World Health Assembly Opens Against Shadows of Pandemic Despair & Hopes Incoming US Administration May Resume Global Health Leadership Role
WHO Director-General Tedros Adhanom Ghebreyesus speaking at WHA 71 in May, 2018 – before the pandemic. Photo: WHO

This year’s 73rd edition of the World Health Assembly resumes virtually on Monday, after a two-day emergency huddle in May – against sharply rising COVID-19 infection rates in Europe and the United States, deep geopolitical divides – and calls for reform of the WHO that could strengthen its mandate but also may be resisted by countries concerned about encroachments on their sovereignty. 

At the same time, rays of hope include the prospect of new vaccines coming on the market in early 2021, promising new drug therapies under develoment, and the fact that some of the poorest countries, primarily in Africa, are weathering the virus much better than wealthier counterparts to the north. 

Add to that “hope-list”, the pending replacement of the most contentious and combative United States President seen in recent history, Donald Trump, with Democratic president-elect Joe Biden – a seasoned negotiator keen on bringing the US back into the multilateral fold. Biden has already said he’d rejoin the WHO on his first day in office, January 20, 2021.

In his victory speech Saturday night in Wilmington, Biden pledged to make the coronavirus pandemic his top priority upon taking office and even well before; he was to convene a senior task force of scientists on the issue as early as Monday, to implement a new strategy on combatting COVID-19.

President-elect Joe Biden says the coronavirus will be at the top of his agenda, in his victory address in Wilmington, Delaware, Saturday evening.

In the wake of the election, the tone of US career diplomats is already sounding a bit more conciliatory. Colin McIff, deputy director of the US Health and Human Services’ Office of Global Affairs tweeted on Saturday: “Looking forward to working with you and all partners for a stronger @WHO next week at a resumed #WHA73.”   

WHO’s Director General Dr Tedros Adhanom Ghebreyesus put out his own olive branch, following on from leaders as diverse as the UK’s Boris Johnson to the head of the African Union, saying in a tweet on Sunday morning, “Congratulations to President-elect Joe Biden and Vice President-Elect Kamala Harris! My WHO colleagues and I look forward to working with you and your teams. Crises like the COVID19 pandemic show the importance of global solidarity in protecting lives and livelihoods.”

That said, the thorny issue of admitting Taiwan as an “observer” to the WHA still could create significant electricity between the United States and its Canadian, European, Australian, South Korean and Japanese allies on the one hand – and China on the other – with big blocs of countries in the African region and elsewhere potentially forced to choose sides right at the start of the WHA tomorrow in a procedural vote.  

That is, unless WHO Director General Dr Tedros Adhanom Ghebreyesus decides to take the heat himself and issue a personal invitation to Taiwan – which he is entitled to do. That could be perceived as a major goodwill gesture to the United States, including president-elect Biden – not to mention the Taiwanese government, which has performed exceptionally in the pandemic.  And judging from a recent series of tweets by the US Mission in Geneva as well as statements by senior US Congressional leaders, Washington is putting on the pressure. 

As one western diplomatic observer told Health Policy Watch, “my understanding is that both paths are technically possible. That doesn’t mean the DG will invite, but in our view he has that power.”


International Health Emergency Resolution & Independent Reviews

Beyond the politics of Taiwan, the most key issues on the weeklong WHA agenda (9-14 November) will revolve around COVID-19, focusing on both the Organization’s and countries’ responses to date, as well as needs going forward. That will include a draft resolution by countries calling for stronger emergency response in the context of the legally binding International Health Regulations. Reports by two independent review committees will also be presented to member states. One looks at the performance of WHO’s own Health Emergencies team. A second  initial report is from an independent panel charged with reviewing pandemic preparedness and response of both the global health organization and countries themselves.  

Along with that, a draft resolution on “Strengthening preparedness for health emergencies: implementation of the international health regulations (IHR),” remains one of the few substantive resolutions to actually be debated and adopted at this WHA session. Other key actions, on COVID, WHO reform and other global health and disease resolutions and strategies, were either adopted in the two-day May virtual meeting. Or they were approved remotely in August, via written exchange, including a “silence procedure” in which a country’s ‘no-comment’ signaled its agreement.    

The resolution on the legally binding International Health Regulations, approved after the first SARS pandemic, asks WHO to examine the need for and potential benefits of, “possible complementary mechanisms to be used by the Director General to alert the global community about the severity and/or magnitude of a public health emergency in order to mobilize necessary support and facilitate international coordination.” 

In plainer language, this would be an “amber” alert, like the orange signal at a traffic light, which would tip off countries to developing emergencies earlier than the current system does – and before they get out of control. Such as signal has been proposed by a diverse range of countries, including the United States and European Union states.

While that technical measure may enjoy wider support, the many other clauses of this resolution also open the door for bigger debates over potentially controversial measures to strengthen WHO’s authority to demand data from countries and enforce surveillance in the framework of the IHR. It remains to be seen how China and its allies will respond to such overtures – in light of the criticism leveled about Beijing’s lack of transparency in sharing data about the virus in the early stages of the pandemic – through to the present where the virus origins remain murky and unexplored.  

While the resolution is couched in typical UN diplomatese, aimed to build consensus, it has other potential hotspots beyond the virus itself.  These include standard  WHO and UN references to sexual and reproductive health rights – which have often been opposed by conservative Middle Eastern nations as well as the United States – in the Trump era. 

Independent Reviews of WHO & Pandemic Response  

Active cases of COVID-19 around the world and COVID-19 deaths globally 8 November 2020 – hitting new records in the USA and Europe.

The other politically-charged debate is likely to revolve around the reports by two independent review committees charged with assessing WHO’s own Emergencies Programme as well as the broader pandemic response by WHO and countries themselves.  

The first, by the the Independent Oversight and Advisory Committee for the WHO’s Health Emergencies Programme, published only last week – provides the most detailed look, to date, at WHO’s internal functioning during the pandemic, following reforms undertaken after the 2014-2016 Ebola epidemic.  It cites as progress a strengthened WHO presence at country level, building greater confidence and cooperation. At the same time, it notes that staffing at country level is “spread thin” shortcomings – with only about 70% of the 1583 budgeted positions at headquarters and in countries having been filled.  In terms of  the timely delivery of urgent health products, critical to emergency response, it says that over the past several years:

“Both WHO staff and partners consistently point to a critical gap in the procurement system and supply chain management of the Organization. Findings suggest that persistent delays in procurement and delivery erode partners’ confidence in WHO’s capacity and accountability on the ground.” However, those shortcomings are being addressed more effectively in the COVID-19 context with a new Inter-Agency coordination cell better linking WHO and other UN and partner organizations on the ground:

Although scarce on details, an initial report by the Independent Panel for Pandemic Preparedness and Response, articulates a vision of a “root and branch” review of pandemic response at country as well as global health level. “Most catastrophes for most people are far-off events, but this pandemic has touched us all,” states the report by the committee, led by two former prime ministers,  Ellen Sirleaf Johnson of Liberia and New Zealand’s Helen Clark, “…It has deepened our resolve to carry out a root and branch review to uncover what could and should have been done better to avert this pandemic, and to propose a plan for all necessary steps to ensure that the world is better prepared in future.” 

Reform, Reform and Reform

While not explicitly on the agenda – as yet – diverse member state proposals for WHO reform are already being developed, and will be hovering in the background of these debates. Key proposals, submitted by Germany and France on the one hand, and the United States, on the other, which are designed to address systemic weaknesses in the Organization laid bare by the pandemic. 

A Franco-German reform proposal, ostensibly circulated as a “non-paper”  focuses on a more reliable funding base for WHO, now highly dependent on “voluntary” contributions by nations; stronger emergency response and legal mandates in emergencies. 

“It is clear that Member States’ (MS) expectations vis-à-vis WHO have by far outgrown their willingness to provide funding to the organization,” states the paper. Over 80 percent of the WHO’s program budget comes from voluntary contributions, the majority of which is from 15 donors. This leads to donor dependency and a gap between what member states wanted implemented and the finances available for it. 

“While the response to COVID-19 offers the great opportunity to reinforce WHO’s leadership role also vis-à-vis other global health actors, it could – if not adequately steered by MS [member states] – lead to further fragmentation in particular in global health security structures,” said the paper, which sets out 10 actions key actions as remedies.

Foremost among there are: increasing assessed and core contributions to WHO; greater member state oversight of WHO health emergencies actions; greater access of WHO mandated experts to investigate potential outbreaks; a stronger, WHO-facilitated coordinated global system for health emergency preparedness and response; and robust reviews of country levels of public health preparedness and compliance with rules for early reporting and sharing of information about threats. 

A more technocratic US proposal, published in September, focuses on a roadmap for strengthening WHO’s speed of gathering data, assessment, reporting and responding to potential epidemic risks, as well as a new “amber” alert for emerging public health emergencies.  

The proposal asks member states to grant more rapid access to outbreak areas by WHO-led response teams and to ensure member state compliance with International Health Regulations obligations – clear references to charges that China failed to act swiftly or transparencly enough in December when evidence of the SARS-CoV-2 virus began circulating.  

“This roadmap sets out areas where we believe there is an opportunity to strengthen the WHO by increasing accountability and its ability to be impartial and objective, improve transparency and its overall effectiveness, by providing it with a more comprehensive set of tools that are fit-for-purpose to address new and emerging threats,” said the US reform proposal. 

“It is essential to strengthen oversight mechanisms and clarify mandates to ensure full transparency and participation by Member States, other global health partners and the public”, the proposal adds, also noting that mechanisms need to be considered to “facilitate more rapid access to outbreak aras for WHO-led response teams… Such access is crucial to the early containment of outbreaks.”

The US proposes that a new  “Intermediate Public Health Alert IPHA or (amber light)” – be incorporated into the legally binding IHR which could signal a developing emergency before it becomes a full-scale global threat. Additionally, greater transparency in the decision making of emergency committees is requested.

The proposal also calls for delinking travel restrictions from trade  in pandemic response –  to minimize the economic impacts of health emergencies and ensure the functioning of global supply chains. 

And, the US proposal also asks for greater powers and budgets to be vested in the new WHO Chief Scientist’s Office “to raise the quality of, and confidence in, guidance documents and normative materials.” 

WHO Executive Board discussion on coronavirus outbreak in early February 2020 , led by Deputy Director General Zsuzsanna Jakab and Emergencies Head Mike Ryan. It was the last face-to-face meeting in Geneva of the governing body before WHO declared an international health emergency.

“We are fully committed to the reform in WHO, which has to be a continuous process,” said Zsuzsanna Jakab, Deputy Director-General of the WHO at a pre-WHA session, co-sponsored by the Geneva Graduate Institute’s Global Health Center and the UN Foundation. “We are also very happy to note that several member states or groups of countries, like the EU, for example, have initiated the reform process…There are also other initiatives from the United States, and we are encouraging member states to bring these initiatives together in a consolidated, coherent way.”

Jakab encouraged member states to continue to “come up with bright ideas on how we can make WHO even better and respond to the ever changing environment” and to bring the initiatives to the Executive Board in January 2021. 

Countries Need To Be Involved & Consulted More 

Clemens Auer, Austria’s Special Envoy for Health to the WHO, at the Global Health Center session on Thursday.

Whatever criticism has been leveled at WHO’s pandemic response, particularly in the early days, the failure has been mutual, most stakeholders will quietly agree. 

At Thursday’s pre-WHA session,  a representative of one member state, Austria, stressed that shortcomings in pandemic response, lie both with the WHO administration but also with core member states that direct its operation.  

“We didn’t do a good job on the multilateral level, on the international level when it comes to [COVID-19] crisis management,” said Clemens Auer, Austria’s Special Envoy for Health to the WHO. 

But countries were also to blame for WHO’s shortcomings, he added.  The 33 Executive Board member states that are the core governing body overseeing WHO’s operations also were notoriously slow to even call for a meeting during the “largest public health crisis of our generation. 

“It took until early October for the Executive Board of the WHO, the governing body next to the World Health Assembly, [to be] convened on issues of COVID.”

Auer spoke at a Global Health Center session entitled, “Backsliding or Building Beyond COVID-19? An Introduction to the Resumed 73rd WHA”. 

Member states need to be more proactive in the interactions at the Executive Board and the World Health Assembly – and that goes for member states from the global South, said Ilona Kickbusch, founding director and chair of the Global Health Centre, at the same session. 

She lamented the fact that the Executive Board’s mandates has been eroded over the years by a series of subtle, but important changes in rules and procedures. “I personally feel one of the worst governance decisions ever taken in the WHO was to change the way the Executive Board functions. It is no longer a board, it is no longer a body that really advises the Director-General and the other member states, and that is reflected in how it functions and it’s reflected in why it’s not called on.” 

US Withdrawal from WHO Is A ‘Positive Disruption’   

Ilona Kickbusch, founding director and chair of the Global Health Center, speaking at the Global Health Center session Thursday.

Even so, Kickbusch described the temporary retreat of the US from the WHO arena – even if reversed by an incoming Biden administration, can also be seen as  a “positive disruption” that creates opportunities for change. 

The vacuum provides an opportunity for regions like the European Union, as well as low and middle income countries to take a stronger lead. 

“With the ‘hegemon’ actually not around for now, can we build a more equitable global health decision making situation, within the WHO, but [also] in global health generally?” asked Kickbusch. Following the recent US moves, for instance, Europe’s role in the WHO was discussed explicitly at an EU Ministerial Council meeting of ministers of health at the end of October, for the first time in recent memory. 

Amidst widespread speculation that the US may rush back to center stage, Kickbusch has taken a more muted attitude saying in one Tweet: “Why not US participation? CooperAtion?  Don’t we need new leadership models in global health?

The crisis also has raised deeper and more systemic issues about how money from a few large country donors, as well as philanthropies, can disproportionately skewer the Organization’s policies and spending priorities. 

The current system is overly reliant upon voluntary donations by countries, rather than assessed contributions and that allows the member states that pay the most to also “call the tune” of the WHO, observed Kickbusch. 

That was echoed by Auer who described how member states “got a wake up call when Donald Trump announced that the US is leaving WHO because all of a sudden we were called…to jump in to fill the financial gap.” 

Meanwhile, a parallel global health architecture also has emerged, led by philanthropies such as the Bill and Melinda Gates Foundation, said Felipe Carvalho, Médecins sans Frontières Access Campaign Coordinator in Brazil. These private actors exercise their own vision about issues related to the licensing and procurement for billions of dollars annually in health products, which in turn curbs some of the decision-making power of member states and civil society. 

Member states also are vulnerable to vested interests, which in turn may lead them to influence WHO’s outreach and agendas on a range of issues, from sugar taxes and tobacco control, Kickbusch added, recalling how Cuba had opposed the 2005  WHO Framework Convention on Tobacco Control because of its production of cigars. 

Ultimately, policymakers need to stand up to such interests, however, if they want to fend off the next big public health crisis, said Kickbusch. And countries in the global south along with the north, need to speak up, she added, saying:  

“The representation of countries, particularly countries of the global south is strong in these bodies…My question is: are the countries of the global south going to use the fact that they have a heck of a lot of votes to actually introduce and push for a stronger WHO?…We need to rely on the countries of the global south, and I hope we can also rely on the European Union…to change the power relationships and the governing processes within that Organization.”

“If a strong alliance of countries wants an independent, strong WHO and a WHO that is less dependent on others who come in and provide support, then they should build that alliance. I do think this is an issue that needs to be taken up, otherwise, I do not think we will get the kinds of changes that we are aiming for.”

Dispute Over Taiwan Issue May Generate Electricity 

Despite the quest for unity, the big question facing the WHA on the morning it resumes, will be the US-backed proposal to reinstate Taiwan as a WHA observer  deferred at the May WHA 73 session, may re-emerge again – with unpredictable results in terms of the big geopolitical divide between China and the USA, western Europe and allies. . 

In May, some 13 member states, led by Belize, submitted a proposal to invite Taiwan as an observer, backed by a strong statement from US Secretary of State Mike Pompeo – and publicly backed by others, including  Canada

That proposal was deferred until the November session. Now, tomorrow, it could be resolved by a sudden, dramatic gesture by Dr Tedros to invite Taiwan. Or it could be subject to a big and potentially bloody debate at the outset of the WHA about whether to take a vote at the start of the Assembly – laying bare again the polarization between China and the US and its allies. 

On Friday, the pro-Taiwan bloc picked up significant diplomatic steam, following a joint call by some 644 European parliamentarians from 25 countries upon Dr Tedros to admit Taiwan as an observer. 

The US Mission in Geneva issued its own statement bluntly asking DG Tedros to take action, saying: “the United States urges Director General Tedros to participate in the upcoming World Health Assembly on November 9-14. That was followed by a tweeted video stating “when the World Health Assembly re-convenes, November 9-14, the people of Taiwan deserve a seat at the table. We urge WHO Director General Tedros to invite Taiwan to participate in the upcoming World Health Assembly.”

Congressional Republican leaders like Senator Marco Rubio make it clear that the US will be watching closely to see if WHO makes such a gesture – perceived in Washington as a important course correction of WHO’s perceived “pro-China” bias in the early pandemic days. 

“Senator Rubio calls on the WHO to allow Taiwan to meaningfully participate in #WHA73,” tweeted Rubio’s media team.  “As many nations face a 2nd wave of #COVID19, Taiwan sets a record for 200 days without infections.  Beijing’s agenda to block Taiwan deprives us all of expertise and threatens global health,” he said under the hashtag #TaiwanCanHelp. 

In fact, Taiwan served as a WHA observer, under a personal invitation from the WHO director genera until  2017 – when the practice was abruptly ended by outgoing WHO DG Margaret Chan, herself a former official in Hong Kong, precisely as Tedros stood for election, and as China was stretching its geopolitical muscle more strenuously in the Asian Pacific region.

Last week, WHO’s leadership last week attempted to shift the decision back to the WHA court: 

“Observership is a question for member states,” said Steven Solomon, principal legal officer for governing bodies of the WHO, at a WHO press conference on Friday, adding only that:  

“Technical work of the Secretariat, of the Director-General with everyone everywhere continues to ensure that we advance the principle of health for all, as embodied in our constitution.”

But in the wake of Joe Biden’s election, a WHO gesture by Tedros to invite Taiwan into the room would be just the show of WHO bipartisanship on the thorny China-Taiwan issue – that could be a test of whether the new Biden administration can not only give, but get something from the global health organization. If not, it could wind up in a vote, which will force non-aligned States in Africa and elsewhere to make a difficult choice about sides. 

Steven Solomon, principal legal officer for governing bodies of the WHO, at a WHO press conference on Friday.

Other World Health Assembly Business

Along with the debates on the IHR Health emergencies framework, the COVID-19 emergency, WHO’s pandemic response and reform initiatives, the weeklong agenda, will cover key themes related to a wide range of other WHO objectives, including efforts to expand primary health care and vaccine coverage, as well as strategies that promote healthier populations.  

New initiatives tackling cervical cancer, tuberculosis, and influenza preparedness feature prominently in the agenda. But as these were in fact already approved remotely by member states in August due to the constraints of the virtual WHA format – the debate over the related resolutions or decisions will in fact be largely rhetorical. Confounding things further, certain sub-issues, such as TB and neglected tropical diseases (NTDs), will be grouped together in member states’ statements – making it more difficult to follow trends in countries’ approaches, attitudes and actions, by theme. 

These features of the virtual format, as well as the fact that civil society responses are also sharply limited, constrain possibilities for genuine dialogue and consensus-building, which is such an important feature at the WHA. Civil society groups have complained about this as well as the limited time allocated to comments by the dozens of organizations that are recognized as WHA observers. Key agenda items are presented here, theme by theme:   

Primary Health Care and Universal Health Coverage: 

Other Health Emergencies topics 

Healthier Populations 

A WHO press release on the upcoming WHA session also cites the big advances that have been achieved – despite the challenges posed by the pandemic. Those include: the establishment of the Access to COVID-19 Tools (ACT) Accelerator; an Immunization Agenda 2030, where WHO updates to member states of progress will be provided.  A civil society primer, by the Geneva Global Health Hub, is presented here. The WHA sessions, all virtual, can be followed online here. 

Image Credits: WHO, Johns Hopkins, HPW/Catherine Saez, Global Health Center.

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