External Affairs

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

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 election.

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 strategies.

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 health.

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@gmail.com