Panelists discuss the future of global health initiatives
From left: Katerini Storeng, Justice Nonvignon, Anders Nordström, and Mercy Mwangangi discuss the future of GHIs at a Geneva Graduate Institute event.

One of the world’s largest global health initiatives (GHI), vaccine alliance Gavi, started in a UNICEF basement with a staff of five people. Nearly 25 years later, Gavi has grown into one of the most influential players on the global health stage, driving progress on key global health challenges.

Yet several experts on global health finance contend that large non-UN multilateral health organizations like Gavi and Global Fund need to gradually turn more of their functions to countries – and devolve into less costly, more country-based institutions. 

The Geneva Graduate Institute hosted a frank conversation on the future of GHIs alongside the 77th World Health Assembly and Gavi and the Global Fund’s soon-to-be launched “replenishment” campaigns.

GHIs have been accused of fragmenting global health efforts, challenging the authority of the World Health Organization (WHO) and privileging donor and private-sector interests while evading accountability.

Remarkable achievement but little transparency

Graph of GAVI's vaccine portfolio
In the nearly 25 years their establishment, global health initiatives have continued to expand their mandates.

Gavi and the Global Fund, the largest of these GHIs, “really challenged the established ways of working through the World Health Organization, of the traditional multilateral system,” said Professor Katerini Storeng from the University of Oslo’s Centre for Development and the Environment. 

“They did so specifically by giving additional seats at the table to commercial companies, civil society organizations and to philanthropic foundations,” she said. 

This novel private-public partnership “fundamentally reshaped global health governance around private sector principles like innovation, technological solutions, and the protection of intellectual property rights,” said Storeng. 

Not only did GHIs introduce a private sector mentality to global health financing, but their model was “quickly embraced,” according to Storeng. One of the most recent examples of the application of the model was with the Gavi-directed global COVAX campaign during the COVID-19 pandemic.

However, Storeng noted that the pandemic reignited old debates, including around how these partnerships are dominated by a handful of powerful GHIs and “the apparent conflict of interest arising from the inclusion of for profit actors into formal institutions of global health governance.” 

Experts have reiterated calls for better coordination between global health partnerships and for their greater alignment with national health plans and priorities. While others have rejected such calls for incremental change asking for more radical reform or even present organizations to be together.

Three main developments have completely altered the GHI landscape, namely a shift towards bureaucratization, expanded mandates, and shifting cooperation with other partners, according to Antoine de Bengy Puyvallée, a PhD Fellow at University of Oslo’s Centre for Development and the Environment. 

GHIs have moved from being coalitions to completely separate organizations with increasingly broader missions. Furthermore, Puyvallée notes that budgets have grown “astronomically,” tripling from 2005 to 2015, meaning more staff and a greater physical footprint in the global health hotspot of Geneva.

Their CEOs are now public figures, and their missions now encompass a wide range of goals beyond their original mandates. Gavi, for example, has expanded its activities to include diagnostics not just vaccinations, noted Puyvallée. 

“You see this journey from vaccinating children to strengthening health systems,” he said. The problem with this growth, however, is the lack of accountability. “Are the boards in control?” 

Chart showing global health fund successes for malaria, TB, and HIV
While global health initiatives like the Global Fund have significantly contributed to global health successes, experts argue for increased self-reliance among GHI funding recipients.

“Moving forward it is wise to think of new ways to keep these partnerships accountable together – a coordination mechanism that goes beyond the traditional ways of being governed by their own boards – otherwise it’s very difficult for accountability,” concluded Puyvallée. 

The Global Fund says that its programs have saved 59 million lives since 2002, making significant strides in reducing deaths from HIV, TB, and malaria. Its 2022 numbers show that HIV prevention services increased by 22% compared to 2021, and the number of people diagnosed and treated for TB increased by 26%.

Calls for transparency and accountability

Making these GHIs more transparent and accountable requires five key strategic shifts, according to Mercy Mwangangi, director of Health Systems Strengthening at AMREF Health Africa, and former co-chair of the Future of Global Health Initiatives. 

These are: investing in primary healthcare, play a catalytic role in strengthening domestic resources, champion for equity when mandates are expanded, achieve strategic and operational coherence, and mobilize research and development. 

These five shifts were identified by the Lusaka Agenda, an international and multi-stakeholder dialogue. 

Mwangangi noted that the Global Fund and Gavi now have a joint partnership around malaria vaccine and health systems strengthening, but asked: “How do we ensure that these shifts lead to in-country implementation?” 

She stressed the need to keep country-level changes and implementation at the forefront through strengthened partnerships “otherwise we’ll just keep going round and round in circles.”

Mwangangi also called for the widespread adoption of the Lusaka Agenda to ensure that  countries have a bigger voice and agency in the GHI ecosystem, but was optimistic about GHI reform. 

“The boards have actually taken ownership of this issue and have shown interest in the Lusaka Agenda,” she added.

However, Anders Nordstrom, a founding member of the Global Fund and former WHO Director General, argued that there is much to do to improve the transparency and accountability of GHIs. 

“The board of the Global Fund should actually discuss the yearly results report. I mean, for business, that’s one of the core responsibilities of a board. You should approve the annual report. 

“That is not happening with the Global Fund. You approve the annual financial statement. There’s no link in between where you spent the money and the annual report. So in their annual report, there are no financial figures. And the annual report is very, very good, actually, but the board is not including it in discussion.”

Nordstrom went on to explain that if the boards do this, they could then “discuss the efficiency and effectiveness of the use of the money.” 

Self reliance and political responsibility

Africa CDC headquarters
Africa CDC in Addis Ababa, Ethiopia – is a promising way for countries to domestically invest in strengthening their health systems.

For countries historically on the receiving end of support from GHIs, there has been a growing concern about health systems independence. 

“Why should initiatives like Gavi buy our basic commodities?” asked Professor Justice Nonvignon, head of Health Economics Unit at Africa CDC and part of the University of Ghana’s Health Economics department. 

Nonvignon argued that countries like Ghana need to domestically fund more robust health efforts, and wean themselves off of dependency. 

Instead of a reliance on GHIs for basic needs, countries should provide domestic funds to buy these commodities, which range from syringes to drugs and vaccines, argued Nonvignon. 

These countries have the means to channel funding to health if they choose to prioritize it, added Nordstrom. 

“There are plenty of resources,” he said, noting that while working in Sierra Leone he was told that “it’s quite a rich country, plenty of diamonds and rare minerals. But where is that money?”

Mwangangi, who works closely with the Kenyan government, shared that it is incredibly difficult for African nations to transition off this dependency. 

“As long as there’s no sunset clause, as long as there’s no forced transition plans and more forced graduation plans, the Ministry of Finance will not move,” she said. 

Reducing reliance on aid, while difficult in the short-term, is a must, said Nonvignon, because it increases a country’s resilience and ability to act fast in an emergency. 

“Cholera is devastating huge populations across central and southern Africa. Where is the time to send a proposal to a fund based in Washington DC or in Geneva?” asked Nonvignon.

“Why is the Global Fund situated in Geneva and not in Nairobi? Why is the Global Fund not in Addis Ababa instead of Geneva? Because it gives a tremendous amount of power.”

In response, Nordstrom noted that much of the global health initiative ecosystem is highly political and “the power is not with the secretariat, it’s not with the directors, it’s with the governments that provide the funding.”

“I’m worried that we’ve got the epidemiology wrong… the majority of people are losing their lives to non-communicable diseases. And the global health partnerships and community are not addressing that at all,” he said, adding that the GHI community has also failed to include the effects of a changing climate. 

Sunsetting GHIs by 2030?

Nonvignon proposed sunsetting GHIs by 2030, because they have a “fundamental design flaw” in that they were established with no end date in mind. 

“We are beginning to see an increase in the desire of our member states [of Africa CDC] to  invest money…we need to push countries to take more responsibility.” 

He noted that the pandemic prompted countries to increase their domestic spending on health, which will increase their long-term financial sustainability but cautioning that reducing aid from GHIs should not mean that philanthropies fill in the gap. 

African countries must “step up,” through regional groupings such as the African Union, he added.

Putting the “onus” on countries themselves will help build global health independence – but countries need to domestically fund their own health efforts, said Mwangangi.

While a termination date for donors may seem drastic, it will at least create the space for conversation about the sustainability of GHIs, and the ability of countries to find their health financing footing.

 

Image Credits: S. Samantaroy/HPW, GAVI, The Global Fund, Africa CDC .

A health worker tests a patient for diabetes.

Like most African countries, non-communicable (NCDs) diseases, including diabetes, is increasing in Zimbabwe. And children are increasingly among the cases that go undetected or treatment until severe symptoms emerge. 

HARARE, Zimbabwe – Ten-year-old Tadisa Sayi already contends with diabetes and when his blood sugar levels spike his mother, Naume Shereketo, endures the mood swings induced by his condition.

Three years ago, Shereketo, a single mother of two, discovered the root cause of her son’s misery during a severe bout of illness.

“It was in 2021. He was weak and vomiting. When I went to the hospital with him, doctors told me he was diabetic,” Shereketo told Health Policy Watch.

“He always says: “Mama, I’m weak’, and some other time he is harsh,” said Shereketo.

Shereketo, a vegetable vendor on the streets of Harare, faces ballooning costs to attend to her son’s special dietary needs.

She struggles to provide the specific foods required for her son’s health. For Sayi, a grade four learner, fruit, vegetables, milk and high-fibre foods, have become a regular but costly part of his diet, costing his mother between $60 and $80 monthly.

Shereketo is puzzled about her son’s diabetes. No one else is diabetic in her family or the boy’s paternal side.

Dr Life Zambezi, the boy’s doctor, confirmed that Sayi had Type 1 diabetes, and said that this can be challenging to manage in young children due to limited support at the community level as well as the difficulty of maintaining strict insulin routines.

Type 1 diabetes, which causes glucose (sugar) in one’s blood to become too high, happens when a person’s body cannot produce a hormone called insulin that controls blood glucose.

Changes in diet also cause rise in Type 2 diabetes

While Type 1 diabetes is generally the result of a genetic condition, children also are being increasingly affected by Type 2 diabetes, as a result of changing diets and lifestyles, according to the UN children’s agency, UNICEF.

Type 2 diabetes typically develops as a result of sedentary lifestyles, obesity and unhealthy eating habits, Zambezi notes. While it’s on the rise in most African countries, and usually associated with adults, he’s seeing more such cases among children.

“Of late, children are also getting Type 2 diabetes, mainly caused by the changes in lifestyle. There is a rise in poor eating habits among children. In most cases they eat processed and unhealthy food leading to childhood obesity and eventually type 2 diabetes,” said Zambezi.  

But diabetic children like Sayi are too often only diagnosed only when they have developed a severe crisis, such as a diabetic coma.

“NCDs in children result from a combination of genetic, environmental and behavioural factors,” Health and Child Care Deputy Minister Dr John Mangwiro explained at the launch. “When a young child is diagnosed with a non-communicable disease, this implies long-term treatment.”

Dr Life Zambezi says that the high cost of insulin has made life miserable for people with diabetes, many of who cannot afford the life-saving medication.

Diabetes incidence in Zimbabwe soaring – although data remains spotty  

Approximately 537 million people worldwide are living with diabetes, according to the according to the International Diabetes Federation (IDF), an umbrella organisation of over 240 national diabetes associations in 160 countries and territories globally.  That includes 422 million people worldwide suffer from type 2 diabetes, the majority living in low- and middle-income countries, according to WHO, of the disease that kills 1.5 million people every year.

That includes approximately  106,400 adults in Zimbabwe living with diabetes Type 1 and 2, a prevalence of 1.5% in the adult population of about 7.1 million, according to the International Diabetes Federation (IDF), an umbrella organisation of national diabetes associations in 160 countries and territories.  

However,  IDF’s local member, the Zimbabwe Diabetic Association, says that’s a woeful underestimate. It estimates that as many as 10 out of every 100 people in Zimbabwe’s population of 17 million had diabetes, including children, as of 2017. But many cases go undiagnosed until the child or adult in question becomes seriously ill.

A 2014 meta-analysis also suggests diabetes incidence has grown exponentially. Prior to 1980, the prevalence of diabetes in Zimbabwe was just 0.44 %, while after 1980 the prevalence was 5.7 %, according to that systematic review. By 2018, prevalence was estimated at 8.5%, according to yet another study. 

As of 2016, Zimbabwe had the third highest estimated per-person cost of diabetes care in sub-Saharan Africa. Insulin’s exorbitant prices also cause many to miss out on essential medication, exacerbating their condition and long-term health risks, Zambezi said.  

Treatment at primary health care level is spotty

Treatment in primary health clinics remains spotty, the studies also suggests.  One small study comparing treatment in primary versus hospital facilities  in Harare, the capital city, found that more patients treated at hospital outpatient clinics ahd received some form of diabetes self-management education (DSME), and had higher levels of diabetes knowledge, as compared to those treated in primary care facilities.  At the same time, people who had consulted a dietician had the best levels of diabetes knowledge and self-care routines. 

“Dietitian-led interventions significantly improved both knowledge and practices, highlighting a need to scale up dietetic intervention, particularly in primary clinics where limited interventions occur,” concluded the July 2019 study led by a researchers at the University of Cape Town and the University of Zimbabwe’s  Department of Community Medicine.

“Though improvements have been made in self-management therapies, there seems to be a high prevalence of hospital admissions with relapse of symptoms in Zimbabwe. Relapse in diabetes predicts poor prognosis,” concluded another, 2021 study, led by the University of Zimbabwe’s Department of Nutrition.

Recognizing those gaps, UNICEF in 2022 launched an initiative in five countries including Zimbabwe, to focus on NCD prevention, detection, treatment and support, particularly in children and young adults.

As part of the grant, funded by the pharma firm, Eli Lilly, Zimbabwe’s Ministry of Health received $2.5 million to educate community health workers and increase support and understanding of various NCDs including diabetes in children.

Late detection and poor management results in adult complications 

Diagnosed with diabetes 20 years ago, 30-year-old Tariro Chiripanyanga is now contending with end-stage kidney disease as a result of poor management of her diabetes.

But until earlier detection and prompt treatment become more of the norm, many children will continue end up with severe complications in early adulthood, Zambezi observed.

One such case is Tariro Chiripanyanga. The youngest of four siblings, Chiripanyanga was diagnosed with Type 1 diabetes at the age of 10.

Today Chiripanyanga is now facing end-stage kidney disease, although she is only 30 years old.

“I was still too young to understand what it meant or how it would affect my life, but that’s when my life changed forever,” Chiripanyanga told Health Policy Watch.

Apart from living with diabetes since childhood, Chiripanyanga was diagnosed with kidney disease six years ago. She needs $30,000 for a kidney transplant, a financial burden neither she nor her family can bear. 

Chiripanyanga’s diabetes has already led to partial blindness, forcing her to drop out of university.

“My life depends on peritoneal dialysis which costs $1,750 monthly,” Chiripanyanga said. “I depend on dialysis until I can get money for a transplant which costs an estimated $30,000 in India.”

Image Credits: Muhidin Issa Michuzi, Jeffrey Moyo.

For many, access to assistive technology can enable independent everyday life.

Only one in five of the people in need of hearing aids and prostheses worldwide can access them, according to a new report by ATscale, a global partnership for assistive technologies and the Clinton Health Access Initiative (CHAI).

Assistive technology (AT) is any device and related systems that can help with everyday activities, improving or restoring the capabilities of a person’s body, ranging from eyeglasses, access ramps, prostheses or smartphones for functionalities such as the text-to-speech option.

The report, issued on the first-ever Day for Assistive Technology, aims to make assistive technology markets more transparent and easier to navigate for the public sector and producers. 

The hope is that comprehensive information will facilitate the choice of quality products, especially for governments in low- and middle-income countries, and encourage companies to expand their reach to new regions of operation, explained Pascal Bijleveld, CEO of ATscale in an interview for Health Policy Watch.

“It’s really about addressing one of the bottlenecks to access, which is the lack of transparency in the markets about what products are available, what are the price ranges, what’s the quality, and so on and so forth,” Bijleveld said.

Many governments lack the capacity to analyse and understand each of the markets and may make sub-optimal product choices.

It is also essential to raise awareness about the benefits of assistive technology and to start public and private initiatives to ensure more people, especially in low-income countries, can attain the AT they need. 

Large gap in access

Getting a AT of need is often the key to a more independent, full life for people with disabilities, unlocking a possibility to live independently, meet with family and friends, study, or work.

Globally, 2.5 billion people need at least one assistive product with the number expected to reach 3.5 billion by 2050 as the world population ages, WHO’s and UNICEF’s report shows. Even though 90% of people in need of an AT in high-income countries can access it, the number drops drastically to only 10% in low- and middle-income countries.

There is a nine-to-one return on investment from providing AT, thanks to unlocked educational outcomes, better paid employment and lower longer-term healthcare costs, an ATscale study from 2022 highlights.

The report systematically analyses markets for several most popular technologies: wheelchairs, glasses, augmentative communication, screen readers, and smartphones. 

Hearing aids, glasses and other assistive technologies can be prohibitively expensive. Taken for granted in wealthy countries, these simple technologies are out of reach for millions globally.

It lists the product types available, describes market specifics and enumerates some of the most important features. For hearing aids, for example, approximately 20 million units are sold annually, with the main market drivers being the ageing population. 

When picking the right device, it’s important to consider its ability to manage background noise and acoustic loops, its resilience against mild shocks, dust or rain, volume control and overall design. Those and other features are tested by several control agencies; to help navigate the market, the report provides a comprehensive list of producers and certificates held by their devices.

The report is only the first step, Bijleveld said and will be changed over the next couple of months into “a web-based platform that will be continuously updated”.

 Producers themselves will want to keep this interactive source of information up to date as a potential advertisement for their products and a guide to the overall market situation.

Raising awareness about the benefits of ATs is on the top of ATscale’s agenda. ”People need to get the word out there,” Bijleveld stressed.

Image Credits: CC.

Drug-resistant bacteria have developed from years of over-prescription of antibiotics.

With less than four months to the United Nations High-Level Meeting (HLM) on Antimicrobial Resistance (AMR), global leaders have proposed a variety of measures to address the growing threat of pathogens that are resistant to antibiotics.

The recently published zero draft of the political declaration for the meeting aims to reduce global deaths caused by bacterial AMR by 10% by 2030 (using 2019 as the baseline).

Mia Mottley, Prime Minister of Barbados and chairperson of the Global Leaders Group on AMR, called for “adequate, predictable and sustainable financing” to address the problem,  including financing for research and development for new antibiotics and the implementation of national action plans on AMR, especially in low- and middle-income countries. 

“Fundamentally, we must focus on prevention across all sectors – clean water, safe and effective sanitation, food security, infection prevention and control in all settings,” Mottley told a lunchtime roundtable during last week’s World Health Assembly.

Prime Minister of Barbados Mia Mottley, who chairs the Global Leaders Group on AMR

“I believe that we should establish an independent panel to monitor and report on the science and the evidence to facilitate collaborative and coordinated action against AMR,” She also called for the quadripartite joint secretariat on AMR to be formalised and adequately resourced. This is made up of the World Health Organization (WHO), the UN Food and Agriculture Organisation (FAO), UN Environment Programme (UNEP), and the World Organisation for Animal Health (WOAH).

The agricultural sector is responsible for the vast majority of antibiotic overuse, leading to drug resistance. 

Threatens to ‘unwind century of medical progress’

“In 2019, 1.3 million deaths resulted directly from bacterial AMR, more than two every minute,” WHO Director-General Dr Tedros Adhanom Ghebreyesus told the meeting.

“AMR threatens to unwind the century of medical progress and also threatens animal health, global food production, food security, and the environment.”

Dr Jean Kaseya, Director-General of Africa CDC, noted over one million deaths in Africa were associated with AMR and 250,000 caused by ARM. 

“Only 1.3% of our labs in Africa are able to perform bacterial resistance testing. It means this data that I’m sharing with you is an underrepresentation of the reality in Africa,” said Kaseya.

Four years ago, the African Union Assembly established a task force to control AMR and recommended that all member states implement national action plans.

“But less than 10% of a member states have national action plans that are fully funded and implemented,” he added.

Kaseya appealed to The Global Fund to expand its mandate from HIV, TB, and malaria to include AMR.

Professor Sally Davies, UK Special Envoy on AMR

Professor Sally Davies, the UK Special Envoy on AMR and a member of the Global Leaders Group, called for the high-level meeting to “truly address the needs of the most vulnerable communities, offering clear support to low and middle-income countries” that carry the greatest burden of this antibiotic emergency and need fair and equitable access to antibiotics and diagnostics.

Surviving AMR

Vanessa Carter developed a drug-resistant infection after a car crash cost her an eye.

South African Vanessa Carter, chair of WHO Taskforce of AMR Survivors, shared her nightmare of being unable to shake an infection after being seriously injured in a car crash in Johannesburg and losing her right eye. 

The infection turned out to be the drug-resistant Methicillin-resistant Staphylococcus aureus (MRSA). Hospital patients, people with wounds, and those who have surgery and medical devices implanted in their bodies are particularly at risk of MRSA.

Carter, who spent a month in hospital, had a prosthetic eye inserted and a number of surgeries.

“In my sixth year of surgeries, and my fourth prosthetic [eye], I went out shopping one day, I came back to the car and I felt moisture on my face. When I pulled down the rearview mirror, I saw this pus seeping out of the cheek of the prosthetic,” Carter told the roundtable meeting.

Her doctor told her she needed emergency surgery, but two weeks’ later the infection came back again.

“I was under the care of different types of specialists, an ENT surgeon, ophthalmologist, plastic surgeon, maxillofacial surgeon, each of them prescribing antibiotics during surgeries,” she added.

After almost a year of continued infections, doctors removed the prosthetic eye and sent it for testing and it was found to be contaminated with MRSA. What followed was a long and harrowing process during which the infection got into Carter’s bones before she was finally cured.

“I’ve been an advocate for the last 11 years and, most recently, we’ve established the WHO Task Force of AMR Survivors,” said Carter.

“Our biggest objective is to bring the human impact. When policy makers and members of the public understand exactly what it is, we can we can empower them. One of the documents we have worked on is a strategic technical guidance document for meaningful patient involvement. I would encourage you to go take a look at it.”

Votes to move to a secret ballot broke down along almost the same geopolitical lines – with 14 opponents (voting here) versus 17 supporters.

The World Health Organization (WHO) Executive Board on Tuesday voted to recognize the US-based Center for Reproductive Rights (CRR) as a non-state actor “in official relations” with it, in a motion carried by a narrow 17-13 margin, with four abstentions.

After multiple rounds of voting, the final vote was by way of a secret ballot.

The decision to grant WHO recognition to the Center, which supports access to sexual and reproductive health services, including abortion, was a hard-won victory for European, Asian and Latin American countries.  But the victory may be  short-lived.

Egypt, backed by a coalition of Middle Eastern and Islamic nations, as well as the 47-member WHO African Group, pledged to  “escalate” the issue to the World Health Assembly (WHA), a promise that it reaffirmed shortly after the vote in the WHO governing body, calling the vote a “politicization” of the global health body.

Egypt’s delegate to the EB (back left) pledges “to pursue” the controversial issue at the World Health Assembly.

“We would like to repeat what we have mentioned yesterday,” said Egypt’s delegate. “That we will pursue reopening of the discussions on this agenda item within the wider quorum of the organization during the upcoming WHA”.

He added that, at the national level, the decision ” is of no weight…  we will not abide by it, and will not consider it in any means”.

“Also, we will join the Russian Federation on their query, which is ‘how could we avoid the repetition of such unpleasant situation?’.. We need the good offices of the WHO in order to avoid the politicization of this organization as it has been experienced frequently in the past few days. “

“The text that was adopted today will not be implemented in Senegal, unless it is compatible with our laws, traditions and values,” said Senegal’s delegate, echoing sentiments expressed by Yemen, Kuwait, Somalia, and other member states in the post-vote discussion. 

National context still prevails

The Netherlands: WHO recognition of non-state actors does not commit member states where, “the national context prevails.”

Member states that supported the move by the 34-member governing body noted that other nations are in no way obliged to cooperate with the Center, or with any other non-state actor, which they oppose.

They stressed that the recognition was being extended solely by the WHO Secretariat, which maintains a wide network of official relations with over 200 non-state actors from civil society, industry federations and professional associations in line with a Framework for Engagement with Non-State Actors (FENSA) approved by the World Health Assembly in 2016.

The vote also awarded WHO recognition to a second non-state actor, Rare Diseases International, whose candidacy was never opposed by member states.

“The Framework of Engagement with Non State Actors (FENSA) is one of WHO normative guidelines, which has been negotiated and agreed by all member states,” The Netherlands pointed out.  “Questioning any non-state actor about its eligibility for admission into an official relationship with WHO after the organization passed the Secretariat’s criteria, undermines a great procedure and sets a harmful precedent for the future agreements.

However “the national context prevails over WHO engagements with non state actors,” she emphasized. 

FENSA framework is supposed to be neutral

The FENSA framework sets out a set of generic criteria for organizations “in official relations” to engage in collaborations with WHO, serve on technical groups and be recognized as “observers” with the right to speak at the annual WHA.

The aim of FENSA, which took years to negotiate and approve, was to create an even playing field in the much-coveted “official relations” designation that would side-step vested interests, particularly of industry or lobbying groups, that contravened WHO aims and priniciples.

Since the approval of FENSA, the handful of recommendations made by WHO each year to the Executive Board, to approve new NSA’s in official relations with WHA, or renew the terms of others, are usually just a matter of protocol, following WHO review and due diligence.

But there is growing pressure on the UN from socially conservative nations to roll back its activities on sexual and reproductive health in a period where many conservative nations still ban abortions, limit access to contraceptives and  criminalize the LGBTQI community.

Proposed WHO Recognition of Center for Reproductive Rights Provokes Storm at WHO Executive Board

As member states pointed out, the CRR has long been recognized by the UN’s Economic and Social Council (ECOSOC),  highlighting how the controversy over its recognition by WHO is a sign of the times, with intensive pushback not only in major powers such as the US and Russia, but also in international forums against the recognition of reproductive health rights long taken for granted in many societies.

Multiple votes are worrisome precedent for WHO governing body

Poland pledges to uphold the “consensus” around the FENSA framework for engagement with non-state actors.

For the EB members, themselves, the repeated votes, including by secret ballot, was yet another worrisome sign of the growing fracture between WHO member states in Europe, the Americas and Asia, which tend to identify themselves as socially and politically liberal, and developing nations in Africa as well as Russia, and the Middle East – where more conservative worldviews prevail.

The result, most member states agree, is the creeping “politicization” of global health agendas and issues. And while everyone also has a different point of view about what is political, it’s clear that it is leading to fewer decisions by consensus and more by lengthy, and often bitter, rounds of votes.

“After a record number of votes in the last week, we are alarmed by the notion that this is now becoming the default way to solve difficult issue,” said Poland’s delegate. “We would like to remind everyone that we adopted the FENSA by consensus, and we should respect it subtle equilibrium for the sake of our collective interests.

Matthew Wilson (center): “What you did was democracy”

“It is essential to preserve the independent, transparent, technical and evidence based role of the World Health Organization. We highly appreciate the efforts of the direct chair and other member states in trying to find a solution we could have all subscribed to. Poland remains committed to decision-making by consensus in this organization, and rejects the notion that the voting is now mainstream. We will spare no effort in supporting effective multilateralism and fostering consensus – with all due respect for different contexts of different countries.”

New EB Chair, Matthew Wilson, who sought to strike a more consensual note after the vote, declared: “What you did was democracy, and that’s not a bad thing.”

A baby gets vaccinated against polio thanks to su

With the first-ever malaria vaccines rolling out across Africa and a next-generation tuberculosis (TB) vaccine in testing, scientific advances are driving an unparalleled expansion of vaccine development. But vaccines in development don’t become immunizations that protect our health without concerted efforts by global initiatives like Gavi, the vaccine alliance, that help bring these life-saving products to the world’s poorest countries.

Next month, Gavi will kick-off a campaign to raise several billion dollars to deliver on its new strategy. The stakes are high: falling short of its target could delay delivery of vaccines to those most in need.

But amidst a rapidly changing global landscape, Gavi’s leadership and board must look inwards and seize the opportunity to reform by adjusting its operational model, addressing how it delivers vaccines in humanitarian and conflict settings, sustaining the impact of its investments, and aligning with other global health initiatives to respond to country priorities.

By Gavi’s own count, it has helped immunize more than a billion children since its launch in 2000. But underlying this remarkable impact is a stark reality: millions of women and children continue to miss out on vaccines. Perhaps most staggering is the fact that close to 15 million children around the world still do not receive basic childhood vaccines, leaving the poorest and most vulnerable susceptible to preventable diseases.

Significant gaps in accessing newer vaccines also exist. Only 20% of girls worldwide have received the human papillomavirus (HPV) vaccine, which protects against the leading cause of cervical cancer.

As Gavi’s leadership and board finalize a new strategy that will cement its priorities over the next five years, we urge attention to three areas to ensure that every child, everywhere, has access to vaccines. 

Rethink criteria for selecting countries

First, Gavi should update how it deems which countries receive support. Since its early days, Gavi has channeled financial support for immunization, based on national income per capita, to the poorest countries that also showed the biggest gaps in immunization access. The model is simple: if national income per capita is below the eligibility line, a country can receive full Gavi support; if it is above the line, then no support is given. But almost 25 years later, it’s time to refine how this works. 

 As a growing number of countries face economic headwinds and stagnating vaccination rates in the post-COVID era, Gavi needs to better match support with a country’s ability to pay for vaccines. And as new vaccines – including for TB – become available, Gavi’s model needs to align with the burden of leading infectious killers. 

As one case in point: four of the highest TB burden countries – India, Indonesia, China, and the Philippines – are no longer or were never eligible for Gavi support. But ironically, they are eligible for financial support for TB diagnosis and treatment from Gavi’s sister organization, The Global Fund for AIDS, TB, and Malaria. This policy mismatch could limit the impact of a new vaccine against a major infectious killer.

Invest more in vaccine delivery innovation

Second, Gavi should play a bigger role in scaling innovations to address the barriers that deter vaccine delivery. COVID-19 laid bare just how critical health systems infrastructure is to stopping disease outbreaks in their tracks. It also proved how useful innovations like digital immunization records can be in boosting vaccine uptake.

 With dedicated resources, Gavi can support partner countries to scale proven innovations for immunization systems they want and need. This could include solar panels for electrification of health clinics, unmanned drones for vaccine delivery, and digital immunization records.

While each of these innovations has been proven to work, Gavi’s investments would fill a critical gap in providing financing to scale, thereby leveraging at-risk early funding by other partners. Gavi’s track record in innovation, including financing mechanisms to scale new vaccine introductions, makes it well placed to do so.

Pilot new financing to ensure country control

Lastly, Gavi should pilot new ways to channel financing to partner countries that puts them in the driver’s seat and respond to national priorities. This is especially timely amidst growing calls to shift the center of gravity for decision-making to countries. 

How can this be achieved? One idea is for Gavi to test a new approach that provides a consolidated envelope of resources to each country, scaled to specific criteria including population size.

One portion could be dedicated to vaccine purchasing, enabling countries to base decisions on their own priorities. The second portion could be carved out for technical support and grants for health systems strengthening. With the 2030 deadline of the Sustainable Development Goals in sight, now is the time to experiment. 

Our collective ability to end the scourge of vaccine-preventable diseases is within reach. And Gavi – provided it is able to reform – remains one of our best bets to get there. At this crucial juncture, its leadership, board, and donors must ensure that Gavi has a fit-for-purpose model with adequate resources to deliver on the unfinished immunization agenda in a shifting global landscape.

Janeen Madan Keller is deputy director of the Global Health Policy Program and a Policy Fellow at the Center for Global Development (CGD), where she leads policy-oriented research focused on the economics of global health challenges. 

Orin Levine has worked to accelerate the introduction of, and access to, vaccines and other proven health interventions in low- and middle-income countries for the past 30 years. He served as a member of Gavi’s board for almost nine years, representing the Bill & Melinda Gates Foundation. He currently serves as a member of the Board on Global Health for the US National Academy of Medicine, and on the Board of Directors for the National Foundation for Infectious Diseases.

 

 

Image Credits: Gavi/Karel Prinsloo 2017, Gavi, the Vaccine Alliance.

WGIHR co-chairs Dr Ashley Bloomfield and Dr Abdullah Asiri and INB co-chair Precious Matsoso.

After two years of intensive negotiations – including long nights this week – the World Health Assembly (WHA) finally passed amendments to the International Health Regulations (IHR)  and committed to completing pandemic agreement talks within a year. 

After failing to agree on the amendments before WHA opened on Monday, member states have been racing to the finish in a drafting committee during this week in meetings that often went into the early hours.

“Tonight we have all won and the world has won. You have made the world safer,” said a hoarse WHO Director-General Dr Tedros Adhanom Ghebreyesus, who lost his voice during the late-night sessions.

The IHR is a legally binding international instrument aimed at preventing the international spread of disease, and requires countries to conduct surveillance for potential international health threats of all kinds and report those to WHO.

The COVID-19 pandemic showed weaknesses in the IHR, including that it did not mention “pandemic”. Member states submitted over 300 proposed amendments to the Working Group on Amendments to the IHR (WGIHR), chaired by New Zealand’s Dr Ashley Bloomfield and Dr Abdullah Asiri of Saudi Arabia.

“The amendments to the International Health Regulations will bolster countries’ ability to detect and respond to future outbreaks and pandemics by strengthening their own national capacities, and coordination between fellow states, on disease surveillance, information sharing and response,” said Tedros. 

WHI Director-General Dr Tedros Adhanom Ghebreyesus: Hoarse but happy

New ‘pandemic emergency’ defined

The amendments include the definition of a “pandemic emergency” – the highest level of alarm – that will trigger more effective international collaboration in response to a disease outbreak that may become a pandemic. 

“Solidarity and equity on strengthening access to medical products and financing” will be strengthened by a “coordinating financial mechanism” to help to “equitably address the needs and priorities of developing countries” to prevent, prepare and respond to pandemics

A States Parties Committee will be set up to facilitate the effective implementation of the amended Regulations, including the creation of National IHR Authorities to improve coordination of implementation of the Regulations within and among countries.

WHA President Dr Edwin Dikoloti strikes the gavel to indicate the passing of the IHR amendments and extension of the INB’s mandate.

“The experience of epidemics and pandemics, from Ebola and Zika to COVID-19 and mpox, showed us where we needed better public health surveillance, response and preparedness mechanisms around the world,” said Bloomfield, who also co-chaired the drafting group.

Countries also agreed to extend the mandate of the Intergovernmental Negotiating Body (INB) established in December 2021, to finish its work to negotiate a pandemic agreement by the World Health Assembly in 2025, or earlier if possible at a special session of the Health Assembly in 2024.

“There was a clear consensus amongst all member states on the need for a further instrument to help the world better fight a full-blown pandemic,” said Precious Matsoso of South Africa, co-chair of the INB and drafting group.

Credit to multilateralism

Member states generally expressed satisfaction with the final agreement, with the European Union and China describing it as proof of the success of multilateralism.

Ethiopian Health Minister Mekdes Daba, on behalf of Africa group, supports the IHR amendments and urges speedy adoption of pandemic agreement

However, Ethiopia’s Health Minister, Mekdes Daba – representing the 47 African member states and Egypt – urged all countries to use the momentum from the adoption of the IHR amendments to propel agreement on the pandemic accord. The INB meets again in July.

When parallel negotiations on a new pandemic agreement sailed into heavy water, there was a risk that the IHR amendments might become a casualty in the bargaining process – particularly from African member states pursuing equitable access to health products in the pandemic agreement.

They feared that the powerful Western countries pushing for the IHR to be passed – the US, European Union, Japan and the UK – would be less inclined to continue negotiating in good faith on the pandemic agreement once the IHR amendments have been passed. 

Meanwhile, Slovakia dissociated itself from the resolution, and Russia and Argentina said they reserved the right to implement amendments – or not – according to their national sovereignty. Costa Rica also expressed reservations about the extension of the INB’s mandate.

Reactions to amendments

Former Prime Minister of New Zealand Helen Clark, who chaired the Independent Panel for Pandemic Preparedness and Response, welcomed the adoption of the amendments.

“These amended International Health Regulations, if fully implemented, can result in a system that can better detect health threats and stop them before they become international emergencies,” said Clark.

“I congratulate WHO member states for agreeing to regulations intended to improve information-sharing about outbreaks, and action to ensure that countries have access to health products to contain outbreaks, including to the financing required. It’s excellent that a pandemic emergency is now defined in the IHRs.

“The world must now urgently make the investments needed to implement them, including in low- and middle-income countries, with the objective of stopping pandemic threats in their tracks.”

However, Nina Schwalbe, CEO of Spark Street Advisors and an independent observer of the pandemic negotiations, expressed “deep disappointment” that all references to compliance have been dropped in the IHR.

“The amendments do not include any provisions for a compliance mechanism. How can countries be held accountable to their commitments with a compliance mechanism?”

This story was edited to add reactions.

Civil society observers Yassen Tcholakov, MSF’s YuanQiong Hu, and KEI’s Thiru Balasubramaniam and Jamie Love outside the negotiating room

GENEVA – There were claps and cheers from inside Room XXVI of the UN’s Palais des Nations as World Health Organization (WHO) member states finally agreed on amendments to the International Health Regulations (IHR) after over two years of negotiations.

After failing to reach an agreement on the amendments before Monday’s start of the World Health Assembly (WHA), member states agreed to try to race to the finish during this week.

A drafting committee has been in intensive talks ever since, and its co-chair, Dr Ashley Bloomfield, told Health Policy Watch on Saturday that he had barely slept for the past few  days.

The IHR is a legally binding international instrument aimed at preventing the international spread of disease, and require countries to conduct surveillance for potential international health threats of all kinds and report those to WHO.

The COVID-19 pandemic showed weaknesses in the IHR, including that it did not mention “pandemic”. Member states submitted over 300 proposed amendments to the Working Group on Amendments to the IHR (WGIHR), chaired by New Zealand’s Bloomfield and Dr Abdullah Asiri of Saudi Arabia.

When parallel negotiations on a new pandemic agreement sailed into heavy water, there was a risk that the IHR amendments might become a casualty in the bargaining process – particularly from African member states pursuing equitable access to health products in the pandemic agreement.

They fear that the powerful Western countries pushing for the IHR to be passed – the US, European Union, Japan and the UK – will be less inclined to continue negotiating in good faith on the pandemic agreement once the IHR amendments have been passed. 

It is much harder for wealthy nations to buy into an agreement that involves compelling pharmaceutical companies to share their products – and the know-how about to make these – with companies and countries in the global south.

At the time of publication, the WHO still had to outline the process to conclude the pandemic agreement negotiations, but this is expected before the WHA closes at midnight on Saturday.

The fight against malaria is facing a new and urgent challenge as climate change and extreme weather events threaten to undermine decades of progress, according to warnings from several countries at the 77th World Health Assembly this week.

“Recent extreme weather events such as flooding in Malawi and other countries have intensified malaria transmission, disproportionately affecting vulnerable populations,” Dr. Tedros Adhanom Ghebreyesus, the director-general of the World Health Organization, told the assembly on Thursday.

France, a leader in the fight against malaria, expressed concern over the lack of funding for malaria response and called for integrating anti-malaria efforts into national health plans, emphasizing that the need for funding has become more urgent as climate change is “increasingly impacting health systems and making them more fragile.”

“We wish to highlight the importance of the One Health approach and the key role of community health workers in local surveillance and awareness of malaria,” the delegation said.

The introduction of new malaria-causing parasite species due to climate change is also putting populations at risk, particularly transitory migrant groups, Costa Rica warned. “We believe it’s essential for international bodies to take these variables into account when allocating resources, both for dealing with public health problems and regional and extra-regional migration,” the country’s delegation said.

Colombia echoed those concerns, noting that “rapidly changing ecosystems are increasing vulnerability and giving rise to new malaria transmission dynamics,” a problem compounded by “increasing migration patterns.”

Eliminating Malaria

Despite the challenges, several countries, including Egypt, Ecuador and Malawi, renewed their commitment to eliminating the disease. Papua New Guinea said partnerships had been crucial to its malaria control initiatives, which focus on prevention, diagnosis, treatment and community engagement.

Malawi is implementing a plan to eliminate malaria by 2030, while Cabo Verde recently became malaria-free, joining just 43 countries worldwide to achieve the milestone and be recognized with this certification by the WHO.

The WHO is adopting a multi-faceted strategy to fight malaria, including new guidelines for countries to prioritize interventions in resource-limited settings and a focus on emerging threats like drug resistance, Dr. Jérôme Salomon, the organization’s assistant director-general for universal health coverage, communicable and non-communicable diseases, said Thursday.

Salomon, reflecting on the achievements of malaria-free countries, stated that key strategies to accelerate progress include introducing new tools like a malaria vaccine and ensuring wider access to existing ones.

“Recent extreme weather events such as flooding in Malawi and other countries have intensified malaria transmission, disproportionately affecting vulnerable populations,” Salomon said, emphasizing the urgency of addressing climate change through proactive mitigation, adaptation, and research.

Investments in primary health care are fundamental, he added, as are efforts to address various factors impacting malaria transmission, including inequities, conflicts, migration, the Covid-19 pandemic and climate change.

Although new tools are becoming available to fight malaria, several challenges are limiting their use, especially in Africa, said a representative from Chad, speaking on behalf of the 47 member states of the WHO’s African region. Chief among them, the delegate said, are shortfalls in funding.

In a joint statement, African countries pressed for greater political commitment and self-reliance in the fight against malaria, appealing for more predictable international aid that aligns with their national policies.

Sudan stressed the importance of tackling security issues to enable far-reaching malaria interventions, while Guinea urged partners to keep supporting immunization efforts and help end repeated malaria outbreaks.

Image Credits: WHO.

Rüdiger Krech, Director of Health Promotion at WHO showing examples of nicotine products with toy-like designs created to attract children.

The tobacco industry is deliberately targeting children with nicotine products, using targeted marketing to lure the younger generation into smoking while publicly promoting e-cigarettes as a less harmful alternative for smokers, according to a new report by the World Health Organization (WHO) and STOP, a tobacco industry watchdog.

The report, released ahead of World No-Tobacco Day on May 31, analyzes ways in which tobacco and nicotine companies design products, implement digital marketing campaigns, and shape policy environments to help them addict youth globally.

“The industry is peddling a narrative that denies or underplays youth addiction,” Jorge Alday, Director of STOP at Vital Strategies, told Health Policy Watch. “If we don’t establish a comprehensive approach and work across agencies, the industry will exploit any loophole or any new opportunity to reach young audiences.”

The report accuses the tobacco industry of targeting children and young people with over 16,000 e-cigarette flavours, employing colourful branding, influencer partnerships, and innovative digital marketing tactics, including the Metaverse.

“The Metaverse could eventually become a virtual shop window like physical or e-commerce stores,” Alday told Health Policy Watch about how the tobacco industry is using new digital forms of marketing.

The tobacco industry is attempting to “replace tobacco users lost to death and disease with a fresh wave of users trapped in addiction,” said Rüdiger Krech, WHO’s Director of Health Promotion, during the report’s launch press conference.

“We see tobacco products taking the shape of chocolates and sweets, candy, taking the form of toys,” Given Kapolyo, the global youth ambassador of the year and an anti-tobacco activist, told reporters. “They’re going out of their way to ensure that they make this product seem very cool.”

The tobacco industry bombards youth with branding, Kapolyo added, targeting areas close to schools, along routes used by young people, and in the digital space.

“These industries are actively targeting schools, children and young people with new products that are essentially a candy-flavoured trap,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, commenting on the youth-targeting strategies of tobacco firms. “How can they talk about harm reduction when they are marketing these dangerous, highly addictive products to children?”

Fewer smokers, more vapes

Christian Lindmeier, WHO’s Spokesperson and Rüdiger Krech, Director of WHO Health Promotion during a press conference launching a report on tobacco firms targeting children in their marketing

While the global number of smokers is declining, with one in five adults smoking in 2020 compared to one in three in 2000, eight million people still die annually because of tobacco use.

The number of e-cigarette users, meanwhile, is growing, especially among the youngest generation. Globally, 37 million children aged 13–15 years use tobacco, and in many countries, vaping is more popular than traditional cigarettes among adolescents. In the WHO European Region, one in five 15-year-olds surveyed reported using e-cigarettes in the past month.

The tobacco industry often frames vaping as a way to reduce the harmful health effects of carcinogenic substances present in cigarettes, but research shows e-cigarette use actually increases conventional cigarette use nearly three times, according to the WHO.

The US Food and Drug Administration says that nicotine-mimicking substances used in vapes to avoid product regulation can be even more addictive than normal nicotine, Reuters reported.

Curbing the industry’s influence

Introducing tobacco taxes in New Zealand successfully lowered the cigarette consumption, also among the youth

Controlling marketing strategies, including digital ones, is an important way to limit tobacco firms’ influence on youth, the report’s authors said.

“How we define terms like advertising, promotion and sponsorship set the stage for what can be regulated now and in the future. This means that regulators should update rules to cover any and all platforms – physical and virtual,” Alday told Health Policy Watch.

Alday cited the recent example of Nigeria, which announced new regulations that will require health warnings for films that contain tobacco imagery. The regulation covers movies, music videos and skits produced in Nollywood, one of the world’s biggest movie industries, Alday said.

The WHO recommends not only a ban on marketing, advertising, and promotion but also creating 100% smoke-free indoor public places, banning flavoured e-cigarettes, and imposing higher taxes, among other strategies.

The latter strategy has shown significant results, as Vital Strategies’ Jeffrey Drope, co-author of the Tobacco Atlas, demonstrated during the State of Tobacco Control press briefing on May 21.

“Raising taxes [is] arguably the most effective and most straightforward solution,” said Drope. With higher prices, “young people don’t start to use tobacco products [and] people who already smoke or use tobacco stop, or cut down.”

New Zealand’s tax policy effectively drove down youth smoking prevalence as prices doubled between 2009 and 2019. It was also able to make a step towards bridging societal gaps between the general and Maori smoking populations.

The UK’s total ban on cigarettes for people born after 2009 is another example of an ambitious health policy, aiming to gradually raise the minimum age required for buying cigarettes until eventually, they become illegal. The regulation law passed its second reading in April, but has been postponed until after the general elections, BBC reported.  The bill has support from the opposition Labour party, a likely winner of the vote, which gives it much chance to be passed in the next term.

“This really has an enormous effect on consumption,” Drope said.

In their closing remarks, speakers at the press conference emphasized the essential role of youth leaders in shaping the future of global tobacco consumption and policy. “Youth leaders have a key role to play in communicating their reality to policymakers, that use of nicotine products is growing rapidly and these products are harming youth, now,” Alday told Health Policy Watch.

“What young people have is … they have each other,” Kapolyo added. “When young voices unite, even governments listen.”