The dash for the pandemic treaty; Understanding the Oxygen crisis: Q&A: Robert Matiru, Unitaid

Geneva Health Files
15 min readMay 14, 2021


Newsletter Edition #55 [The Weekly Primer]

Originally published May 11th, 2021 on Geneva Health Files.


It seems as if Geneva is being made and remade in a matter of days. If this weren’t for a landlocked country, the analogy of a tsunami of changes sweeping over Diplomatic Geneva would have worked well.

Just last week, the U.S. decision to engage with discussions on the TRIPS waiver at the WTO upended trade policy calculations. This week began with WHO member states grappling with the real possibility of a pandemic treaty. This is being done at an astonishing speed.

Who would have anticipated that this seemingly sequestered city on the placid shores of Lac Léman would be witnessing these swift changes on so many fronts, simultaneously?

While we are firmly in the trenches in Geneva, the chaos, turmoil, and realities worldwide continue to challenge and crash against the forces of shaping global health policy-making here.

This week we bring you an interview with an expert to help us make sense of the absolute tragedy of preventable deaths as a result of access to medical oxygen in the context of COVID-19. Do read and share.

Also sharing a timely discussion from earlier in the week on the pandemic treaty proposal organized by the Geneva Global Health Hub that brought together senior WHO officials, academics, and practitioners on this critical issue. We made a brief presentation based on our reporting on this. You can watch it here.

Finally: while we write keeping our harshest critics in mind, we are always encouraged by our kindest readers. Thank you for writing to us with your messages of appreciation and encouragement. We are still a good distance away from financial viability, but your messages telling us that our work matters, really helps us during these times. Most grateful for your time and engagement.

Until Friday!



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A number of countries have faced difficulties in accessing medical oxygen to cope with COVID-19, including in South Asia where many deaths have resulted from a lack of access to oxygen supplies. In February 2021, before the Indian oxygen crisis plunged cities like New Delhi into chaos, WHO had said, that COVID-19 oxygen emergency was impacting more than half a million people in low- and middle-income countries every day, as demand surged. It had assessed needs for US$90 million in immediate funding to meet the demand in 20 low- and middle-income countries (LMICs). A COVID-19 Oxygen Emergency Taskforce was set up under the ACT-Accelerator Therapeutics pillar “to measure oxygen demand, work with financing partners, and secure oxygen supplies and technical support for worst-affected countries.” (Also see COVID-19 Oxygen Needs Tracker.)

The Indian crisis laid bare the difficulties in scaling and ensuring access to oxygen supplies. This resulted in numerous preventable deaths, for a number of reasons including lack of preparedness at the country level. This surely has lessons for other countries. Geneva Health Files spoke to Robert Matiru, Director of Programmes at Unitaid, who is also advises the ACT Accelerator on therapeutics.

Robert Matiru, Unitaid

[Geneva Health Files] 1. What has led to the difficulties in accessing medical oxygen in many parts of the world, including in India?

[Robert Matiru] It’s worth distinguishing between India and other LMICs — in India, there is a relatively well-developed health system and local oxygen supply is there, but a lack of planning for an outbreak at this scale, and limited prioritisation have resulted in oxygen not being where it is needed in the country. We are starting to see this improve now, with gas being diverted from industry and supplies arriving in parts of the country where it is needed most, helped by multilateral and bilateral responses.

For many other LMICs, the difficulties are more systemic and long-term. Even before COVID-19, oxygen supply in LMICs was inadequate. The problem is complex: tools to diagnose respiratory distress are often not well-embedded in health systems, and sustaining oxygen supplies is an expensive, long-term commitment, and equipment is poorly designed for use in low-resource healthcare settings. Oxygen concentrators are often not designed to withstand the difficult conditions found in many LMICs, oxygen piping systems needed to deliver oxygen to the bedside are lacking or often not well-maintained, and complex logistics mean oxygen cylinders don’t always reach their destination on-time. Medical oxygen is supplied by six major companies, but in countries there is a lack of market competition, which often results in higher prices and access issues.

All of these issues have been compounded by the impact of COVID-19. While oxygen is vital for the effective treatment — alongside corticosteroids — of patients with severe and critical COVID-19, access in LMICs is limited due to the cost, infrastructure and logistical barriers outlined above. In the COVID-19 response thus far, diagnostics, PPE and vaccines have been prioritised over medical oxygen, despite it being so essential.

[GHF] 2. What could the international community have done to prevent such a crisis? Were the mechanisms in the ACT Accelerator, deficient to anticipate and prepare for such a demand for medical oxygen?

[RM] It’s important to recognise that oxygen supply is a complicated space for the reasons highlighted in the previous response. COVID-19 outbreaks at this scale are unpredictable. Last year, global development agencies invested more than US$ 150 million in oxygen products and services for LMICs, but that is just a fraction of what is required for a comprehensive and sustainable response to address the unprecedented surge in demand for medical oxygen that we are seeing now due to COVID-19. At end of last year ACT-A called on donor countries to invest in ten times this figure, at a minimum, for COVID-19 related annual oxygen needs in LMICs. We are far from receiving even a fraction of that. To amplify the urgency and size of the need, as well as accelerate efforts to support countries, the ACT-A Oxygen Emergency Taskforce was launched in February and is coordinating with global health partners and civil society to raise awareness and funding, plan better and ensure operational readiness to act when subsequent outbreaks occur, but also with a view to implementing resilient oxygen systems. This is already in action with O2 Taskforce partners actively supporting countries to assess and cost their context-specific needs and to access available funding through the Global Fund’s C19RM process and via the World Bank’s loan mechanism. In parallel, governments need to start prioritizing oxygen as part of their COVID-19 response plans, but also for the long-term, so oxygen supply is available to those who need it.

[GHF] 3. You have said that a lack of competition in the medical gas market has increased the costs of oxygen, and has resulted in countries having to pay a premium for an essential medicine. Can you elaborate?

[RM] The market is dominated by six major companies — the lack of competition between providers drives prices higher, and prices are quite variable from country to country. Certain companies dominate markets in certain countries, and across regions. This makes it hard for governments to negotiate on price and supply, particularly during times of surging demand. It’s worth noting that medical gas is not seen as hugely profitable compared to gas for industry, which is where most of these companies’ interests lie. There is little incentive to engage and supply medical oxygen, especially when there is red tape such as local regulations which can take time and cost money.

As a Taskforce, we would like industry to be part of the solution and are actively determining which market interventions are the most appropriate, high-priority and cost-effective, so that engagement with these companies is targeted and clear. A major focus of the investments the Taskforce is calling for, will need to be directed at addressing entrenched oxygen market failures.

[GHF] 4. What should countries do domestically to prepare for demands for medical oxygen? In your assessment, why have certain countries done well on this, and why have certain countries failed on preparing for the demand for oxygen?

[RM] Countries need to follow the epidemiological data (which relies on having good testing in place — this is unfortunately not a given in many LMICs) and plan for surges, positioning oxygen supplies to meet anticipated demand, but also plan for the long-term. It’s important to have an appropriate mix of oxygen solutions in place that suits the country’s needs best.

[GHF] 5. In the context of India, how quickly can international supplies rush in to help? Have the offers of help there made a difference?

[RM] Other partners working on the ground, such as Unicef, WHO, CHAI and PATH are probably better-placed to answer this question. But as an overview — the response has been rapid and significant as reported in the media. Taskforce partners have contributed to the effort (e.g. WHO and Unicef have supplied thousands of O2 concentrators; PATH/CHAI are helping install Pressure Swing Absorption plants) and the global health community is engaging directly with the Government of India to ensure that any support meets the urgent need, and will have the intended impact. Due to the unprecedented level of demand, there are supply constraints and long lead times for certain commodities such as concentrators and pressure swing absorption (PSA) plants. The O2 Taskforce is working to improve supply conditions so that appropriate products and services can move as quickly as possible as cases continue to surge around the world. It is now crucial to collaborate with and support other at-risk countries in the regions and elsewhere with surge preparation to support LMICs through both the acute needs in the coming weeks and the more sustained needs we will inevitably see through this year and next.



  • A decision-text to kick start discussions towards a pandemic treaty is being considered by member states this week. Member states will consider establishing an intergovernmental meeting (IGM) to draft and negotiate a WHO framework convention on pandemic preparedness and response.
  • In line with timelines discussed in internal EU documents that Geneva Health Files has seen, this IGM is expected to convene its first meeting not later than the end of June 2021. According to the draft text, “meetings of the IGM shall be held either in person, virtually or in hybrid format” and shall conduct its work in accordance with Rule 86 of the WHA rules or procedure of the Health Assembly.
  • The resolution also asks the DG of WHO to convene the first meeting of the IGM, facilitate discussions and to allocate the necessary resources for the IGM to carry out its mandate.

Some excerpts from this decision-text:

“…In accordance with Rule 41 of its Rules of Procedure, to establish an Intergovernmental Meeting (IGM) open to all Member States and Associate Members to draft and negotiate a WHO framework convention on pandemic preparedness and response for consideration by the World Health Assembly under Article 19 of the WHO Constitution;

…..the IGM shall have two Co-Chairs to be nominated by the President of the World Health Assembly following a transparent consultative process and designated by the IGM, and six vice co-chairs representing each one of WHO’s regions who shall facilitate the work of the IGM in consultation with Member States.

…The IGM will submit the proposed text of the WHO framework convention on pandemic preparedness and response, through the Executive Board, to a special session of the World Health Assembly with a view to its being convened in the first quarter of 2022, for its consideration and adoption in accordance with Article 19 of the WHO Constitution…”

At the recent event on the pandemic treaty, we discussed on what this haste in undertaking these critical negotiations mean for developing countries who are still fire-fighting the pandemic and have uneven, inadequate capacities. In addition, as we have found in our reporting, the discussions have been perceived to be top-down and driven by a small number of influential member states. In addition, a variety of interest groups have their fingers in the pandemic treaty pie.

  • Sources indicated to us that a zero-draft of the pandemic treaty has already been drawn up by a few member states, raising concerns on the multilateral nature of these discussions. We have not seen this draft yet. At the event, Jaouad Mahjour, WHO Assistant Director-General Emergency Preparedness, denied that such a zero-draft of the treaty already exists. (We will be happy if we are proven wrong)

WHO, Germany launch new global hub for pandemic and epidemic intelligence: WHO

  • A key development, to be read along with the discussions on the pandemic treaty. It was made clear at the briefing where this announcement was made, that this is the way WHO is going to work now and in the future, dedicated engagements with select member states on specific issues. (Also, do keep in mind, Germany’s stance on the TRIPS waiver proposal, particularly its opposition to the Biden administration support for discussions on the waiver.)

Report of the Review Committee on the Functioning of the International Health Regulations (2005) during the COVID-19 response: WHO

A74/16 Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme

Joint Statement on transparency and data integrity International Coalition of Medicines Regulatory Authorities (ICMRA) and WHO



Vaccine diplomacy: inside Biden’s decision on Covid patents — Financial Times

  • Inside the Biden administration and the USTR: a blow by blow account.

“ “Nobody really thought Biden was going to take on the pharmaceutical lobby, [they thought] that he would be too scared,” said Brandon Barford, a partner at the Washington-based consultancy Beacon Policy Advisers. “But before the financial crisis [of 2008], everybody thought the financial services industry was untouchable, then that changed. This week showed that pharma companies are the new banks.” ….

..The president and his advisers were particularly persuaded by the diplomatic reasons to back a waiver, said those briefed on the meeting. “This is not the measure to end the pandemic,” said one person within the administration. “But it does make sense politically.”

Financial Times

Biden makes the EU look like the bad guys: Politico

G20 commits to ‘full financing’ of WHO scheme to buy COVID vaccines, drugs — draft: Reuters

Europe prepares late entry in vaccine diplomacy race: Politico

  • A bit late in the game for this perhaps. Yesterday WHO DG Tedros said: “There are three ways of engagement. One is cooperation, second is competition, and the third is confrontation or conflict. To end this pandemic, the only choice is cooperation. ‘Vaccine diplomacy’ is not cooperation. It’s actually geopolitical maneuvering.”
  • But keep in mind the EU has exported over 200 million doses for 44 countries.

“…But capitals are feeling humiliated that Russia, China and India seemed to have taken all the credit for supplying vaccines — while Europe is vilified for reserving twice as many doses as needed to immunize the whole bloc

…So now, European capitals are eyeing ways to maximize their vaccine diplomacy by sending doses to strategically important places.

Some are still open to working with COVAX, just as long as the global distribution initiative works with them to help the EU fulfill its geopolitical goals while giving unneeded doses to countries in need….

…There’s also private grumbling that lack of vocal leadership from the [European] Council is making it hard to convince national leaders to pitch in doses. Neither Council President Charles Michel nor Portugal, which holds the rotating Council presidency, have pushed for donation benchmarks. ..”


Why some researchers oppose unrestricted sharing of coronavirus genome data: Nature

  • Must read.

“Fears of inequitable data use are amplified by the fact that only 0.3% of COVID-19 vaccines have gone to low-income countries. “Imagine Africans working so hard to contribute to a database that’s used to make or update vaccines, and then we don’t get access to the vaccines,” says Christian Happi, a microbiologist at the African Centre of Excellence for Genomics of Infectious Diseases in Ede, Nigeria. “It’s very demoralizing.” “

… “ …But such caution runs contrary to the growing open-source movement. As of 4 May, an online letter calling for researchers to put genome sequences in the public domain was signed by 778 scientists at universities and pharmaceutical companies — 99% of them based in Europe, the United States and Canada. Rolf Apweiler, the co-director of the group that posted the letter in late January, the European Bioinformatics Institute near Cambridge, UK, tells Nature, “Sequencing is not for enriching the career of individual researchers, but for fighting a pandemic.”


What would a WTO intellectual property waiver on Covid-19 vaccines mean for India?

  • A slew of suggestions for the Indian government:

“India needs to walk the talk…

1. India hasn’t implemented the TRIPS flexibilities and Doha Declaration, despite having intellectual property rights laws that empower it. Section 92 (compulsory licensing) and Section 100 (using patented inventions for government purposes) in the Patents Act, provide these flexibilities that the Union government seems too meek to utilise even during a pandemic. This was specifically noticed by the Supreme Court in its recent order in the suo motu matter on the Covid-19 situation in the country, as well as the Delhi High Court.”

Is the Shine Starting to Come Off Bill Gates’s Halo? The Nation

  • If you have to read one story this week, this is it.

“Buried in CureVac’s SEC filings is an agreement between the Gates Foundation, CureVac, and GlaxoSmithKline (GSK), noting, “Subject to the other terms of this agreement, BMGF hereby releases CureVac of any and all Global Access Commitments” concerning the use of the company’s “mRNA technology platform” in developing one or more vaccines that are redacted. “

The Nation

India and Its Vaccine Maker Stumble Over Their Pandemic Promises: New York Times

“Serum won Mr. Modi’s favor in part because it fit the government’s narrative of a self-reliant India that was ready to take its place among the world’s major powers. Now both Mr. Modi’s government and Serum have been humbled, and their ambitions are being called into question.”

New York Times

Why Joe Biden Punched Big Pharma in the Nose Over Covid Vaccines: BIG by Matt Stoller on Substack

  • “It’s a signal that the American order is changing.” A must-read. (He says: “As an aside, I worked on the Hill for six years, and USTR was always the center of corporate power in government. For USTR to go against pharma is truly the world turned upside down.”)

“So making sure we have a global vaccination campaign looks like a logistical challenge, but also a necessary one. That said, there’s a fly in the ointment, a ghoulish incentive at work for Pfizer, BioNTech, and Moderna.

….The ghoulish part, however, is why there will need to be annual boosters. It’s not because the vaccine strength wanes over time, though that might happen. It’s because, as D’Amelio told Wall Street, there will be new variants emerging from abroad that can evade the vaccine. And how will variants emerge abroad? Well as outbreaks occur in non-vaccinated parts of the world, new strains will naturally occur as the virus mutates. If the rest of the world gets vaccinated, however, new variants won’t arise. ..”

Matt Stoller on BIG


“The Institute for Health Metrics and Evaluation estimates that India will see a staggering 1 million deaths from COVID-19 by Aug 1. If that outcome were to happen, Modi’s Government would be responsible for presiding over a self-inflicted national catastrophe. India squandered its early successes in controlling COVID-19. Until April, the government’s COVID-19 taskforce had not met in months. The consequences of that decision are clear before us, and India must now restructure its response while the crisis rages. The success of that effort will depend on the government owning up to its mistakes, providing responsible leadership and transparency, and implementing a public health response that has science at its heart.”

The Lancet

The covid-19 vaccine patent waiver: a crucial step towards a “people’s vaccine”: BMJ

“An IP waiver would allow other producers to step in and make raw materials for export for all the current vaccines, industrial parts, and components. It would also simplify agreements for eventual production of more doses. But an IP waiver alone will not solve the covid-19 vaccine access challenge. Two further steps will need to be taken to reach a people’s vaccine. Step two is a transfer of technical know-how from vaccine makers in the global north to regional hubs or directly to manufacturers in the global south. Step three is vast subsidization of manufacturing in LICs and LMICs.”




Obituary: Heesob Nam

Tributes to Heesob Nam (1966–2021), South Korean IP activist


How inclusive are the discussions on the pandemic treaty? All countries would benefit from knowing more about the experts in this group:

Calling out protectionist trade approaches:

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