A  bitter debate over proposed WHO recognition of a non-profit center for reproductive health rights, erupted in full force at the WHO Executive Board on Monday – after a tumultuous week of the World Health Assembly where member states largely skirted the increasingly contentious issue of sexual and reproductive health rights.

The proposal by the WHO Secretariat the US-based Center for Reproductive Rights be designated as a non-state actor in “official relations” with WHO – drew fierce opposition from member state blocs of the Eastern Mediterranean and African region – with Qatar threatening to escalate the issue and potentially the criteria for admitting non-state actors into official relations to the World Health Assembly if the WHO recognition of official relations with the organization is approved by the EB.

Qatar, speaking on behalf of the Eastern Mediterranean Region, which extends from Tunisia to Afghanistan, also rejected a compromise proposal by WHO Director General Dr Tedros Adhanom Ghebreyesus to admit the Center on a one-year trial basis – pitched by the DG as the deadlocked session drew to a close, and postponing a decision until Tuesday.

“We are against the introduction of official relations with the Center for Reproductive Rights, with all means give the controversial concepts they promote. And regardless of the decision of the esteemed executive members in this regard, we will seek further discussions on this matter within the wider quora of the WHA,” said Qatar’s representative.

His remarks were echoed by Egypt, Tunisia, Iran, Morocco, Pakistan, Yemen and Senegal, speaking on behalf of 47 African member states, as well as the Russian Federation.

“We firmly stand against the introduction of official relations with the Center for Reproductive Rights due to the controversial concepts they promote,” Egypt said, warning that: “Regardless of the outcome of the decision by the board today, we will seek to escalate this matter to further discussion within wider quorum of the World Health Assembly.”

Some 217 non-state actors, ranging from non-profits advocacy groups to professional associations of doctors, nurses and other health workers, as well as agro- and pharma industry-backed federations, are currently recognized as being “in official WHO relations.”

Raises broader questions over WHO’s entire process for engaging with NSAs

The designation, which allows the NSAs to participate as observers at the WHA, as well as opening a door to WHO technical and working groups, is only granted after a proven track record of collaborations with the global health agency. The designation is granted in accordance with a strict criteria, known as the Framework for Engagement with Non-State Actors (FENSA), intended to protect the organization from vested interests, especially industry influence.

The FENSA framework was painstakingly negotiated and approved by member states nearly a decade ago, so as to create an even playing field for organizations to work with the global health agency. It includes a lengthy and rigorous trial period, and agreement with a WHO technical unit on a collaboration plan, so that in fact, only a handful or less of new non-state actors are approved every year. Member state review of new, proposed NSA actors, has therefore been largely perfunctory – following the recommendations set by the WHO administration.

Rejecting WHO’s recommendation would set a dangerous precedent

A large number of European Union member states, as well as the USA, Canada, Australia and a broad non-EU group of member states led by Mexico, expressed concern that the divisive debate could also rip across the entire FENSA process, paintstakingly developed over a number of years by WHA together with legal advisors. It could make any new organization’s candidacy  for the treasured “in official relations” designation, subject to a diverse range of political pressure and influences – rather than technical criteria, they warned.

“We share concerns regarding the negative precedent it would set, we would say if the EB decided to reopen that recommendation in any way,” Mexico’s delegate said. “We member states negotiated and agreed to it by consensus having a robust framework of this nature provides value to the organization, but only if we use it. We are therefore deeply concerned that despite the non state actors having fulfilled the necessary requirements… the EB in January, did not agree.

” We agreed to postpone the decision until this session. Five months have passed, during which the EB  chair conducted extensive and inclusive consultations to find a solution… which resulted in an adequate, good faith proposal,” she said, apparently referring to Tedros’ compromise proposal for a one-year trial period of recognition – as compared to the normal multi-year term.

“‘We regret that this proposal has not been accepted,” added Mexico’s delegate. “We acknowledge the concerns of some allegations on the work of this particular NSA.

“It is worth recalling that ultimately, it is the state-led WHO governing bodies which direct the work of this organization. Therefore, applying a selective approach to the work of single entities undermines well-established and effective governance procedures. It risks setting an unhelpful precedent negatively impacting the efficient and effective, effective governance of the organization –  and politicizing routine decisions that we should trust the Secretary to make in the framework of its mandate,” Mexico said, in a statement supported by other non-EU European countries as well as a seven other Latin American countries including Chile,  the Dominican Republic, Ecuador, Panama, Peru, Uruguay – and echoed separately by Brazil.

Morocco sounds softer note – Thailand and Israel also support

Israel, whose appointment to the EB was bitterly denounced last week, and again this morning by rival states, including Palestine, also expressed support for admitting the Center, saying “We regret the exclusion of important stakeholders, and we believe that a dialogue with all relevant stakeholders is essential.”

Thailand, meanwhile, pointed to a new WHO resolution approved only last week promoting “social inclusion” and said that recognizing the Center would walk the talk on that issue:  “Approving the Center of Reproductive Rights as an entity in official relations would be a concrete example of expanding social participation in WHO’s work, or commitment to involve non state actors in meaningful ways and showing the broader perspective, a more comprehensive approach in global health.”

Morocco, meanwhile, appeared to break ranks with other Arab and African states, appealing for consensus around the WHO Secretariat’s proposal to extend official relations to the Center.

While “there are national laws and concerns to be considered, my delegation would like to reiterate its  trust in the application of eligibility criteria and due diligence when it comes to collaboration of NSAs with the WHO,” Morocco’s delegate stated.

“I note that collaboration between the WHO and the Center has been established and for years work has been carried out on the ground. That’s the reality. Our discussions today are a second stage, we’re opening up new prospects when it comes to artificial relations, in processes led by member states.

“So my delegation is strongly attached, and promoting, the consensus based adoption of this proposal, noting similar cases, with a view to strengthening the credibility of our work and the constructive cooperation spirit that has always prevailed within our Executive Board.”

Tedros proposes a one-year trial period for Center

In a late afternoon intervention, Tedros proposed to the EB that opponents of recognition consider a one-year trial period for the Center, as a recognized WHO NSA – rather than the usual multi-year term. But as of early evening, that compromise proposal also seemed doomed to failure. Meanwhile, the EB suspended its discussion until Tuesday, with members on both sides  loathe to continue debating after a string of late nights at last week’s WHA.

Tedros, speaking before critics of the Center’s recognition, said that WHO member states that WHO’s work needs to “stick to science and evidence.”  And according to that evidence, efforts to repress access to abortion only leads to more maternal and newborn deaths, he said, also citing his own experience as Minister of Health in Ethiopia.

“The Ethiopian Parliament passed a law on abortion when I was Minister of Health,” Tedros related.  “That law was passed because of practical problems we were facing. The maternal mortality rate was very, very high. And two of the leading causes of death were postpartum hemorrhage and unsafe abortion. Of course there were other reasons. But the Parliament was very courageous, and since the bill was passed, the maternal mortality rate has declined.”

Two decades later, the very same drivers remain an issue in many countries today, he said, citing a meeting with ministers of health last week on the sidelines of the World Health Assembly, on their high maternal mortality rates, “And in many of the countries, the two leading cause of deaths for mothers are postpartum hemorrhage and unsafe abortion,” he related, noting that even if women are not supported by legal abortion frameworks, “they will do it [seek abortions] anyway. That’s a real problem in some countries.”

Ultimately, it  is poor women, not the rich, who die from illegal abortions, Tedros pointed out, adding: “when a mother is dying, and when we know that why they are dying, we cannot just look the other way.”