INB co-chairs Roland Driece (centre) and Precious Matsoso (right) at the seventh meeting of the intergovernmental negotiating body.

At the start of the seventh round of negotiations on a pandemic agreement on Monday, a number of European countries asserted that any changes to intellectual property (IP) rights should be thrashed out at the World Trade Organization (WTO) – not the World Health Organization (WHO). 

IP rights are one of the most controversial aspects of the pandemic agreement negotiations and, with a negotiating text finally before WHO member states, sharp disagreements were once again evident at the Monday plenary of the intergovernmental negotiating body (INB).

Describing the text as an “improvement”, the European Union nonetheless expressed concerns about clauses on IP, technology transfer and finance in the text.

Germany, Sweden, Ireland and the UK were more direct in their opposition to any attempts to undermine IP protection, stating that discussions belong at the WTO.

“Speaking as one of those Geneva ambassadors who has the good fortune to cover both the United Nations and the World Trade Organisation, I do need to reaffirm our conviction that the WTO is the appropriate forum to discuss our obligations on intellectual property,” said the UK representative.

US representative Colin McIff and Ambassador Pamela Hamamoto.

Meanwhile, the US stated that “eliminating intellectual property protections will not effectively improve equitable access during pandemic emergencies, and will in fact harm the systems that have served us well in the past. 

“The United States believes strongly in IP protections which serve to fuel investment and innovation. We agree that more timely access to these innovations should be central to our discussions and are exploring options to prioritise the availability of medical counter-measures for developing countries during future pandemic emergencies.”

Articles 10 (on sustainable production) and 11 (tech transfer and know-how) appear to be the thorns in their flesh. 

Article 10 simply “encourages” entities – particularly those that get significant public financing – to grant “non-exclusive, royalty-free licences to any manufacturers, particularly from developing countries, to use their intellectual property” to develop “pre-pandemic and pandemic diagnostics, vaccines and therapeutics”.

Article 11 is more explicit, committing parties during pandemics to “time-bound waivers of intellectual property rights to accelerate or scale up the manufacturing of pandemic-related products”.

During the stakeholder session, Knowledge Ecology International (KEI) described the text’s provisions on IP limitation as “well-intentioned but problematic”.

“Parties do not need to refer to the WTO TRIPS agreement or a waiver. Global rules on exceptions are broad enough. What is needed is the implementation of laws and use of exceptions at the national level, to address IP issues in a way that is useful,” said KEI.

KEI’s Thiru Balasubramaniam

WTO appeals for synergies

The WTO appealed for “synergies and complementarity” between its processes and bodies and the “trade-related elements of the INB’s draft negotiating text”.

These include consideration by the TRIPS Council of extending “to COVID-19 therapeutics and diagnostics the 2022 ministerial decision on the TRIPS Agreement”, discussions in the Council for Trading Goods on “export restrictions, regulatory requirements, international coordination, transparency, and trade facilitation”, and “mapping manufacturing capacities and demand” to develop a “global supply chain and logistics network”. 

Meanwhile, the World Intellectual Property Organization (WIPO) asserted that “any outcome from the INB process should not affect the rights and obligations and the other existing international agreements” and that “protection of IP rights is important for the development of new medical products”.

Meanwhile, the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) said that the parts of the current text would undermine the innovation ecosystem that enabled the pharmaceutical industry’s “ability to rapidly develop medical countermeasures”.

The IFPMA also warned of “unnecessary bureaucratic hurdles” that “will deter the scientific research”.

“The draft lacks a clear strategy for a robust procurement mechanism for low-income countries and fails to adequately address trade barriers that could hinder the global distribution of medical supplies,” added the IFPMA.

‘Common but differentiated responsibilities’

The Equity Group and Africa Group objected to the removal of common but differentiated responsibilities (CBDR) – a term usually used in climate talks to indicate that, while all countries have responsibilities, economic differences mean they cannot all have the same level of responsibilities. 

The Equity Group, which represents 29 countries across regions – including Brazil, China, South Africa and Pakistan – stated that CBDR is important for “international solidarity and inclusivity”. 

“CBDR should be included in the treaty with a view to achieving equity and attaining the highest standard of health for all,” said South Africa for the Equity Group.

South Africa’s Ambassador Mxolisi Nkosi on behalf of the Equity Group

The group “has developed textual proposals to be included in the draft negotiating texts that will lead to the realisation of equity as a central mandate”, noted South Africa.

The group wants stronger equity language in eight sections: Article Seven (health and care workforce), Article Nine (research and development), Article 10 (sustainable production), Article 11 (technology transfer), Article 12 (access and benefit sharing), Article 13 (supply chain and logistics), Article 19 (implementation support) and Article 20 (financing). 

The Africa Group also appealed for health sector strengthening to include a prohibition on wealthy countries poaching health workers from poorer countries.

Lack of gender equity

Last week, Medecins sans Frontieres (MSF) noted that “there is no reference to sexual and reproductive rights services in the text, “gender equity” has been deleted from general principles, and “gender inequalities” is only mentioned in the articles on health workforce and international cooperation and collaboration.

The Pandemic Action Network (PAN) also raised the text’s failure to include “gender equity language for persons in vulnerable situations”. 

“Equity and human rights must explicitly include gender. Parties must agree to collect and report gender-disaggregated data, uphold social protections and protect the full spectrum of essential health services for all emergencies,” said PAN. 

The Office of the High Commissioner for Human Rights also noted the lack of references to gender and human rights (three mentions each).

Meanwhile, the Independent Panel on Pandemic Preparedness and Response called for “definitive, results-oriented language” that commits countries to invest in building regional resilience by defined dates. 

Modalities still undecided

There was widespread member state support for the start of “direct negotiations” focused on the most important aspects of the draft – which is now being referred to as an “agreement” – rather than the more legally binding accord or treaty.

However, there was also some support for the continuation of informal meetings to address contentious articles – particularly during the month-long break between the first part of this INB meeting this week and its second session on 4-6 December.

Ethiopia’s Ambassador Tsegab Kebebew on behalf of the Africa Group

However, Ethiopia on behalf of the Africa Group, rejected the informal meetings as a “parallel process”.

The Africa and Equity Groups, as well as countries from the Americas, want to start with the most contentious part of the draft, Chapter Two which covers equity.

The INB co-chairs appealed for member states not to repeat their well-known positions “twenty months into negotiations”, but to move forward to find consensus.

The US also “urged consideration of industry and stakeholder views, which will be essential for the future implementation of this agreement”. 

“This outreach needs to be done with greater intensity given these partnerships will provide important information about the viability of many proposals in that text,” said the US.

Japan also requested dialogue with “relevant stakeholders, including research institutes, industry, and civil society”, particularly with “entities which will be involved in the implementation of this draft agreement”.

Israel-Palestine conflict clouds discussion

The Israeli-Palestinian conflict cast a long shadow over the INB meeting, with a number of countries stating their support of one or the other during their comments on the draft. The most tense exchange came from representatives of the territories.

“A pandemic situation is in front of our doors in Palestine as the sewage pumping system is not operational any more,” warned the representative from Palestine.

Palestine appealed for international assistance, including “air-tight body bags, help with extracting bodies, as well as trucks and bulldozers, medicines, medical equipment and, “the most urgent, water, food and fuel for hospitals, ambulances and health care access in general”.

“No place is safe in the occupied Palestinian territory – the West Bank including East Jerusalem and the Gaza Strip,” he concluded, noting that over 9000 Palestinians had been killed in the month-long conflict.

However, Israel’s representative accused the Palestinian Authority of giving “a free pass to a genocidal terrorist organisation which unleashed its terror on Israel people on October 7”.  

“It’s certainly perplexing that the delegation does not condemn the action of Hamas when on October 7, they committed the slaughter of Jewish people, not for anything they have done, but because of who they were. 

“When Hamas entered southern Israel and slaughtered, raped, tortured and murdered 1400 people, they were civilians,” noted Israel’s delegate, calling on Palestine to “condemn Hamas for using the Palestinians as humans shields and for “the slaughter of 1400 people on October 7,” he concluded.

The INB co-chairs allowed comments on the conflict but conceded at the close of the meeting that this had slowed progress and that Tuesday’s meeting would still need to decide on the modalities for negotiations.

Snakebite is a complex and neglected issue that requires a multifactorial strategy, including conservation, community engagement, scientific research and robust healthcare delivery, according to experts who recently participated in a Global Health Matters podcast.

In the most recent episode of Global Health Matters, host Garry Aslanyan speaks with Fan Hui Wen and Thea Litschka-Koen, snakebite gurus in Brazil and Eswatini, who reveal untold truths about snake bites in their communities and the complexities associated with producing and administering antivenom. He also talks with Diogo Martins, the research lead for snakebite at Wellcome in the United Kingdom.

How big is the snakebite challenge?

The World Health Organization estimates that 5.4 million people are bitten by snakes every year, and nearly 140,000 people die.

“The burden is quite big,” Martins says, explaining that of the 5 million people who are bitten each year, 2 to 2.5 million are venomous bites. “We’re talking about 100,000 deaths every year, and this is most likely an underestimation. And four times more of that will live for the rest of their lives with, unfortunately, amputations PTSD and that’s a huge burden.

“And we’ve done a little bit of desk research about how that compares with many other popular global health issues, and it’s actually quite a substantial amount of years lived with disability, and it’s quite expressive that people just do not know much about it because it feels a little bit remote to many of us, unfortunately,” Martins says.

How can we treat snakebites?

While antivenom is the best treatment for a venomous snakebite, many complexities are associated with producing and administering antivenom, the experts explain. In addition, according to Litschka-Koen, a lot of clinicians have no faith in antivenom, in part because of the ineffectiveness of the antivenoms that are currently on the market.

“There is no regulation regarding the effectiveness of the antivenom,” Litschka-Koen, founder and chairperson of the Eswatini Antivenom Foundation, says. “To produce antivenom is not difficult. To go through the pre-clinical trials it is incredibly costly.

“I had no idea how difficult and costly and cumbersome it was actually to produce this product. If it does happen, it needs to be very well regulated,” she continues. “It needs to go through the processes, and it needs to be monitored. Otherwise, we’re going to go back 10 years, and we’re going to be in the situation again where the doctors say, what’s the point of using antivenom? It doesn’t work.”

She says that countries can and should start producing their antivenom. However, if they do not, then good antivenoms need to be made accessible. Currently, many antivenoms carry a high price tag, making them out of reach for many people living in low- or middle-income societies.

“It’s inconceivable that … you can have patients having patients having to pay $100 in many geographies to solve one episode of a snakebite,” Martins notes. “We cannot have individuals that earn $1.50 a day and have the unfortunate circumstance of crossing paths with a venomous snake, and suddenly all of their savings are gone, not to even mention other impacts socially and economically.”

Listen to more episodes of Global Health Matters here.

Image Credits: TDR/Global Health Matters.

Same place two months apart. Above: AQI 78, 8th of September, 2023, below: AQI 479, 3rd November, 2023

Within hours, the Delhi government closed schools and announced traffic and construction curbs, but experts are questioning whether the government is tackling the right causes. Meanwhile, a database reporting the contribution of pollution from farm fires has been discontinued by the national government. The air quality forecast remains bleak.

Delhi’s air pollution suddenly got a whole lot worse on the 2nd of November, hitting the government’s own defined ‘severe’ levels of 379.2 micrograms/m3 of PM2.5 for the 24-hour period. 

Despite rising levels of awareness and preparedness for air pollution emergencies, the deterioration in air quality was not anticipated by the Air Quality Early Warning System run by the Central government. 

Unlike in years past,  officials both at the national and Delhi state level were quick to respond – reflecting the growing awareness of air pollution’s health harms over the past few years. 

Within hours, Delhi’s Chief Minister Arvind Kejriwal closed primary schools, and the national government launched an 8-point plan to curb pollution emissions, including a system of ‘differential’ fares for public transit to encourage off-peak bus travel. 

But despite the measures the latest forecast shows the next few days may continue to see severe air pollution or at best ‘very poor.’ This translates into pollution levels that are roughly eight times the WHO 24-hour average guideline standard for PM2.5 levels, widely regarded as the best indicator of health-harmful pollutants. 

And the immediate outlook remains bleak. ‘Severe or Very Poor’ air quality is forecast for six days starting on the 3rd of November. 

Stubble burning may, or may not, be the leading factor 

Delhi’s haze of 2nd November, 2023: The barely visible building is about 700 metres away, when the hourly PM 2.5 level in this location was a little over 450 micrograms/cubic metre (µg/m3). The WHO’s safe limit for a day is 15 µg/m3.

While many have cited the stubble burning by farmers in rural states north of Delhi, as a key driver for seasonally high levels of pollution in the late fall and early winter, local sources may also be playing a larger role in the leading factor in the current emergency, experts said. 

The fact is that this year, the number of stubble fires burning in Punjab, the state that produces the lion’s share, had declined by about half their seasonal rate, as of the 1st of November. 

In their quest for sources, some experts were now pointing squarely at Delhi and surrounding cities – where cooking from biomass, traffic and industrial emissions may now be the leading factors. 

Additionally, there are the classic weather conditions faced by Delhi at this time of year, when falling temperatures, low wind speeds and a lack of rainfall all trap pollutants closer to the ground. Confounding the issues, one leading government data source on air pollution sources, maintained by the System of Air Quality and Weather Forecasting and Research (SAFAR), has been discontinued, making it more difficult to attribute the sources of pollution at all.

Living in a Haze

On Thursday, the usual morning haze lingered on and appeared to get worse as the day wore on. Visibility fell, and many people complained of sore throats, running noses and fever. Social media was buzzing with pictures and complaints demanding to know how this is allowed to happen year after year. 

Preliminary data shows that levels of PM 2.5, fine particulates that are the most common indicator for health risks, shot up beyond 250 micrograms/cubic metre (µg/m3) on average across India’s capital around 2-3 p.m. Thursday afternoon. That’s 17 times greater than WHO’s 24-hour standard of just 15 (µg/m3) . 

The mid-afternoon spike was also unusual. As it’s the hottest part of the day, pollutants tend to rise with the heat thereby reducing ground-level pollution. 

The pollution emergency was not forecast although satellites and at least one supercomputer are now being used in India to track air quality.

Eight-point graded response plan announced 

The main body in charge of controlling pollution in and around Delhi, the Commission for Air Quality Management (CAQM) blamed meteorological and climate conditions as “highly unfavourable.” The air quality index (AQI) was only expected to worsen in the coming days, it also warned.

As the AQI hit ‘severe’ it triggered multiple responses. Government officials gave the go-ahead for an 8-point action plan – under a programme called Graded Response Action Plan (GRAP). 

Topping the list is more vacuuming and mechanised sweeping of roads and sprinkling water to suppress dust. 

The government also introduced differential rates on Delhi’s public transport system to encourage off-peak travel to reduce traffic congestion.

Bus frequency has also been increased and special shuttles are being started for central government employees, a senior official of the Government of Delhi, Mr Ashish Kundra told Health Policy Watch. 

The Committee also announced a  ban on all construction and demolition projects except for essential hospitals, defence, metro and other infrastructure. 

They announced restrictions on the movement of older vehicles that fail to meet the latest pollution standards within Delhi and four bordering cities (Gurgugram, Faridabad, Ghaziabad and Gautam Budh Nagar a.k.a. Noida.)

Officials Divided: To Walk Or Not To Walk

But there appear to be cracks in the air pollution control system. It goes beyond the well-publicised discussion around a basic shortage of staff. 

In the first 24 hours of the crisis, there’s been contradictory health advice to residents from two top agencies. 

Notably, the CAQM, controlled by the Central government, says those in Delhi and its neighbourhood should “walk or use cycles for short distances.” SAFAR, also controlled by the Central government (they have the said supercomputer), says “everyone” should avoid all physical activity outdoors and “give a miss to walk today.”

Scientists have documented how even short-term exposure to hazardous levels of PM 2.5 are linked to premature mortality, increased emergency room visits and hospital admissions for acute and chronic cardiovascular and respiratory conditions.  As a result they have generally recommended restricting outdoor physical activity on high-pollution days.

Focusing on the wrong pollutants? 

A look at the curbs announced by the CAQM also shows that there is an emphasis on controlling construction and road dust. 

However, the contribution of these sources to Delhi’s current air pollution problem is very marginal, according to daily source attribution data generated by the Ministry of Earth Sciences. 

Known as the Decision Support System for Air Quality Management in Delhi (DSS). This is the one India-based reference point remaining for unraveling air pollution sources following the discontinuation of the SAFAR database.

For 2 November, the DSS showed Delhi’s construction as contributing  2% of ambient air pollution, while road dust and waste burning contributed just 1% each. 

In contrast, the largest proportion of pollution currently was from biomass burning – 25% according to the DSS database. This latter presumably includes the thousands of crop stubble farm fires burning up north in the states of Punjab and Haryana – but it also could include local household sources of heating and cooking. 

Delhi-area transport accounted for about 14%. Meanwhile, another 30% of emissions are transported into the city from 19 nearby towns. 

Another 16% of emissions originate from areas beyond the Delhi region – although there is no further detail on the types of sources here, as well. 

Notably, more precise data on the source apportionment of farm fires used to be provided by the SAFAR database, operated by the Centre’s Ministry of Earth Science, until only a year ago and cancelled for reasons that no one has managed to explain. 

Given a dearth of information about sources, then, major questions remain about how effective are the measures being taken in Delhi in the current air pollution crisis. 

Farm Fires vs Delhi’s Own Pollution

Satellite data shows that the number of farm fires in the north Indian state of Punjab has sharply declined compared to a year ago, but have begun to rise now. Source: CEEW.

Many farmers burn the residual stubble from the paddy harvest in order to sow the next crop, largely wheat, by mid-November. It’s the most economical way specially for marginal farmers to do so given how expensive manual labour or machines are. 

The governing party of Punjab, Aam Aadmi Party (AAP) is also in power in Delhi. It had promised to reduce the number of farm fires by half this year; last year there were almost 50,000. The data so far shows that that seems to be on track. The fire count till the 1st of November, i.e. a day before the air quality turned ‘severe’, was under 9,000 compared to over 17,000 a year ago at the same time.

However, the fires are rising daily. The four-day average till 1st November was 2,200 compared to under 900 a week earlier. The number of fires is expected to rise till mid-November when the wheat must be sowed. 

The smoke appears to be smothering Delhi. While the DSS data showed it was contributing a quarter of the pollution, the EU space programme posted that a “thick smoke blanket (from the stubble fires in the northwestern states) is engulfing” the capital.

Additionally, the CAQM stated that there was a sudden increase in the number of farm fires, combined with unfavourable meteorological conditions (low wind speed) moving pollution to Delhi. 

However, some experts point out that the lower number of farm fires underscores a greater truth. 

“The contribution from fires or any sources will continue to remain debated as there is not a clear consensus on the emissions inventory being used to develop these models” for source attribution. 

“Despite lower levels of burning in the same period this year (vis-à-vis) last year, we see that the AQ is as bad, if not worse than last year, and this points to the other sources that exist within the NCR that need better coordination to address. 

“In two weeks’ time, we will have to shift focus to those more persistent sources that pollute our air throughout the year. The role of meteorology must be discounted at all times- what we cannot control, we cannot obsess over and blame. We can only bring down our emissions,” says Karthik Ganesan, Fellow, Council on Energy, Environment and Water (CEEW.)

Drug regulatory authorities of Switzerland, the Republic of Korea and Singapore have become the first three countries to be listed as WHO-Listed Authorities (WLA) and can be used as a point of reference for the approval of new drugs and vaccines.

The drug regulatory authorities of Switzerland, the Republic of Korea and Singapore have become the first three countries to be listed as WHO-Listed Authorities (WLA) that can be used as a point of reference for other countries’ deliberations on approval of new drugs and vaccines.

The WHO’s recently established WLA framework is intended to create an evidenced-based pathway for regulatory authorities operating at an advanced level of performance to be globally recognized.

The overall aim is to provide a point of reference for other national authorities in their consideration of new drugs for approval. This can help promote faster and more robust regulatory reviews in other countries of new, and potentially significant medical products that some national authorities may not have the resources to evaluate thoroughly on their own.

Traditionally, WHO as well as many low-and middle-income countries looked to the regulatory decisions of the US Food and Drug Administration (US FDA) or the European Medicines Agency (EMA) for guidance in their own national approval of new drugs and medicines.

However, the reference to the US FDA and EMA has always been informal and relatively ad-hoc.

WLA label creates a more systematic pathway for international recognition

The newly created WLA label aims to correct this by creating a more systematic pathway to international recognition for a national regulatory agency. That should signal to other countries that the agency meets WHO and other internationally recognized regulatory standards and practices.

A technical advisory group on WHO-Listed Authorities (TAG-WLA), which met for the first time in September at WHO headquarters in Geneva, made the designations based on a set of criteria established for the WLA framework. The group’s key task is to provide independent, strategic, and technical advice to the WHO as it decides who to add to the WLA. The group has 14 members from the six WHO regions with a broad range of expertise.

Asked by Health Policy Watch why the FDA and EMA hadn’t been granted certification yet, a WHO spokesperson said, “several stringent regulatory authorities (SRA) already initiated discussions with WHO on the process towards WLA.”

But the spokesperson added, “The decision to apply for evaluation and listing as a WLA is voluntary, and no selection is conducted by WHO; rather, it is initiated by or on behalf of the regulatory authority (RA) if satisfies one of the criteria.” They are:

  • The RA is on the list of transitional WLAs (tWLA).
  • The RA has attained at least overall Maturity Level (ML) 3 as determined through a formal benchmarking against the WHO Global Benchmarking Tool (GBT).

“Once eligibility is confirmed, the RA must undergo a performance evaluation process,” the spokesperson added, noting that the process is further described in a new Operational Guidance.

WLA designation applies to medicines, not medical devices

The WLA framework is currently only applicable to medicines [including multisource (generics), and new medicines (new chemical entities) and/or biotherapeutics and/or similar biotherapeutic products], and vaccines. Medical devices, including in vitro diagnostics, as well as blood and blood derivatives are not in the scope of the WLA, WHO said.

The newly WHO-certified authorities include the Health Sciences Authority (HSA), Singapore; the Ministry of Food and Drug Safety (MFDS), Republic of Korea; and the Swiss Agency for Therapeutic Products (Swissmedic), Switzerland. The listing indicated that the regulatory authority has complied with all the indicators and requirements specified by WHO.

“This achievement is the result of investment by the Governments of the Republic of Korea, Singapore and Switzerland in the strengthening of their regulatory systems and reaffirms the collaboration between WHO and the three Governments in promoting confidence, trust and further reliance on authorities that have attained this global recognition, through the transparent and evidence-based pathway for designating and listing of WLAs,” said Dr Yukiko Nakatani, assistant director-general for Access to Medicines and Health Products.

Although the WLA designation will provide a pathway for other countries in deliberating regulatory decisions, the WHO spokesperson  stressed that “the ultimate responsibility and decision for using or adopting the regulatory decisions taken by a WLA resides with the users (e.g., other regulatory authorities, procurement agencies) and will depend on the specific context and scope of its intended use.”

Image Credits: Unsplash.

 

People’s exposure to heat is increasing in Ethiopia due to climate change, which is also causing water shortage.

Heat is the deadliest of extreme weather events, and heat-related mortality could be 30 times higher than previously thought, killing 500,000 people annually between 2000 and 2019.

Yet only half the world’s governments have heat warning services, less than a quarter (23%) of health ministries use meteorological information to monitor climate-sensitive health risks, and only 26 countries have climate-informed, heat-health early warning systems.

These are some of the key findings of the 2023 State of Climate Services Report, prepared by the World Meteorological Organization (WMO) and partners, which was released on Thursday.

In assessing progress made in climate services for health globally, the report finds the health sector “ill-prepared to safeguard society”.

Addressing the report’s launch, WMO Secretary-General Prof Petteri Taalas said that, by the latter part of this century, “we are going to face very severe combined heat and humidity stress cases, especially at low latitudes”.

Prof Petteri Taalas, WMO Secretary General

Taalas added that, typically, during heatwaves, air quality was also poor: “When we had the 2003 heatwave Europe, there were 75,000 casualties and a large part of the deaths were related to poor air quality as we had a fairly high concentration of surface ozone.

“During these kinds of events, especially in urban areas, we also have challenges with ultrafine particles. That was the case in 2010, when Russia was facing a heat wave and 50,000 people died. There was also fairly poor air quality due to forest fires and peat fires, and we faced a similar situation in Canada this year,” said Taalas.

“And we know from the most recent IPCC [Intergovernmental Panel on Climate Change] report that practically the whole world has been experiencing an increase of heat waves. About half of the planet has been facing increased flooding events and a third has faced drought,” he added. 

Climate impacts on health

World Health Organization (WHO) Director-General Dr Tedros Adhanon Ghebreyesus said the report “highlights the need for tailored climate information to support the health sector on a wide range of functions from heat health warning systems to mapping the risk of infectious diseases”. 

“It also calls for more to be done to prepare the health community for future shocks and pressures due to climate variability. Going forward, we must work together to make high-quality climate services available to all communities and support the health and well-being of people facing the impacts of climate change,” added Tedros.

Maria Neira, WHO’s Director of the Environment, Climate Change and Health, said that the data generated by the WMO and partners was key in assisting the health sector.

“If we use this very powerful data, and we put it at the services of the health care system, we can be better prepared to respond and prevent events from heat waves to other extreme weather events to drought, to potential outbreaks of infectious diseases,” said Neira.

Joy Shumake-Guillemot, Lead of the WHO/WMO Joint Climate and Health Office at WMO, summarising some of the report’s key findings.

Joy Shumake-Guillemot, WHO/WMO Joint Climate and Health office lead, detailed the “wide and varied” impact of climate on health, from the spread of infectious diseases such as dengue and malaria to impacts on food systems and air quality.

But she said one positive is that health has become a policy priority within the national climate policies in almost all countries and there is a “huge opportunity” to bring together climate adaptation and climate science to “help inform the decisions and policymakers to prepare communities that are vulnerable to climate change worldwide to adapt to the health risks”.

As usual, lack of finances is a problem. Currently, just 0.2% of total bilateral and multilateral adaptation finance supports health-focused projects. 

Fiji is vulnerable to sea levels rising and floods, exacerbating waterborne and vector-borne diseases.

The report includes case studies of successful partnerships between health and meteorological services. In Fiji, for example, the Ministry of Health and the meteorological services have data-sharing agreements to track waterborne and vector-borne diseases as the country battles with sea level rise and extreme weather events.

Argentina’s public institutions have been working with their research community to develop evidence-based public warnings for extreme heat for specific locations and populations. 

“In the first year of the launch of this heat-health early warning system, Argentina has launched 987 alerts across the country that have helped their public services and their communities to better prepare for the heat season,” said Shumake-Guillemot.

Meanwhile, in Europe an estimated 40 million people suffer from seasonal allergies and the region’s AutoPollen project predicts, detects and reports pollen concentrations in real time to doctors, patients and allergy patient associations via an online system and mobile app.

Way forward to COP28 and beyond

“Despite examples of success, data shows that the health sector is under-utilizing available climate knowledge and tools. At the same time, climate services need to be further enhanced to fully satisfy the health sector requirements,” the report notes.

Meanwhile, Neira told the launch that health is firmly on the agenda of the next global climate meeting, COP28.

“There will be a special ministerial high-level roundtable and the first-ever health day at COP28,” said Neira.

“This is not only to raise the voice of the health community to explain how bad [climate change] is impacting our health, but to ask for more action and to demonstrate that the health community is now very much into the political agenda and in pushing for the reduction of emissions and adaptation,” she added.

Wellcome Trust’s Madeleine Thomson, head of impacts and adaptation, predicts “a tsunami of demand coming to the climate community for climate information relevant to health”. 

“At the moment, we do not have a well-developed health community that is capacitated to ask the right questions, seek the right partnerships, and engage effectively,” said Thomson, but added that a lot more could be done to bring the health and climate communities together.

Image Credits: Oxfam East Africa.

A climate early warning system in Zambia.

Wealthy nations are falling tens of billions of dollars short of their pledge to help climate-vulnerable regions adapt to a warming planet, widening an already vast gap in funding and leaving millions at risk, according to a new report from the UN Environment Programme (UNEP).

The report, released on Thursday, found that international financial flows for climate adaptation in developing countries fell to just $21 billion in 2021, down 15% from a peak of $25.2 billion between 2017 and 2020.

This is a fraction of the estimated cost of helping low-income countries adapt to the worst effects of climate change, which UNEP estimates to be 10 to 18 times greater than current levels.

The annual gap in adaptation financing alone is now estimated at $194 billion to $366 billion, an increase of 50% from the UNEP’s estimate from last year.

The $21 billion provided by advanced economies in 2021 is equal to just $3 for each of the 6.82 billion people living in the 152 countries classified as developing by the International Monetary Fund. 

Adaptation costs in climate-vulnerable countries will soar as the planet warms, UNEP warned, exacerbating the adaptation gap unless countries step up to provide funding.

“The world is sleeping on adaptation even when the wake-up call that nature has been sending us is becoming ever more shrill,” Inger Andersen, Executive Director of UNEP, said at a press conference on Thursday. “This year we saw temperature records again being broken. We saw more floods, more heat waves, more droughts, and more wildfires [inflict] misery upon very vulnerable communities.”

The UNEP report comes as the world heads into the final quarter of what is set to be the hottest year on record. The average global temperature on a third of days in 2023 has already exceeded 1.5C over pre-industrial levels. 

“The international community should be throwing billions of dollars at helping developing nations to adapt to these impacts – but it isn’t,” said Andersen.

The UNEP report also sets the stage for COP29, the critical UN climate summit to be held in Dubai later this month. World leaders at the two-week summit will attempt to reverse the current trajectory of global fossil fuel emissions, which is on track to warm the planet by 2.4C to 2.8C by 2100 under a business-as-usual scenario.

A study published in Nature on Monday found that the planet will be locked into a future over 1.5C in just under three years, in early 2029.

“Storms, fires, floods, drought and extreme temperatures are becoming more frequent and more ferocious, and they’re on course to get far worse,” UN Secretary-General Antonio Guterres said in a statement accompanying the UNEP report. 

“Yet as needs rise, action is stalling,” said Guterres. “The world must take action to close the adaptation gap and deliver climate justice.” 

Why is the adaptation gap widening? 

The adaptation gap – the difference between the amount of money needed to allow developing countries to adapt to climate change and the financing that governments have made available – is widening as the risks posed by climate change in developing countries escalate. 

Three main reasons explain the widening gap.

First, climate change is happening faster and with more severe impacts than previously thought. This means countries on the frontlines of the climate crisis need to do more to adapt, which requires more money. Fifty-five of the world’s most vulnerable economies have already lost over $500 billion to the climate crisis in the past two decades, according to a recent study.

“On the basis of the IPCC’s (Intergovernmental Panel on Climate Change) sixth assessment report, we anticipate higher impacts from climate change, even in the short term,” said Paul Watkiss, lead author of the finance section of the UNEP report. “Higher [climate] impacts means we have to do more adaptation.”

Second, international funding for adaptation is not keeping pace with the increasingly urgent needs of developing countries. International public adaptation finance fell by 15% in 2021, despite the proven economic benefits of investing in adaptation.

Every $1 billion invested in infrastructure to protect people from coastal flooding could save $14 billion in economic damages, UNEP found. And for every $16 billion invested in agriculture each year, 78 million people could be spared climate crisis-related starvation or chronic hunger.

The authors of the UNEP report attribute the drop in adaptation funding in 2021 to the financial pressures caused by the COVID-19 pandemic and the war in Ukraine. However, they also noted that the $3 billion lost is a drop in the ocean compared to the $194 billion to $366 billion that developing countries need.

“Our estimates of the costs of adaptation of increasing, and at the same time, the financing is at least plateauing, or even decreasing,” said Watkiss. “And so the gap widens.” 

Third, developing countries are reporting more accurate data on their adaptation needs, helping UNEP to better forecast problems it may not have had sufficient data to include in previous reports. 

As more data comes in, UNEP is able to quantify more needs, suggesting that the current UN estimate of the adaptation gap likely remains too low.

Unkept promises underline the scale of the adaptation funding gap

Action zone at the COP26 venue in Glasgow, Scotland where this rotating globe hanging from the ceiling reminds delegates of what they are trying to save.

Unfulfilled climate funding pledges from advanced economies expose the vast gap between rhetoric and reality in adaptation funding.

In 2009, advanced economies pledged $100 billion per year by 2020 to help developing countries mitigate and adapt to climate change. This pledge was reaffirmed in the Paris Agreement in 2015, but eight years later, it has yet to be fully met.

“The numbers are not that big: if you compare the $100 billion to the money that the United States spends on its military, and that was spent on COVID or to save its banks, this is peanuts,” Pieter Pauw, a co-author of the UNEP report told Reuters. “It is time for developed countries to step up and provide more.” 

At the COP26 climate summit in Glasgow in 2021, rich countries made another pledge: to double adaptation funding to $40 billion annually by 2025. But with the shortfall in adaptation funding already at $366 billion, this pledge is no longer sufficient.  

“Even if the promise that we made together in Glasgow in 2021 to double adaptation finance support to 40 billion per year by 2025 were to be met – and that doesn’t look likely – the finance gap would fall by only five to 10%,” said Andersen.

Timeline of the emergence of loss and damage in the climate negotiations, culminating in the historic agreement at COP27 last year. The agreement to establish a loss and damage fund is now under threat.

The historic loss and damage fund agreed upon at COP27 in Egypt last year is also in jeopardy due to financing disputes between rich and developing countries, Politico reported this week. 

The question of who should pay for the damages caused by climate change, which is disproportionately impacting developing countries, has returned to the forefront of international climate negotiations.

The United States and Europe, two of the world’s largest historical emitters of greenhouse gases, are facing renewed calls to be held liable for their disproportionate contributions to the problem.

The United States, which resisted calls for a loss and damage fund for decades, is reportedly ready to exit negotiations on the fund if language holding them liable for their disproportionate contributions to global greenhouse gas emissions is not dropped. 

The agreement on the establishment of a loss and damage fund at last year’s COP27 summit in Egypt provided hope that this contentious issue could finally be resolved. However, the recent impasse over the fund has raised concerns that it could be derailed, threatening a critical step towards climate justice.

“We’re at a breaking point,” Avinash Persaud, the lead negotiator for Barbados and aide to Barbados Prime Minister Mia Mottley, told Politico.

A breakdown in negotiations “will break COP,” Persaud added. “I feel that not enough people are sufficiently worried about that”.

Adaptation has limits

In Guinea, rural women form cooperatives where members learn how to plant a vitamin-rich tree called Moringa and how to clean, dry and sell its leaves. Used as medicine or a dietary supplement by societies around the world, Moringa also supports biodiversity and prevents soil erosion.

Adaptation measures such as early warning systems, sea walls, and mangrove restoration are essential for helping communities cope with the impacts of climate change.

Early warning systems help people evacuate ahead of extreme weather events, sea walls protect coastal communities from sea level rise and storm surges, and the restoration of natural ecosystems such as mangroves alleviates flooding and, in the case of Lagos, Nigeria, stops the city from going under water. 

But as the planet warms, warming seas and a rapidly changing climate are pushing these measures to their limits.

“The evidence is clear that climate impacts are rising and are increasingly translating into limits to adaptation,” said Henry Neufeldt, Chief Scientific Editor of the UNEP report. “Some of these may already have been reached.“

Hurricane Otis, which struck Acapulco, Mexico, in September 2023, is a prime example of these limits. The storm rapidly intensified from a tropical storm to a category 5 hurricane overnight, leaving residents off guard and meteorologists struggling to explain what happened.

Powerful hurricanes can normally be observed by meteorologists for weeks prior to landfall. But as the planet warms, sea levels are rising and storms are becoming more unpredictable, limiting the ability of early warning systems to reliably protect coastal communities from extreme weather.

In just 12 hours, Hurricane Otis’ strength more than doubled, reaching record wind speeds of 257 kilometres per hour at landfall. The residents of Acapulco had no time to evacuate, leaving 100 people dead or missing and wreaking vast destruction on the resort town.

“Every day, every week, every month and every year from now on within our lifetimes, things are going to get worse and not a single country in the world is prepared,” said Andersen. “We are inadequately investing and planning on climate adaptation, and that leaves the world exposed.” 

Adaptation: Essential for billions facing climate impacts, despite limits

Climate adaptation measures have limits, but they are essential for the lives and safety of billions of people around the world who are already facing the effects of climate change.

Every decimal increase in the planet’s temperature affects millions. Nowhere is the need for adaptation more acute than in Africa, where at least 15,700 people have been killed and 34 million affected by extreme weather disasters in 2023 so far, according to an investigation by Carbon Brief.

Meanwhile, more than 29 million people continue to face unrelenting drought conditions in Ethiopia, Somalia, Kenya, Djibouti, Mauritania, and Niger, and more than 3,000 people were killed in flash floods in the Democratic Republic of the Congo and Rwanda in May.

Debt-laden countries, suffocating under debt repayments that exceed healthcare spending, face a spiral of rebuilding, sacrificing basic needs, and losing lives if climate adaptation funding is not secured.

“Developing countries, poor countries that are really having difficulties having a balanced budget, will have to divest from education, from infrastructure, health, to simply feed some of their people and respond to major disasters and major catastrophes,” said Ibrahim Thiaw, Executive Secretary of the United Nations Convention to Combat Desertification (UNCCD). “This is the reality of the world today.” 

Projected annual deaths attributable to climate change in 2030 and 2050, according to the Intergovernmental Panel on Climate Change.

Without financial support to help regions adapt to climate change, front-line communities will face conflict and mass migration, Thiaw warned.

“What is left to a young Somali, Haitian, or Sahelian when there is nothing left? When there is no ecosystem to provide food, capital, or natural capital, what is left for them to do but flee?” Thiaw asked.

“People do not fight each other simply because they hate each other,” Thiaw said, on how climate change fuels conflict. “They fight because they are competing for survival.”

Even if global greenhouse gas emissions are halted tomorrow, the planet will continue to warm for decades. The International Energy Agency projected earlier this month that fossil fuel demand will peak by 2030 but remain constant through 2050, nowhere near enough to stop the planet from warming.

“That adaptation finance in the world is actually shrinking at a time when we are calling for a doubling of adaptation is actually quite remarkable,” Thiaw said. “Climate change is hitting more and more, and international climate finance is declining – so where are we going? What impact will it have on the poorest and most vulnerable communities?”

Image Credits: UNDEP, Joe Saade/ UN Women.

GARDP executive director Manica Balasegaram, whose partnership has led the trial.

The world may soon have a new antibiotic to treat gonorrhoea after a successful phase 3 trial of an oral pill, zoliflodacin, that was led and sponsored by a non-profit organisation.

The results were announced late Wednesday by the Global Antibiotic Research and Development Partnership (GARDP), which conducted the trial in collaboration with Innoviva Specialty Therapeutics.

The gonorrhoea bacteria – Neisseria gonorrhoeae – has slowly grown resistant to many classes of antibiotics, leaving injectable ceftriaxone in combination with oral azithromycin, as the last available recommended treatment for gonorrhoea globally.

In a 2017 World Health Organization (WHO) survey of 77 countries, 97% reported cases of drug resistance to common gonorrhoea antibiotics, while two-thirds reported resistance or decreased susceptibility to the last option for treatment with a single drug. Recent reports of emerging ceftriaxone-resistant gonorrhoea infections have heightened the urgency for new antibiotics.

Zoliflodacin showed “statistical non-inferiority” when compared to the standard regimen – and it is much easier to administer as it’s one pill rather than an injection and a pill.

Meanwhile, previous studies have shown that zoliflodacin is active against multi-drug resistant strains of Neisseria gonorrhoeae, including those resistant to ceftriaxone and azithromycin, with no cross-resistance with other antibiotics. 

“The outcome of this study is a potential game changer for sexual health,” said Professor Edward W Hook III, the study’s protocol chair and Emeritus Professor of Medicine at the University of Alabama in Birmingham, US.

“In addition to the potential benefits for patients with infections with resistant strains of Neisseria gonorrhoeae, the potential lack of cross-resistance with other antibiotics and the oral route of administration will simplify gonorrhoea therapy for clinicians worldwide.”

Gonorrhoea bacteria cells.

Non-profit ‘fix’

Gonorrhoea is one of the top three most common sexually transmitted infections with over 82 million new annual infections – mostly in Africa. If left untreated, it can also cause infertility in women, life-threatening ectopic pregnancies, pelvic inflammatory disease and sterility in men.

While the WHO designated gonorrhoea as a “priority pathogen”, no new treatments have been trialled in the past 40 years.

This is the first trial of a priority pathogen led by a non-profit organisation.

“Despite the extremely high public health value, there has been a lack of investment to develop new drugs for gonorrhoea,” said Dr Manica Balasegaram, GARDP’s executive director.

“The zoliflodacin programme demonstrates that it is possible to develop antibiotic treatments targeting multidrug-resistant bacteria that pose the greatest public health threat, and which may not otherwise get developed.”

Meanwhile, Professor Glenda Gray, GARDP board member and President of the South African Medical Research Council (SAMRC), said that “GARDP’s model can play a crucial role in helping to fix the public health failure at the heart of the global AMR crisis and is a significant step forward in the treatment of gonorrhoea”.

The trial involved 930 patients with uncomplicated gonorrhoea and included men, women, adolescents and people living with HIV. Around half the trial participants came from South Africa, with other trial sites in Belgium, the Netherlands, Thailand, and the US.

First-line treatment?

Sinead Delany-Moretlwe, principal investigator for the trial in South Africa

Prof Sinead Delany-Moretlwe, principal investigator for the trial in South Africa, said that the trial had been conducted under difficult circumstances during the height of the COVID-19 pandemic.

“The huge investment in HIV trial infrastructure has really given South African scientists the capacity to do trials in infectious diseases and to yield results that can be submitted to a range of regulatory authorities,” Delany-Moretlwe told Health Policy Watch.

While countries’ medicine regulators still need to grant approval for the drug, parties involved in the trial have discussed an implementation strategy – including whether zoliflodacin should be given as a first-line drug.

“Because it’s an easier drug to administer, if the cost is affordable, it makes sense to implement it [as a first-line treatment],” Delany-Moretlwe, research director of Wits RHI at the University of Witwatersrand in Johannesburg, South Africa.

“And ceftriaxone is not just used to treat gonorrhoea, so it is important to protect a class of drug that is used for more than gonorrhoea in terms of good antibiotic stewardship.”

Another factor in favour of using zoliflodacin for first-line treatment is that it has a unique mechanism that inhibits a crucial bacterial enzyme, which can also help to avoid the emergence of resistance.

Applying for approvals

“GARDP has the right to register and commercialise the product in more than three-quarters of the world’s countries, including all low-income countries, most middle-income countries, and several high-income countries,” according to a GARDP spokesperson. 

However, Innoviva affiliate Entasis Therapeutics has commercial rights for zoliflodacin in the lucrative markets of North America, Europe, Asia-Pacific and Latin America.

“Our aim is to provide sustainable access to an affordable product but we are unable to give further details at this time, as we move into negotiations with commercial partners,” a GARDP spokesperson told Health Policy Watch.

GARDP and Innoviva ST will apply for approval with the US Food and Drug Administration (FDA), and initiate registration activities in South Africa and Thailand shortly after FDA submission. 

“Once approval is obtained in these two countries, we will expand access to zoliflodacin through a process of collaborative approvals within a number of countries,” said GARDP, depending on “the public health need and on the epidemiological situation in each country”.  

Meanwhile, Innoviva CEO Pavel Raifeld said that treatment “could have a profound effect on how physicians approach gonorrhoea infections, as an oral alternative to an injection could improve patient access and compliance, as well as help reduce the increasing spread of antibiotic-resistant strains of the disease”.

The GARDP trial was funded with support from the governments of Germany, UK, Japan, the Netherlands, Switzerland and Luxembourg, as well as the Canton of Geneva, the South African MRC, and the Leo Model Foundation. It builds on a phase 2 clinical trial sponsored by the US National Institute of Allergy and Infectious Diseases (NIAID).

WHO-SEARO 76th Regional Committee Session in New Delhi
WHO-SEARO Regional Director Poonam Khetrapal Singh at the 76th Regional Committee Session in New Delhi, meeting this week in Delhi, where she announced that Bangladesh has become the world’s first country to eliminate visceral leishmaniasis or kala azar.

Bangladesh has become the first country globally to be validated by the World Health Organization for the elimination of visceral leishmaniasis or kala azar, as a public health problem.

VL, a life-threatening neglected tropical disease (NTD) caused by a parasite transmitted by sandflies,  affects some one million people worldwide every year, mostly in Southeast Asia and North Africa.

Bangladesh, India, and Nepal accounted for 70% of the global cases between 2004 and 2008. By 2016, Bangladesh and Nepal brought down the number of cases drastically while the burden in India remains relatively high. While death rates are relatively low, disfigurement of limbs, sexual organs, etc. create huge levels of disability among those untreated.

However, new diagnostics and tools have helped make big inroads in morbidity.

The country achieved the elimination target of less than one case per 10,000 population at the sub-district level in 2017. It has managed to sustain that progress despite the COVID-19 pandemic, leading to the WHO elimination milestone, said WHO Regional Director Poonam Khetrapal Singh speaking at the SEARO Regional Committee meeting ongoing in Delhi this week, where the achievement was announced. .

At the meeting the global health agency also noted that the DPR Korea has eliminated rubella and Maldives has interrupted transmission of leprosy – another NTD.

Maldives has not reported a leprosy case for more than five years now, WHO said, making it the first country in the world to officially verify interruption of transmission, through a concerted effort to reduce stigma and discrimination so that people infected could be diagnosed, treated and cured.

NTDs are a diverse group of 20 tropical infections that are common in low-income regions of Africa, Asia, and the Americas. They are also often under-researched and ignored by the research community and pharmaceutical companies. WHO’s NTD Roadmap aims to reduce by 90% the number of people requiring treatment for NTDs by 2030.

“Neglected tropical diseases like lymphatic filariasis, visceral leishmaniasis and leprosy, along with the threat to children and young people posed by rubella, require continued national leadership, commitment and collaborative action by countries and health partners worldwide,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus, in a WHO statement. “These achievements will positively impact the lives of the most vulnerable populations now and in the future,” he added.

Image Credits: WHO.

Dr Tlaleng Mofokeng (right), the United Nations Special Rapporteur on the Right to Health

Tackling inequities in food, nutrition and health outcomes needs a rights-based approach to food and nutrition, based on equality and centred on historically marginalised individuals and communities, according to Dr Tlaleng Mofokeng, the United Nations (UN) Special Rapporteur on the Right to Health.

“The intersection of the right to health and right to food is central to achieving substantive equality and realising sustainable development, human rights, lasting peace and security,” Mofokeng told a New York audience at the launch of her report on food, nutrition and the right to health.

“Ultra-processed products, with marketing strategies that disproportionately target children, racial and ethnic minorities, and people from socially disadvantaged backgrounds, have replicated colonial power structures and dynamics, with traditional diets and food cultures being replaced by diets largely shaped by corporations headquartered in historically powerful and wealthy countries,” said Mofokeng at the launch, which was hosted by Vital Strategies.

She called for mandatory front-of-package nutrition labelling, and fiscal and food policies consistent with the obligation of member states to protect the right to health and health-related rights.

“Within the context of food and nutrition, the obligation to respect human rights requires that states not engage in any conduct that is likely to result in preventable, diet-related morbidity or mortality, such as incentivizing the consumption of unhealthy foods and beverages,” according to the report.

Mofokeng also raised the issue of land expropriation, occupation and destruction, noting that this “eliminates the ability of Indigenous Peoples and other local communities to produce their own food for a healthy diet and turns food into a commodity controlled by those in power, thus violating their right to adequate food and health.’.

“Food is more than nutrition. Besides being one of the most common sources of pleasure, food is a social glue,” she said.

GPMB co-chair Joy Phumaphi, Dr Tedros and co-chair Kolinda Grabar-Kitarovic at the launch of the board’s 2023 annual report.

 The world’s preparedness for the next pandemic is “perilously fragile”, with gaps that “leave us dangerously exposed to a future threat”, according to the Global Preparedness Monitoring Board (GPMB) in its 2023 annual report released on Monday.

“We lack the solid foundations needed to ensure current efforts for preparedness can be brought together to build an enduring bridge to a state of security. This is made more fragile by lack of trust both between and within countries,” said Kolinda Grabar-Kitarovic, co-chair of the GPMB.

“To counter a mistrust, we need to address its root causes, which is why this GPMB report places great emphasis on equity, accountability, leadership and coherence as underpinning factors for preparedness,” said Grabar-Kitarovic, former President of Croatia, at the launch of the report at the World Health Organization (WHO) headquarters in Geneva.

The GPMB is an independent body convened by the WHO and the World Bank in 2018 to ensure preparedness for global health crises.

Co-chair Kolinda Grabar-Kitarovic

Areas of decline from “already low levels of preparedness” include the global coordination of research and development (R&D); efforts to address misinformation; the participation of low and middle-income countries (LMIC) in the governance of pandemic preparedness; the lack of financing, and lack of independent monitoring. 

“Equity is not a ‘nice to have’ embellishment of global preparedness, it is its beating heart. Global security will be reached only when everyone regardless of geography is valued and assured equal access,” the report stresses.

‘Canary in the coal mine’

“We call these shortcomings ‘canary in the coal mine issues’ because these are the earliest signals of systematic problems. Without concrete commitments for financing and monitoring, preparedness capacities are likely to regress further over the coming years,” warned Grabar-Kitarovic.

However, the report identifies the negotiations to establish a WHO pandemic agreement, improved One Health surveillance capacity, community engagement and regional laboratory capacity as areas of progress. 

“The key takeaways are that our ability to deal with a potential new pandemic threat remains inadequate, and the world has insufficient capacities to guarantee our safety,” concluded Grabar-Kitarovic.

Joy Phumaphi, GPMB co-chair

Co-chair Joy Phumaphi said that the report, the fourth produced by the GPMB since its establishment shortly before the COVID-19 pandemic, is the first to use a new monitoring framework. The board assessed 30 indicators using a stop light grading system – yet not a single indicator scored “green” (full preparedness).

GPMB scoring 2023: green = excellent, yellow = good, orange = incomplete, red = poor. (Arrows = improving/ declining.)

Phumaphi, Botswana’s former health minister, characterised as “deeply troubling” the global failures to increase preparedness financing to meet the needs identified since COVID-19 and to integrate independent monitoring into reforms to health sector architecture.

Geopolitical tensions and competing demands for resources are also weakening countries’ resolve needed to close the pandemic response gaps, according to the board.

The report identifies four key priorities to repair the weaknesses in global preparedness, namely: strengthening monitoring and accountability; reforming the global financing system for pandemic prevention, preparedness and response (PPPR),  more comprehensive, equitable and robust R&D and supply chains; and stronger multi-sectoral, multi-stakeholder engagement.

Tedros agrees with independent monitoring 

“Our assessment reveals that current mechanisms for PPPR monitoring and accountability do not provide a complete picture,” said GPMB member Bente Angell-Hansen. 

“They tend to focus on systems and capacities and give less attention to important aspects of leadership, effectiveness and equity. They are mostly based on self-assessment with limited independent monitoring.”

Angell-Hansen added that a “critical weakness” in the current drafts of the pandemic agreement and the amendments to the International Health Regulations (IHR) was their lack of provisions for independent monitoring.

To address this shortcoming, the board proposes “independent monitoring to complement self-assessment and peer review, at all levels, nationally, regionally and globally” – as well as in the pandemic agreement and IHR amendments.

Speaking at the launch, WHO Director-General Dr Tedros Adhanom Ghebreyesus agreed with the board’s call for “independent monitoring and accountability mechanisms to be embedded in the ongoing reforms including the WHO pandemic agreement”. 

“In fact, it was the need for independent monitoring that impelled then-World Bank President Jim Kim and I to set up the GPMB in 2018. You cannot have accountability without monitoring, which provides accurate and timely information for turning commitments into effective action,” Tedros told the launch.

There has been furious lobbying for independent PPPR monitoring from a number of groups, including the Independent Panel for Pandemic Preparedness and Response. 

Financing needs ‘fundamental reform’

Board member Naoko Ishii outlined the world’s failure to raise adequate. sustainable financing as a key finding, with global research financing and global common goods financing being the worst resourced.

”Only 40% of countries have domestic contingency funds that could be used for health emergencies across the board,” said Ishii.

The report also highlights that global PPPR financing is “inefficient, uncoordinated, and insufficiently aligned to country needs and processes” and that the Pandemic Fund is far short of its aim of $10 billion.

“PPPR financing requires fundamental reform to free it from the limitations of development assistance and place it on a sustainable footing, based on burden-sharing,” recommends the report. “Strengthening PPPR requires ensuring sustainable financing for WHO and other international organisations working on PPPR.”

The report also proposes that the immediate funding gaps be addressed “to enable greater national investments and bolster international financing through new modalities and sources of financing”.

Governance: ‘Everything, everywhere all at once’

“Global health has become more crowded – much too crowded probably – and the governance of PPPR is deeply fragmented and lacks coherence. Some of us feel like in the Hollywood movie, ‘Everything Everywhere All at Once’,” said board member Ilona Kickbusch, chair of the Global Health Centre at Geneva’s Graduate Institute of International and Development Studies.

“None of the capacities we assess this year are adequate,” added Kickbusch. “And this after so many decades of work in this issue. There are multiple parallel efforts, some of which overlap but which still leave gaps, particularly in relation to equity, research and development and access to medical countermeasures.”

Ilona Kickbusch

Furthermore, “there is no strategic plan to coordinate the whole of UN, whole-of-society response to health emergencies and our governance structures struggle to provide the necessary leadership and unity to guide us through the pandemic”, she added.

While the pandemic agreement may address these gaps, the GPMB expressed concern about the slow pace of negotiations and “the challenges and divides that are holding back progress”. 

“Member states must redouble efforts to finalise the agreement before May 2024 when the World Health Assembly meets. Our collective preparedness against the next pandemic depends on it,” stressed Kickbusch.

Tedros agreed with her: “I think you know, I have made clear to our member states that there is no time to waste. Another pandemic or global health emergency could come at any time, just as it did in 2019.”

Describing the pandemic agreement as “a generational agreement that must be written by the generation with the lived experience of a pandemic”, he urged the board to “continue your advocacy with, and for, member states to work with a greater sense of urgency, with a particular focus on the most difficult issues”.

On a positive note, Kickbusch said that during the course of the COVID-19 response, member states had come to recognise the central and vital role of the WHO in health emergencies. 

“They have demonstrated their renewed trust in WHO by increasing their assessed contributions to correct the incoherence that has plagued PPPR governance. This empowerment of WHO at the centre of global health is essential, complemented with efforts to strengthen the whole of UN multi-sectoral response to pandemics,” said Kickbusch.

More equitable R&D

The board’s Victor Dzau said that, while global R&D spending overall is “at a record high of almost $1.7 trillion per year, 80% of spending is concentrated in 10 countries – most of which are high income”. 

No “effective global mechanism to set priorities and coordinate pandemic R&D means that the world cannot prioritise countermeasures development” for the most harmful pathogens or deliver pandemic products according to need, said Dzau.

“Low and middle-income countries are inadequately represented in decision-making and coordination processes. This means that their needs are fully met in resource allocation,” he added.

To address this, the GPMB proposes “strengthening regional capacities for R&D, manufacturing and supply” which will help to address “the inequities in global access to medical countermeasures”.

Board member Chris Elias outlines the R&D proposals

Finally, the board calls on global, regional and national leaders to “fully institutionalise preparedness measures that work in the collective interests of all”, and to address the four key priorities it has identified to “repair the weaknesses in global preparedness”.