systems in silos and then protect public health together.”

This has exacerbated the crisis in less developed EU countries, such as Bulgaria, which produces many doctors and nurses but loses them to richer countries within the bloc whose health systems can offer higher salaries. 

“It is a no-brainer that the health workforce is a public good across EU member states,” Josep Figueras, director of the European Health Observatory told Health Policy Watch. “If professionals can cross borders, we need to work together [because] unfortunately the migration is only going in one direction.”

Threats identified a decade ago fuelling today’s health workforce crisis

Percentage of doctors over the age of 55 in the WHO European region.

The 2010 ministerial meeting in La Hulpe, a leafy suburb on the outskirts of Brussels, predicted the outlines of Europe’s current health workforce crisis with astounding precision.

The outcome document warned of the urgent need to improve “forecasting future health workforce needs” through the collection of “high-quality and comparable data” across the EU.  

Today, this remains one of the bloc’s biggest blind spots, according to Sandra Gallina, Director General for Health and Food Safety at the European Commission.

“I am a numbers person, and I can tell you we need to improve the measuring of where we are, what we need and where we should be going,” Gallina said at a closed-door media briefing on Wednesday.

“We need to be better at planning and forecasting needs for the workforce – there are medical deserts already appearing,” she added, referring to geographic areas across the EU where people have limited or no access to healthcare services due to staffing shortages.

Another problem identified by the ministerial meeting – “the ageing of the population and of the health workforce” – has not gone away, either. 

Europe’s medical workforce is ageing at a staggering rate. Across Europe, the average doctor is over 55 years old. In 13 countries, at least 40% of doctors are over 55 and will retire within the next decade. Italy has the oldest medical workforce in Europe, with nearly 60% of doctors over 55. 

“That means that in the next few years, more than 40% of these doctors will be retiring,” Tomas Zapata, unit lead for health workforce and health services at WHO’s European Office said on Thursday. 

“That’s a tsunami of retirements,” said Zapata.

Doctors under mounting pressure 

A comic about the health workforce crisis produced by artists at the European Health Forum in Gastein, Austria.

As Europe’s doctors retire and burn out at a rapid pace, the remaining workforce is coming under increasing pressure.

Alvaro Cerame, the young Spanish doctor chairing the European Junior Doctors Association’s Medical Workforce Committee, said it is not uncommon for doctors who come in for 24-hour on-call shifts to continue working without a break up to 36 hours.

The 2010 meeting identified this problem as well, stressing the “importance of attractive working environments [and] working conditions” for “guaranteeing the quality and safety of the care provided”. 

This overstretched workforce is not only harming doctors, nurses, and other healthcare workers but also actively endangering patients.

“There is no doubt that when you work for so many hours — like in any sector — you will not be able to provide quality care, and it is going to put patients at risk,” Cerame said. “States and healthcare systems need to provide safe working conditions for healthcare workers and safe conditions for the patients who are in the healthcare system.”

Where are nurses and medical graduates going? 

Junior doctors are “starting to understand that they are not personally responsible for a failing system”, said Antanas Montvila, Vice-President of the European Junior Doctors Association.

The paradox of Europe’s health worker crisis is that there are more doctors, nurses, and other health workers than ever working in health systems across the region. 

The WHO European region has the most doctors and nurses per capita in the world. Over the past eight years, the region has seen an 8% increase in the density of doctors and a 12% increase in the density of nurses per capita.

But these impressive gains mask a hidden problem: nursing and medical school graduates are not staying in the workforce.

Despite a 37% increase in medical graduates and a 26% increase in nursing graduates in the WHO European region over the past decade, the number of healthcare workers has not kept pace with demand. In fact, Europe’s medical and nursing graduate output has outpaced workforce growth by 29% and 14%, respectively.

The gap is even wider than the WHO figures suggest, as Europe also imports a significant number of healthcare workers from lower-income countries in Africa and Asia. These workers face even bigger retention challenges due to migration policies and visa requirements.

So where are Europe’s medical and nursing graduates going?

“Nobody knows. We have around 30% [of graduates] that are missing somehow, people who are trained but not retained in the health care workforce,” Francisco Ribeiro Mourão, treasurer of the European Junior Doctors Association (EJD), told Health Policy Watch.

The EJD has been trying to fill this knowledge gap and will release a report on the European healthcare workforce next month. But for now, it remains unclear which sectors are gaining the nursing and medical graduates that the health workforce is losing.

“In Austria, for example, like 30% of medical students don’t enter the workforce,” Antatas Montvila, vice president of the EJD and a radiologist in Lithuania, told Health Policy Watch about the findings of the report.

The European Health Observatory’s Figueras cautioned that the report’s methodology and findings, which are not yet public, may require further analysis, telling Health Policy Watch that burnout and workforce migration are the likeliest causes for the gap identified in the report.

Whatever the cause, Europe’s front line doctors see a system that is failing them and their patients.

“According to our research and communicating with our members, we feel that these recent resignations were more or less like silent protests,” Montvila said. “The health system is failing, and it is extremely inefficient.”

“The previous generation, they will still tend to work overtime or in their free time,” Montvila concluded. “But I think that juniors are starting to understand that they are not personally responsible for a failing system.”

‘It’s democracy, man’ 

Sandra Gallina is the Director General for Health and Food Safety at the European Commission.

European Commission officials, health experts, and politicians say that the bloc has the tools to fix its health workforce crisis, but pressure from civil society and voters across Europe must increase if the issue is to rise to the top of the agenda.

“Member states need to ask the Commission, need to ask the elected politicians to push this agenda because the tools are there – it’s all there, it’s just political will, bloody political will,” said Figueras. 

“We need civil society, we need the press, we need a bottom-up push from member states for the EU to take [it] on,” Figueras added. 

Sara Cerdas, the Portuguese doctor and MEP, agreed that pressure from civil society is key, noting the dominance of direct messaging to EU politicians from lobbyists and interest groups compared to its citizens.

“There needs to be more pressure to discuss this at the EU level, and we cannot do that alone as politicians,” said Cerdas.

Gallina, one of the EU’s most senior health officials, echoed a similar sentiment on Wednesday, saying the EU is ready to take action.

“We are all watching this space,” said Gallina. “This is also a matter for voters and citizens to take into their hands.”

“It’s democracy, man,” Gallina said. 

Image Credits: Thijs ter Haar, EHFG.

Dr Muhammad Ali Pate

After working in prestigious international positions, Nigeria’s new health minister has returned to rebuild the health system of Africa’s most populous country.

Excitement turned to disappointment in the global health sector when Dr Muhammad Ali Pate was announced as CEO-designate of the global vaccine alliance, Gavi, then withdrew six weeks before assuming the position.

Pate was an ideal candidate with extensive experience in Africa and globally, including as Nigeria’s health minister, World Bank global director of the Health, Nutrition and Population Global Practice, and Professor of Public Health Leadership at Harvard Chan School of Public Health.

On 22 August, a few weeks after withdrawing from the Gavi position, Pate assumed office as Nigeria’s Coordinating Minister of Health and Social Welfare, a super-ministry that encompasses two huge portfolios – unlike back in 2011 when Pate was appointed as health minister.

A medical doctor trained in both internal medicine and infectious diseases as well as an MBA in health sector management, Pate is renowned for his contributions to combating infectious diseases and the field of public health financing.

Pate’s success rests heavily on his ability to reinvigorate the Nigerian system in Africa’s most populous nation with over 225 million people and numerous disease outbreaks.

In mid-2022, former president Muhammadu Buhari signed Nigeria’s National Health Insurance Authority Bill 2022 into law, declaring that it will provide health insurance coverage for all Nigerians. Buhari also signed new legislation to overhaul mental health care. 

In March 2022, The Lancet Nigeria Commission identified key barriers to optimal health in the country as “ineffective use of available resources, a dearth of robust population-level health and mortality data, insufficient financing for health and health care, sub-optimal deployment of available health funding to purchase health services, and large population inequities”.

Pate was one of the listed authors, which also reported that “about 40% of Nigerians live in poverty, in social conditions that create ill health, and with the ever-present risk of catastrophic expenditures from high out-of-pocket spending for health”.

“We propose an ambitious programme of healthcare reform to deliver a centrally determined, locally delivered health system,” the report declared.

“The goal of government should be to provide health insurance coverage for 83 million poor Nigerians who cannot afford to pay premiums. Implementation of a reinvigorated National Strategic Health Development Plan (NSHDP III) should be supported by structured and explicit approaches to ensure that federal, state and local governments deliver and are held accountable for non-delivery. NSHDP III should be supported by a ring-fenced budget and have a longer horizon of at least a decade during which common rules should apply to all parts of the system.”

Meanwhile, the Ibrahim Abubakar, lead author of the report, described consolidated health insurance as a viable option for solving some of Nigeria’s health financing challenges, based on the previous administration’s introduction of a health insurance law.

Immunization and health workforce

During Pate’s screening process by Nigerian lawmakers before being appointed minister, he stressed the need for the country to spend more on health: “Domestic financing represents the prioritization that we give to health. We’re not spending enough. Even with limited revenue, there is room to increase the allocation for health. Without doing it, inadvertently, we are outsourcing the prioritization of health to external actors.”

With many communicable diseases being entirely preventable with simple and inexpensive vaccines that only cost $1 to $2, Pate also said during the screening process that it is unfortunate that some regions in Nigeria have some of the worst immunization coverage in the world.

“Going forward, under the renewal agenda of the president, I’m pleading that we prioritize investments in health, and investments in the things that can prevent diseases that can protect our children who are the future of this country,” Pate told the lawmakers.

Regarding addressing the emigration of health workers, Pate said this would be tackled via a dual approach of improving the conditions of service: “We need to renew that contract within the context of health to make it more conducive to return the health workers that we produce, to deploy them effectively, to train them where needed and to give them the tools where they can work with those tools to serve.” 

He also pledged support for initiatives to attract the country’s health experts abroad to return to contribute their wealth of experience to improve the country’s health sector and health indices.

Outbreak preparedness 

Before Pate’s nomination, Salma Ibrahim Anas was appointed special adviser on health to the president. Anas said the current administration’s renewed hope aims to attain health for all through an efficient and effective universal health care coverage (UHC) system using the continuum model as contained in the sustainable development goals (SDGs) which Nigeria is committed to.

“The overall goal is to move Nigeria closer to universal health care coverage with a key focus on reducing the gap between those that are in need and those that use health services,” she added.

In addition to the UHC goals, Pate highlighted the need to improve Nigeria’s preparedness for future disease outbreaks which he said entails strengthening public health institutions and agencies, laboratory infrastructures, training frontline health workers and building public trust in health authorities. 

The country faces numerous health threats and outbreaks, the most recent being diphtheria outbreaks.

He also raised the need for Nigeria to prioritize building and expanding its strategic national stockpile of tools that could be in short supply or difficult to procure during global epidemics.

He also stressed the need for Nigeria to invest in “medical industrialization” so that local manufacturing of vaccines, drugs, and other pharmaceutical and medical products can grow in the country.

In an earlier interview, Pate told Health Policy Watch that medical industrialization is a policy that needs to be implemented to provide both the commodities needed and to create jobs.

“There’s a whole value chain in health. Health is not just about the commodities that we use, there’s an economic imperative as well, as we see in many other countries. There is the need to harness and unlock the market potential of the private sector in health, to manufacture, to produce and also to deliver services in terms of capital,” he said.

High hopes

Nigerian lawmaker, Senator Abdul Ningi, said that there is wide support for Pate’s appointment: “He is a minister to look out for because of his pedigree. I have no doubt that Prof Pate has come to add value to our nation.” .

Toyin Saraki, founder of the Wellbeing Foundation Africa and Global Health Ambassador for the WHO Foundation, described Pate’s latest position as an exceptional appointment. 

“With a track record of bridging gaps and evidence-driven actions and advocacy for equitable healthcare, Dr Pate is poised to bring about revolutionary changes in Nigeria’s healthcare system,” she said.

She expressed confidence that under Pate’s guidance, Nigeria’s health and social welfare sectors will “once again witness remarkable advancements, improved access to healthcare services, and a renewed focus on the wellbeing of every individual, shaping a brighter healthcare landscape for generations to come”.

WHO Western Pacific Regional Committee meeting at WPRO headquarters in Manila, Philippines.

The World Health Organization (WHO) is busy electing new leaders in three of its six regions.  Previous articles  have considered the issues at stake and the candidates competing for the position of regional director in WHO’s Eastern Mediterranean Regional Office (EMRO) and the South-East Asia Regional Office (SEARO). This article, the final one in the series, considers the dynamics at play in the Western Pacific Regional Office (WPRO), where member states will meet in Manila on 16-20 October to elect the region’s new director. 

 The election comes under strained circumstances with the dismissal in March 2023 of the previous regional director, Dr Takeshi Kasai, for  “abusive, racist, and unethical behaviour”. The decision by the region’s member states was a landmark because WHO is not historically known for its decisive approach towards staff misconduct following staff complaints and allegations. However,  under Director General Tedros’s zero-tolerance policy, a tougher stance is evident. 

 WPRO comprises 1.9 billion people in 37  countries and areas straddling a vast geography  from the steppes of North Asia to remote islands in the depths of the Pacific and icy Antarctic fringes.  For the past year, it has been under the interim leadership of former WHO Deputy Director General and European Regional Director, Dr Zsuzsanna Jakab.

 A far-flung region of rampant geopolitics

WHO’s WPRO region has tremendous geographic breadth, as well as deep political divisions and population diversity.

 The Western Pacific region covers 27 sovereign nations (Australia, Brunei, Cambodia, China, Cook Islands, Fiji, Japan, Kiribati, Lao, Malaysia, Marshall Islands, Micronesia, Mongolia,  Nauru, New Zealand, Niue, Palau, Papua New Guinea, Philippines, South Korea, Samoa, Singapore, Solomon Islands, Tonga, Tuvalu, Vanuatu, Vietnam. It also includes 10 territories administered by China (Hong Kong and Macau), France (New Caledonia, Wallis and Futuna, French Polynesia), New Zealand (Tokelau),  UK (Pitcairn Island) and US (Guam, Northern Mariana Islands).  

Then there is Taiwan’s paradox of  24 million people – larger than most WPRO members – but with no formal voice in the WPRO Regional Committee mechanisms, unlike, say, Pitcairn (population around 50).  Taiwan is excluded by decisions of WHO governance, and the Organization is at pains to avoid offending China. Even ad hoc Taiwanese participation in WHO technical events with Beijing’s permission has lessened as China asserts belligerent sovereignty.

Normally, the election of a regional director at a distant WHO outpost would not set the blood racing.  WPRO is different. Its Pacific rim is a region of  intense geopolitical competition as a repository of oil, gas, fish, and precious sea-bed resources coveted by regional and global powers. There is almost daily confrontation as  China contests the rights of others such as the Philippines, Canada, Japan and US to navigate the South and East China seas which are major international trade routes. 

China’s unilateral claims to large maritime territory have been rejected by international courts as also its occupation of islands belonging to others, construction of artificial islands, and even claims to submerged reefs. An assertive China  that sees the region as its own backyard is embroiled in territorial disputes with Japan, The Republic of Korea, Vietnam, Philippines, Brunei, and Malaysia.

Meanwhile, under WHO’s constitution, out-of-region powers that administer territories within the region vote on their behalf. Thus France, UK, and US  are part of WPRO’s 30 voting member states. They also happen to be allied with Australia, Japan, South Korea, and Philippines in an increasingly muscular security pact to counter China.

A WHO field staff talks to a woman fetching water from a water catchment tank in Kiribati, one of the Pacific Island nations threatened by climate change and sea level rise – while straddling regional geopolitical tensions.

Inevitably, the tiny Pacific island states – each with a precious vote in WHO fora – are caught in the middle. Ending a long period of neglect, they are being showered with economic largesse and other inducements. The Solomon Islands have already joined the China camp and others such as Palau and Kiribati have been coerced to de-recognise Taiwan and agree to deals that advantage Beijing’s business and military interests. 

Climate change poses existential threats to small island states

SIDS
Small Island Developing States face unique and specific challenges and vulnerabilities.

There is a fearful existentialist underpinning. Rising sea levels from climate change may mean that some island states will disappear in coming decades. Where will their people go? Most would prefer to make new lives in the United States or Australia rather than in China.

Why should such power games affect the  small matter of an election in the branch office of a technical body? It is because health is securitised in geopolitics.  Human health and access to essential supplies to sustain it contributes to the strength of nations and is an area of intense competition.  

This is evident with the  still-continuing controversy into the origins of the Covid-19 pandemic, and China’s refusal to share information with WHO or allow unhindered investigatory access.  That came after earlier accusations against China for covering up the spread of SARS. Avian influenza also originated in China, and with massive environmental and climate changes underway in the region, further pandemic-potential organisms are expected to originate there. Will China cooperate better in future pandemics?  

 With trust among nations at an all-time low, an additional concern is bio-insecurity through the weaponisation of disease-causing organisms, with uncontrolled artificial intelligence accelerating their development. With China and US glaring at  each other across the Pacific, the international framework of law that could block such sinister developments is badly frayed. A new health security race is underway.

 Who wants to run WPRO?

WPRO’s Dr Takeshi Kasai, who began his term as WPRO Regional Director in 2019, and was dismissed in March 2023.  Five contenders are running to replace him.

Following Kasai’s dismissal in March, there are now five contenders for the regional directorship.

 Dr Song Li of China,  is a respected practitioner and influential advocate for reproductive, maternal and child health at home and abroad, participating in strategic WHO fora along the way. Her career has seen her focused in this area without apparent wider public health orientation. 

 Dr Song Li is quietly professional but will China refrain from influencing her so that she can function genuinely independently? Chinese incumbents in international organisations often remain under obligation to their own authorities, and can even be summoned home if they displease their masters.

 Dr Susan Mercado of the Philippines is also a dual citizen of the United States.  She is passionate about public and global health with extensive experience in government in policy and legislative support roles. During COVID-19, she acted as a strategic advisor to the Red Cross in Asia and also worked for 15 years in WPRO itself where she was involved in change management.  Recipient of many awards, her work has spanned food systems, anti-tobacco advocacy, climate change, AIDS, COVID-19, mental health, NCDs, emergency health, health communications, and capacity building

 Dr Jimmie Rodgers of the Solomon Islands, an ally of China, has public health qualifications, and strong diplomatic, organisational and management skills. He led the Secretariat of the South Pacific Community with commendations from many countries, and latterly as Secretary to the Prime Minister, including competently handling COVID-19.   He accepts his lack of Asia experience but counters, in his own words, that his wife is Chinese which ensures that he is “exposed to and is well-schooled in Asian culture” which will be an “advantage” in WPRO.

Dr Saia Ma’u Piukala of Tonga is its health minister, having also held portfolios in public enterprises, and internal affairs, after an early surgical career. He chairs the Pacific Ministers of Health Group and is also experienced in WHO governance, having served on its Executive Board, WPRO’s Regional Committee, and High-Level Commission on NCDs.

Dr Tran Thi Giang Huong of Vietnam has a public health and health emergencies background. Currently serving as divisional director at WPRO she was a major player in the region’s Covid-19 response. She has previously worked in senior roles in the Ministry of Health handling international co-operation, after a career in paediatrics.  

Will a good election process be enough?

 WPRO is alone among the three regional offices in holding an open forum where candidates presented themselves and faced questions from electors. Reviewing that and the written applications, Mercado appears to have won the hustings through the scope of her experience, her understanding of issues, her vision and deliverables, and the empathy and fluency of her communications.

 However, all acquitted themselves well and the region is fortunate to have a diverse slate of credible contenders of both genders. There is also general consensus on the region’s needs,  including changing the toxic culture of the regional office. The desired health policies and strategies to tackle ageing, non-communicable diseases and mental illness, climate change and disasters, new infectious threats and anti-microbial resistance, finishing off old conditions and advancing universal health coverage are not contentious despite the diversity of size, culture and development status of WPRO’s membership.

And WPRO’s feverish geopolitics suggest that the technical merits of the candidates as reflected in their CVs and applications may not be enough in deciding on the best appointment. Perhaps the region is best served by a regional director who can rise above and bridge the divisions among nations while holding firm to fundamental WHO principles for advancing the health of all.

 That requires strong moral and political leadership to defend humanity against looming risks and dangers. Will that be asking too much?

Mukesh Kapila

Mukesh Kapila is a physician and public health specialist who has worked in 120 countries, including as a former United Nations (UN) Resident and Humanitarian Coordinator in Sudan and a UN Special Adviser in Afghanistan.

Image Credits: WHO /WPRO, WHO/WPRO , WHO / Yoshi Shimizu, WHO.

Europe’s health systems are facing a perfect storm of challenges, with a post-COVID budget crunch, ageing population and health workforce crisis threatening long-term stability.

BAD HOFGASTEIN, Austria – European health systems, among the best-funded and most equitable in the world, face a barrage of threats to their long-term stability, highlighting the difficulty of achieving and maintaining universal health coverage even in the world’s wealthiest regions.

Experts and political leaders from across the World Health Organization’s (WHO) European region are gathered at the annual European Health Forum meeting in the idyllic resort town of Bad Hofgastein, Austria, this week to debate how to navigate Europe through the labyrinth of threats to the universal health care enjoyed by most of its citizens.

A rapidly ageing population, growing healthcare worker shortages, underinvestment in health systems and external shocks such as climate change and inflation driven by the Russian invasion of Ukraine are putting Europe’s healthcare systems through a battery of stress tests as the bloc looks to move on from the COVID-19 pandemic.

The threats faced by health systems of the European Union are shared across the WHO European region, which includes non-EU Scandinavian countries, Switzerland, the United Kingdom, Turkey, Russia and former Soviet Republics.

“The time is ticking on climate, the time is ticking on demographics, and on sustainability in economic terms,” said Sandra Gallina, Director General for Health and Food Safety at the European Commission. “We are talking about very sophisticated [health] systems … now we need to somehow make them sustainable.”

Post-COVID budget crunch threatens health systems

Christopher Fearne, Malta’s Deputy Prime Minister and Health Minister, was the President of the 73rd World Health Assembly.

The European Union is moving on from the COVID era, but the end of crisis legislation is threatening to create a new set of crises of its own.

During the COVID-19 emergency, EU countries were granted the flexibility to spend beyond the 3.5% annual budget spending deficit mandated by the bloc, allowing countries with strong and weak healthcare systems alike to spend as they saw fit to respond to the virus.

That leniency is set to end on December 31, 2023, and as governments face massive cuts to overall public spending, health is likely to be one of the first items on the chopping block.

“Coupled with inflation and shrinking economies, governments have much less to spend and will have much less leeway with the budgets than they have now,” said Christopher Fearne, deputy prime minister of Malta and Europe’s longest-serving health minister. “The biggest victim of all of this could very well be health.”

Fearne is one of many European Union health ministers who will need to cut back on health spending if the bloc’s rigid budgetary rules are put back in place come January.

“The budgets member states will present to the [EU] Commission in October of this year are already starting to reflect this,” said Fearne. “Government spending will have to come down drastically, and of course, health is going to be one of the spheres which will be impacted.”

But Fearne and his fellow ministers argue there is a clear solution: count health as an investment, not a cost against national budgets.

“We need to look at this question of whether health spending should be reflected in the national budgets – at the moment, it is,” said Fearne. “This means next year governments are going to be very, very, very, very tight with spending.”

Government budget cuts are poised to deliver a shock to the health sector, which is already grappling with the new costs of climate change and the ongoing cost-of-living crisis. Efforts to decarbonize national health systems are also likely to be deprioritized as governments triage increasingly scarce funding.

Health experts warn that the cuts could have a devastating impact on the quality of care for Europeans. Longer wait times, reduced access to services, and a decline in the quality of care are all likely consequences of the cuts.

If public spending on health across the bloc falls, Fearne warned, the door will be left open for private industry to step into the vacuum in Europe’s health sector, with unpredictable results.

The EU health budget passed in 2021 earmarked a record €5.4 billion for spending on health – 11 times the amount apportioned in the previous budget for the 2014-2020 period.

Budgets still consider health a cost, not an investment

Sandra Gallina is the Director General for Health and Food Safety at the European Commission.

In principle, European Commission officials such as Gallina agree with the notion of health as an investment.

“People started to believe a bit more in the words ‘investing in health’: that health is not a cost, but is an investment,” Gallina said, discussing the evolving attitudes of EU officials during the COVID-19 crisis. “Now, not all believe in it, but I believe that [among] a fair share of the actors around me, meaning the people that in the end decide … there was a paradigm shift.”

However, Gallina was more measured in her response to concerns about the pressure on the budget of smaller EU member states raised by Fearne on Wednesday, clarifying that “no promises” could be made that health might be exempted from the budget crunch.

“Budget discipline is budget discipline,” Gallina said. “The only gloomy part I have in my toolbox is that I need to find sustainability soon, meaning economic viability which is good for the budgets of member states.”

Gallina added that Europe needs to find a way to balance the need for financial sustainability with maintaining the high-quality public health system that is, and should remain, a key pillar of the EU’s identity. She held up the heavily privatized healthcare system in the United States, which she had just visited after attending the United Nations General Assembly in New York City last week, as an example of what she does not want for Europe.

“Europe is a good place and we need to protect it,” she said. “We need to not let it erode and arrive at a different reality which is not Europe.”

Dr Hans Kluge, director of the World Health Organization’s European Region, warned that the historic rise in economic inequality amid record profits for private corporations is undermining the resilience of health systems in Europe and around the world.

“We have never seen that extreme poverty and extreme wealth have risen simultaneously and sharply,” said Kluge. “We see giant corporations paying almost no, or few taxes, having unimaginable benefits, while for the first time in recent history, we have more and more children going to bed in the evening with a hungry stomach in the richest countries in our region.”

“Our region is not the disaster-resilient region it used to be,” he said.

Europe’s health workforce crisis: a ‘ticking time bomb’ 

Despite having more doctors, nurses, and primary care workers than ever before, Europe faces a paradox: the shortage of health workers is growing, is larger than it has been in decades, and is still worsening.

Today, the World Health Organization’s 53-member European region is short an estimated 1.8 million health workers. That number is expected to climb to 4 million by 2030 if nothing is done to correct its course.

“The number one problem is the health worker crisis we have here in Europe because there is no health without the health workforce,” said Kluge. “We are facing a ticking time bomb.”

The COVID-19 pandemic exposed and exacerbated the deep-rooted problems facing Europe’s health workforce. Burnout, low pay, and dangerous working conditions are driving healthcare workers away from hospitals across the continent in droves.

Around 40% of healthcare workers are grappling with depression and anxiety, while 70% report feeling burned out, according to the ‘Time to Act’ WHO Europe report published last year.

Attrition rates among health workers are climbing, and as they do, more stress is placed on those who stay.

“Some steps have been taken, but not enough has been done,” said Alvaro Cerame, chairperson for the Medical Workforce Committee of the European Junior Doctors Association. “We need to be a political priority.”

Nearly 50,000 European health workers lost their lives to COVID-19. Those who survived the pandemic continue to struggle through high burdens from mental health, physical exhaustion, and the death of colleagues — from COVID or suicide — which make remaining on the frontlines unbearable for many.

“Let’s remember these are the brave souls who saved society on the frontline of the pandemic,” said Kluge. “The health providers I meet, they love what they do.”

“It is not a job, It’s a vocation,” he said. “The people leaving the workforce simply have no choice, and the despair I see is — truly, as a medical doctor myself — really heartbreaking.”

UK health worker strikes are a warning shot

Strikes across the UK’s National Health Service have resulted in over one million cancelled medical appointments to date.

Subpar pay and hazardous working conditions have sparked healthcare worker strikes across Europe. The ongoing strikes in the United Kingdom, which have snowballed into an uncontrollable crisis that just passed the bleak milestone of one million cancelled medical appointments, are a warning to other European countries of the consequences of neglecting their health workforce.

“There are strikes that then create huge issues, but it is not the moment of the strike that is important — it’s the long-term vision of where you get the staff and how we deal with staff shortages,” said Gallina. “We need to be better at planning and forecasting needs for the workforce.”

Europe’s doctors are also ageing out of work at an alarming rate, and the continent is not churning out enough new doctors to replace them. On average, 30% of doctors in Europe are over 55, and in 13 countries, at least 40% of doctors are over 55 and will retire within the next decade. Italy has the oldest medical workforce in Europe, with nearly 60% of doctors over the age of 55.

If more people in the health workforce today leave, the gap will grow into a gulf, with potentially disastrous consequences for healthcare quality and access.

“We need first to focus on retaining the health workers we already have because it takes a long time to produce more,” said Kluge. “So let’s retain and motivate the people we have by improving their working conditions and making the profession more attractive.”

Europe’s Aging Population: A Challenge for Healthcare

Percentage of medical doctors in WHO European region countries aged 55 and older, 2020 or latest.

Beyond Europe’s ageing doctors lies a more fundamental problem: a rapidly ageing population. As people live longer, they are more likely to develop chronic diseases, which can put a strain on healthcare resources.

The demographic shift has already prompted many European countries, including France, to raise the retirement age in order to correct budgetary imbalances that emerge when too few working people support a system of socialized healthcare and pension benefits.

While Europe’s demographic evolution towards an older society is inevitable, the solution over the long term, experts say, must be to reduce the pressure created by avoidable demands on the healthcare system in the first place. That means ensuring that more people enjoy more “healthy life years” through middle age and as they grow older.

This can be achieved through promoting health literacy and proactively combating avoidable health problems like obesity through education and awareness-raising, as well as tax, environment, and food policies that enable healthier choices and lifestyles.

“Expecting to turn a big tanker of more than 500 million people fast is not fair,” said Gallina. “[But] where we want to arrive is a future that is sustainable for everybody, where is no inequality within countries or within member states.”

Image Credits: EHFG, Chris Marchmant.