[Ip-health] The Wire: From Financing to Divergent Interests, a Spectrum of Challenges Await the Next WHO Chief

Thiru Balasubramaniam thiru at keionline.org
Tue Jun 13 04:35:50 PDT 2017



>From Financing to Divergent Interests, a Spectrum of Challenges Await the
Next WHO Chief


The 70th World Health Assembly saw the election of a new leader, a strong
resolution on battling cancer and unexpected coalitions around access to
medicines, among others.

Tedros Adhanom Ghebreyesus takes over as WHO director general on July 1.
Credit: Reuters

Geneva, Switzerland: The momentous 70th World Health Assembly (WHA), the
annual meeting of all the member states of the WHO, which took place from
May 22-31, elected a new leader and cruised through 80 items on its agenda
with more than 3,500 delegates in attendance. The WHO, with 194 countries
as members, is the UN agency responsible for setting global health policy.

Unprecedented in its nearly seven decades of existence, the WHO elected its
first ever director general (DG) from Africa, Tedros Adhanom Ghebreyesus of
Ethiopia, who won by 133 votes in a final round of an election, winning
easily against David Nabarro of the UK and Sania Nishtar of Pakistan. In
its previous report on the elections, The Wire discussed the new process
that included most member states of the WHO (186 this year), who voted in a
secret ballot to elect the leader during three rounds of elections in the
final vote. (Unlike the practice hitherto, where only a 34-member Executive
Board would have a say in the elections, now all 194 member states get to
vote. A few countries were ineligible to vote this year because of
non-payment of dues to the WHO.) Allegations of human rights violations and
questions on the response to outbreaks in Ethiopia did not affect his

The new DG-elect Tedros takes over from Margaret Chan in a few weeks, on
July 1. Chan steps down after ten eventful years at the helm of the
organisation, a difficult period that saw a range of outbreaks, weakening
finances, contemporaneous developments including changing dynamics in the
governance of global health due to the rise of private actors and the
emergence of competing forums.

Apart from the historic election, the assembly addressed wide-ranging
matters of global health, such as a resolution on aiming to improve cancer
prevention and treatment, and endorsing evidence-based policymaking,
including suggestions for taxation to reduce sugar consumption to fight
non-communicable diseases. There were several competing side events in
addition to a full agenda of proceedings at the assembly.

In the twilight period of this transition, before the new DG-elect takes
office, the events at the WHA were a reminder that governing public health
is strewn with difficult choices and challenges which the new leader of the
WHO has to negotiate.

This WHA wrapper will take a look at some of the immediate challenges
facing the new DG-elect and highlight only few of the many substantive
issues taken up at the assembly. The Wire spoke to a cross section of
representatives from delegations of several countries, apart from experts
and commentators, who had gathered for over a week in Geneva.

What’s in store for the new DG-elect

It is indisputable that for the first of such a broad-based election,
Tedros (he has clarified that he is usually known by his first name) comes
into office with unparalleled political support and capital. A doctorate in
community health, Tedros has been a former minister for both health and
foreign affairs in Ethiopia. He also brings to the WHO experience from his
previous stints at The Global Fund to Fight for AIDS, Tuberculosis and
Malaria, and the immunisation agency GAVI. He is the first non-medical
doctor to lead an organisation full of doctors and epidemiologists, among
other technical specialists. He is widely recognised for his practitioner’s
approach to public health. As he gets ready to assume office, there are
strong expectations that he must become a global leader and not just a
leader for African countries.

One early indicator of his commitment to challenge the status quo and push
member states into action will be demonstrated by the kind of cabinet he
will appoint and the people he will surround himself with, former WHO
officials familiar with its governance said. In the days since the
election, Tedros is being seen as someone serious and committed, not the
least because he is listening and talking to experts and making notes,
insiders say.

Pushing for universal health coverage (UHC) has been the cornerstone of his
campaign – an objective many member states, including India with its
budgetary cuts to public health, will benefit from. All roads lead to UHC,
he has said.

The financing of the WHO is one of the most critical and immediate
challenges Tedros faces. The assembly approved a budget of $4.4 billion for
2018-2019 that the new DG must first raise to continue to fund various
programmes at the WHO.

The organisation’s programme budget is serviced by both assessed and
voluntary contributions. More than 80% of the total funding comes in the
form of voluntary contributions that are earmarked for spending, making it
is less flexible for the WHO to respond in emergencies. Some countries will
push against the earmarking of funds, one delegate said.

It will be a priority for the new DG to increase the current 20% of overall
funding which is not earmarked to pursue legitimate policy objectives in a
nimble manner. There will be calls for increase in assessed contributions.
During the assembly, countries responded with only a 3% increase in such
contributions as against a 10% increase sought by Chan. (Assessed
contributions are calculated relative to the country’s wealth and
population, and such contributions are the dues countries pay in order to
be a member of the organisation.)

Countries want WHO to do more, not less even as the finances of the WHO are
under pressure. From ably responding to emergencies servicing (servicing an
expanding agenda on global health security), continuing to set norms for
health including setting standards and vetting drugs to even shaping
policies on sharing genetic resources of viruses, there is much the WHO is
expected to do.

The organisation’s overt dependence on three major donors – the US, UK and
the Bill and Melinda Gates Foundation – makes it less flexible. This is
further complicated in the context of uncertain funding from the US, which
accounted for more than 30% of the total voluntary contributions to the WHO
among member states in 2016. But observers are hopeful and say that Tedros
has enough leeway with the US to be able to ensure adequate funding.

Not everyone is worried about the impact of a reduced contribution from the
US. “We are talking of about $420 million a year if the US pulls out
completely, which they won’t. Reductions in voluntary contributions for
areas like sexual and reproductive rights are more likely. I think other
countries will step up. It is not about the money, but about the political
leverage that a country can get by investing in the WHO,” Mathias Bonk, an
independent global health expert and former WHO consultant from Germany,
told The Wire during the assembly. Germany and Norway are willing to step
up funding if needed, sources indicated.

Nevertheless, much is at stake. To understand how precarious the financing
situation is, take the case of polio, some commentators have pointed out.
Even as there is much optimism as the disease nears eradication, drying up
of funds for polio, stakeholders fear, will affect other health services
including salaries for personnel that piggyback on the existing financing
and infrastructure.

These are the kinds of immediate challenges Tedros is stepping into.

A contentious report shelved for now

The diverse interests inherent at the WHO – another dilemma that Tedros
faces – were best exemplified by the unravelling of discussions around the
shortage of medicines during the assembly.

Ensuring access and cheaper medicines are only one of the highly political
challenges that the organisation faces. High drug prices have become a
reality world over and the outcry has gained a life of its own. The issue
will not go away anytime soon. It appears that it has transcended
passionate calls from only civil society organisations. Unaffordable
medicines have slipped into mainstream political discussions including at
the US elections last year. It has consistently gained attention within the
EU in countries including Austria and the Netherlands. Voters in developed
countries might begin to compel their governments to deliver on bringing
drug prices down, experts say.

And yet, there is tension between efforts to engage in discussions to find
ways to lower drug prices and those that seek to ensure higher protection
for pharmaceutical companies. This tension is obvious in institutions such
as the WHO that has as its members from both countries in the North, home
to the biggest pharmaceutical companies, and the developing countries with
larger disease burdens and poor access to health services and medicines.

Alongside WHO processes on the matter, former UN Secretary General Ban
Ki-Moon in 2015 commissioned a report and set up a panel  to review
proposals and make recommendations to address “the policy incoherence”
between rights holders, international human rights law, trade rules and
public health. The UN high level panel report on access to medicines was
released in 2016 and made recommendations as per its mandate. As reported
earlier, the US has repeatedly called the report flawed and criticised the
mandate of the panel. However, countries including India, Brazil and others
pushed for the report to be discussed in forums including the WHO, WTO and
the UN Human Rights Council. (One of the recommendations of the report
calls for governments to “refrain from explicit or implicit threats,
tactics or strategies that undermine the right of WTO Members to use TRIPS
[Trade Related Intellectual Property Rights] flexibilities.”)

At the assembly, countries were hoping to discuss the report under an item
called addressing the global shortage of, and access to, medicines and
vaccines. However, no sooner than the item was up for discussion, India
made an unexpected announcement to hold informal consultations on the
matter with the US, in order to “find consensual language on shortage,
access to medicines”. This was met with surprise and raised brows. Brazil
supported the informal consultations, even as countries such as Canada,
South Africa and Switzerland, among others, sought answers on issues of
transparency and governance in such a process. (Norway, for example, wanted
to know if a text would emerge out of the informal consultations.) The
optics of India and Brazil aligning with the US, especially on access to
medicines, was unusual to say the least.

The outcome of these informal discussions resulted in the adoption of a
proposal brought by India, supported by the US, to discuss access to
medicines as an agenda item at the WHO Executive Board meeting in January
2018. A number of countries supported this and called for discussions ahead
of the next Executive Board meeting.

It was difficult to confirm for certain what followed, but it seemed that
the US had been successful in deferring a discussion on a report it did not
like. There was no response to an email sent to the US mission in Geneva.
It remains unclear to what extent discussions on this report can be revived
in the future.

Several unconfirmed reports allege that India was asked to go slow on
pushing the ‘contentious’ report during a bilateral meeting with the US
earlier that week. The Indian delegation denied this. “The aim will be to
build consensus on the access to medicines with other member states, ahead
of the Executive Board in January 2018. There is no change in our position
on this,” C.K. Mishra, health secretary, government of India told The Wire
on the sidelines of the assembly. In its statement, India called for
greater mutual cooperation and said, “We cannot permit the advantage that
could be ours being frittered away by going solo.”

It appears that the picture is more complicated than only “bilateral
pressure” from the US. It seems that some developing countries wish to walk
around this ‘no-go’ that the US has insisted on with respect to the report,
but would like to take forward the discussions on access to medicines
further. There is recognition that there needs to be another strategy to
draw the US into discussions on access, outside of this report. (“No point
banging on a closed door,” said one delegate.) In addition, efforts will be
made to push for some of the recommendations of the report, albeit in a
different form, some developing countries delegates told The Wire.
Understandably, delegates did not wish to share future negotiation

A source also mentioned a desire on both sides to avoid confrontation and
explore the space for an informal dialogue. While the stance of the Donald
Trump administration with respect to access to medicines is not entirely
clear, it seems that there could be spaces for negotiation opening up on
these issues, a source said. “Some good people have been put in charge of
health in the US. This shows the administration is serious,” he added.

Irrespective of whatever strategy is employed in the future, for now it
appears that the US got what it wanted – to reign in any discussion of the
UN report on access to medicines at the WHO. Efforts by South Africa to
push for a “standing item” on the UN report were left with little support
from other member states and Chan. The report will now be discussed under
the broader item on shortage of and access to medicines at the next
Executive Board meeting.

A standing item is usually an item that is always included in the agenda of
the body concerned. This requires a decision by the Assembly that a
particular item shall be henceforth included in the provisional agenda of
future health assemblies until and unless a future WHA decides otherwise, a
health law expert in Geneva told The Wire. The US was not in favour of a
standing item on the UN report.

India supplies 60% of the vaccines globally and 55% of the drugs produced
in the country are exported, and is thus seen as the natural leader of the
south. “India’s voice has often been muted by its reluctance to be seen as
squarely opposing the US and other Northern countries. Increasingly, Indian
negotiators seem to have their hands tied by signals from Delhi not to push
beyond a point in challenging the agenda of Northern countries. The coming
days will perhaps provide an indication if India would work to build the
solidarity of the South or continue to play an ambiguous role,” Amit
Sengupta, associate global coordinator, People’s Health Movement, a global
network of grassroots health activists, civil society organisations and
academic institutions, told The Wire.

While some countries have long feared a fragmentation in the coalition of
developing countries who come together to push for greater and cheaper
access to medicines, new support may be coming from other quarters,
including developed countries such as The Netherlands, Norway, Canada and
Austria among others based on their public statements on high prices of
drugs. (In a related development, member states came together to reject
“value-based” pricing on medicines, during the fair-pricing event also held
last month in The Netherlands.)

The above is just one example of the politics that confronts the new
DG-elect. Some countries are hopeful given the willingness Tedros showed in
examining the recommendations made in the UN report, during the first
interaction with the press he had in the morning after his election. “I
think access to drugs should be a very important component of addressing
universal health coverage,” he had said. To what extent he will take up
this issue remains to be seen, given some perceptions that the WHO
secretariat is not always nonpartisan.

Some key resolutions at the WHA

Resolution on cancer prevention and treatment

A significant resolution to fight cancer was adopted by the assembly to
address prevention, diagnostics and care, in addition to a call for
implementing commitments at national levels. Among a host of other tasks,
the WHO has also been asked work on a report examining issues of pricing,
transparency, access and affordability of drugs for the prevention and
treatment of cancer.

The disagreements on the language of intellectual property-related issues
were already done away with from the draft text of this resolution.
Specifically, the language on delinking the cost of research and
development from prices of cancer drugs was removed. Efforts to push for
feasibility studies to delink R&D costs from drug prices to examine
alternatives for high drug prices were not successful.

In a letter ahead of the assembly, economists, public health advocates and
civil society organisations had pointed out that new cancer medicines
approved by the US FDA from 2010 to 2016 were not included in the WHO Model
List of Essential Medicines. “..Many are rationed or not reimbursed even in
high income countries, because of the price,” the letter had said.

At a side event on the cancer resolution, Ellen t’Hoen, a medicines law and
policy scholar gave an example of imatinib, a cancer drug that has a cost
of production between $119-159, but a market price between $30,000 and
$100,000 annually.

Despite the weaker language, it is largely agreed that there was now
“enough mandate” in the resolution for the WHO to work on improving
affordability and accessibility of drugs. “We see the resolution on the
prevention and treatment of cancer, as an opening for a wider push for
access to medicines at the WHO. In the past, a lot more has been achieved
with relatively less ambitious resolutions. For this to succeed though,
national capitals must own it and undertake feasibility studies on
delinkage,” James Love from Knowledge Ecology International said during an
interview at the assembly.

Taxation as ammunition to fight non-communicable diseases

Another issue closely watched, among others, was the discussion around
non-communicable diseases (NCDs). These diseases, of which cancer is one,
accounted for 70% of deaths globally in 2015. Worryingly, low and middle
income countries account for 75% of these deaths. But fighting these
diseases in the larger interest of public health is running counter to
strong commercial interests.

Main risk factors contributing to NCDs include unhealthy diets, alcohol and
tobacco use, physical inactivity and environmental determinants such as air
pollution. Such factors are caused by what have been called “commercial
determinants of health”, that scholars have defined as “strategies and
approaches used by the private sector to promote products and choices that
are detrimental to health”.

Last week, the assembly “endorsed” a set of policy options based on latest
evidence so that countries could tailor their efforts to prevent and
control these diseases. But this was not without resistance – from the US
and Italy. The US merely “noted” and did not endorse the document. These
efforts sought to rectify “misaligned public policies” in agriculture,
commerce, education, energy, health, finance, trade and social security.

This has also to be seen in preparation for a high-level meeting at the UN
General Assembly in 2018. Countries had earlier committed to achieve a 25%
reduction in premature mortality from NCDs by 2025. The NCDs programme in
the WHO continues to be underfunded.

Policy-speak at the WHO is an alphabet soup of acronyms and
cryptic-sounding documents. In question, at the assembly is a technical
document referred to as ‘Appendix III’ which is a helpful primer of sorts
containing evidence-based policy options and cost-effective interventions
for countries to map their own plans and policies to fight NCDs.

Since 2013, this primer has been updated in order to keep up with the
evolution of scientific evidence and cost-effectiveness of interventions,
as an advocate from NCD Alliance explains here. Of the slew of evidence,
the taxation of sugar-sweetened beverages to prevent overweight and
obesity, tax rate increases for tobacco products and a reduction in salt
intake are some of the suggestions among a total of 16 such “best-buys” or
interventions that are aimed at addressing risks contributing to NCDs.

There were protracted discussions where the US argued that taxation matters
were sovereign and therefore did not endorse the measures. The US said that
it would “disassociate from the operative paragraph I (OPI) of the adopted
NCD resolution which endorsed Appendix III”. But a majority of the
countries accepted and endorsed the documents, which activists have hailed
as victory.

In her last speech as DG at the WHA, Chan said “Scientific evidence is the
bedrock of policy. Protect it. No one knows whether evidence will retain
its persuasive power in what many now describe as a post-truth world.”

Going into his first term at the WHO, the next DG has also to restore the
relevance of the institution. Many believe that global health has outgrown
the WHO, and the organisation needs more economists and other specialists
and not only doctors to deal with issues of trade, intellectual property
and services.

WHO risks losing leadership in an area where other forums including the WTO
or others such as the G20 assume importance in setting the agenda for

For example, next week, Brazil, China, Fiji, India and South Africa have
sought discussions on ‘Intellectual Property and the Public Interest’ at
the TRIPS Council meeting at the WTO, to discuss compulsory licensing of
drugs and other related issues in the first of a series. This also shows
that the WHO may not be the only forum where some of these critical issues
will be taken up.

Though there is cynicism on expanding the private sector’s role in
financing and governance of the WHO, member states do look up to this
public institution for guidance and believe in the primacy of the WHO to
decide on health issues.

Priti Patnaik is a Geneva-based journalist and researcher. She has
previously worked as a consultant in the UN system including at the WHO.
She can be reached at patnaik.reporting at gmail.com

Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International
41 22 791 6727
thiru at keionline.org

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