More Reliable Funding for WHO, Slow Progress on Pandemic Reform & Ukraine Controversy – What to Watch at the World Health Assembly
Members of the WHO Working Group on Sustainable Finance hammer out the final agreement on increasing member state contributions in late April. Germany’s Björn Kümmel, who led the negotiations, on far left.

More stable funding for WHO, but only incremental progress on reforms in global pandemic response are expected out of the upcoming World Health Assembly, where member states also will debate and discuss over two dozen other critical health issues that don’t always make the headlines.  

The 75th World Health Assembly, WHO’s annual meeting of member states, opens Sunday with the prospect of diplomatic fireworks over Russia’s invasion of Ukraine and only incremental progress likely on reforms that critics say are urgently needed to strengthen the health agency’s hand in preparing for, and responding, to pandemic risks.

On the brighter side, a draft member-state agreement to bolster the WHO’s financial stability is expected to win approval after months of closed-door negotiations. The new formula involves a commitment to raise member state annual “assessed” contributions to 50% of WHO’s core budget by the end of the decade. 

Currently such fixed contributions only comprise about 17% of WHO’s budget, while a handful of rich countries and philanthropies cover an outsized portion of the global health agency’s costs – also exerting untoward influence over priorities, some critics say.  

The past two WHAs – held virtually during the pandemic – both saw demands for reforms at the top, tensions over the WHO’s investigation into the origins of SARS-CoV-2, calls for better global emergency and pandemic preparedness, and pleas for more funding to both WHO and low- and middle income countries to address widening health inequalities

The theme of this year’s WHA, which runs from 22-28 May,  is “Health for peace, peace for health”, given the emergency in Ukraine, just how much uptake there will be of the theme, in spirit as well as in name, remains to be seen.

Other core issues risk being sidelined

A woman brings her child to a clinic in Wajirat in Southern Tigray in Ethiopia to be checked for malnutrition in late summer 2021 – since then a months-long blockade on all health supplies has devastated the region even more.

Alongside that bloody conflict, there are worries that other urgent issues risk being sidelined at the conference. These range from burning health and humanitarian crises in places like Tigray and Afghanistan, but also other core health issues, from neglected tropical disease to the worldwide epidemic of non-communicable diseases, as well as longer-term plans to improve pandemic response.

Indeed,  in a moment of big expectations where delegates meet face to face for the first time in two years – actual results may be disappointing to those hoping for swift reforms in global rules around pandemic response. 

UN-wide, Russia’s invasion of Ukraine has diverted attention from the pandemic which was an overriding focus of politics and media for nearly two years. That, in turn, leaves a “closing window of opportunity” for key reforms, said Olaf Wientzek, Director of Multilateral Dialogue at the Geneva-based branch of Konrad-Adenauer-Stiftung, a German foundation, in an interview with Health Policy Watch ahead of the WHA.

Pandemic preparedness: A closing window for change

Former Liberian President Ellen Johnson Sirleaf (left) and Former New Zealand Prime Minister Helen Clark (right), co-chairs of The Independent Panel.

In a stiffly worded update, released just ahead of the WHA meeting, the former co-chairs of the Independent Panel on pandemic preparedness and response said the world is little more prepared to cope with a pandemic threat today than it was when the COVID-19 crisis began.

“Should a new health threat arise this year, the world would largely have to draw on the same tools it had at the end of 2019,” Helen Clark, former prime minister of New Zealand and co-chair of the Independent Panel for Pandemic Preparedness and Response, told a pre-assembly press briefing. 

Their scathing original report, released at last year’s WHA, levelled criticism throughout, from an “under-powered” WHO to “absent” global political leadership.

“The weak links that we identified then still exist today, and without more concrete efforts to fix them, we could find ourselves once again scrambling to protect people from a new pandemic threat,” added Clark, who co-authored the report with Ellen Johnson Sirleaf, former president of Liberia.   

Timing: Reforms could take years

At the current pace, processes likely to be initiated by the World Health Assembly this session “could take many years”, Clark and Sirleaf warned, citing as examples: 

  • The increase of assessed contributions to cover 50% of WHO’s base budget, which may not take full effect until 2030. 
  • Amendments to the International Health Regulations that govern WHO’s emergency powers, which have been proposed as a short-term fix in a broken system, “may take until May 2024 to be agreed, and then another year to come into force”, they added. (The timetable to negotiate and ratify a comprehensive new global pandemic convention or accord would be even longer. 
  • At the same time, efforts to include all pandemic reform issues into a new legal instrument, whether it turns out to be a convention or a treaty, could result in a “watered-down instrument, or none-at-all.” 

Along the way, ”critical issues, including WHO’s authority to report, and investigate health threats based on the precautionary principle, may be lost in negotiation,” the former Panel co-chairs stated. 

Real reforms in IHR unlikely before 2025

Loyce Pace, Assistant Secretary for Global Affairs, US Department of Health and Human Services, addresses the WHO Executive Board meeting, 24-29 February, 2022.

Yet despite all the flashing warning lights,  the inherently slow and conservative nature of WHA assemblies, along with the still-evolving humanitarian emergency in Ukraine – will make faster action by WHO member states highly unlikely.

As just one example, the United States had in January submitted a draft WHA proposal for a series of pinpoint amendments to the International Health Regulations, the 17 year-old set of rules currently governing countries’ responses to health emergencies. Key among those was a tight 48- hour timetable for countries to report emerging threats – and another 48 hours for WHO to respond – something that can take weeks or months now.  

But final agreement on any IHR amendments is now likely to be punted to 2024, confirmed Switzerland’s Ambassador for Global Health, Nora Kronig Romero, in a media briefing on Wednesday.  

Agreement on a process for a process  

This year’s WHA is expected to agree only a process for making new IHR amendments – inviting all member states to throw their own reform proposals into the ring by 30 September, 2022.  

The proposals would then be negotiated, with hoped-for adoption by May 2024, according to the draft WHA decision, which has been leaked and circulated by civil society.  

It would be at least another year before any agreed-upon reforms actually take effect – keeping the status quo until 2025.  And that is only if this WHA session agrees to a companion measure that would reduce the waiting period in which new IHR amendments would actually come into force from two-years to one year.  

The conundrum of a pandemic treaty 

People wear face masks to prevent the spread of coronavirus as they commute inside a metro station at the height of the COVID-19 pandemic.

To make matters more complex, a separate, but related, Intergovernmental Negotiating Body (INB) operating under WHA mandate is supposed to be guiding the more comprehensive effort to  negotiate a new pandemic convention, treaty or other legal instrument. WHA agreed to take steps toward creating such a legal instrument in a special session in November 2021, and to set the stage for the INB negotiations, public hearings were held in April

The risk, however, is that member states may be forced to negotiate in two parallel processes, one supposedly “short-term” reforms in the IHR and the other a longer term process to create a new convention – without real clarity about how they are really related. 

That would be confusing for everyone – and particularly challenging for low- and middle income countries with more limited capacity, Dame Barbara Stocking, of the ad-hoc Panel for a Global Health Convention, told Health Policy Watch. 

“We’ve got concerns that we must not get two lines of negotiations going, because it makes it really difficult for low-income countries with limited mission staff in Geneva to keep up,” she said.  

To avoid duplication, member states need to decide firmly and soon if and how existing IHR rules, and any new amendments to the IHR, might be taken up into a new pandemic convention –  perhaps as a wholesale “protocol.” 

Leadership: Status quo at the top, and a reshuffle just below

WHO Director General Dr Tedros Adhanom Ghebreyesus is poised to be reelected for another term during this WHA session.

Against the paralysis of member states over pandemic reform, WHO Director General Dr Tedros Adhanom Ghebreyesus is expected to be re-elected for another five-year term during the WHA. Paradoxically, while Tedros is the first Director-General to be elected from an African state, his nomination to a second term was co-sponsored by Germany, France and other European states after he fell out of favour with the government in his home country, Ethiopia, due to his Tigrayan identity. 

There could, however, be changes elsewhere in senior leadership, in an effort to show major donors like the United States that the WHO is intent on becoming more “fit-for-purpose” in responding to emergencies, diplomatic sources have told Health Policy Watch. A reshuffle is likely to include the departure of Mike Ryan, who has led the agency’s pandemic response through two years. 

While supporters see Ryan as a dedicated professional, critics also say he has been unduly slow and cautious at key moments, as a loyal footsoldier to Tedros.

This has included criticism that it took too long for the WHO to declare a public health emergency for COVID-19, and then, the agency took months to acknowledge that the virus is “airborne”, leading to a very delayed recommendation for the public use of face masks.

Non-communicable diseases and more: The health crises that don’t make headlines

A draft WHO roadmap to reduce deaths from non-communicable diseases is expected to be discussed at the WHA.

Meanwhile topline issues like Tedros election, Ukraine and the COVID-19 pandemic may grab the limelight, but there are more than two dozen other core health issues before the Assembly, in what may be the heaviest agenda yet seen by the global health body.

These range from progress reports on cervical cancer elimination, polio eradication, and maternal and child nutrition, to neglected tropical diseases and ways to advance “One Health” approaches to reducing outbreak risks through better management of environmental risks. 

The WHA also will discuss a draft WHO roadmap for reducing deaths from non-communicable diseases (NCDs) by one third by 2030. Non-communicable diseases kill about 41 million people each year – equivalent to about 7 in 10 global deaths, according to the WHO.

The Sustainable Development Goal target 3.4 for reducing NCDs is already wildly ambitious in light of the world’s increasing taste for ultra-processed foods and unhealthy diets, sedentary lifestyles, as well as toxic chemical and air pollution exposures. But the roadmap, however detailed on traditional health issues like smoking cessation and screening, barely touches these other problems – mentioning air pollution, which kills 7 million people every year from NCDs, only in passing. 

There is also diminishing support from donor countries for initiatives to combat NCDs in low- and middle-income countries, where the highest proportion of deaths now occur – due to the huge drain on resources created by the Ukraine war. 

Resolution on clinical trials transparency  

Nathalie Strub-Wourgaft, Director of Neglected Tropical Diseases at DNDi.

Another initiative, being closely watched by medicines access advocates, is a resolution sponsored by the United Kingdom asking member states to require greater transparency in the reporting of clinical trial protocols and results from publicly funded research. 

Informal drafts of the resolution, which is not yet finalized, include measures asking member states that fund clinical trials to require: public posting of trial protocols in a reputable online database; and reporting of negative trial results – which often are buried. 

Civil advocates say such requirements are critical to ensuring research results can be relevant to the broad public good, and particularly low- and middle income countries. 

And to prepare for future pandemics, protocols for clinical trial reporting should also allow researchers to quickly and accurately aggregate from small trials of new treatments to better assess their impact,  Nathalie Strub-Wourgaft told Health Policy Watch, in an exclusive interview.  

DRC sexual abuse: New details

Ebola response workers in the DRC

The WHA will also review  a report from WHO Director General Tedros about the measures it has taken to respond to the sexual exploitation and abuse scandal involving WHO staff and consultants in the Democratic Republic of Congo, which was first reported in September 2020 by The New Humanitarian and the Thomson Reuters Foundation.

The update contains details of WHO’s measures taken to overhaul its culture and operations, including:

  • The WHO has funded support for 92 victims and survivors and children born as a result of abuse.
  • The WHO intends to enlist a women-led legal aid NGO to provide “full legal aid to up to 25 victims and survivors” in 2022.
  • As of February, some 13,000 staff and non-staff worldwide had completed a new, mandatory training programme on preventing sexual exploitation and abuse. 
  • There’s a new, global team of 15 people who are experts in conducting sexual misconduct investigations. About 70 percent of them are women.

An dedicated unit has been created in WHO’s Office of Internal Oversight Services (IOS) “to investigate the allegations of sexual exploitation, abuse, harrassment.” The creation of a  separate judiciary channel reporting directly to the Director General, generated some debate at the January Executive Board meeting, although EB members agreed to it exceptionally.  

The politics of procedure: Ukraine and Russia

A Ukrainian refugee family with 11 children entering Romania at the Isaccea border crossing in March 2022.

Before delegates even get to the core issues at stake at the WHA, however, they will have to get past the contentious issue of Russia’s invasion of Ukraine. 

That could rear its head on Sunday’s ceremonial opening day, when member states must approve the WHA’s “General Committee” that oversees the week’s proceedings. 

That committee was originally supposed to include Russia. But the WHO’s European member states, most of which staunchly back Ukraine, substituted Russia for Armenia at the last minute.  

Meanwhile, the General Committee will then be in charge of approving the agenda, likely to include a resolution being circulated by Ukraine, Canada, the United States, and the EU condemning the Russian invasion and calling for more WHO measures to address the health impacts. 

So if Russia objects to being excluded from the powerful committee, the assembly will face a very long roll call vote by all 194 WHA members – with African, Asian, and Latin American states forced to take sides over the geopolitical conflict on the opening day of the gathering. 

And if that is not enough, there may also be a dispute at the outset of the WHA over Taiwan’s request to be seated as an observer – a status that it was granted until 2016 at the invitation of the WHO Director General.

Since the election of a more hardline Taiwanese government, China has however opposed this ceremonial gesture, and Tedros has not dared to defy Beijing.  However, more recently a growing list of countries worried about China’s geopolitical ambitions have begun to support Taiwan’s quest for a seat.  This year, it includes the parliamentary reprsentatives of Germany’s governing coalition parties, who even made their support public.

See the links to the WHA agenda here and proceedings here: 

Image Credits: WHO, Germany's UN Mission in Geneva , UNICEF/Christine Nesbitt, @TheIndPanel, Flickr: IMF Photo/Joaquin Sarmiento, NCD Alliance, WHO AFRO, UNICEF.

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