"The Art of the Possible": Unpacking the Negotiations on the Amendments to the International Health Regulations [The Files Interview]
Newsletter Edition #99 [Treaty Talks - IHR]
Hi,
Health diplomats in Geneva have barely recovered from an intense and historic World Health Assembly that concluded on June 1, 2024. But the story is still fresh!
Given the milestone achieved at the Assembly, in terms of adopting the amendments to the International Health Regulations, we were keen on capturing the tension, the drama and the diplomatic nous, all of which combined in this moment, resulting in consensus.
In this edition, I am delighted to bring you an exclusive interview with senior public health experts Ashley Bloomfield and Abdullah Asiri, who led these decisive negotiations on the amendments to the International Health Regulations.
We hope you enjoy reading, and listening, to this behind-the-scenes recounting on the final days and hours that led to consensus, and the eventual adoption of these amendments at the World Health Assembly recently.
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Priti
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I. THE GENEVA HEALTH FILES INTERVIEW
A. IN CONVERSATION WITH ASHLEY BLOOMFIELD
"The Art of the Possible": Unpacking the Negotiations on the Amendments to the International Health Regulations
On June, 1 2024, member states of the World Health Organization reached consensus on key changes to international rules that govern the response to health emergencies.
Countries adopted the amendments to the International Health Regulations after two years of intense negotiations.
This has been heralded as a success for multilateralism in a period of difficult geopolitical challenges, but the process has also been a triumph of determination in getting more than 190 countries to agree on how the world can better prepare and respond to health emergencies.
Earlier this month, we spoke with Co-Chair Ashley Bloomfield from New Zealand to seek his reflections on the process and the key turning points in these negotiations. We also have a written interview with Co-Chair Abdullah Asiri that follows below.
Being scrupulously fair and shielding the process form political instability were identified by the Co-Chairs as one of the many factors that led to success.
The Working Group to amend the IHR had a six-member bureau.
Read on!
Listen here:
Podcast produced by Parth Chandna
Priti Patnaik [PP]:Thanks so much for joining us today. And it is really useful to listen to your reflections about… three weeks after the conclusion of the World Health Assembly, where the amendments to the IHR were adopted. So how do you assess the success of the amendments to the IHR?
Ashley Bloomfield [AB]:
Well, I guess the first measure of success is that we got agreement on a package and that was adopted by consensus. And given the challenging geopolitical climate we're living in, I think that's no small feat and so I think that's important for us to take as both a win and also as an indication that actually if you put the work in, it can pay off.
I guess the second question is, then, you know, are these amendments, the ones that are worth having?. Are they meaningful? And my assessment is that they are. I don't think they can be dismissed as simply technical or watered down amendments. And in particular, I think that the new provisions in Article 13 around equitable access to relevant health products, the new Article 44bis establishing the coordinating financial mechanism. And in the preceding Article 44 that really just sort of strengthens the obligations on state parties to assist each other. And then, of course, the Article 54 which establishes this implementation committee to help support the implementation of these changes. I think these are all significant amendments. So overall, I think [it was] a successful process. And of course, there's still work to be done, and the pandemic agreement itself is not completed, but in terms of the IHR, it's good to have met that really important milestone.
[PP]: Thank you so much. I wanted to also ask you, in terms of better preparedness and prevention, what were some of the amendments that have been adopted that you think are watershed going forward?
[AB]:
Well, I guess let's start that by just, you know, sharing the perspective I have on the IHR. And whilst a lot of the focus has been on the pandemic agreement, there are two aspects of the IHR that I think that are fundamental to prevention and preparedness.
The first is the fact that they are signed up to by 196 states parties, and they've got a very wide subscription. Whereas, you know, even once a pandemic agreement is agreed and ratified, it's unlikely to reach that sort of universal level of application. So that's a real strength of the IHR.
The second goes then to the content. And you know, what are the elements that will really help strengthen prevention and preparedness? Well, in particular, these stronger obligations, including the obligations around financing that all states parties share, in a sense, to help ensure that no country is left behind, that all countries are able to build the capability and capacity to, you know, have appropriate surveillance in place, to protect, to detect outbreaks early, to intervene early, to prevent them escalating, and certainly to prevent them becoming public health emergencies and and even further than that, a pandemic emergency.
So I'm particularly pleased about those strengthened obligations on countries to support and assist each other, and then, of course, to ensure that there's adequate financing so that developing countries can implement the obligations. And there are some additional capabilities and capacities outlined in Annex 1 that are new and that will help in that, in that strengthening of prevention and preparation.
[PP]: It will help our listeners and our readers understand specifically on financing, in terms of implementation of the amendments, on the financing article, what will that look like, you know, in the coming months and years?
[AB]:
Yeah, this is an amendment I'm particularly pleased with. And in terms of how this played out, it wasn't until the second to last day at the World Health Assembly that this proposal to, in a sense, [to] built on some fantastic work that had been done as [a] part of the pandemic agreement and led there by one of the Bureau members…. Ambassador Tovar…. It had been sort of elaborated in Article 20 of the of the draft pandemic agreement to establish the coordinating financial mechanism, so to be able to sort of lift that and establish that within the IHR, so that [gets] a wider, more universal application, but secondly, that it can be established more quickly.
That's a real win, listeners and those who have followed this process will know that there was a really big sticking point between, sort of the global north and south about the different views on the requirement or not for a new fund. And so coordinating financial mechanism provides, you know, a really solid and now kind of legally binding obligation for states parties, to the IHR, to lean in to ensure that this platform is established and the work on that can start, you know immediately.
The new amendments don't come into force for another 10 months for the majority of countries…. sorry, for another 12 months for the majority of countries. But the work to establish the coordinating financial mechanism so that when the implementation committee meets for its first time, which could be, you know, anywhere in 12 months, just past 12 months time, that this mechanism can be established, the work that's already been undertaken by WHO can be built on.
The financial and funding mechanisms that are already there can be much better matched up to the needs of developing countries. And there's also the specific provision that was included in the agreed text, that if new financing is required, or if new sources of financing are required, then those will be looked into. So there's an obligation there, that's in this legally binding document, which is a really good outcome, and the work on that can start very promptly.
[PP]: Thank you for laying that out for us. And the other key question, you know, on the substantive issues that I wanted to understand from you is, let's say, 5 to 10 years down the line, people are looking back at these set of amendments, and if you had to explain to them the significance of, you know, having equity related language in these set of amendments. How would you sort of explain the significance of it in terms from an operational point of view, particularly for developing countries. This is the first time that you've had equity related language, not only the principles, but also in the amendments to Article 13. How would you sort of explain to people looking at it years from now?
[AB]:
Yes. So look, this was a really important theme and driver of all the discussions. There was barely an hour that went by in our more than 40 days of discussions where this notion and this topic, and this importance around equity came up. And of course, it was driven by what we found happened during the pandemic, where, unfortunately, the ability to access resources, to access vaccines, treatments, other medical products that were needed to actually mount a proper response to the pandemic and individual countries.
So there was just deep and inequitable access to those in developing countries [which] were not able to get the support and the resources and the products they needed. It is a key driver of these amendments.
It's one thing to have equity and solidarity included in the principles. But what everybody was universally focused on was making sure [that] there were tangible, meaningful changes to the IHR.
As I said at the start of the podcast, in my first response to see that it actually carried through after many tough hours of negotiation, into equitable access to relevant health products as part of a response, into the establishment of a financing mechanism that will really help support developing countries to be able to prevent and prepare for and respond to outbreaks.
And then, this provision in Article 54bis that established this implementation committee that really was intended to, and I would hope, looking back in 10 years time, has seen a much greater degree of collective accountability, and in support of all countries to make sure that there is, that sort of real solidarity and international response to these outbreaks when they occur.
[PP]: All right, thank you. Dr Bloomfield, you know, a lot of people think that the amendments and in general, the IHR’s are geared towards responsibilities of WHO, as opposed to state parties. How would you respond to this kind of perception or critique?
[AB]:
Well, for my part, I don't take it as a critique, because the IHR, they are, in equal measure, a set of obligations for both the WHO and for the states parties, the obligation that the WHO are ones that state parties have agreed to, and have agreed that the WHO should be accounted be responsible for and accountable for.
But equally, there are many measures in the IHR, both the original IHR and indeed as part of the amendments that create strong obligations on states parties, and in many areas, those have been strengthened with these amendments. So both are of equal value and equally important. And I think you'll see through this amendment process that the obligations and the accountability on state parties and the WHO have been strengthened alike….. and I think that's a good outcome.
[PP]: I know we are coming close to the period where you have to go as well, but I really want to sort of get a glimpse of, you know, the process. There are two parts to this. One is whether, you know, we all acknowledge the difficult geopolitical environment accompanying these and underlying these negotiations. Do you think that the process would have been easier if you had, let's say, a more sober geopolitical environment? That's one and secondly, it would be really nice if you could recount, you know, the final days and hours that led to the eventual consensus.
[AB]:
Sure. Well, in terms of the first question there, I've been involved in a few, not necessarily treaty type negotiations or legal instrument negotiations, but negotiations around that, the WHO on , these sorts of matters. And in the last nearly 20 years, I've been around the WHO, none of them have been easy. And, you know, the development of the work to agree on the Framework Convention on Tobacco Control took many years, and the work to agree on this ,the IHR 2005 likewise took many years. And in 2005 I was there for 48 hours, the last two days of negotiations on those and there were residual, tricky issues that took everybody's skill, diplomacy and hard work to find a solution to, in that sense, these negotiations were no different.
They're always challenging, and they always require an enormous amount of hard work. And for some reason, they always seem to require people working in the small hours of the night at some point or other, which certainly happened to us on a couple of nights.
So though, in a sense that was what was expected, but we were working in an environment where, as you pointed out, I mean, it is a very complex geopolitical environment. At that the same World Health Assembly, where these were adopted two weeks ago, there were, I think, at least 10 votes that the DG said on different matters, issues around Gaza, issues around the war in Ukraine, of course, these are very tricky, troubling issues and, and so in many respects, it made our work more challenging, but it also meant that, you know, success was also sweeter, in a sense.
And also did show, I think, that if the right environment is created, and if space is given, and if people into each other, and if global health diplomacy is deployed by everybody, then you can reach a consensus, which is what we did.
In terms of your second question. Well, you know, one of the things I would point out is that our work was supposed to end at the end of April, and we hadn't got there. So we put aside the extra two days on the 17th and 18th of May, and the second of those days turned into a very long day till four the following morning, and then we came back and did another five hours on the Saturday, and we still weren't there.
So we agreed and got the support of the Health Assembly to continue our work during that week of the WHA. And in, you know, really what we were down to then was those last few tricky issues around the implementation committee, around some of the elements of the relevant health products, and, of course, financing and so those were the issues we spent a lot of time on. And it wasn't just the formal discussions at a number of points in time.
As chair , I would take, you know, call for a break and ask delegations to get together, because I had, you know, as Chair myself and Dr Asiri for many months, and with the bureau had been putting forward [the] bureau's text.
We got to the point where really our job was to make sure that the right people got together and worked through options that could then be considered in the room. And of course, right towards the end, as you can expect , there were certain things that certain delegations needed. They were getting instructions from their capitals. And we just had to… all showed, you know, every delegation had to show flexibility. And I would often talk about and thank those who were showing silent flexibility, who were making silent interventions. So in other words, those who, even if they might have had a view or a position on an issue, would just in the interest of helping move the process along, would just not necessarily ask for the floor.
So I mean, one other point I would make is, as the days went by through the World Health Assembly, and as we say greened more of the text, we got more and more agreed. Then the stakes also get higher, and people's level of commitment and investment in finalizing the process becomes even greater. So there's more at stake. And so by Friday, yes, we went till two in the morning.
But then, especially, having had a really productive discussion that day on the financing mechanism, I had a strong feeling that the next day we would be able to finish our work and, sure enough, those final things did fall into place.
And, everybody felt that, you know, they had got what they needed to be able to join a consensus. So that was, I think, a really key achievement, also to know that we were going to be able to take it to be plenary later that evening and have those changes adopted by consensus, rather than being in a position where there were sort of one or two measures that might force a vote and to avoid a vote was a really important outcome.
[PP]: Right. Thanks so much. I think there were also a lot of expectations building in, [heading into] you know, the conclusion of the assembly that that consensus on the IHR was a preferred outcome from the highest levels. Just one quick question, on technology transfer, which was also a sticking point, how did that get resolved? Are you able to share that with us?
[AB]:
Yes. So there was a particular sticking point around the technology transfer, and this is around the language of voluntary and mutually agreed terms for technology transfer, and that remained a point where we couldn't get consensus on, and we had several suggestions that we could not get consensus on ways to include that language in the IHR and so the resolution of that, I think, a very thoughtful proposal had been put forward by one of the delegations just, you know, a couple of weeks [ago], that we finally settled on.
It was essentially just to not specify technology transfer and not specify the voluntary, mutually agreed terms [of] language so that we could find a way through it. And just to use a more general phrase that you'll see there in Article 13 that talks about other relevant measures, and that was the way through that.
So, you know, it's the art of the possible, and that, I think everyone, by that time, had agreed that it may not be anybody's preference, but it was something that everybody could live with, and then found us a way through it. And of course, this issue is likely to have further discussion and further debate and further sort of focus in the ongoing pandemic agreement discussions. But in terms of the IHR we felt, we found an elegant way through that [which] everybody can live with and which still leaves open the option of technology transfer. And I'm sure there will be further work done on that.
[PP]: Indeed, I think a lot of diplomats do think that the amendments to the IHR are a starting point, and some of these conversations and negotiations will continue, you know, in the realm of the pandemic agreement. So before I let you go, just one last question, which is that, you know, a lot of people are looking at the set of negotiations as a success, not only inside global health, but also beyond. If you could share, very briefly, lessons or factors that work to your advantage in sort of successfully steering this to a conclusion. What are some of the lessons you would offer fellow diplomats also in other forums [such] as the WGHR Bureau ?
[AB]:
Sure. Well, one of the challenges we have, we've talked about the sort of the general, multilateral environment. One of the other challenges, of course, was doing these two processes in parallel, because there were overlapping issues, and we often ended up with negotiations on pandemic agreement issues happening in our process, and I'm sure vice- versa.
So saying in terms of your question about what worked, and we've reflected on this as a bureau, and we met last week on Tuesday evening, just to reflect back and and in a way, to celebrate success, but also just to really listen to each other about , what we thought had worked well and perhaps assisted us achieving the outcome we were looking for.
And most prominent among those was the fact that as the bureau, we gel very well, and we worked hard on a sort of establishing, I guess, our own culture, and that was a culture of teamwork, a culture of joint decision making and taking responsibility for those joint decision so that was important , you know, showing that sort of collective leadership.
Because the Bureau members are each there to be a link person for their regions, and to act as a two way communicator, to bring issues through, but also to communicate out, to provide that intelligence that really assisted us in the process.
And I think the, you know, another key feature was just the way that Dr Asiri and myself and other Bureau members worked with countries. The role of Bureau members that especially that co- chairs, or chair of these processes, even though people know I'm from New Zealand and Dr Asiri from Saudi Arabia. The role is an independent one…..It's a facilitator one.
We're not there to represent our country's position, so trying to be scrupulously fair, to listen to all sides, to all positions without judgement, to know when the time is right, to sort of to push a little bit, to nudge a little bit, to keep the process going, not to be not to be seen, to be intervening too much.
So I think that building trust and confidence. So, you know, by our third or fourth meeting, we had the delegations and the group asking us, then, as a bureau, to work up proposals, and one of the things we decided to do right from the start, when we put any purpose forward, was to provide a rationale for all those proposals.
And I do think that was something that really helped us, that actually it wasn't just, you know, here's our wording, and then it looked like it could have come out of a black box. Actually, we made it really clear every change we suggested, every proposal we put forward, why we were putting that particular proposal forward, and I think that really assisted in, first of all, maintaining and building the trust, but also in transparency, and therefore moving the process along.
[PP]: Thank you so much for joining us, Dr Bloomfield, and for sharing your reflections. And I know that it's pretty late in New Zealand, I really appreciate your time.
[AB]:
Thank you, and thank you for your interest and involvement in the process too, Priti and all the very best. And let's hope I see you again and the Geneva crew at some time in the near future.
Bhadra Gopakumar prooduced this transcript.
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B. WRITTEN INTERVIEW: DR ABDULLAH ASIRI
1. [Geneva Health Files: GHF] How do you assess the success of the amendments to the IHR?
[ABDULLAH ASIRI: AA]
We think the modifications were a significant turning point in improving international health security, improving coordination and collaboration, and tackling equity concerns in health emergencies.
2. [GHF] Why are the adopted amendments important? What specific provisions are key to changing Pandemic Prevention Preparedness Response?
[AA]
Among the approved modifications are focused technical changes that enhance the way the IHR runs. The amendment adds equity and solidarity principles to the IHR. These new principles facilitate fair access to relevant health products during a public health response and urge states to support each other in preventing, preparing for, and responding to disease outbreaks.
3. [GHF] What were the key factors that led to an eventual consensus between countries on the amendments?
[AA]
Multiple factors enabled unanimity. Establishing credibility and trust relied heavily on the committed and accommodating bureau. Delegates from member states demonstrated professionalism and comprehension of the process's urgency and significance. Furthermore, and no less significant, was the enormous assistance from the WHO secretariat.
4. [GHF] What were some of the key turning points in the final days that led to the adoption on the final day of the 77th World Health Assembly on June 1, 2024?
[AA]
The bureau continued to offer text and solicit member state input in the last weeks of the talks, determined to maintain hope. All was done to be in line with the INB and shield the procedure from political instability. The setting was prepared for a consensus at the assembly, and Dr. Bloomfield's mastery of late-night sessions made all the difference.
5. [GHF] What were the most challenging aspects in leading these negotiations during this two year process?
[AA]
Running the WGIHR and the INB concurrently was a significant challenge. It was imperative to properly unravel the obvious link between the IHR amendments and the talks of the pandemic pact. Managing many meetings and paying close enough attention to details proved a challenge for member states with small delegations.
6. [GHF] Based on your experience, what lessons would you offer to international negotiations processes in the future, including forums outside of WHO?
[AA]
Despite geopolitical issues, the world agreed on the modified IHR. A glimpse of optimism can be seen here. Trust can be gained by active participation and a vision for the greater good. I believe that active negotiations, which involve proposing and asking for counter proposals, are effective in facilitating such discussions. Being inclusive and transparent are essential.
7. [GHF] Some critics believe that the amendments do not go far enough to address the equity measures to better respond to health emergencies. What would be your response to them?
[AA]
Equity extends well beyond IHR. The WGIHR takes pride in its role as the group that introduced equity and solidarity into the IHR.
The updated IHR clearly defines the definition of a health emergency continuum, but it does not address what should be done in the event of a pandemic. Therefore, equity discussion has to continue in the INB process.
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