The splintering of the centre of global health

Geneva Health Files
8 min readJan 7, 2021

Originally published on November 12th, 2020 on Geneva Health Files


The World Health Assembly draws all member states of World Health Organization to discuss health challenges, review actions, debate proposals and set future goals. It entrusts the secretariat to consult and engage with countries and other actors to coordinate vast areas of global health policy. This complex mechanism, some say, is now under threat. In this story, we will see why process matters and how it eventually impacts member states participation during the worst health emergency in a century.

In addition, concomitant developments this week, dominated global health agenda. This crowded out the Assembly. Events that unfolded outside of the multilateral governance framework are likely to have lasting ramifications on the future of global health governance.

This week, the Paris Peace Forum not only raised funds for the global pandemic response, it was significant in solidifying the roles of key donors of the ACT Accelerator and appeared to be a de facto declaration of formalizing this mechanism.

In addition, this week also saw the first steps towards the European Health Union which envisions among others, “declaration of an EU emergency situation”. It problematically raises questions on the trust that WHO commands in the midst of the pandemic.


The resumed session of the 73rd World Health Assembly is underway. Notwithstanding the virtual nature of the meeting, that has undoubtedly contributed to inadequate transparency and engagement, there are more fundamental issues at stake than merely the process of consultation.

Last month members of the Executive Board lamented the lack of a global multilateral mechanisms to guide the response to the pandemic. This was reiterated by Austria’s Clemens Martin Auer at a recent event. This week member states continued to push for the need for more multilateral engagement. But some observers point out, that without a specific framework for consultations, this is not useful.

To understand the significance of this assembly in the context of the flux of changes in global health, Geneva Health Files spoke to an experienced observer who has long worked with a range of countries on health matters. The expert chose to be anonymous.

“It not merely consulting member states, or informing countries about decisions on the response to the pandemic. But the secretariat has to essentially seek approval from member states on many of these matters,” a source who works closely with many health missions in Geneva said. Increasingly, there is insufficient time for more strategic thinking and preparation for key meetings, some countries are understood to have said.

In the context of the response to the pandemic, there is a perception that while they are being consulted to an extent, some of their questions and demands do not find representation in forums outside of WHO, including at Gavi’s vaccines initiatives for the pandemic — the COVAX facility, for example. A lot of the decisions are made outside of WHO and then it is a “fait accompli”, countries have to take it or leave it, the source said.

“Consultation with countries should go beyond moral rhetorical support”, the source said.

Given the prolonged nature of the pandemic, consultations on key issues have been inadequate. Countries have to be alerted on many matters, that they would otherwise have been involved with, if it were not for the crisis.

“The Assembly now risks being reduced to a ‘rubber-stamp’ simply endorsing whatever is brought to it. Ideally, countries must take charge and instruct WHO,” the source who did not wish to be named said.

Given the urgency of the pandemic, no country wishes to be seen as being too critical of WHO efforts, or risk being seen as too “obstructionist” and hence reserve their discomfort with the ACT Accelerator mechanisms. (To be sure, at the Assembly, a number of countries expressed support to ACT Accelerator mechanisms while pushing for more involvement in the decisions. Some say, many low and middle income countries have no choice. The ACT Accelerator was given a carte blanche but it has not yet delivered as per expectations, not the least because of acute financing shortfalls.)

To an extent, member states are to be blamed for letting the pandemic response “to drift out of WHO,” as one observer said, also pointing to the composition of the Executive Board. Experts such as Ilona Kickbusch have said that countries in the global south have not effectively used their political power although they are a part of the Executive Board.

Countries must urge WHO to use its constitutional powers, one expert said. And some countries such as Kenya, for example, have said so.

“Nothing stops WHO from using its constitutional mandate to take the difficult decisions on access issues. Instead, it has simply tasked the Medicines Patents Pool to get the COVID-19 Technology Access Pool to work. And that has been a non-starter”, the source said. WHO sees C-TAP as a medium to long term solution and not an immediate one, as also reiterated by top officials at the Assembly this week.

There have been instances in the past where external actors have assumed charge on critical issues within WHO including for example work on substandard and falsified medicines. It then took a lot of effort by member states to steer it back into the multilateral framework, the source recounted.

Countries such as Zimbabwe have cautioned against relying too much on the private sector and raised questions on risks of conflicts of interest, in a statement during this Assembly.

Similarly, the discussions on reforms have been overwhelmingly framed by Northern interests, aligning heavily towards global health security. So far, many developing countries have not put their visions on what WHO reforms should look like. Any discussions on reforms will be carried out in the way it has already been framed.

Even as there were calls for solidarity during the Assembly, when it came to discussing questions on access, the divide continued among WHO member states. Many countries said equitable access to medical products were important, even as they expressed reservations on South Africa and India’s TRIPS Waiver proposal at the WTO.

“Solidarity is not fairness”, the source said.

“We see funds donated by high income countries and other actors, but this results in low and middle income countries not asking questions on access, which is a legitimate right irrespective of solidarity. You may have a seat at the table, but it does not mean you are equal partners. But in a pandemic everyone is affected,” the person said. (The source cited the example of the R&D Observatory, seen by many as a quid pro quo tool to avoid discussions on a binding R&D treaty)

“When the pandemic will be over in Europe and North America, it does not mean it will be over everywhere”, the source said.

Presenting to the Assembly, Bruce Aylward, of WHO, responsible for coordination of the ACT Accelerator, highlighted the differential level of access across countries, which he said should be solved by political and financial will.

Image Credit: ACT Accelerator Investment Case November 2020 [Urgent Priorities & Financing Requirements at 10 November 2020]


Countries have relied on the ACT Accelerator to deliver COVID-19 medical products. Yet, the mechanism faces critical shortfall more than eight months into the pandemic.

This week WHO published a new investment case for the ACT Accelerator underscoring an immediate need of US$ 4.579 billion. WHO says “Urgent ACT-Accelerator financing needs for near-term deliverables is US$ 4.579 million to support priority clinical trials and product assessments, the scale-up of production capacities, product procurement, and crucial country readiness and delivery activities”

But in fact, the need is bigger. In a report on the recent meeting of Facilitation Council of the ACT Accelerator, Development Today said, “… the original ask will be increased by USD 10 billion to support weak health systems in developing countries.” (The total ask for the ACT-A is now pegged to be nearly $48 billion. (For full story read: “COVID19 support scheme faces massive funding crisis, calls for USD 10b more to prevent collapse of health systems”))

It also reported that there recognition that “The focus in ACT-A has been skewed in favour of procuring products, especially vaccines, with much less attention on the weakness of health systems in developing countries. Without addressing this, the overwhelming attention on COVID19 could cripple these systems.”

Development Today

Although nearly $10 billion has been pledged to the Accelerator, only a part has actually been disbursed. (Our source raised the question of donor countries taking control of the governance of the ACT Accelerator mechanisms without fully translating the pledges into funds to finance pandemic response globally).

As this story went to print, The Paris Peace Forum was expected to raise $500 million from France, Spain, the UK, the Gates Foundation and others towards the ACT Accelerator.

As important as raising funds for the pandemic response, the Forum was significant in driving home the message that donors to the ACT Accelerator, including the Bill & Melinda Gates Foundation, are of the view that the structures and mechanisms must continue.

It may be safe to assume that this multi-stakeholder arrangement of the ACT Accelerator is here to stay — an important take-away from the Paris Peace Forum, reminiscent of European Commission’s pledging event in May 2020.


WHO’s financing woes have had an impact on a range of matters from emergencies to staff capacities. But it has continued to hold on its crucial leadership on normative functions, crucial for all countries, especially for low and middle income countries.

For now, it seems the EU, although a supporter of WHO reforms, has chosen to make its own rules when it comes to addressing health challenges. This week saw a bold declaration by the European Commission towards a European Health Union. (See Politico’s Commission fires first shots in battle for more health power)

“According to Health Commissioner Stella Kyriakides, who presented details of what the Commission envisions by a “European Health Union,” the EU would be able to declare its own health emergencies independent of the World Health Organization; create EU-wide pandemic preparedness plans; develop a new agency for health emergencies; require countries to submit more health data (for example, hospital bed availability and critical-care capacity); allow the EU’s infectious disease agency to actually make policy recommendations to member countries; and task the EU’s medicines agency with managing shortages of medicines and medical devices.”

Politico, 11.11.20

The commission outlined its approach for dealing with cross-border threats in a report, “Building a European Health Union: Reinforcing the EU’s resilience for cross-border health threats”. The commission has proposed a new regulation on serious cross-border threats to health. It aims to strengthen preparedness, reinforce surveillance, improve data reporting and declare an EU emergency situation in order to trigger “increased coordination and allow for the development, stockpiling and procurement of crisis relevant products”, the commission has said.

What this means for EU member states in terms of letting the Commission decide their health agenda, is less clear. But the message for WHO is unequivocally clear.

Subscribe to the Geneva Health Files newsletter:

Write to us: or

Follow us on Twitter: @filesgeneva & @pretpat



Geneva Health Files

A newsletter from the capital of global health, reporting on politics, policies and power.