Competing visions for W.H.O. reforms
Originally published January 8th, 2021 on Geneva Health Files
Not that member states needed more reasons to urgently consider WHO reforms, but China gave them a fresh impetus just the same, earlier this week. A year after the novel coronavirus was first detected in Wuhan, China, it appears that the gloves are off.
Dr Tedros Adhanom Ghebreyesus, WHO director-general, expressed his disappointment on Tuesday this week, when scientists who had been en route to China to begin investigations on the origins of SAR-CoV-2, were turned away as a result of alleged delays in internal procedures.
These developments will undoubtedly influence and set the tone on how these reforms discussions will be shaped in the coming months. Countries are keen on working on a resolution related to reforms, to be tabled at the World Health Assembly in May 2021.
But before that, ahead of the Executive Board meeting this month, January 18–26, countries have begun informal consultations on aligning their visions for WHO reforms. More than 20 countries have put forward proposals, or joined others in powering reforms-related discussions at WHO.
From empowering IHR emergency committees to benefit sharing on pathogen samples, there are strong proposals from countries.
Geneva Health Files had reported earlier on proposals from Germany-France, U.S. Brazil, and others. A number of other groups of countries including the Support Group for Global Infectious Disease Response (G4IDR) that includes South Korea, Singapore, Turkey, United Arab Emirates, Morocco, Kenya, Mexico, and Peru, have also presented proposals for reforms. Chile, also supported by Guatemala, Ecuador, Peru, Uruguay has a proposal under discussion. The Coalition for a Universal Health Protection Architecture which includes Switzerland, Nepal, Oman, Botswana have made suggestions on reforms. It is understood that Japan and Australia have also put forward proposals on reforms. We had briefly flagged India’s views on reforms late last year when it was first published.
All these different proposals are now being discussed with overlapping areas of interest being mapped and analysed, according to documents seen by Geneva Health Files. In this story we parse through the emerging areas of consensus among these member states on WHO reforms in the context of this pandemic. We examine a few features in some of these proposals collectively, which gives us an indication of countries’ priorities for reforms at WHO triggered by COVID-19.
A number of areas for reform emerge consistently across proposals including on IHR implementation and the need for revision; funding of WHO’s emergencies work; WHO’s working relationship with other UN agencies (ex: FAO, OIE, IATA, CBD among others) in the context of this pandemic and beyond; WHO access to outbreak areas and reporting back to member states; sharing of samples.
While working towards a resolution on reforms in the coming months, member states are also expected to refer to the work of other committees and panels including the IHR, the Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme (IOAC) and the The Independent Panel for Pandemic Preparedness and Response.
The discussions are guided within the context of the preparedness resolution WHA 73.8. Strengthening preparedness for health emergencies: implementation of the International Health Regulations (2005), which was adopted at the resumed de minimis session of the Assembly in November 2020.
We have used our discretion and understanding to categorize different aspects of the reforms proposals to provide greater clarity for readers, also taking cues from how countries are approaching these discussions based on documents under discussion.
THE ROLE OF WHO
While there is agreement on the overall importance of WHO in the context of pandemic preparedness and response, countries including Germany, France, Brazil, the U.S. and Chile, specifically call for greater member state oversight and guidance on WHO’s emergencies work.
Chile, for example, suggests, improving standards of transparency and states participation. Reforms must aim assure legitimacy of multilateral institutions involved in response to emergencies, it says.
Countries seem to largely agree that WHO must be strengthened to effectively lead and address pandemic preparedness and response. As we reported earlier, the U.S. and Brazil, suggest strengthening WHO by “increasing accountability and its ability to be impartial, objective, improve transparency…”. Switzerland and others, called for “a universal, multilateral order, with the WHO as the leading and coordinating organization.”.
Australia has deemed “Building an independent and authoritative World Health Organization” as a top priority. The country also suggests supporting strong WHO operations on the ground including by strengthening WHO emergencies programme. It suggests strengthening authority of the WHO under the International Health Regulations (2005), by enhancing WHO’s monitoring of State Party compliance with IHR obligations to ensure the timely sharing of information on public health risks and strengthening WHO’s authority to investigate novel disease outbreaks to enable it to effectively advise on the risks of international spread and requirements for international cooperation. It also called for supporting WHO’s normative work to ensure timely, evidence-based scientific and technical guidance.
On other issues including on tracking zoonotic diseases in the future, the U.S. and Brazil have said “The existing tripartite agreement for antimicrobial resistance (AMR) serves as a model and starting point for broader efforts to track and respond to zoonotic diseases, but further action is needed.”
GOVERNANCE OF THE EMERGENCIES PROGRAMME
Countries have a number of suggestions on improving governance related aspects specifically concerning the emergencies work of WHO.
Japan has suggested that countries could explore “the idea of placing a permanent independent oversight institution for the WHO Health Emergencies (Programme) outside of the WHO or under the EC, as well as improving the structure and operation of the Global Pandemic Monitoring Board (GPMB) to ensure independence from the WHO.”
Switzerland and others, have suggested that the IHR may be reviewed and amended “with a focus on governance mechanisms such as a universal periodic review under the WHO health emergencies programme”
India has made one of the most comprehensive arguments in linking the governance process of the emergencies work to the wider governance discussions at WHO overall — essentially pushing for greater member states participation in all levels of governance, specifically on technical matters. (Do note that the other countries have also in the past raised concerns on improving the role of the EB within WHO)
In its proposal, India says:
“The two policy making organs of the WHO i.e. the World Health Assembly and the Executive Board are currently playing a peripheral role. (This is more pronounced in case of the Executive Board). Being a technical Organisation, most of the work in WHO is done in Technical Committees composed of independent experts.
Moreover, in light of the growing risks associated with emergence of disease outbreaks the role of the Independent Oversight and Advisory Committee (IOAC), responsible for the performance of the WHO Health Emergencies Programme (WHE), becomes extremely crucial. It is necessary for this oversight mechanism to be strengthened and the inputs of Member States to be integrated.
These inputs need not only be taken during EB or WHA but there should be a mechanism for concurrent and regular coordination of IOAC with member states.”
It therefore recommends:
“It is important that the member States have a greater say in the functioning of the WHO, given that it is the States which are responsible for implementation on ground of the technical advice and recommendations coming from the WHO. There is a need to devise specific mechanisms like a Standing Committee of the Executive Board to ensure effective supervision by member States. There is also a need to including look at the functioning and composition of various technical committees to make them more effective and responsive to the priorities and recommendations of the Member States.
…. Additionally, there is a need of effective representation of the developing nations and the high disease burden countries on different decision-making processes in WHO’s Technical Committees. WHO should also consider actively leveraging the support of experts, academicians and policy makers from the high disease burden nations in the decision making and policy formulation processes.
A proper review of the format & functioning of Executive Board & World Health Assembly should also to be taken up for them to be an effective engagement tools with the Member States instead of the present set up where in the format of Executive Board & World Health Assembly are repetitive. There must be an accountability mechanism to indicate what follow up action on the interventions of member states in EB and WHA has been initiated by WHO Head Quarters, Regional Office and Country Office.”
Germany and France had already made strong arguments in favour of “a general increase of assessed contributions and of core voluntary contributions to cover WHO’s core business (base programme).” In their proposal, these countries highlighted that the lack of flexibility WHO has in its funding, given that only 20% is in the form of assessed contributions and the rest are voluntary in nature that are earmarked. In addition, WHO has long been overshadowed by its richer partners in global health.
On the emergencies programme, Germany and France want to ensure sustainable financing of WHO’s work in health emergencies by all 194 member states through an increase of assessed and core voluntary contributions “with the aim to fully finance the GPW pillar 2 and thus ensure WHO’s ability to act in crisis without immediate need for funding appeals”
Interestingly, countries also want greater oversight on the way WHO raises funds.
Brazil and the US have said that while the WHO Solidarity Fund and the WHO Foundation are helpful in broadening the donor base, “any new funding sources need Member State oversight”. (They have also called for the empowerment of the Chief Scientist’s Office at WHO, in compliance with Framework of Engagement with Non-State Actors (FENSA), with sufficient budget and staffing, and make global expertise available to all levels of WHO.)
Japan believes that “It is critical to strengthen the effectiveness, transparency and accountability of various WHO funding mechanisms (e.g. Strategic Preparedness and Response Plan (SPRP), WHO Solidarity Response Fund, WHO Foundation”
On funding matters, India says, “There is a need to ensure that extra budgetary or voluntary contributions are unearmarked to ensure that the WHO has necessary flexibility for its usage in areas where they are required the most. There is also a need to look at increasing the regular budget of the WHO so that most of the core activities of the WHO are financed from it, without putting an overwhelming financial burden on developing countries.”
Further, India also suggests deeper member states involvement in the way funds are spent:
“… Ensuring transparency of funding mechanism and accountability framework: Presently, only broad-based priorities are discussed with member states and in respect of selection of activities, their expenditure and concurrent monitoring, there is no regular and institutional mechanism involving the member states. There is no collaborative mechanism wherein the actual projects and activities are decided in consultation with member states, there is no review with respect to value for money and whether projects are being done as per the member states priorities or if there are abnormal delays. Without the same, the technical assistance to member states primarily is neither transparent nor adding the required value to the member states. There is an urgent need for effective involvement of Member States in discussions on budget implementation and spending. This is imperative to strengthen efforts towards enhancing cost efficiencies and value for money proposition.”
“Establishing strong and robust financial accountability frameworks will enable maintaining integrity in financial flows. It is also crucial to establish significant amount of transparency with respect to data reporting and disbursement of funds for increased accountability….There is no framework or mechanism to ensure that the details on funding & financing are disclosed at a micro level which is a crucial element. There should be a quarterly review of ongoing WHO activities in the country by Member States with the WHO Country Office so as to align expenditure by WHO in consonance with country priorities.”
ON IHR REFORMS
Countries have elaborated comprehensively what reforms of the IHR(2005) should look like.
Overall, there seems to be agreement between these countries on introducing a universal periodic review mechanism for health emergencies including on national preparedness and implementation of the core capacities of the IHR (2005).
There also seems to be alignment between countries on considering a periodic joint external evaluation (JEE) of the state’s public health capacities, to assess core capacities and preparedness. (Japan suggests making such external evaluations compulsory.)
Australia suggests strengthening implementation of the IHR (2005), including robust monitoring and evaluation mechanisms. It suggests “strengthening the IHR Monitoring and Evaluation Framework, including the Joint External Evaluation process, to deliver universal periodic review and link findings to technical and, if appropriate, financial assistance where needed.”
Korea representing the G4IDR suggests, “…we should first focus on strengthening the implementation of the existing IHR but should also be open to discussions on the amendment of the Regulations in the long term.”
Korea and partners also highlight review of digital technologies and implications on human rights: “… the IHR’s provisions on human rights (e.g., Articles 32 — Treatment of travelers and 42 — Implementation of health measures) and the treatment of personal data (Article 45) can be strengthened by providing more detailed guidelines to States Parties on using digital technologies for public health purposes in accordance with international human rights law. “
Japan suggests, improvement of the process of notification, consultation and verification. It seeks clarifications on “whether and how the WHO will engage in consultation and collaboration with the member state(s) concerned. The elaboration process should be conducted on scientific grounds free from political interference.”
ON SHARING INFORMATION UNDER IHR
Korea and others suggest creating new criteria and guidelines on the type and scope of information that States Parties must communicate to WHO. And have sought for “a real-time information-sharing platform, in which States Parties may have direct access to information provided to WHO by State Parties under Article 6, through their designated focal points.” Standardization of ways to trace contacts once events have been notified has also been suggested for better sharing of information.
The U.S. and Brazil have asked WHO to issue updated guidance for itself, Member States and non-state actors of the expectations, after the initial notification of an event, as a part of their proposal for reform.
Chile also spelt out the need for a “real-time monitoring system, allowing, inter alia, the pooling of information, resources and best practices across International Health Protection Architecture.” It suggested an online space to exchange real-time information with regard to eventual events of concern occurring in the region.
EMPOWERING THE IHR EMERGENCY COMMITTEES
A number of countries have suggested empowering the Emergency Committee including by improving transparency in its proceedings. (See this New York Times Story: In hunt for virus source, WHO let China take charge — that raised questions around the emergency committee meeting on January 23 2020.)
Australia suggests, incentivising State Parties to share information early to support Emergency Committee deliberations; increasing the visibility of public health considerations that inform Emergency Committee deliberations and recommendations to the WHO Director-General regarding PHEIC declarations.
Korea on behalf of G4IDR suggests, “The group believes that the transparency of the deliberations should be enhanced by requiring the Committee to produce a detailed report of its proceedings, similar to the WHO SAGE Immunization reports, keeping in mind legitimate reasons to protect the confidentiality of certain types of information that the Committee has considered…. requiring members of the IHR Expert Roster to complete periodic, online training on the IHR and lessons learned from past Emergency Committee meetings. The Committee member’s declarations of interest should also be published together with the meeting report to increase accountability and build confidence.”
ON THE DECLARATION OF A PHEIC
Given the ubiquitous nature of COVID-19, the acronym PHEIC which stands for ‘Public Health Emergency of International Concern’, nearly became an everyday term during the current pandemic.
Countries agree that declaration of a PHEIC has been politically contentious and worse. Critics say the delay in classifying the outbreak of novel coronavirus (2019-nCoV) as a PHEIC, likely costed the world millions of lives.
Countries agree that there should be an intermediate level of alert in the declaration of a PHEIC. In order to allow for a gradual PHEIC declaration, it has been variously suggested that the current mechanism should be revised to have a stepped level of alerts, or a traffic light system, some have called an amber light system of alert to streamline and encourage transparency on public health threats. Switzerland and others in the coalition have suggested a regional approach to declare PHEIC at the regional levels.
Korea and its partners, propose “Director-General should have the option to issue — following the advice of the Emergency Committee, an intermediate level of PHEIC. The benefit of this approach should be carefully considered against the risks posed by a delayed international response to a localized outbreak. Such a modified alert system should include clear criteria for determination of the intermediate level, as well as the scale of coordination of an international response.”
India suggests “It is important to devise objective criteria with clear parameters for declaring PHEIC. It should also be possible for DG WHO to declare a PHEIC if in his/her assessment there is a broad agreement, though not a consensus, within the IHR Emergency Committee and not to wait for a consensus to emerge. The emphasis must be on transparency and promptness in the declaration process.”
Overall, some countries appear to be on the same page in terms of demanding quicker access to outbreak areas. As reported earlier, Germany and France have called for enabling WHO mandated international experts to independently investigate and assess (potential) outbreaks as early as possible. They have also suggested strengthening “WHO’s network and teams to immediately perform outbreak investigation and allowing WHO-led multinational teams to access territories of States Parties to investigate any potential outbreak or health emergency at any time.” Chile has called for WHO to dispatch on-site assessment missions once information is available on an eventual virus.
ON TRAVEL AND TRADE RESTRICTIONS
The pandemic year of 2020, saw international trade plummet and freeze on account of not only lockdowns across countries, but also because of protectionist trade measures resulting in hoarding of essential supplies.
The reforms discussions on the trade and travel measures in the context of IHR seeks to address this.
In its proposal, Korea suggests “establishing a principle on the facilitation of essential movement could contribute to the IHR’s objective of avoiding unnecessary interference with international traffic.” Providing new guidelines or best practices, particularly on when travel restrictions may be necessary and how impact on supply chains can be avoided, could assist in implementing this principle, it has said.
Lessons from the COVID-19 outbreak indicate that “IHR’s provisions on additional health measures can be improved by requiring States Parties to provide more detailed information about the public health rationale behind such measures. Such additional information could include, for example, the risk assessment criteria used to implement different levels of restrictive measures to combat a public health threat,” Korea says in its proposal.
The U.S. and Brazil have called for de-linking travel from trade restrictions under emergency conditions, “with the goal of maximizing public health measures while minimizing economic impacts”. They have sought for an evidence-based process to develop recommendations on the appropriate role of domestic and international travel restrictions within a suite of preparedness and response interventions, in close consultation with other relevant organizations and tailored to the circumstances of relevant industries, such as cruise ships, air travel and shipping,” the American-Brazilian proposal says.
SAMPLE SHARING OF PATHOGENS
Sharing of genomic sequences during COVID-19 dramatically hastened the research and response to the disease. And yet, countries’ largely have not dealt with the subject of sample sharing of pathogens in a comprehensive manner. (See an agenda item on the same, coming up at the Executive Board later this month.)
The U.S. and Brazil have discussed the sharing of pathogens in the context of preparedness. In their proposal they say “”…promote safe and rapid sample sharing of pathogens of pandemic potential or high risk, including during the assessment phase.”
Japan has said countries should be encouraged to notify the WHO of significant information including samples of pathogens in the early stages of an outbreak. “The following two actions should be given as soon as possible, even during the assessment phase: (i) promptly reporting to the WHO once the Member State(s) obtain information, especially of an unknown virus or suspicious cases, and (ii) sharing important information, including samples of pathogens, with the WHO.”
India has suggested the development of a global framework or specialised protocols for benefit sharing for non-influenza pandemics on the lines of PIP Framework consistent with the objectives of the CBD and its Nagoya Protocol. India has also called for the creation of a Global Framework for Management of Infectious Diseases & Pandemics.
In its update to the Executive Board this month, WHO has said:
Between 28 January and 11 June 2020, the reference laboratories in Abu Dhabi (United Arab Emirates), Atlanta (United States of America), Beijing (China), Berlin (Germany), Bilthoven (Netherlands), Dakar (Senegal), Geneva (Switzerland), Hong Kong SAR (China), Johannesburg (South Africa), Koltsovo (Russian Federation), London (United Kingdom), Melbourne (Australia), Mexico City (Mexico), Muscat (Oman), Nagasaki (Japan), Paris (France), Phnom Penh (Cambodia), Pune (India), Rio de Janeiro (Brazil), Rome (Italy), (Netherlands) and Singapore, received 100 shipments of specimens (multiple specimens per shipment) from the following 61 countries:
Afghanistan, Albania, Algeria, Bahrain, Belarus, Belize, Bosnia and Herzegovina, Burkina Faso, Cameroon, Colombia, Comoros, Costa Rica, Côte d’Ivoire, Cyprus, Czech Republic, Democratic Republic of the Congo, Estonia, Eswatini, Ethiopia, Fiji, Guatemala, Iceland, India, Islamic Republic of Iran, Jamaica, Kazakhstan, Kenya, Kyrgyzstan, Lao People’s Democratic Republic, Latvia, Lebanon, Liberia, Lithuania, Luxembourg, Mauritius, Mongolia, Mozambique, Nepal, New Zealand, Niger, Nigeria, North Macedonia, Pakistan, Paraguay, Qatar, Republic of Moldova, Romania, Serbia, Slovakia, South Africa, South Sudan, Sri Lanka, Sudan, Tajikistan, Timor-Leste, Tunisia, Uganda, Ukraine, Uzbekistan, Viet Nam and Zimbabwe.
ON EQUITABLE ACCESS
Countries have not elaborated much on this important issue of equitable access in the context of preparedness and pandemics, even as some countries are currently weighing decisions to cut doses of vaccines in order to reach greater numbers of vulnerable people.
The U.S. and Brazil suggest, “Once COVID-19 countermeasures are developed, all countries must benefit from equitable access. Based on the experiences with access to medical products for COVID-19, strategies for medical countermeasures for future pandemics could be developed.”
Switzerland and others in the coalition say, ““Ensure the supply capacities of health products at global and country level for a rapid response in times of crisis.”
In its proposal, India says:
Access to therapeutics, vaccines and diagnostics: It has been felt that the TRIPS flexibilities provided for public health, under Doha Declaration, may not be sufficient to deal with crises such as COVID 19 pandemic. There have been instances of restrictions on trade in public health goods in the initial phase of COVID 19. Also, as a reflection of vaccine nationalism, some developed countries have been signing bilateral agreements with vaccine manufacturers, leaving very little space for developing countries to get fair, affordable and equitable access to the same. India and South Africa have moved a proposal at the WTO for a COVID 19 specific waiver of some of the provisions of TRIPS Agreement. Lack of awareness of TRIPS flexibilities and an enabling national mechanism has made it difficult for the developing countries to benefit from these provisions.
It is important to ensure fair, affordable, and equitable access to all tools for combating COVID 19 pandemic and, therefore, the need to build a framework for their allocation. The WHO is working in this direction and its work should be supported. The tools for COVID 19 pandemic such as vaccines are a global public good and TRIPS waiver as proposed by India and South Africa would go a long way in effective international and national response to COVID 19 pandemic.
In the coming months, countries will work together to decisively shape not only how WHO functions during emergencies, but will likely refashion the priorities of the organization itself.