‘You can’t chicken out now,” warned INB co-chair Precious Matsoso.

World Health Organization (WHO) member states abandoned careful diplomatic language at the start of the final round of negotiations for a pandemic agreement on Monday (18 March), exposing deep divisions between countries from the global North and South.

An unprecedented 11 African countries spoke during the two-hour opening session, largely expressing support for the latest pandemic agreement draft as a “good start” for text-based negotiations.

But the opposite was so for developed countries. Switzerland, which is home to numerous pharmaceutical companies, said that it “does not accept the text in its current state”. 

Switzerland does not accept the draft text.

The US and UK said it was a “step backwards” – as did the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) commenting during the later stakeholder session.

Africa stands firm on PABS

Ethiopia, on behalf of the African region’s 47 member states and Egypt, wants “concrete outcomes” on key priorities, including “a pathogen access and benefit-sharing system (PABS) that establishes on an equal footing footing a multilateral system with binding terms and conditions for access and legal certainty or for sharing of both monetary and non-monetary benefit”.

PABS is one of the most contentious clauses of the draft text. Article 12 proposes a WHO PABS system whereby countries share biological materials and genetic sequence data (GSD) of pathogens with pandemic potential with a “WHO-coordinated laboratory networks (CLNs) and sequence databases (SDBs)”.

If manufacturers want access to these, they will need to conclude legally binding contracts with WHO, pay annual contributions, and reserve 10% of pandemic products produced as a result to be distributed for free and 10% at not-for-profit prices during pandemics and outbreaks of international concern.

South Africa at INB 9

South Africa stated further terms related to PABS: “We highlight the sovereign right of member states to control access over their genetic resources. We emphasise that such multilateral PABS system must be on an equal footing with binding terms and conditions for access and legal certainty for sharing of both monetary and non monetary benefits.”

Bangladesh, representing a diverse group of 31 countries known as the Equity Group, wants “access to pathogens and benefit sharing on equal footing”.

Lack of legal certainty

Bangladesh also called for an action-oriented agreement with clear deliverables that addresses the lack of “legal certainty” for timely, equitable access to health products.

“To operationalize equity, we need to clearly delineate obligations with responsibilities on various parties, including mentioning developed countries vis a vis developing countries, which is missing in the current negotiating text,” said India for the WHO South East Asia Region (SEARO). 

“We are not supportive of any parallel or breakaway sessions or processes where small delegations will possibly be left out,” it added – something that developed countries support but smaller delegations say they cannot manage.

“Be frank,” urged Australia at INB 9

Australia, speaking for Canada, New Zealand, Norway and the United Kingdom, called for “significant pragmatism and a fundamental change in the way that we are working” to get to an agreement. 

“The proposed text, in addition to not being streamlined into clear legal commitments, does not fully capitalise on the progress made through the subgroups. It includes concerning elements that do not bring us closer but rather contribute to polarisation and significant aspects that are neither practical nor implementable,” added Australia.

“We have to be ready to be frank with one another. Listen carefully and find common ground and we need working modalities that enable us to do that.” 

‘Red lines’ included

“At this late stage, it is not productive to reintroduce challenging concepts such as CBDR [common but differentiated responsibility], intellectual property waivers and new funding vehicles that do not have a chance of achieving consensus,” said the US.

“We have stated very clearly on multiple occasions that these are red lines,” it added. “We have run out of time to be revisiting provisions that are not implementable, not feasible or contrary to national law.”

The European Union (EU) lamented the “significant dilution” of pandemic prevention and preparedness. It also claimed that the text “could have been an opportunity to find an agreement in key areas such as technology transfer and intellectual property, financing, and PABS at the time where stakeholders have never been more ready to make a decisive contribution to benefit sharing” – but did not elaborate on what such an opportunity could look like. 

For Germany, the revised text “still contains some elements that have been clearly identified as non-consensual” as well as “still lacking crucial elements, for example, to improve prevention preparedness in order to make sure that we are not hit by a pandemic like COVID again”.

The European Union at INB 9

‘You can’t chicken out now’

“You can’t chicken out now. You’ve already agreed. So because this is now in a legal text, perhaps what you need to do is to determine which of those elements should be obligatory,” cajoled Precious Matsoso, co-chair of the intergovernmental negotiating body (INB) which has been steering the negotiations.

“One hundred percent said equity was important, finance was important, capacity building and strengthening of countries was important. Surely that can change now when you’re supposed to start the negotiations.”

But the INB Bureau was also criticised for not including in the text agreements reached in the four sub-groups that facilitated earlier negotiations and for dispensing with small group discussions.

Areas of agreement

Pointing to “critical areas” that still need to be agreed, WHO Director General Dr Tedros Adhanom Gebreyesus focused on what has been agreed: “Importantly, you agree on what you’re trying to achieve. You agree on the need for predictable and sustainable financing for pandemic preparedness and response. You agree on the need for an equitable system for access and benefits. You agree on the need to engage the private sector. 

“We would have a much bigger problem if you did not agree on the fundamental objectives of the agreement. But you do now you need to agree on how to achieve these objectives. I have every confidence that you can and will.”

Text-based negotiations are proceeding in plenary from now until the end of this ninth INB meeting on 28 March, the eve of Easter. Evening sessions will not go beyond 6.30pm to accommodate Muslim delegates observing Ramadan. However, a Saturday session has been added to give the process extra time.

A vaccinator marks the little finger of a child who has been vaccinated, Sudan, November 2020.

Sudan will resume immunising children against polio after detecting circulating vaccine-derived poliovirus type 2 (cVDPV2) in its waster water, as six other African countries have reported either cases or positive environmental samples over the past two weeks.

Mali and Nigeria reported one case each, Yemen reported three cases and Angola, Côte d’Ivoire and Sierra Leone reported positive environmental samples.

Sudan’s Federal Ministry of Health (FMOH) announced that it will launch a polio vaccination campaign next month after cVDPV2 was detected in six wastewater samples between last September and January.

The states of Red Sea, Kassala, Gedaref, River Nile, Northern, White Nile, Blue Nile and Sennar are being targeted.

War, heatwave undermine health services

War between two opposing military forces in Sudan has halted the country’s immunisation drive for an entire year. To make matters worse, the country is in the grips of a debilitating heatwave with temperatures exceeding 40ºC. Schools were closed from Monday and are expected to remain closed for at least two weeks.

Looting and attacks on health facilities have also affected services, with over a million polio vaccines destroyed as a result.

The breakdown in health services, including routine vaccination, significantly increases the risk of spread of communicable diseases amid outbreaks of cholera, dengue, malaria and measles reported from numerous states.

Sudan reported the emergence of variant poliovirus type 2 in January 2024. It was detected in six wastewater samples collected from September 2023 to January 2024 in the Port Sudan locality, Red Sea State.

The FMOH, with support from the World Health Organization (WHO), has completed field investigations and a risk assessment to determine the extent of the virus circulation. 

This new detection comes 14 months after Sudan declared an outbreak of variant poliovirus type 2, from an unrelated emergence of the virus, which was detected in a 4-year-old child in West Darfur in October 2022. 

In response to that outbreak, the FMOH, in collaboration with the United Nations Children’s Fund (UNICEF) and WHO, delivered and distributed 10.3 million doses of oral polio vaccine in a nationwide polio vaccination campaign in March 2023, reaching around 8.7 million children aged under 5 years (98% of all children of this age group in Sudan).

Wastewater detection

“While no vaccination campaign has taken place since April 2023 due to the ongoing conflict, surveillance for poliovirus in children – conducted by searching intensely for acute flaccid paralysis (AFP), the most common indicator of polio infection – and in wastewater has been strengthened to swiftly detect any presence of the virus,” according to the WHO.

While the FMOH has not found any children paralysed due to the new emergence, the detection of poliovirus in wastewater samples means that children across the country are at high risk. 

“The new detection has only redoubled our commitment to safeguarding our children’s future. In collaboration with partners, we are mobilising an outbreak response campaign to ensure that every child under five years in accessible areas receives the polio vaccine, and special plans will follow for hard-to-reach areas,” said Dr Dalya Eltayeb, Director-General of Primary Health Care in Sudan’s FMOH.

There is no cure for polio, a highly infectious viral disease that mainly affects children aged under five years, but it can be prevented through vaccination. Caregivers must ensure that during upcoming vaccination campaigns, all children aged under 5 years receive oral polio vaccine drops every time they are offered. They should also receive routine vaccinations according to their age.

“The ongoing war is undoing the enormous gains the country has registered on childhood vaccinations,” said Dr Tedla Damte, Chief of Health and Nutrition at UNICEF Sudan.

“Millions of displaced children on the move cannot be protected against life-threatening diseases, like polio, yet these can be prevented through vaccination. Health systems are overstretched, subsequently impacting the delivery of health services including vaccinations. UNICEF remains committed to supporting vaccination campaigns to protect children, no matter what,” he emphasised.  

Image Credits: WHO Sudan.

Members of the drafting group of the intergovernmental negotiating body (INB).

Two final – and likely sleepless – weeks of negotiation on the pandemic agreement begin on Monday, and negotiators have been urged to bring in their principals to ensure speed up decision-making.

The negotiations may well be extended but, for now, this ninth meeting of the World Health Organization (WHO) intergovernmental negotiating body (INB) is set to end on the eve of the Easter weekend on 28 March and includes a weekend session.

“Since we have now a few weeks left, I think the engagement of the highest level of leaders will be important to give you more space for compromise because it’s through compromise and collaboration that we can get to the finish line,” WHO Director General Dr Tedros Adhanom Ghebreyesus told negotiators at the last INB meeting.

Tedros also appealed to the leaders of the G20 to assist with the negotiations when he addressed them this week.

“Your leadership is now needed more than ever, with the deadline approaching for the pandemic agreement and amendments to the International Health Regulations,” Tedros told the leaders who were meeting in Brazil.

Lack of consensus on critical areas

Noting that the World Health Assembly is less than 10 weeks away, Tedros told the G20 that the was a lack of consensus at the INB on “critical areas”.

Four INB subgroups have been working to find solutions on four key issues, One Health; sustainable production, technology transfer and supply chains; pathogen access and benefit sharing; and implementation support and financing, he added.

“The subgroups have each submitted their reports to the INB bureau, which has integrated their recommendations into the revised text of the agreement, which was circulated to member states last week. Starting on Monday next week, the INB will meet for the final time, and I sincerely hope that member states will begin to converge on these key issues,” Tedros urged.

“If we miss the opportunity to put in place a pandemic agreement and a stronger IHR, we risk losing momentum. More importantly, we risk leaving the world exposed to the same shortcomings that hampered the global response to COVID-19: a lack of coordination, a lack of sharing information, and a lack of equity.”

Civil society concerns

The Pandemic Action Network (PAN) has highlighted “the agreement’s unclear legal status, intellectual property questions, and pandemic prevention, preparedness, and response financing strategy” as  “top concerns”. 

PAN and others have developed a civil society version of the pandemic agreement that they aim to present to negotiators – also civil society organisations are not allowed to be in the room during the negotiations.

Meanwhile, in a laudable sign of transparency, the Europe Union has published its text-based proposals.

However, anything can happen in the next two weeks of negotiations as negotiators are fond of stressing: “nothing is decided until everything is decided”.

Practical questions left to COP?

Many practical questions about how the pandemic agreement will be implemented – including how to finance countries’ pandemic prevention, preparedness and response (PPPR) – seem likely to be left to the proposed Conference of Parties (COP).

For example, according to the latest pandemic agreement draft, a “Coordinating Financial Mechanism” will support the implementation of the pandemic agreement and the International Health Regulations (IHR) (see Article 20).

But Professor Garrett Wallace Brown, chair of Global Health Policy at the University of Leeds, told a Geneva Global Health Hub (G2H2) media briefing on Tuesday that “final decisions about the details of the coordinating mechanism are being offloaded to the Conference of the Parties (COP), which I think is a wise decision given the circumstances”. 

“There are only nine negotiating days left and there are lots of details to work through. But I think it’s only wise if the COP is representative, inclusive, proportional to risk and deliberative, meaning a move away from business as usual,” said Wallace Bown.

He added that in his conversations with INB negotiators, “what they want to do is make the wording strong enough to show that there’s a commitment to a coordinating mechanism and a commitment to financing those”.

Africa holding out for equity

Dr Jean Kaseya

Africa Centre for Disease Control and Prevention Director General Dr Jean Kaseya told Health Policy Watch recently that he had travelled to Geneva to discussion the pandemic agreement negotiations with African ambassadors.

“The African Union Assembly approved the common African position. That is the tool that is leading that is facilitating the discussion for the pandemic treaty,” said Kaseya.

“But let me tell you there are only two words for me summarising this pandemic treaty. The first one is equity. The second one is respect. These are the two words that are really driving Africans who are negotiating. You have got everything around these two words. When we are talking about financing, when we talk about pathogen access and benefit sharing, everything is around respect and equity.”

The Africa Group of 47 member states plus Egypt have been pushing hard for countries that share the genetic and biological information of pathogens with pandemic potential to derive benefits in return from manufacturers who make products from this information.

Preserve ‘innovative ecosystem’, urges pharma 

However, the head of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) has described the latest draft as “a step backwards rather than forwards”.

IFPMA Director-General Thomas Cueni, appealed for the agreement to both “take steps to ensure equity in access to medicines and vaccines in future pandemics” while also “preserving the innovation ecosystem that delivered a vaccine just 326 days after the SARS-CoV2 genome sequence was first sequenced”.

Article 12 of the current draft proposes that manufacturers pay an annual subscription fee to a yet-to-be-formed World Health Organization (WHO) Pathogen Access and Benefit-Sharing (PABS) System in exchange for “rapid, systematic and timely access to biological materials of pathogens with pandemic potential and the genetic sequence data (GSD) for such pathogens”.

The article also proposes that manufacturers provide “real-time contributions of relevant diagnostics, therapeutics or vaccines” with 10% free and 10% at not-for-profit prices during public health emergencies of international concern.

But Cueni believes that “conditions, uncertainties, and negotiations surrounding pathogen access will cause delays in the developing medical countermeasures, leading to significant public health consequences, including loss of lives and unnecessary economic pressures”.

‘Compromise and collaboration, not competition’

Meanwhile, Tedros said that although time is tight, “if there is political commitment to have a deal we will have the agreement by May 2024”,

“Instead of really competing on issues, we have to focus on constructive problem-solving. It is not the problem of the North. It is not the problem of the South. It’s our problem. This is about preparing the world to fight a common enemy. So compromise and collaboration will be the way forward rather than competition.” 

He told the G20 that “there is no reason negotiations on the pandemic agreement and the IHR cannot be finalised in the next 10 weeks”, but that this will require “courage and compromise” – and leadership.

“The leadership of G20 countries in the next nine weeks, and especially in the next two weeks, is vital. We cannot – we must not – miss this generational opportunity.”

HIV medicine dolutegravir.

The World Health Organization (WHO) recently reported drug resistance to the world’s gold-standard antiretroviral medicine, dolutegravir  “exceeding levels observed in clinical trials” – with resistance ranging from 3.9% to 19.6%.

This was potentially very bad news as dolutegravir has been the recommended first- and second-line HIV treatment for all population groups since 2018 – but the WHO told Health Policy Watch this week that the drug resistance was largely related to patients not adhering to treatment properly rather than growing resistance to the medicine.

Dolutegravir is “more effective, easier to take, and has fewer side effects than other drugs currently in use” with “a high genetic barrier to developing drug resistance”, according to the WHO.

It is used in antiretroviral therapy (ART) in combination with tenofovir and lamivudine, and its use has led to “very high levels of viral load suppression at the population level, often in excess of 90% or even 95%”, according to WHO. 

Country reports on resistance

The reports on resistance come from country surveys in Uganda, Ukraine, Malawi and Mozambique, WHO told Health Policy Watch.

In Uganda, Ukraine and Malawi, the levels of resistance to dolutegravir ranged from 3.9% to 8.6% in adults, ranging from those who had never taken ART to those with some exposure to the drugs.

But in Mozambique, the survey involved people experienced with treatment who had transitioned to a dolutegravir-containing regimen while having high HIV viral loads. And in this instance, resistance reached 19.6%. 

“Overwhelmingly, data suggest that non-adherence to treatment is the primary reason for viral non-suppression in people taking dolutegrivar, not drug resistance,” said the WHO spokesperson.

“Levels of HIV drug resistance observed to the integrase inhibitor dolutegravir are much lower than resistance levels observed in populations failing non-nucleoside reverse transcriptase inhibitors (NNRTIs)-based antiretroviral therapy,” added WHO.

NNRTIs refer to a class of ARVs that block an HIV enzyme called reverse transcriptase, which prevents the virus from replicating. Efavirenz, the previous WHO-recommended first-line HIV treatment regimen, was an NNRTI.

“In populations not achieving viral suppression on NNRTI-based ART, we saw levels of resistance from 70-90%. The combination of higher levels of viral load suppression and the much lower levels of acquired drug resistance affirm the global guidelines’ change from NNRTI- to dolutegravir-based treatment,” the WHO added.

The WHO official noted that there was still “much to learn about dolutegravir resistance”, with “very early and limited data” suggesting that “very large proportions of people not achieving viral suppression” on the dolutegravir would do so with “enhanced adherence support”. 

Dolutegravir and TB medication 

Meanwhile, a new clinical trial has found that people newly diagnosed with HIV fared well when given preventative treatment for tuberculosis at the same time as dolutegravir.

These results were released at the recent Conference on Retroviruses and Opportunistic Infections in Denver, Colorado.

“Each year, there are an estimated 670,000 new TB cases among people living with HIV and an estimated 167,000 deaths from TB-related HIV,” according to a media release from the Aurum Institute, one of the research partners in the trial.

The trial – called DOLPHIN-TOO – focused on whether the efficacy of dolutegravir in people living with HIV who had never previously been treated with ARVs was affected by prophylactic TB treatment – either the standard isoniazid (6H) or the newer regimen comprising of a weekly dose of isoniazid and rifapentine for three months referred to as 3HP.

The results showed that, while people in the 3HP group did have lower levels of dolutegravir in their bloodstream than people in the 6H group, they were able to achieve an undetectable level of HIV virus in blood by eight weeks and maintain this for the length of the six-month study. 

Minimal side effects were seen, none were severe, and the majority were resolved with continuation of therapy. 

Previous research released at the Union World Conference on Lung Health in November of 2023, had provided information on the safety and efficacy of the use of 3HP and dolutegravir  together, but without data on the drug levels in the blood.

“This study points to the use of short course TB preventive treatment in people who are newly diagnosed with HIV and are at highest risk of active TB disease,” according to a media release from Aurum.  

Medication-related harm accounts for a half of preventable harm in medical care

As many as one in 20 patients experience avoidable side effects from medication that they use, with this figure rising to 7% in developing countries. 

The causes range from taking the medication at the wrong time, which could result in minor side effects, to taking an  inappropriate drug, which might result in unpredicted harm as serious as yet another disease or even death.

Such errors are not that scarce, concludes Dr Maria Panagioti, senior lecturer in primary care and Health Services Research at the University of Manchester and one of the authors of a new World Health Organization (WHO) systematic review “Global burden of preventable medication-related harm”. 

The global cost associated with administering unsafe care is estimated at $ 40 billion each year, WHO says.

“Without measurement, action to drive improvements are not possible, regardless of context,” said Dr Neelam Dhingra, head of  WHO’s Patient Safety Unit, during a webinar on the new guidance. 

While developing new treatments and better policies is important, much progress in healthcare can be achieved as a result of simply “doing no harm,” she said.

Errors occur, reduction targets are scarce

Only 18% of WHO member countries have a national target for reducing medication-related harm.

Seven years ago, WHO established a Medication Without Harm challenge in which it setting the goal of reducing harm by incorrect medication by half in five years. This was followed by a Global Patient Safety Action Plan, approved by the World Health Assembly in 2019. But much remains to be done.

“Assessing the burden of patient harm and also medication-related harm is a critical part of measuring patient safety,” Dhingra highlighted. “However, this truly remains a challenging agenda still.”

According to the new systematic review, half of all avoidable harm in medical care is related to medication, and a quarter of mediciation’s preventable harm can have severe or even life-threatening consequences.

Medication error is often avoidable. Yet, it is experienced by 5% of all patients.

Many mistakes occur in specific contexts, such as when patients are already taking many different kinds of medication (polypharmacy) that interact with one another, or patients who transition between caretakers, or in situations where high risk drugs are used.

Areas of improvement

The new WHO policy brief proposes key areas for addressing the risks including better communication and engagement of patients and patient organisations. With good public awareness of medication effects, it is easier for patients themselves to identify errors, such as the prescription of the wrong drug by a pharmacist.

Four domains and three key areas outlined in the WHO’s Global Patient Safety Action Plan

Healthcare workers should also receive training on medication harm, the brief notes. Better health worker conditions also reduce the risk of errors from factors such as fatigue and multi-tasking.

Identification of high risk drugs and additional care in their management is also critical. 

There is a “huge burden of preventable harm due to unsafe medication practices and medication errors,” Dhingra noted. ”Action is required at all levels, […] and we need to implement safe systems and practices for medic medications.”

Image Credits: WHO/Quinn Mattingly, WHO, WHO.

monkeypox
Patient participating in a clinical trial of Tpoxx, an antiviral treatment for the mpox virus, in the Democratic Republic of Congo.

A leading Geneva-based global health organization has decried the lack of tests available for mpox in the Democratic Republic of the Congo (DRC) – where an outbreak declared in 2023 continues unchecked – saying that children are the main victims. 

“The mpox situation in the DRC is deeply alarming and the lack of tests for both mpox and HIV means it’s unclear just how bad the mpox situation is and what the underlying comorbidities are,” said Dr Ayoade Alakija, Chair of the Board at FIND in a press release.

According to FIND, a global non-profit dedicated to accelerating access to diagnostics, only 16% of suspected mpox cases in DRC undergo a PCR test. Among suspected cases that are tested, six out of ten test results are positive, underlining the degree of under-estimation of confirmed mpox cases.

“Testing capacity for mpox and HIV in the DRC is severely limited, meaning that many likely cases of mpox in the country are treated as suspected cases only,” Dr Sergio Carmona, FIND CEO and chief medical officer said.

Left unchecked – virus risks further spread abroad

Alakija compared the current mpox outbreak in the DRC with the situation during the COVID-19 pandemic, when many African countries were left behind in terms of tests and treatments and vaccines.

Left unchecked, the deadly Clade I form of the mpox virus now circulating in the DRC risks spreading further in Africa and beyond, she warned. 

“The people that are being prioritized for tests, treatment and vaccination are not in the outbreak countries in Africa,” she noted, referring to the rollout of measures in high- and middle-income countries over the past two years to counter the much milder, Clade I, form of the mpox virus that exploded in 2022. 

“We can either mobilize resources and fight the deadly mpox outbreak now in the DRC, or we can let the virus continue to spread and fight it when it is imported into other countries,” Alakija  said.

DRC outbreak is the largest ever recorded

According to the US Centers for Disease Control (US CDC) the current DRC mpox outbreak is the largest ever recorded, with cases reported in 22 out of the DRCs 26 provinces. Some 12,569 suspected cases and 581 deaths have been reported since 1 January 2023.  

From the start of 2022 to January 2024, the DRC reported 21,630 suspected MPXV cases and 1,003 deaths. Around 85% of deaths in this period were children under 15 years of age, according to WHO data.  

Epidemic curve shown by month for cases reported to WHO from the African region. Recent cases mostly in DRC.

Potentially ‘distinct’ Clade I strain and new patterns of transmission 

Mpox is a viral infection, which belongs to the same virus family as smallpox. It was traditionally confined to remote, rural areas of central and western Africa, where transmission was sporadic and occurred primarily through human contact with rodents and other small mammals. 

The virus burst onto the global arena in 2022 when WHO declared a global health emergency after the milder, Clade II form of mpox, began to spread through dozens of countries worldwide, infecting thousands of people, mainly through sexual transmission, and particularly men having sex with men. 

The global health emergency was declared over in 2023 following the scale up of diagnostics and vaccination in middle- and high-income countries, aimed at high-risk groups. 

Over the past year, however, global health authorities have expressed rising alarm over the increased circulation of the more deadly Clade 1 of mpox throughout central and east Africa – including through patterns of sexual transmission, including heterosexual transmission, not previously seen. 

In the case of the eastern DRC, female sex workers found to be among the leading groups transmitting the disease, along with transmission through close familial or community contacts, according to a study published Tuesday on the pre-print health sciences platform, MedRxiv. The study looked at transmission patterns in the city of Kamituga, in DRC’s south Kivu province.  

The sustained community-level transmission of mpox now seen in Kamituga “is….  being driven by a distinct Clade I mpox strain, possibly a novel subgroup, as confirmed with qPCR,” the researchers from over a dozen countries found. 

Mpox has similar symptoms as smallpox, including painful blisters and rash, fever, chills and fatigue. In the case of the milder, Clade II form of the virus, most patients recover after a few weeks of supportive care, WHO says.

Image Credits: WHO.

COVID-19 screening in Bangkok, Thailand: Financing future pandemic preparedness and response is unclear.

Many practical questions about how the pandemic agreement will be implemented – including how to finance countries’ pandemic prevention, preparedness and response (PPPR) – seem likely to be ceded to the Conference of Parties (COP).

According to the latest pandemic agreement draft, a “Coordinating Financial Mechanism” will support the implementation of the pandemic agreement and the International Health Regulations (IHR) (see Article 20).

“There’s a key debate with Article 20 within the negotiations about whether the coordinating mechanism should be hosted by the Pandemic Fund, the World Health Organization (WHO), or whether a new entity should be created,” Professor Garrett Wallace Brown, chair of Global Health Policy at the University of Leeds, told a Geneva Global Health Hub (G2H2) media briefing on Tuesday.

“There’s seemingly little appetite for a new institution, and there is a strong narrative being promoted for the Pandemic Fund in order to decrease fragmentation,” added Wallace Brown, who is director-designate of new WHO Collaboration Centre for Health Systems and Health Security.

The Pandemic Fund’s Priya Basu has made a strong bid for her entity to become this mechanism, telling Devex this week that a new fund to support PPPR would mean “duplication”.

Professor Garrett Wallace Brown, chair of Global Health Policy at the University of Leeds

But Wallace Brown said that “final decisions about the details of the coordinating mechanism are being offloaded to the Conference of the Parties (COP), which I think is a wise decision given the circumstances”. 

“There are only nine negotiating days left and there are lots of details to work through. But I think it’s only wise if the COP is representative, inclusive, proportional to risk and deliberative, meaning a move away from business as usual.”

In conversation with delegates involved in the Intergovernmental Negotiating Body (INB) thrashing out the pandemic agreement, Wallace Brown said that “what they want to do is make the wording strong enough to show that there’s a commitment to a coordinating mechanism and a commitment to financing those”.

In addition, they were “being somewhat more clear about what types of financing and what types of mechanisms would be housed underneath that, but offshoring those details for 12 months – I’m suggesting 24 months – to try to work out exactly how that is done”. 

Domestic funds?

According to the draft, the financing mechanism would include a pooled fund for PPPR, and may include “contributions received as part of operations of the [Pathogen Access and Benefit-Sharing System], voluntary funds from both states and non-state actors and other contributions to be agreed upon by the Conference of the Parties”.

G2H2 co-chair Nicoletta Dentico

However, G2H2 co-chair Nicoletta Dentico warned that poorer countries were mired in debt and debt cancellation should be a consideration to help these countries.

“Fifty four low-income countries with severe debt problems had to spend more money on debt servicing than on the COVID disease in 2020,” said Dentico, who heads the global health justice program at Society for International Development (SID).

“Contrary to the WHO Framework Convention on Tobacco Control, the [pandemic agreement] text opened for the final negotiations stubbornly ignores the repeated calls for legal safeguards that are indispensable to immunise the treaty implementation and financing from vested corporate interests,” added Dentico.

Mariska Meurs from the Dutch health NGO WEMOS, warned that “domestic funding for pandemic prevention preparedness and response must not undermine other domestic public health priorities”. 

“The draft pandemic treaty text worryingly includes ‘innovative financing mechanisms’, which often means using public funds not for heath, but to attract private-for-profit investors. Instead, the pandemic treaty should embrace the most obvious and fair avenues for funding pandemic prevention, preparedness and response: global tax justice and debt cancellation”.

“But undermining other domestic public health priorities is exactly what we’ve seen happening under COVID-19. We’ve witnessed the shifts in global and domestic funding and how funding for basic health care has gone down,” warned Meurs.

“The text, as it lies before us now, does not acknowledge or try to remedy this.”

Mariska Meurs from the Dutch health NGO WEMOS

“The draft pandemic treaty text worryingly includes ‘innovative financing mechanisms’, which often means using public funds not for heath, but to attract private-for-profit investors. Instead, the pandemic treaty should embrace the most obvious and fair avenues for funding pandemic prevention, preparedness and response: global tax justice and debt cancellation,” said Meurs.

Pandemic Fund ‘black box’

Low and middle-income countries are more in favour of the pandemic financing mechanism being housed in the WHO “because they see it as being more representative” than the Pandemic Fund, said Wallace Brown.

But donors “are less keen because they see it as a mechanism that would give them less control of how funds are spent”.

However, for the Pandemic Fund to become the PPPR mechanism would require “radical changes” not “minor tweaks as we’re currently being told”. 

Some of the problems with the fund, are that it only focuses on three elements of PPPR and this “creates vertical silos”, and there is no explicit guidance in the fund’s governance framework on “how equity will be addressed in either the fund process or with reference to prioritise beneficiaries of programmes”, according to Wallace Brown.

In addition, the first round of funding was eight times over-subscribed but the selection process “was not clear”.

“Applications that met the scorecard threshold for funding had to be rejected, and it remains unclear exactly how the governing board made their final decisions,” he added.

Describing his personal view on the way forward as “agnostic”, Wallace Brown said he had been studying the Pandemic Fund for a while and “think it’s a bit of a black box”. 

However, the WHO would need capacity building to become the mechanism 

“They do handle funds, they have the contingency fund for emergencies. They are able to make funding available to people and have processes for that, but they don’t have it at the same scale as a World Bank,” he said.

“Or there could even be a third entity. So at the moment, I’m remaining agnostic. I think there needs to be better analysis, better evidence to decide what works and what doesn’t work” – and these kinds of details “won’t be decided in nine days”.

Image Credits: Prachatai/Flickr.

Lab technician at a pharmaceutical company conducting a test.

The new draft of the pandemic agreement “is a step backwards rather than forwards”, according to Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA). 

“It is critical that any agreement takes steps to ensure equity in access to medicines and vaccines in future pandemics, whilst preserving the innovation ecosystem that delivered a vaccine just 326 days after the SARS-CoV2 genome sequence was first sequenced,” said Cueni.

 Article 12 of the current draft proposes that manufacturers pay an annual subscription fee to a yet-to-be-formed World Health Organization (WHO) Pathogen Access and Benefit-Sharing (PABS) System.

In exchange, they would get “rapid, systematic and timely access to biological materials of pathogens with pandemic potential and the genetic sequence data (GSD) for such pathogens”.

The article also proposes that manufacturers provide “real-time contributions of relevant diagnostics, therapeutics or vaccines” with 10% free and 10% at not-for-profit prices during public health emergencies of international concern or pandemics.

‘Uncertainties will cause delays’

But Cueni was dubious: “Stringent requirements for accessing pathogen data would severely impact responses to future pandemics and basic research and development (R&D).

“Conditions, uncertainties, and negotiations surrounding pathogen access will cause delays in the developing medical countermeasures, leading to significant public health consequences, including loss of lives and unnecessary economic pressures. In the COVID-19 pandemic context, even a one-month delay could have meant an extra 400,000 lives lost.”

The pharmaceutical industry has warned that a mandatory financial contribution could dis-incentivise companies from joining the PABS system.

“The pharmaceutical industry is determined to continue to play our part in these final stages – sharing our experience, evidence and expertise to help deliver an agreement that will better protect the world when the next pandemic hits,” Cueni said.

Thomas Cueni, Director General of the IFPMA.

This week, the biopharmaceutical industry published a statement on how companies can work between pandemics – as well as when a pandemic hits – to deliver equitable access to medical countermeasures on the basis of public health risks, needs and demands.”

The statement was signed by a broad range of trade associations aside from the IFPMA, including the Developing Countries Vaccine Manufacturers Network, DCVMN, Europe (EFPIA), the US (PhRMA) and Japan (JPMA), and the Biotechnology Innovation Organization (BIO).

The companies detail the commitments to pre- and during pandemic measures.  These include improving surveillance; research on pathogens of pandemic potential; voluntary licensing and technology transfer based on “mutually agreed terms to improve geographic diversity of manufacturing”; real-time allocation of part of production, and equity-based tiered pricing.

Companies are also engaged in ongoing activities to support health system preparedness, whether by building clinical trial and regulatory capacity and harmonization, health care worker and community health worker trainings, or the continual investment needed to establish and maintain new technologies and platforms.

“With a final draft of a pandemic agreement now published, negotiators should redouble their efforts to find consensus as there is still much work to be done before an agreement can be reached, added Cueni. 

Previously, Cueni warned that “It would be better to have no pandemic treaty than a bad pandemic treaty.”

Image Credits: AMR Industry Alliance, World Health Summit.

Accra has reduced traffic crashes by 20% over seven years

CAPE TOWN – From Accra to Kathmandu, a global partnership of 74 cities has had remarkable success in addressing some of the key drivers of sickness and death since it was launched seven years ago.

Ghana’s capital city, Accra, has cut traffic crashes by 20%. In India, Bengaluru is virtually smoke-free – not even hookahs are allowed. Nepal’s Kathmandu has installed air quality sensors to assess air pollution while a number of Latin American cities are supporting better nutrition of their school children. 

“The Partnership for Health Cities (PHC) was formed in 2017 to address non-communicable diseases (NCDs) and injuries, which are responsible for 80% of deaths globally,” said Bloomberg Philanthropies’ Kelly Larson, welcoming city representatives to the PHC’s summit in Cape Town this week.  

“This opportunity for us to come together is very unique because we are all facing the same challenges and you can learn so much from one another. We really do believe in the power of cities to make change. We are here to support you in your efforts to know that you are leading the way on this,” added Larson, whose organisation supports the partnership, along with the World Health Organization (WHO) and Vital Strategies.

The partnership started with 54 cities but now consists of 74 cities that collectively represent over 300 million people.

Each city in the PHC chooses to work in one of six key work areas: food policy, overdose prevention, tobacco control, road safety, safe and active mobility (such as promoting cycling) or data surveillance.

The cities are encouraged to root their work in public health policies and to win as much public support as possible for these. The PHC’s  Policy Accelerator supports cities to create and implement these policies.

“Cities are a place where people are particularly at risk. There is a huge concentration of people exposed to risk of NCD and injuries,” said the WHO’s Etienne Krug.

“But cities are a particularly good place to think about interventions for a number of reasons,” he added. “First of all, they enforce national laws but they can also enhance these with additional regulations. City leaders are geographically close to their populations. It is easier for multi-sectoral approaches than at national level.”

Bengaluru: A model smoke-free city

Bengaluru in India has become a model smoke-free city

India’s Dr Vishal Rao has been an advocate for smoke-free laws for a number of years in Bengaluru (Bangalore) and its state, Karnataka. This is hardly surprising as a head and neck surgical oncologist at a cancer hospital and has treated numerous tumours in the thyroid, parotid, and salivary glands caused by tobacco use.

“We first prioritised creating a policy framework around smoking, and have built this policy around the three R’s – making somebody responsible, have it reviewed and reported,” Rao told Health Policy Watch.

Dr Vishal Rao from Bengaluru

“We prioritised smoke free policy because we realised that Bengaluru is a cosmopolitan  economic hub with a very vibrant culture of pubs, clubs, cafes, bars and restaurants, all of which were rampantly violating the smoke free laws,” said Rao, who is also a member of the Karnataka government’s High Power Committee on Tobacco Control.

“Reducing and protecting the non-smokers required a comprehensive approach of policy intervention which is why the mayor and the [state] commissioner came out with the government order completely banning smoking in hotels, bars, restaurants, clubs, pubs and cafes unless they have a designated smoking room which is compliant with the law,” said Rao.

The requirements for these designated smoking rooms were so onerous – including no sales or services of any sort being allowed – that most places opted not to set them up.

A couple of weeks back, the state government also banned hookah bars – including hookah with tobacco, flavoured and herbal hookah – becoming the first state to do so. The pushback has been immediate, with the Hookah Association lodging around 12 litigation cases against the new laws, said Rao.

For Rao, the partnership is less about the grants cities get and more about sharing strategies, tactics and “allowing champions to emerge” to promote the various themes – his city won an award at last year’s summit for its efforts.

Accra: All the laws but little implementation

Rita Agyen Takyi is an advisor to Accra’s mayor on international affairs

Rita Agyen Takyi is an advisor to Accra’s mayor on international affairs and the city’s focal person on road safety, the issue her city has chosen.

“Ghana has all the laws. But we needed enforcement, implementation and public awareness,” Takyi told Health Policy Watch. Accra’s Bloomberg Road Safety initiative started in 2015 and it joined the partnership at its launch in 2017.

Over half the city’s road traffic deaths involved pedestrians, cyclists and motorcyclists. Public awareness campaigns have included encouraging the use of seat belts and helmets, speed limit signs and speed detectors for traffic police, direction signs painted on roads and fixed painted bollards to prevent motorcyclists from entering pedestrian crossings.

“We have reduced traffic crashes by 22% since 2021/22,” said Takyi, who also credits this success to Accra bringing different stakeholders “out of their silos” and into one forum with a common goal.

Latin American cities prioritise food policy

Five cities in Latin America have chosen to focus on food policy. Quito in Ecuador is concerned with the nutrition of children, the city’s Marysol Ruilova told the Cape Town summit.

Quito has developed a policy requiring only healthy foods to be advertised near and at schools, and is also providing clean free water in 20 pilot schools.

However, since the COVID-19 pandemic, there has been an increase in child malnutrition so the city has focused on school feeding schemes.

Cordoba is focusing on school nutrition, including promoting water

Similarly, Córdoba in Argentina is preparing to restrict the sale and advertising of unhealthy food and beverages in schools and requiring healthy alternatives, while 

Cali in Colombia is also ensuring that scholars have access to nutritious and wholesome meals during school hours.

Lima in  Peru is also working to create healthier school environments through enforcement of a new policy that restricts sales and advertising of unhealthy products. Montevideo in Uruguay is incentivizing food services to provide healthier meals to public sector workers, through its “Healthy Canteens” initiative.

Cape Town: Socio-economic determinants of health

Cape Town mayor Geordin Hill-Lewis addresses the opening of the summit.

Host city Cape Town has been involved in tobacco control and food policy-related initiatives while part of the PHP.

“Against the backdrop of incredibly challenging national economic circumstances and very deep and wide local poverty, our city is still demonstrating progress,” Mayor Geordin Hill-Lewis told the summit.“But you cannot build a prosperous city or achieve our dream of a city of hope without also focusing on public health in a serious way.”

One of the things that Cape Town is currently focusing on is identifying and addressing the socio-economic determinants of health in the city and addressing these through infrastructure planning, service provision and job creation.

“Cape Town has a very high burden of NCDs and other preventable deaths. And, while we have a good understanding of the various factors that contribute to that burden, this programme will provide crucial information that can help determine strategies going forward,” according to Councillor Patricia Van der Ross.

Image Credits: Partnership for Health Cities, Kerry Cullinan.

HPV vaccine
The WHO set an ambitious goal of having 90% of girls vaccinated against HPV by 2030

Eliminating cervical cancer is within reach, thanks to new commitments by governments, donors and other partners, including pledges of almost $600 million, made at the first-ever global forum on cervical cancer in Cartagena de Indias in Colombia.

Every two minutes, a woman dies from cervical cancer, although vaccination against human papillomavirus (HPV), the leading cause of cervical cancer, can prevent the vast majority of cases. 

Cervical cancer is the fourth most common cancer in women worldwide, but disproportionately affects women and their families in low and middle-income countries (LMICs). 

Less than 5% of women in many LMICs are ever screened for cervical cancer, and over 90% of the 348 000 cervical cancer deaths in 2022 took place in LMICs. 

Furthermore, only one in five adolescent girls were vaccinated against HPV in 2022. 

Country commitments

global cervical cancer mortality heat map
Low and middle income countries experience the highest burden of cervical cancer

However, a number of countries stepped up at the forum. These include the Democratic Republic of Congo (DRC), which has committed to introduce the HPV vaccine as early as possible, targeting girls aged 9 to 14 years.

Ethiopia aims to reach at least 95% of all 14-year-old girls with the HPV vaccine this year, and screen one million eligible women every year for cervical cancer and to treat 90% of those screened who present with positive precancerous lesions. 

Further, HPV single dose has been approved to be introduced this year and scaled up as part of the country’s Expanded Program on Immunization plans.

Africa’s most populous country, Nigeria, has committed to vaccinating 80% of girls 9 to 14 years old by 2026, including those who are no longer at school.

The nearly $600 million in new funding includes $180 million from the Bill and Melinda Gates Foundation, $10 million from UNICEF, and $400 million from the World Bank. 

Elimination of a cancer

Press conference at the global cervical cancer elimination forum
Experts gathered in Colombia to discuss global collaboration for cervical cancer elimination

“If these ambitions to expand vaccine coverage and strengthen screening and treatment programs are fully realized, the world could eliminate a cancer for the first time,” according to the World Health Organization (WHO).

In 2022, the WHO revised its HPV vaccination recommendation from two to one-dose of the HPV vaccine, making it much easier and cheaper for countries to reach those who need it.

The WHO Americas region made a similar recommendation 2023, and WHO’s African regional just followed suit with its own recommendation. 

“We have the knowledge and the tools to make cervical cancer history, but vaccination, screening and treatment programmes are still not reaching the scale required,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. 

“This first global forum is an important opportunity for governments and partners to invest in the global elimination strategy and addressing the inequities that deny women and girls access to the life-saving tools they need.” 

However, many LMICs face an uphill battle. Malawian Minister of Health Kandodo Chiponda described the challenges her country faces at the forum’s opening plenary. 

Some 60% of Malawi’s population of over 20 million is under 35, and cervical cancer is the highest cancer burden, with the incidence rate as high as 70 per 100,000. Mortality figures are 52 per 100,000, said Chiponda, who also announced the opening of the first ever cancer center in Malawi. 

Chiponda noted that women have limited time and resources to seek care, limited access to screening and diagnostic services, and are subject to misinformation about vaccinations. 

She emphasized the need for cross-sector collaborations and the strengthening of primary healthcare to reach women and girls in remote areas.

‘Miracle of modern medicine’

WHO director general
“Cervical cancer is a disease of inequity” – Dr. Tedros Adhanom Ghebreyesus, WHO Director-General

“The HPV vaccine is one of the most impactful vaccines on the planet and has already helped save thousands of lives,” said Aurélia Nguyen, Gavi’s chief programme officer. 

Despite the efficiency and safety of the HPV vaccine, high costs, supply chain issues, and difficulties in reaching remote populations keep the vaccine out of reach for many.

“More girls urgently deserve the same protection, which is why in partnership with countries, Gavi has set an ambitious goal to help vaccinate 86 million adolescent girls by 2025. With bold commitment and decisive action, we can look forward to a future where cervical cancer has been eliminated for good.” 

Describing HPV vaccines as “a miracle of modern medicine”, Dr Chris Elias, the Bill and Melinda Gates Foundation’s president of global development, said that there is “no reason why women should die from cervical cancer.”

“Now is the time for governments and partners around the world to increase HPV vaccine access and protect future generations from cervical cancer.” 

Image Credits: Unsplash, IARC/WHO, Global Cervical Cancer Elimination Forum, GCCEF/WHO.