Members of the WHO Working Group on Sustainable Finance hammer out the final agreement on increasing member state contributions in 2022, Germany’s Björn Kümmel on far left.

Encouraging donors that make voluntary contributions to the World Health Organization’s (WHO) budget to enable these to be flexibly allocated rather than ringfenced for specific programmes might be more effective to “resolve the structural defect of WHO’s funding model than periodically calling for more assessed contributions from member states”.

This is according to a new paper published in the BMJ, which reveals that 88% of WHO’s biennial programme budget comes from “voluntary contributions” – almost 10% higher than the four-fifths that the organisation claims on its website.

WHO gets its money from two main sources – the assessed contributions (ACs) of member states, which are flexible, and voluntary contributions (VCs) from member states and non-state actors that are “overwhelmingly earmarked” for specific programmes and projects.

“While ACs remain at their mid-1990s levels because of the zero growth policies of the 1980s and 1990s, VCs have increased over the last decade from 75% to 88%,” the UK-based authors note, based on WHO figures from between 2010 and 2021.

Researchers Obichukwu Iwunna, Jonathan Kennedy and Andrew Harmer note that, as voluntary contributions are earmarked for donor-specified programmes and projects, “there are concerns that this trend has diverted focus away from WHO’s strategic priorities, made coordination and attaining coherence more difficult, undermined WHO’s democratic structures and given undue power to a handful of wealthy donors”.

“Surprisingly, the share of voluntary contributions provided by upper middle-income countries was consistently less than the share by lower-middle-income countries. Furthermore, in terms of their share of voluntary contributions, we found that upper middle-income countries contributed the least proportion of their gross national income to WHO.”

“Conversely, ACs have fallen gradually, from 25% of WHO’s biennial programme pudget in the 2010–11 biennium to 12% in 2020–21. As a percentage of WHO’s total revenue, VCs to the General Fund constituted 60% in 2010–11, increasing to 84% in 2020–21.”

The researchers urge the Agile Member States Task Group on Strengthening WHO’s Budgetary, Programmatic and Financing Governance to “broaden its focus on VCs to include research to better understand why donors prefer to voluntarily fund WHO”, focusing on “the incentives that determine donor support for specified and flexible voluntary contributions”.

Image Credits: Germany's UN Mission in Geneva .

Pro-abortion demonstrators in the US

Hundreds of executives from US pharmaceutical and biotech companies have condemned as “judicial activism” last Friday’s ruling by a US District judge in Texas that the Food and Drug Administration (FDA) had erred by approving the abortion pill, mifepristone.

The FDA, US Department of Justice and the drug manufacturer, Danco Laboratories have opposed the ruling, which will now be heard by the US Court of Appeals for the Fifth Circuit.

In court papers filed on Monday, the US government and Danco asked the appeal court for a decision by Thursday and the court has asked the groups opposed to mifepristone’s approval to respond to the government by midnight Tuesday.

Meanwhile, on April 7, just hours after the Texas ruling, another US District Court Judge Thomas Rice, ruled in the state of Washington that the FDA must ensure that mifepristone is available in 17 states and the District of Columbia, which had immediately sued to preserve access to the drug. 

If there is disagreement at the US Appeals Court, where the contradictory rulings are now headed, the matter will go to the US Supreme Court, which is dominated by anti-abortion judges.

Texas judge Matthew Kacsmaryk’s original ruling banning the drug was based on a legal claim brought by a number of anti-abortion groups led by the Alliance Defending Freedom (ADF); the groups claimed that the FDA had “improperly approved” mifepristone more than two decades ago. ADF is also the faith-based litigator group that also succeeded in the appeal to the US Surpeme Court to overturn the 1973 Roe v Wade ruling on 24 June 2022 – a ruling that upended 50 years of US abortion rights protection at the federal level.  

The Trump-appointed Kacsmaryk is renowned for his conservative views. While working for the conservative Christian legal organisation, First Liberty Institute, between 2014 and 2019, he also argued against a Washington law mandating pharmacies to provide contraceptives.

“Justice Kacsmaryk’s act of judicial interference has set a precedent for diminishing the FDA’s authority over drug approvals, and in doing so, creates uncertainty for the entire biopharma industry,” according to the biopharma executives in an open letter published on Monday.

“If courts can overturn drug approvals without regard for science or evidence, or for the complexity required to fully vet the safety and efficacy of new drugs, any medicine is at risk for the same outcome as mifepristone,” they add. 

Meanwhile, US Health Secretary Xavier Becerra told PBS that the decision was “reckless”, and that the Biden administration  would fight to ensure that women had access to the medication.

“We intend to do everything to make sure it’s available to them not just in a week, but moving forward, period, because mifepristone is one of the safest and most effective medicines that we have seen over the last 20 years to help women with their health care, especially abortion care,” Becerra said.

“If a judge decides to substitute his preference, his personal opinion for that of scientists and medical professionals, what drug isn’t subject to some kind of legal challenge?” he added.

Mifepristone, together with misoprostol, is used in 60% of abortions within the first 10 weeks of pregnancy.

It has also become the only abortion method for women living in US states such as Alabama, Mississippi and Texas, where abortions are outlawed but women are able to purchase the drugs online from other states.

Several states such as Washington, California, Connecticut and Massachusetts have started stockpiling mifepristone pills to ensure access if the Texas decision stands, according to Stat News.

Should the ruling stand, women in states where abortion is still legal will have to undergo medical abortions that are riskier and more costly.

Image Credits: Gayatri Malhotra/ Unsplash.

WHO

Seventy-five years ago on Friday – World Health Day – the World Health Organization’s (WHO) founding constitution became the first document to formally recognize health as a human right. Three-quarters of a century later, a WHO battered by the COVID-19 pandemic is juggling how to adapt to new health threats with achieving its most basic mission: public health for all. 

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” reads the opening passage of the 1948 constitution, still in effect to this day. 

“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”

Nearly 80 million people died in the two world wars in the years leading up to the establishment of WHO. Many lives were lost not from bullets or mortar shells, but from famine and disease. 

The wars, like the COVID-19 pandemic, touched all corners of the world, creating a sense of shared destiny that led to the establishment of the United Nations and its agencies to safeguard the world from another global conflict.

“In the beginning [of the pandemic], the entire world faced the same uncertain threat — and same uncertain future. That feeling of shared fate was the reason the WHO was founded 75 years ago, as countries were rebuilding after the collective trauma of World War II,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “It’s why the authors of the WHO’s constitution affirmed both that health is a human right, and that the health of all people is fundamental to peace and security.”

Two decades later, the world agreed to the WHO’s International Health Regulations, a framework for cooperation on preparedness and response to health threats that has defined the landscape of international global health ever since. 

In 1978, in the mountains of present-day Kazakhstan, the world upped its health ambitions by ratifying the Alma-Ata declaration, whose slogan set a deadline for the end of the millennium for what remains the WHO’s key unfulfilled ambition: “Health for all”. 

The finish line is far out of sight despite decades of progress

WHO
The First World Health Assembly opened in the Palais des Nations, Geneva, on 24 June, 1948, with 53 of the Organization’s 55 Member States represented, as well as nine countries not yet members.

The goal of universal health coverage remains as distant as ever, but remarkable progress has been made in the WHO’s lifetime. 

Life expectancy globally has increased from 46 to 73 years, with the biggest gains found in the world’s poorest countries. Smallpox, a scourge on humankind for thousands of years, has been eradicated. Polio is not far behind, with cases falling by 99.9% since the 1980s. 

While the HIV and TB epidemics stubbornly fight on, they are significantly diminished. HIV and TB diagnoses that once equalled a death sentence are now treatable. 

Maternal mortality has fallen by a third and child mortality has been cut in half. Significant progress has also been made against a series of neglected diseases like river blindness, sleeping sickness, leishmaniasis, and many others. 

“The WHO can’t claim sole credit for these successes – the very nature of what we do involves working with partners to support countries as they implement policies and programs that drive change,” Tedros said. “But it’s difficult to imagine the world would have seen the same improvements in health had the WHO not existed.” 

But for every problem solved, five more remain in their place.

The eradication of smallpox from the world was certified by the Global Commission, an independent panel of scientists drawn from 19 nations, in December 1979 at WHO Headquarters in Geneva.

Progress against TB and malaria has stalled. Noncommunicable diseases like cardiovascular disease, diabetes and cancers now account for 70% of all deaths globally. 

The efficacy of life-saving antimicrobials pioneered in the mid-1950s are under threat due to over-use and unregulated use in sectors like agriculture and pharmaceuticals. 

Climate change is ushering in a new era of health threats intertwined with pollution and natural disasters. Air pollution kills nearly seven million people every year.

Access to health services remains vastly unequal between and within countries. Since 2000, access to essential services has increased significantly, but at least half the world’s population still lacks access to one or more services like family planning, basic sanitation or access to a health worker. 

“Often this is because of where people live, their gender, their age, or who they are,” said Tedros. “They are people living in poverty, refugees and migrants, people with disabilities, unique minorities or other marginalized groups.”

WHO estimates the world will face a shortage of some 10 million health and care workers by 2030. The most serious shortages will be in the poorest countries as skilled workers migrate to higher paying jobs in rich nations.  

The number of people facing financial hardship due to out-of-pocket health expenses increased by a third to almost two billion people in 2017. 

COVID-19 – along with exposing deadly flaws in global pandemic response systems – disrupted health services and economies, further increasing the number of people unable to afford to treat their health needs.

“The world needs the WHO now more than ever,” Tedros said.

Paycheck to paycheck: expectations of WHO outgrow a stagnant budget

WHO
Over time, countries have ceded their roles in funding the WHO to private charities with specific health objectives, leaving the organization with less money to focus on its core mission.

Few people outside global health circles realize that the WHO operates on a shoestring budget. The organization tasked with bringing about universal health coverage for all does not even have one dollar for each of the world’s eight billion people.

For 2023, its adjusted budget is just $7.5 billion. The world’s largest economy, the United States, contributed just $680,000 – approximately 0.00000292% of its GDP.

In contrast to its budget, expectations of the WHO have grown over the decades. It effectively operates as a second health ministry in many of the world’s most impoverished regions, financing primary-care clinics, quarterbacking emergency and routine vaccine programmes, and providing medical training and guidance to local health authorities and staff.

The increased frequency of natural disasters driven by climate change have also forced WHO to take on new responsibilities as an emergency responder, providing things like sanitation services, essential medical supplies and staff support in affected countries and difficult to reach regions like northwestern Syria. 

After the earthquakes struck, WHO Director-General Tedros Adhanom Ghebreyesus (centre) became the first top UN official to visit northwestern Syria since the start of its civil war over a decade ago.

In the last year alone, WHO teams responded to over 70 global health emergencies, including the return of Ebola in Uganda, cholera outbreaks in over two dozen countries and the Mpox epidemic. 

WHO also had boots on the ground to meet health needs in the conflicts in Ethiopia, Syria, Ukraine, and Yemen, and sent aid and staff to assist people hit by the floods in Pakistan and severe droughts in the Sahel and Horn of Africa. 

And not all funding given to WHO is created equal. Over 80% of the organization’s budget consists of “voluntary contributions”, which donors designate to be spent on specific initiatives like fighting HIV or malaria. This leaves under a fifth of the WHO’s already miniscule budget to be spent flexibly on its core mission of supporting public health. 

This lack of agency in the WHO’s ability to direct funding has become increasingly acute due to the rise of influential private charities like the Bill & Melinda Gates foundation and Gavi, the vaccine alliance. Between them, they account for 15% of the WHO’s budget, all of which is earmarked for specific projects dictated by the charities.

The voluntary nature of these contributions also makes them unpredictable, creating serious budgeting challenges for some of the WHO’s most essential responsibilities.  

“Much of the WHO’s work doesn’t make headlines,” Tedros said. “We bring experts together to distill the best science into treatment guidelines on which many countries rely. We set global standards like the International Classification of Diseases. We name pharmaceutical substances, monitor disease patterns, and provide technical advice to more than 150 countries on strengthening their health systems.

“Much of it is unglamorous, painstaking, and slow-moving work,” he said. “But it makes a huge difference.”

The Pandemic Treaty: towards a new approach to global health 

The WHO’s next chapter is prearing the world for the next pandemic, with member states currently negotiating a pandemic accord that aims to address the many weaknesses exposed by COVID-19 – the most glaring being equitable access to medicines and vaccines.

Vaccine hoarding by wealthy nations during COVID-19 was a sharp reminder of an earlier epidemic of HIV, when poorer countries only got access to life-saving antiretroviral medication to a decade after wealthier countries.

The WHO has proposed that it gets 20% of “pandemic products” manufactured during the next pandemic – including medicine, vaccine and protective equipment. It will then allocate this to poorer countries. 

There are huge differences in opinion and approach amongst member states, with these negotiations being the biggest challenge facing the WHO in recent times.

However, Tedros remains optimistic that member states will choose the right way forward.

“The WHO belongs not to those of us who work for it, but to the nations and people of the world who created it 75 years ago, with a vision for a healthier, safer, fairer world,” Tedros said. “Our vision remains unchanged: The highest possible standard of health for all people.”

Image Credits: US Mission Geneva, WHO, WHO.

Pamela Hamamoto, lead US negotiator on the WHO pandemic accord.

International NGOs and activists have called out the US for siding with China to exclude the public from seeing drafts of the pandemic accord as it is being negotiated by World Health Organization (WHO) member states.

“The attempt to create a veil of secrecy now surrounding the substantive and technical text-based negotiations on the WHO pandemic treaty sets a dangerous precedent for norm-setting at the multilateral level,” the group says in a letter sent on Wednesday to the US Secretary of Health & Human Services, Xavier Becerra, and Secretary of State Antony Blinken.

Excluding the public “undermines trust in the process at a time when attacks on the WHO and on the pandemic accord are increasing”, according to the letter signatories, which include Health Action International (HAI), Knowledge Ecology International (KEI), Oxfam America, People’s Vaccine Alliance (PVA), Public Citizen and STOPAIDS. 

“No one doubts the ability of industry lobbyists to obtain access to the negotiating text documents, creating an information and influence asymmetry that is inappropriate for public health norm-setting,” they added.

China and US opposition

The letter arises from China and US opposition to a proposal by the European Union (EU) that “all inputs and additions to the zero draft should be available to all stakeholders”, which was made during the fourth meeting of the WHO’s Intergovernmental Negotiating Body (INB) that is thrashing out the accord.

However, China insisted that the marked-up version of the pandemic treaty zero draft should be circulated only to “drafting group participants”, and this was backed by the US.

US Ambassador Pamela Hamamoto stated: “I think at this stage, I have some concern about sharing the draft to all stakeholders given where we are in the process and so I just want to be careful about that and certainly if we are sharing it with all stakeholders [we] would support removing the attribution of member states.”

In contrast to the INB process, negotiations at the World Intellectual Property Organization (WIPO) are public, and observers can access the draft texts under discussion, including those with member-state attributions, the signatories pointed out.

Extended deadline for textual submissions

INB co-chair Precious Matsoso closing the 5th INB meeting.

Meanwhile, the fifth INB meeting concluded on Thursday evening with a brief public report indicating that the deadline for member states’ textual submissions has been extended from 14 to 22 April.

The INB Bureau has undertaken to get a compilation report of the submissions back to states a month later, by 22 May, with a report on the process due to be made to the World Health Assembly, which also starts on 21 May.

The next meeting of the INB’s drafting group is from 12 to 16  June, and the sixth INB meeting is set for 17-21 July.

Concluding INB5, co-chair Precious Matsoso thanked delegates for their hard work.

“We’re really grateful for this level of commitment and and the trust you’ve bestowed upon the Secretariat in the bureau,” said Matsoso.

“It’s very tight and it’s very difficult, and it will get even more difficult as we progress,” she warned.

“But we surely will do our best and hope that we can produce a product that we’ll all be proud of and that will make this world feel safer. Ten years from now, we must look back and say we made the right decisions.

The closing session, which was open to the public, was over in a few minutes after delegates agreed to the meeting report that was shown on screen. The key decisions are captured below.

Image Credits: E Fletcher/Health Policy Watch .

Dr Ahmed Ouma, Africa CDC’s acting director

The Africa Centres for Disease Control and Prevention (Africa CDC) recommends that countries on the continent move rapidly to automated disease reporting systems across the continent to cope with disease outbreaks, as Nigeria grapples with Lassa fever and Malawi and Mozambique struggle with cholera.

“There has been an expected slowdown [in COVID-19 reporting] because of the nature of work at the country level with so many competing priorities for the data managers,” said Dr Ahmed Ouma, Africa CDC’s acting director. 

During the acute phase of the COVID-19 pandemic, countries were able to provide real-time COVID-19 updates regarding the case and fatality counts, but this is no longer the case, Ouma told the Africa CDC press briefing on Thursday.

“With the acute phase of the COVID-19 pandemic gone, every other responsibility steps in. All the other small outbreaks that were not being given a keen attention now need attention, the routine health services meet attention. The regular work of that particular individual in the data center still is required,” he said.

In Nigeria, during the acute phase of the COVID-19 pandemic, the Nigeria Center for Disease Control and Prevention (NCDC) gave nightly updates on case counts, tests and deaths. But the most recent data for the disease in the country was for 31 March as the country tracks several other diseases.  In 2023, there have been 823 confirmed cases of Lass fever and 144 deaths, for example.

“When you reach a chronic phase in that disease outbreak, that pressure is less. What we are asking and working with these public health institutions across the continent to do is to have a regular way of getting the information and then releasing the information,” Ouma added.

Nigeria’s Lassa fever outbreak

In Nigeria, 24 states and 98 local government areas have confirmed at least one case of Lassa fever this year according to the NCDC. 

Humans usually become infected with Lassa virus from exposure to urine or faeces of infected Mastomys rats, which they can then spread to other people via bodily secretions.

In its latest Lassa fever Situation Report, the center revealed that the country has confirmed 142 more cases of Lassa fever in 2023 than within the same period in 2022 when 681 cases were reported. The number of confirmed deaths so far this year,  144, is also higher than deaths recorded within the same period in 2022 (127).

Three states – Ondo, Edo, and Bauchi – account for almost three-quarters (72%) of all confirmed Lassa fever cases.

Meanwhile, 38 health workers have been infected this year 2023, with late presentation responsible for the case fatality ratio of 17.5%. Other challenges include poor health-seeking behaviour due to the high cost of treatment, poor environmental sanitation conditions in high-burden communities and a lack of awareness in high-burden communities.

NCDC said its response to the outbreak is through a One Health approach in affected local government areas, enhanced surveillance (contact tracing and active case finding) in affected states, monitoring of outbreak emergency composite indicators to guide action, diagnosis of all samples in the Eight Lassa fever testing laboratories across Nigeria, among others.

COVID-19 vaccinations reach 421 million 

Over 421 million people are now fully vaccinated against COVID-19, representing 45.33% of the target population. Some 101 million people have received their booster doses from across the continent. 

Out of 1.105 billion COVID-19 vaccine doses received on the continent, 1.065 billion doses have been administered, representing a 96% administration rate. 

“We continue to work with our member states and our partners to increase availability of COVID-19 vaccines on the continent,” Ouma said.

WHO revealed that most countries saw the biggest jump in vaccine coverage from campaigns that were held from September to December of 2022. 

“In Cameroon, for example, the number of vaccinated people doubled after a mass-vaccination campaign in November. Mozambique has been one of the project’s success stories; nearly two-thirds of the country’s population has been fully vaccinated,” WHO stated.

Dengue Chikungunya Zika
The Aedes aegypti mosquito is the carrier of dengue, zika and chikungunya.

Climate change is driving the spread of mosquito-borne arboviruses – dengue, chikungunya and Zika – into new areas, thus leading the world to newer crises, the World Health Organization (WHO) warned this week.

Several countries in the Americas region have reported an increase in dengue, zika and chikungunya cases and that the pattern might repeat in the northern hemisphere in the summer. 

“It worries us that the mosquito and these diseases have been increasing with climate change, by altitude and by latitude, so now we are seeing transmission where we didn’t see it before,” said Dr Diana Rojas Alvarez, the WHO technical lead for zika and chikungunya. 

In South America, these new transmission areas are further south on the continent whereas, in the northern hemisphere, cases have been reported in the south of Europe.

Major cities in Argentina and Bolivia have issued dengue health alerts this year, while Colombia, Uruguay, Bolivia, Peru and Paraguay have reported cases in new geographical areas, including those at higher altitudes.

Diseases like dengue, chikungunya and Zika are prominent in the tropical and subtropical regions of the world. They are transmitted by mosquitoes belonging to the Aedes genus type that breed in water, so an increase in rainfall, as well as more stored water during droughts, encourage increased breeding.

Dengue accounts for by far the most arbovirus cases in humans, and the caseload more than doubled between 2021 and 2022, from 1.2 million to 2.8 million cases, the WHO reported last month.

In 2000, there were half a million dengue cases being reported globally, but 2019 recorded 5.2 million cases, said Dr Raman Velayudhan, the WHO unit head for the global program on control of neglected tropical diseases. 

“In 2022, we had an increase of dengue in many parts of the world. In the Americas region, they recorded 2.8 million cases with more than 1200 deaths. The geographic spread of dengue is expanding,” he added. 

“This is really worrying because this shows that climate change has played a key role in facilitating the spread of the vector, the mosquitoes, down south. In 2023, we already have more than 441,000 cases in the American region and more than 100 deaths due to dengue.” 

Chikungunya alert

There has also been a leap in chikungunya cases, Velayudha reported.

“Currently we have around 135,000 cases (of chikungunya) as of 31 March in the Americas, compared with about 50,000 cases during the first semester of 2022,” he said.

“If we want to compare the number of weekly cases, the average weekly cases that are reported in the Americas are from two to 3000 [in 2022] and this year we had a record number of almost 35,000 cases in just one week,” Alvarez pointed out. 

In February, the WHO’s Americas body, the Pan American Health Organization (PAHO), issued an epidemiological alert warning member states to “intensify actions to prepare health care services, including the diagnosis and proper management of cases, to face possible outbreaks of chikungunya and other arbovirus diseases, to minimize deaths and complications from these diseases”.

Although the number of Zika cases has been declining since 2017, around 40,000 cases are still being reported annually from 89 countries and territories. 

Terming the current distribution of disease-causing mosquitoes “alarming”, Alvarez said that wherever the mosquitoes are present, the population would be exposed. She added that when people travel after being exposed to these mosquitoes, the risk of transmission is multiplied. 

“The current situation in the southern hemisphere could be an anticipation of what might happen in the northern part of South America, Central America, and the Caribbean. We should also be prepared to detect some cases during spring and summer in Europe and in the northern hemisphere, also in Southeast Asia, because the arbovirus season starts later there.”

Vaccines in the pipeline

For dengue, there is currently one vaccine licensed in around 20 countries, Velayudhan said. “It is effective in people who’ve had dengue once.”

There are two more vaccines in the pipeline, in various stages of trials. 

“The second vaccine developed by Takeda is currently under evaluation by our committee. We hope a recommendation may come towards the end of this year. We also have a third vaccine which is completing its studies right now and probably may come in for a recommendation to WHO in 2024,” he explained. 

Two antiviral drugs to combat dengue have completed phase one safety trials. “We also hope the pandemic has given an opportunity to have several studies on antivirals, and some of these antivirals may be beneficial to dengue and chikungunya and other arboviruses.” 

Similarly, there are three vaccines against chikungunya that are currently in the pipeline, completing phase three trials. “They are applying for different approvals in the countries. So hopefully we will have chikungunya vaccines coming up soon,” Alvarez said. 

She added that for Zika, there had been 45 vaccine candidates in the pipeline but none had gone further than phase one trials due to lack of funding. 

“However, the advancements with specific treatments for chikungunya to prevent Zika congenital syndrome and other neurological complications is ongoing. There are some phase two trials on monoclonal antibodies and potential treatments to prevent complications,” she said.  

Image Credits: James Gathany/ PHIL, CDC, Public Domain.

Ghana’s Health Minister Kwaku Agyeman Manu

Around half of the world’s health workers experienced burnout during the COVID-19 pandemic, while 55 countries face serious shortages of health workers – exacerbated by the poaching of skilled staff by wealthier countries.

Many countries are struggling to retain health workers, ensure they are equitably distributed, there is an adequate skills mix, and battling to mitigate their health workers mobility and migration.

These were some of the issues that delegates grappled with at the Fifth Global Forum on Human Resources for Health held over the past three days in Geneva.

“If we’re going to make progress in the mid-to-long-term, there’s a more immediate challenge that we need to solve and that is the burnout.. how to support individual health workers to become as productive as they can and deal with the immediate challenges around post-traumatic stress disorder,” Professor James Buchan from the Health Foundation told the closing plenary.

Professor James Buchan

 

“We’ve clearly identified the central role of government in taking forward the agenda in terms of protecting and investing [in health workers], which is primarily a government responsibility, but we also recognise there are many stakeholders which are part of the solution and we need to come at this together,” he added.

“Mobility and migration, have been with us as a core concern for many years now. But because of the pandemic, become even more pronounced. Demand for healthcare workers is up. Supply is constrained.” 

Africa is facing the most pressing challenges, with a projected shortage of 5.3 million health workers by 2030.

‘Walk the talk’

Ghana’s Health Minister Kwaku Agyeman Manu appealed to global delegates to support the Africa Health Workforce Investment Charter, which his country spearheaded last year after COVID-19 exposed continental weaknesses. 

The charter aims to align and stimulate investments to halve the inequities in access to health workers, especially in countries with the greatest shortages.

“The 5.3 million shortage comes amid 30% unemployment or underemployment among graduates,” said Manu.

“We are also adversely impacted by unmanaged migration. This is not just an African problem for Africa. The world is interdependent, and we must act together.

“ It is time for governments to show leadership in health workforce investments. It is time for us to align and synergize efforts with all partners in prioritising health workforce investments. It is time to walk the talk,” Manu concluded, appealing for global support for the charter

Ghana itself has managed to increase its workforce by 90,000 despite financial constraints.

Global expert committee to be set up

Dr Tedros Adhanom Ghebreyesus

In response to the challenges, World Health Organization (WHO) Director General Dr Tedros Adhanom Ghebreyesus announced at the closing plenary that he would establish “a multisectoral advisory group of experts that will provide me with the evidence for action in support of national health policy and workforce priorities”.

“This advisory group will comprise government and partners with expertise from education, finance, gender, economy, held and labour, and will report to a WHO global policy group, which will include me, and the six regional directors,” said Tedros.

WHO is recommending that all countries increase the graduation of health personnel to reach 8 to 12% of the active workforce per annum. This means that a country with a total of 5000 physicians would need to graduate between 400 and 600 physicians each year to maintain and improve capacity in relation to population needs and health system demand.

Some of the key outcomes of the forum will be taken forward to the United Nations General Assembly’s High-Level Meetings on Universal Health Coverage and Pandemic Prevention, Preparedness and Response in September 2023.

infertility
“Infertility affects millions,” WHO Director-General Tedros Adhanom Ghebreyesus said at the report’s launch. “Even still, it remains understudied, and solutions underfunded, and inaccessible.”

One in six people worldwide experiences infertility at some point in their lifetime, according to a World Health Organization (WHO) report containing the first global infertility estimates in over a decade.

Around 17.5% of adults experience infertility with little variation across regions and country income groups. Lifetime prevalence was 17.8% in high-income countries and 16.5% in low- and middle-income countries.

“The report reveals an important truth – infertility does not discriminate,” said WHO director-general Dr Tedros Adhanom Ghebreyesus. “The sheer proportion of people affected shows the need to widen access to fertility care and ensure this issue is no longer sidelined in health research and policy so that safe, effective and affordable ways to attain parenthood are available for those who seek it.”

WHO experts said there is not enough evidence to make a judgement on whether infertility is rising or not. Previous estimates published by WHO in 2012 also did not find evidence of increasing infertility rates.

“We cannot, based on the data that we have, say that infertility is increasing or constant,” said Dr James Kiarie, head of contraception and fertility care at WHO. “Probably the jury is still out on that question.”

WHO researchers defined infertility as the inability to achieve pregnancy after a year of unprotected sexual intercourse.

The report, which reviewed over 130 studies on infertility from 1990 to 2021, provides strong evidence of the global prevalence of infertility. But the fragmented nature of the data held researchers back from being able to disaggregate by factors like age, sex, or cause, making it difficult to assess which populations need to be prioritised for fertility care and what risks should be targeted by policymakers.

“The causes of infertility are varied and often complex, and it is something that both men and women experience,” said Tedros. “Indeed, a wide variety of people, in all regions, may require fertility care.

“Access to sexual and reproductive health services is the primary way for people to have the best chance of having the number of children they desire. However, in most countries, these services are inadequate.”

Out-of-pocket costs and social pressures are where inequalities lie

infertility
In low- and middle-income countries, a single in-vitro fertilization cycle can cost as much as their per capita GDPs, WHO said.

Infertility rates are similar in all regions around the world, but their economic costs to households are not. Dr Pascale Allotey, Director of Sexual and Reproductive Health and Research at WHO, called the health care costs in poorer countries “catastrophic”.

“The cost of fertility care is an immense challenge for many people, increasing inequity and creating impoverishment and hardship, especially for the poorest households and individuals,” Allotey said. “Millions of people face catastrophic health care costs, making this a serious equity issue and very frequently a medical poverty trap.”

Dr Gitau Mburu, a fertility research scientist at the WHO, said the data analysed in the report showed how much people in countries where children are expected of a family are willing to sacrifice financially to achieve a successful pregnancy.

“In many low- and middle-income countries, a single cycle of in vitro fertilization (IVF) costs more than their average annual per capita income,” Mburu said. “Such extraordinary expenditures … all too often catapult [people] into household poverty as a direct consequence of seeking care for infertility.”

To many women in countries where motherhood is still viewed as their primary role, the consequences of failing to have children can be devastating. The pressure to sacrifice financially to achieve that goal can often feel like an obligation, Allotey said.

Societal pressures

“Procreation comes with a significant societal pressure in countries like mine,” said Allotey, a native of Ghana. “Pregnancy remains critical to the perception of womanhood and of the perception of a couple.”

Failure is often met with stigma, mental health consequences, and in the worst cases domestic violence triggered by the woman’s failure to conceive.

“People with infertility often experience anxiety and depression with ramifications for people’s mental and psychosocial wellbeing,” Allotey said. “There is an increased risk of intimate partner violence associated with infertility as relationships are tested.”

In his closing remarks accompanying the release of the report on Monday, the WHO director-general said the report should be a wake-up call to governments to stop sidelining fertility care.

“For millions around the world, the path to parenthood can be difficult to access, if not impossible,” Tedros said. “It is my hope that governments use this report to develop evidence-based policies and adopt proven solutions, as part of their efforts to strengthen health systems to help people fulfil their fertility intentions and live healthier lives.”

Image Credits: CC, CC.

Dr Raquel Child Goldenberg, Director of the Office of International Relations and Cooperation in Chile’s Ministry of Health

Strong primary health care, nurturing the health workforce and legal flexibility emerged as key COVID-19 lessons at a high-level roundtable at the Fifth Global Forum for Human Resources for Health, which opened on Monday.

Chile gave its healthworkers life insurance, more holidays and extra pay during the pandemic, said Chilean health official Dr Raquel Child Goldenberg.

“It was really important to have measures to protect health workers. They were stressed, and they had a hard workload,” explained Goldenberg, Director of the Office of International Relations and Cooperation in the Ministry of Health.

“The government proposed different measures and legislation to take care of health workers. For instance, if health workers faell sick with COVID-19, that was declared a profession-related disease and there were different kinds of treatment and measures to protect them.”

The Chilean government also empowered the health ministry to employ healthworkers not authorised to work in the country.

Building community health 

Dr Atul Gawande, Assistant Administrator of Global Health at the US Agency for International Development

Dr Atul Gawande, Assistant Administrator of Global Health at the US Agency for International Development stressed that a country’s strength in any pandemic response “is only as good as the health system that you’ve built”.

“And therefore our investment at this time in protecting that frontline primary health care workforce is absolutely critical,” said Gawande. 

“We’ve come through the first global reduction in life expectancy since World War Two and in order and that damage did not come just because of the direct damage of the virus. It became because we had diverted resources from health workers. It came because the financial landscape for health has changed dramatically. And the prioritisation of the primary health care workforce is critical.”

Gawande conceded that the US “did not have a strong, broad commitment to community health work”, and needed to undergo “reverse innovation” during COVID-19 “when tens of thousands of community health workers were brought in”.

“We heard the lesson that you have to hire and train people from the community. And many of the communities where the lowest rates of vaccination and the highest rates of deaths were occurring were the lowest income, least provided for. So those places became the places to invest in raising those community health workers and creating that outreach capability.”

Tapping into informal networks

Dr Lino Tom, Papua New Guinea’s health minister.

At the other end of the wealth spectrum from the US, Papua New Guinea had no choice but to use an “informal system where we asked the community leaders to actually identify people which they can send to our health facilities to help,” said Dr Lino Tom, the country’s health minister.

Initially, his country could not even process COVID-19 tests.

As a result of these glaring shortcomings, Papua New Guinea is establishing a stand-alone medical university and a national laboratory. 

But, lamented Tom, “we’ve seen a lot of brain drain and it’s quite difficult when you don’t have the resources to retain people you have within your system”.

Mozambique’s health minister, Dr Armindo Tiago, said that his country had to adopt a flexible approach to health workers during the pandemic in light of the dire shortage. In addition, the country was so short of personal protective equipment (PPE) it had to ration it to the most at-risk workers.

“Mozambique is still in different emergencies,” added Tiago. “We went out of COVID but then we went into polio. Then we went into cholera, and we have terrorists in the north of Mozambique. We need to still mobilise resources to respond to current emergencies.”

Mozambique’s health minister, Dr Armindo Tiago,

Non-partisan approach

Portuguese MP Dr Ricardo Baptista Leite stressed that the issue of richer countries poaching healthworkers away from lower-income countries had to be addressed, possibly by the pandemic treaty currently being negotiated.

“We need to have regional planning and we have to have regional commitments. One country in a region benefiting from the health workforce and all the others not benefiting will lead to huge problems. we need to do this in a way of a common good approach,” Leite stressed. 

“We also need to use digitization for healthcare system reform, and stronger monitoring mechanisms in terms of health care, workers satisfaction, and also using compassionate care indicators,” added Leite, who used the forum to announce that he was leaving parliament to become the new CEO of the International Digital Health and Artificial Intelligence Research Collaborative, I-DAIR.

Leite said that Portugal had been so successful in addressing COVID-19 because the main political parties took a non-partisan approach and stood together. 

Parliament declared a state of emergency, and during this phase, chronic patients were able to get electronic prescriptions for three to six months’ supply which were delivered by community pharmacies.

“People trust institutions and trust health institutions,” he added. “Many people ask me how was Portugal successful in vaccination. When neighbouring countries in the European Union were below 60%, Portugal was over 90% vaccination. And it’s because, especially after the 1974 revolution, the public health structure invested tremendously in health literacy.

Primary healthcare family doctors, who are paid according to health outcomes, played a critical part during COVID, and so did community pharmacies, he added.

Oman’s Dr Fatma Al Ajmi, Undersecretary for Financial and Administrative Affairs

 Oman’s Dr Fatma Al Ajmi, Undersecretary for Financial and Administrative Affairs, said that primary health care is “very solid” in her country, and this had enabled it to contain the impact of COVID-19.

“From the initial stage, factor one was the focus was on the protection of healthcare worker and the public,” said Al Ajmi. 

A mental health hotline was established to support healthcare workers, and committees were activated in each hospital where psychologists and psychiatrists were available to offer support.

It solved its shortage of PPE by encouraging local manufacturers to produce it, she added.

Dr Tedros Adhanom Ghebreyesus opens the fifth meeting of the intergovernmental negotiating body.

The fifth meeting of the Intergovernmental Negotiating Body (INB) to draft a pandemic accord started on Monday with acknowledgement by World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus that it faces a very tight timeframe.

“There is now only one year until the World Health Assembly in May 2024, which will consider the outcome of your efforts,” said Tedros. “This is a very tight timeframe, especially for a global negotiation. But from what you have accomplished so far, I am confident again that you have the will and commitment to reach a consensus in 11 months.”

Tedros noted that the WHO’s Constitution, itself a treaty adopted in 1946, “affirms not only that health is a fundamental human right for all people, but also that the health of all people is fundamental to the attainment of peace and security and is dependent upon the fullest cooperation of individual individuals and states”.

“This INB is a renewed commitment to that principle, a renewed commitment to protect populations, communities, and individuals from public health threats,” he added, enumerating the current health outbreaks including Marburg, Ebola and cholera in 70 countries.

“These are reminders of why we need to work collectively to strengthen pandemic prevention, preparedness and response. Protecting lives and livelihoods is not charity. We must move beyond that paradigm. And that’s what your important work is about with its focus on consensus, inclusivity and transparency. As you navigate the negotiation phase, I urge you to keep listening to and supporting one another,” Tedros concluded.

Brief public opening

The INB was open to the public for 23 minutes before moving into closed “drafting” sessions until Thursday afternoon when it will give a brief public reportback.

However, before it closed, the INB bureau reported on the three informal sessions it had held in the past month since the last INB meeting that covered five topics.

The first session on 17 March covered predictable global supply chain and logistics network (article six of the zero draft), during which the panellists noted that the existing text already covered most elements but suggested that some of the legally binding aspects “could further enhance obligations”. 

The second topic that day covered ‘One Health’ (article 18), with some member states questioning whether, given the breadth of the topic, an entirely separate instrument may be considered. 

The second session on 20 March also covered two topics. The first focused on the transfer of technology and know-how (article seven) with speakers from the WHO, World Trade Orgaization (WTO) and the World Intellectual Property Organization (WIPO) reflecting on what worked well during the COVID pandemic, such as that the period of licencing was shortened from an average of three years to one year. They also discussed what could be improved for the future, including the pre-selection of manufacturers and setting up templates for licencing.

The second topic looked at stable and equitably distributed production (also article seven). Panellists highlighted a few areas that could be further enhanced, for example, incentivising the manufacturing industry, investing in a highly skilled workforce and ensuring the sustainability of production capacity across all regions. 

The third and final session on 22 March covered the pathogen access and benefit sharing system (article 10), with panellists highlighting that, for an equitable system to be operational, it had to be transparent and have financing, the active involvement of the private sector, and possibly a coordination committee. 

The INB Bureau also met with the Bureau dealing with changes to the International Health Regulations (IHR), reported co-chair Roland Driece.

Reflecting that many representatives sat on both structures, Driece said that the two processes were “complementary”, and the “interlinkages between those two processes… are critical for the success of both instruments”.