Heavy agenda for looming World Health Assembly as Covid still dominates

Tedros Adhanom Ghebreyesus, director general of the World Health Organization (WHO) delivers his statement, during the first day of the 72nd World Health Assembly, May 2019. (KEYSTONE/Salvatore Di Nolfi)

Conquering the Covid-19 pandemic will inevitably be the main topic of discussion at the impending 74th session of the World Health Assembly. Global health experts weigh in on what to expect and what should be prioritised at the upcoming event.

The World Health Organization’s (WHO) annual ministerial assembly will open online on Monday, with health delegates from its 194 member states tasked with wading through a heavy agenda dominated by how to fix the Covid-ridden health system and step up the global response to future crises.

“It is time to elevate the threat of pandemics at the level of other existential threats such as nuclear accidents,” Dr Joanne Liu, former International president of Médecins Sans Frontières (MSF) and a member of the Independent Panel for Pandemic and Preparedness Response (IPPR) told Geneva Solutions.

“This is why we call it a ‘Chernobyl moment in the 21st century’. If we want to move fast and in a sustainable way this scale up is necessary.” The findings of the independent review panel, set up by the WHO to examine the international Covid-19 response and published last week, will be at centre of discussions next week.

What is the WHA and why is it important? As the decision-making body of the World Health Organization (WHO), the annual WHA meet-up gives member states the opportunity to chime in on the WHO’s policy direction, governance, budget spending and health priorities.

Starting on Monday, the eight-day assembly, while officially hosted in Geneva, will take place online for the second year in a row, bringing together 194 member states who aim to tackle a range of health issues from antimicrobial resistance to non-communicable diseases. In total, over 2,750 people have registered to the event including civil society organisations.

Exhibiting the largest agenda ever, with over 72 items, global health experts shed light on areas that they expect will dominate this 74th session.

Pushing for legally binding instruments. Hot on the agenda are talks for a “pandemic treaty” or convention to better prevent, prepare and respond to infectious disease outbreaks. First floated by the European Council’s president Charles Michel in November, the idea has so far been backed by 25 countries, including the WHO, however some of the major powers including the US and China have yet to commit.

The organisation’s treaty-making powers have only been used once in its history to create the Framework Convention on Tobacco Control (FCTC), and is one of three decision-making tools the WHA has at its disposal, including its recommendation powers used the majority of the time, and its regulation tool that formed the basis of the International Health Regulations.

Speaking at a press briefing on Wednesday, Steven Solomon, principal legal officer at the WHO said: “What's so interesting about this upcoming World Health Assembly is that all three tools will be considered for possible needs in response to the pandemic.”

Read also: World leaders back treaty idea for future pandemics

Although the intricacies of the treaty are yet to be discussed, Dr Antoine Flahault, director of the University of Geneva’s Institute for global health, told Geneva Solutions a pandemic treaty should guarantee the power of investigation from an early stage.

“With Covid, it would have been useful to have a pandemic preparedness treaty to allow full, independent, rapid investigation into the inception of the pandemic. As we have seen in the China example and the investigation in Wuhan, we missed the chance to scrutinise the origins of the pandemic early on, which has potentially devastating effects,” said Flahault.

Bearing this in mind, when convening a Public Health Emergency of International Concern (PHEIC), the formal declaration by WHO of “an extraordinary event which is determined to constitute a public health risk to other states through the international spread of disease”, the pandemic should be treated in a similar way to the treaty on the non-proliferation of nuclear weapons or World Trade Organizations directives, “giving it the same level of power and impact, so that when violated sanctions are imposed,” he added.

In Liu’s opinion this should go beyond agreeing on rules, and would instead like to see more “action and accountability”.

Cementing the power of the WHO to fight off future health crises and eradicate current pandemic. At an informal level, countries have been working amongst themselves to agree on strengthening the WHO preparedness and response to health emergencies, and it is hoped these recommendations will be made at the WHA, according to Solomon.

In the recent report by The Independent Panel, co-chaired by the former prime minister of New Zealand, Helen Clark, and former president of Liberia, Ellen Johnson Sirleaf,  weak links were found in both preparedness and response - including a broken global emergency alert system, a hesitant WHO and patchy country responses.  Lessons from previous pandemics were not incorporated either, the panel found, citing for example, the 2009 H1N1 influenza response.

Read also: WHO independent panel slams slow Covid-19 response

Along with supporting a Pandemic Treaty, as a way to make pandemic responses a higher political priority backed by a stronger legal mandate, the Independent Panel also urged that WHA member states push for the creation of a Global Health Threats Council, with plans to put the idea forward at the United Nations General Assembly (UNGA) in September.

“By having this at the highest level it gives it the attention it deserves. We want it at the UNGA after discussion at the WHA, giving heads of states and governments the opportunity to take up ownership it needs,” said Liu.

WHO's Political Independence. In order for the WHO to flourish and have the appropriate means to address the current and future pandemics, the global health experts also believe the political independence of the WHO also needs to be discussed frankly as a top priority at the WHA.

This includes a recommendation by the Independent Panel that member states limit the WHO director general’s tenure to just one term of no more than seven years - as compared to the system today, whereby he can hold office for up to two, five year terms.

The hope is that this would shield the WHO chief from political pressures during his tenure - and from pressures to collude with certain member states in order to secure re-election for a second term.

Instead of a seven-year non-renewable-term, Flahault, however, advocates for a five-year non-renewable term. Still, the main message of independence and autonomy remains the same.

Governance and funding without strings attached. When it comes to coughing up the cash it seems member states have stayed put on increasing their contributions. Philanthropic actors such as the Bill and Melinda Gates Foundation have filled the void by becoming major funders of global health and the WHO, which has been met with large criticism by member states for having too much influence.

However, both Flahault and Liu say the blame should be shifted from philanthropies for doing the job of countries. Shockingly, “the total WHO budget for example is hardly above the budget of most teaching hospitals in high income countries, such as University of Geneva Hospital,” explained Flahault.

Read also: Bill Gates is ready to spend more on global health - governments should too, says foundation official

The WHO should be robust and agile enough to respond to and anticipate health crises. As such the question of reform including its governance structures often looms.

But for Flahault this takes up both a lot of energy and time, as “nobody is happy when the next crisis comes and calls for reform”. The focus should be on giving the WHO the mandate to coordinate and lead on health matters, Flahault added.

The question of vaccine equity. “One of the priorities of the WHA to be discussed with urgency is  the production of vaccines, technology transfer and patent waivers,”  Flahault also said.

While the final decisions over an intellectual property waiver on Covid vaccines and other health products would be made in the World Trade Organization, WHA statements and discussions will also have an influence.

The WHA debate will also come on the heels of a critical Global Health Summit of the Group of 20 (G-20). Outcomes of Friday’s G-20 meeting, hosted by the Italian government and the European Commission, will also set the texture of high-income country positions in the WHA proceedings.

A draft G-20 “Rome Declaration” seen by Health Policy Watch,  makes no mention of the proposed IP waiver - referring only to the potential for “voluntary… technology transfer and licensing partnerships”.  And although the leaders of the G-20 will also affirm their support for the WHO and the Gavi vaccine alliance co-sponsored ACT Accelerator initiative, which aims to hasten the distribution of Covid-19 vaccines, drugs and tests across the world, they fall short of clearly committing desperately needed funding to it.

A weak G-20 commitment would be a blow to the WHO-backed scheme, said Flauhault, adding that if there was sufficient political will, the US and its allies could potentially vaccinate the whole planet.

“It would cost about 27 billions of dollars to immunise the world population, which is affordable. A country like the US, which I am not saying should vaccinate the world, could however do so if it wanted to. If not high income countries should invest in doing so as soon as possible,” Flahault said.

At the same time, this year’s WHA will see solid support from the United States, following the change in administration - and Washington is expected to be a big player in the proceedings.

Read also: Fauci signals new chapter in US relations with the WHO

“The US body-language is quite important because they have recently been a big defender for multilateralism,” said Liu.

“These are good signals for global health and particularly during the pandemic.  They are pushing back on the waivers of patents, and should also really consider funding the Covax equitable vaccine sharing scheme,”  Flahault added.

Covid will become a pandemic of the poor if neglected now. In the absence of strong action by wealthy donor countries at the G-20 and the WHA, the trajectory of Covid risks the disease becoming a “pandemic of the poor”, Liu warns.

For Liu, if the opportunity is not seized at this year’s WHA to adequately address the pandemic by taking bold decisions and committing to actions then she believes Covid will become an endemic disease, mostly limited to low and middle income countries, whilst high income countries leave the rest of the world behind.

“My biggest worry is that high income countries will pull themselves out of the grip of Covid-19 because they will vaccinate the population, and have herd immunity. Low and middle income countries will then be stuck, just like what happened with  HIV  and Tuberculosis,” she said.

The question of Taiwan. In 2008, Taiwan was invited every year to the WHA as an “observer” but since 2016, this invitation - at the discretion of the WHO Director General - ceased to be made - after the Taiwanese elections that brought a new government into power took a more hard-line stance toward China.

In the wake of the pandemic, which saw allegations of a Chinese cover-up of the pandemic’s origins and critical transmission data,  there have  been growing  calls to renew the invitation to Taipei - beginning already last year.

For this year’s WHA, some 13 WHO member states have called for Taiwan to be allowed to participate, with the issue set to be discussed on Monday.  This includes  the G-7 (Group of Seven most industrialised countries), which for the first time have formally endorsed Taiwan’s attendance at the WHA.

The participation of Taiwan is critical for scientific reasons,  says Flahault. “In global health and security terms, there is absolutely no doubt that Taiwan should be one of the full members of the WHA. The way the country has managed the pandemic offers great tools and lessons which will be important knowledge to share at the WHA and it is a pity if we do not get this,” he said.

From Taiwan to vaccine equity, the challenge throughout all of the WHA debates will be for all individual member states to rise above their own narrow set of national or geopolitical interests - recognising that the pandemic is a threat to all.

“What I expect from the WHA is that member states show exemplary leadership. This year has to be a game changer in terms of response and preparedness to pandemic,” said Liu.