The 146th Executive Board meeting of the WHO was like an investment case in action for donors.
Here was WHO leadership noting the passing of key resolutions, lending support to new initiatives, urging countries to work together to arrive at a consensus on vexatious issues, while briefing technical experts and the media every day on the emerging outbreak of novel Coronavirus (Covid-19). In the midst of this, it was also responding to calls to reform the International Health Regulations in order to give WHO more nimble-footedness in addressing emergencies. The gigantic global health machine was in motion for all to see. This past month has also seen WHO take on disinformation and fake news. So there was much for donors to see, especially and not the least, the dwindling reserves of the Contingency Fund for Emergencies – now at less than $20 million.
The technical is the political
The dynamics of political health diplomacy were playing out in the main arena where a few member states gathered to variously speak for Taiwan’s inclusion in WHO processes and China dissuading them for “hyping up” the issue. WHO technocrats and member states expressed solidarity with China and cautioned against stigmatizing affected people.
On a number of occasions, member states were reminded to stick to “technical discussions”, and not veer into political matters including on Taiwan and Palestine. But apart from these traditionally complicated political questions, the current dynamic unfolding between China and USA in the context of the coronavirus (Covid-19), has been a story to watch, particularly the travel and trade related decisions. It has inevitably drawn WHO into this bilateral dynamic. At another event in the same week, questions were raised on whether WHO had praised China too soon in its efforts to fight the outbreak, even as there were reports on forced restrictions on movements of people within the country. A member from the senior WHO leadership who was present, said “Damned if you do, damned if you don’t”. And added that it is only in hindsight that one can make these judgments, but for the time being the limited number of cases outside to China, showed that “something was working”. There is no doubt Director-General Tedros has had to walk a tightrope in delivering technical expertise, liaising with a multitude of actors to address the outbreak, while being rooted in political realities and operating in varied cultural contexts. (Earlier this week, in a budget proposal the US government suggested a 50% cut in its funding to WHO.)
Like wheels within wheels, smaller, hugely pertinent informal negotiations rolled on throughout the week, many of which had commenced earlier to the meeting. Countries huddled together were engaged in long drawn discussions trying to reach a consensus or hammering out a compromise including on matters pushing for deeper engagement on price and availability of drugs, or asking for stricter norms to address alcohol related deaths, among others.
Access to medicines
Meetings at WHO are a great indicator of national priorities in many countries. It was sobering to hear the United States of America, several times during the week, somewhat restrained in its voice compared to previous years. Observers were of the view that high prices of drugs have become a flash point domestically in many countries including USA. High income countries have been coalescing around efforts for greater transparency around prices of medicines. Unlike before, it seems countries may not have to struggle any more to have these issues on the WHO agenda. It might not be totally coincidental that it has finally become “an issue”, ever since high income countries started experiencing strains on their budgets in trying to procure expensive medicines.
After five rounds of consultations, a proposal initiated and facilitated by Brazil eventually gathered enough support for it to be co-sponsored by a broad spectrum of more than 40 countries including the European Union, to arrive at a consensus.
Essentially, the decision adopted by the Board, seeks to give a “political push” to prior commitments made to implement the recommendations of the Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property (GSPoA) review in 2018 [WHA71(9)]. Further the DG has been asked to convene informal consultations amongst countries in 2020 to “further discuss the recommendations of the review panel not emanating from the global strategy and plan of action on public health, innovation and intellectual property”. Some countries believe that these issues were beyond the original scope of the GSPoA including discussions on improving transparency in R&D costs, discussions on shortages of medicines and asking countries to commit to spending at least 0.01% of their gross domestic product to basic and applied research relevant to the health needs of developing countries.
In addition, the DG has also been tasked with convening informal consultations in 2020 on promoting and monitoring transparency of medicines and actions to prevent shortages.
It is understood that Switzerland and the USA were opposing efforts for greater transparency of costs around research and development. Also, that there was resistance on language around shortage of drugs. One source alluded to the hesitation on the part of some member states to commit resources to prevent shortage of drugs.
Finally, the decision mandates the DG to allocate resources to implement prioritized actions addressed to the WHO secretariat as mentioned in the GSPoA review. The DG has also been asked to report on the progress on the implementation to the Assembly in 2021 following a discussion at the Executive Board.
Discussions and negotiations around access to medicines have matured and have acquired a dynamic of their own. After all, the Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property (GSPoA) is a dozen years old.
And in a sign of things to come, other issues have come to the fore.
The buzz around alcohol negotiations at the EB
Of the number of competing objectives, negotiations around tougher policies to address alcohol-related deaths, to an extent, had observers guessing till the penultimate day of the closure of the meeting on how the discussions would conclude.
Somewhat similar to the access to medicines ecosystem, a few big “producer” countries and others opposed stronger policies although the burden of deaths on account of harmful consumption of alcohol is distributed across the board causing 3 million deaths annually. There has been a worldwide increase in harmful alcohol consumption, particularly in low- and middle-income countries, in the last ten years. This effectively means that WHO and member states efforts on this have failed.
USA, UK, Japan, and Brazil mounted the strongest opposition apart from Haiti, Australia, New Zealand and Canada. However, France, Germany, Italy, also big producers, did not oppose, a source said. (The biggest overall alcohol burden is in Europe – which is the heaviest alcohol consuming region and has the biggest burden of harm.)
The decision was eventually sponsored by Bangladesh, Bhutan, India, Indonesia, Islamic Republic of Iran, Philippines, the Russian Federation, Sierra Leone, Sri Lanka, Thailand and Viet Nam, Norway and the European Union.
It appeared trade officials had trumped health officials on this matter and this could be attributed to the silence from certain countries in the African Union on this issue, according to people close to the discussions. But this could not be confirmed.
While sponsors of the decision had pushed for legally binding norms to address alcohol-related deaths, the final decision compromised on “an action plan” (2022–2030) to effectively implement the older Global Strategy to Reduce the Harmful Use of Alcohol that was adopted in 2010. They also managed to push for greater allocation of resources to address this effectively. The countries also managed to retain language on linkages to cancer – “sufficient evidence for carcinogenicity of alcohol and a causal contribution of the use of alcohol to the development of several types of cancers in humans”.
The DG has also been asked to develop a technical report on the harmful use of alcohol related to cross-border alcohol marketing, advertising and promotional activities, including those targeting youth and adolescents, that will also inform the development of the action plan.
Although less ambitious than what they hoped for, supporters of the decision called the adoption of the decision as historic. It is expected that addressing alcohol-related deaths will continue to remain on the agenda and might even break out of the larger umbrella on non-communicable diseases and demand its own policy space.
According to a few experts associated with the discussions, member states were “not in a mood to negotiate a binding treaty”, but others believe that it is a matter of time before lessons from the tobacco treaty can be transposed on to a framework to monitor alcohol-related deaths.
WHO is also a curious place. Countries that took progressive positions on access to medicines found themselves fighting stronger policies on fighting alcohol-related deaths, in effect contributing to risks of cancer-related deaths linked to harmful use of alcohol.
All of this emphasises the need for continued checks and balances – which is what civil society groups are most worried about – the shrinking of the space that could affect their ability to engage with WHO and its member states on key issues such as this.
The homogenising of civil society and non-state actors
Concerns were raised about WHO’s efforts to limit the participation of public interest civil society groups in governing body meetings in terms of the number of representatives and the number of statements they can make. More importantly, by lumping non-state actors including civil society and commercial actors into clusters or constituencies without taking into account their diversity, WHO could impinge on meaningful engagement and reduce the efficiency and effectiveness of its interactions with such groups, members from civil society reckon. After all, these groups represent a wide variety of expertise and positions in a range of thematic areas that directly inform the work of WHO.
The organization surely needs to do both – enable deeper engagement with public interest civil society actors and also prevent conflicts of interest and undue influence on WHO by commercial actors – both of whom are in official relations with WHO. At the Board meeting, WHO said it will work on a detailed engagement strategy in the coming year and will implement “the constituency model” in a limited manner.
Questions over WHO transformation remain
While member states were deeply appreciative of WHO’s efforts particularly on emergencies, and other areas of work, they also drew attention to and expressed concern over WHO’s slow pace on its transformation agenda, its hiring of consultants, and in particular, the lack of clarity on the WHO Foundation.
Overall, it seemed multilateralism was doing alright – something donors must recognise. Countries spoke of solidarity and global health security in the same breath.