Health Emergencies Engulf WHO & its Priorities: A Wrap of WHA 75
Newsletter Edition #139 [The Friday Deep Dives]
The world’s ability to deal with complexity has grown several times during the pandemic of COVID-19. But this also means that the pace at which decisions are made has quickened to keep up with ever-changing realities.
At the World Health Assembly this week, one could notice that even the glacial pace at which multilateral decision-making occurs, has somewhat become faster. It has also become inevitably messier. The technical collided with the political, and there has been some collateral damage including the fact that not all voices were heard, but decisions were taken nevertheless.
Member states re-elected DG Tedros, committed in principle to pay more to WHO, took a hard stand against Russia, adopted a resolution on clinical trials, discussed WHO’s role in the global health architecture, among many others areas of global health policy.
WHO has taken a decisive political position with respect to Ukraine. And now bigger responsibility rests on it for all current and future political flash points, as critics unfailingly point out, citing examples of Palestine, Iraq and Syria among others. (Will we, for instance, see discussion condemning gun violence at WHO?)
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I. A WRAP OF WHA 75
Health Emergencies Engulf WHO and its Priorities
Seldom has WHO been forced to take such a decisive political stand, during its existence for three-quarters of a century. It may have now set a precedent that will be difficult to walk away from, in the future.
This week will likely be seen as a watershed moment for WHO, when scores of member states pushed through a politically significant resolution, albeit, one that may be limited in practical terms, condemning “in the strongest terms Russian Federation’s military aggression against Ukraine, including attacks on health care facilities documented via the WHO’s Surveillance System for Attacks on Health Care (SSA)”.
The 75th World Health Assembly became a melting pot for geopolitics, global health security, wars and health emergencies. Sparks flew and brought countries together, even as diplomats clashed on process and meaning across many discussions.
As the foundations are being laid for a new architecture for global health, WHO’s role is being re-cast in definitive terms, one where governing, coordinating and responding to health emergencies could overshadow its larger role in international health policy-making. The on-going World Health Assembly that drew delegates from the world over, in the first in-person meeting in over two years, provides indications on the current and future role of WHO.
In a competing agenda with scores of items, discussions on emergencies towered head and shoulders, over other priorities. In the first few days of this Assembly, member states re-elected DG Tedros Adhanom Ghebreyesus, committed in principle to pay more to WHO, took a decisive stand against the Russian invasion of Ukraine, adopted a resolution on clinical trials, and discussed WHO’s role in the global health architecture, among many others matters of deliberation.
The US might manage to claw out a hard-won resolution, despite initial reservations by some member states including Iran and the African Union. Countries will now formally set in motion a process of amending the International Health Regulations. But expect opposition and an articulation of region-specific priorities on these issues in the coming weeks and months ahead.
Our edition today tries to capture and understand the significance of these decisions.
THE UKRAINIAN RESOLUTION
While the former resolution was won by 88 in favor and 12 against, the latter was rejected with 15 in favor and 66 against. Of the 194 member states, 183 had rights to vote. Around 30 delegations were absent. And abstentions were significant, 53 for Ukrainian resolution, and 70 for the Russian one. Fewer numbers were present at the time of the vote for the Russian proposal.
The endorsed resolution says,
“…Expressing grave concerns over the ongoing health emergency in Ukraine and refugee receiving and hosting countries, triggered by the Russian Federation’s aggression against Ukraine, resulting in conflict-related trauma and injuries as well as increased risks of illness and death from non-communicable diseases (NCDs), of emergence and spread of infectious diseases, of mental health and psychosocial health deterioration, of human trafficking, of gender-based violence, and of sexual and reproductive health including maternal and child health deterioration…
….DECIDES that continued action by the Russian Federation to the detriment of the health situation in Ukraine, at regional and global levels, would necessitate that the Assembly should consider the application of relevant articles of WHO Constitution”
It also asks of the DG to “submit to the Seventy-sixth World Health Assembly in 2023, through the 152nd session of the Executive Board, a report on the implementation of the present resolution, including an assessment of the direct and indirect impact of the Russian Federation`s aggression against Ukraine on the health of the population of Ukraine, as well as regional and wider than regional health impacts.”
During the discussion, some member states also gave statements justifying their votes on each of these resolutions. (See statement by the US here.)
Some believe that the resolution at WHO has little meaning.
David P Fidler, Senior Fellow, Global Health and Cybersecurity at the Council on Foreign Relations told Geneva Health Files:
“The WHA resolution on the armed conflict in Ukraine is the most prominent action taken so far under the assembly's theme of "Health for Peace, Peace for Health." The resolution condemns the health horrors that Russian aggression against Ukraine has created. But less than half of the total number of WHO member states voted for the resolution. This tepid support is revealing because the resolution does nothing more than condemn Russia. Despite stating that Russia's aggression satisfies the "exceptional circumstances" test in the WHO Constitution that permits the assembly to impose sanctions, the resolution punted deciding whether Russia should face consequences for the blood on its hands until the assembly meets next year. Countries and international organizations have so frequently condemned Russia's aggression that another condemnation without consequences hardly qualifies as a "health for peace" moment. The weakness of the resolution also underscores how irrelevant the World Health Organization is in combating Russian aggression and resurrecting "peace for health." "
But without doubt, it puts WHO in a difficult position where negotiating politics and health will become even more frought.
Gian Luca Burci, Adjunct Professor in International Law at the Graduate Institute in Geneva and a former legal counsel at WHO, told us:
“It is unusual for the WHA to take such a forceful stand against a member state, but it's not the first time. Take the by now ritualistic annual resolutions against Israel - but they have not led to the imposition of sanctions, as the resolution against the Russian Federation threatens to do. Second, back in the 1960s and 1970s, the WHA imposed sanctions against South Africa and Portugal such as the loss of vote in the Assembly. South Africa did not participate as a consequence until the election of the first post-Apartheid government in 1994. Article 7 of the Constitution is the legal basis for the imposition of such sanctions.”
“…The resolution (on Ukraine) in my view creates problems for the secretariat, both Geneva and EURO (WHO’s European Office), that have to implement measures targeting directly a member state, in particular the request by the European Regional Committee to relocate the Moscow NCD office to another country. WHO is not an antagonistic organization and the emphasis has historically been on engaging even with countries that were under sanctions from other quarters, such as Myanmar or Afghanistan during the first Taliban government.”
(Article 7 WHO Constitution: If a Member fails to meet its financial obligations to the Organization or in other exceptional circumstances, the Health Assembly may, on such conditions as it thinks proper, suspend the voting privileges and services to which a Member is entitled. The Health Assembly shall have the authority to restore such voting privileges and services.)
A RESOLUTION ON THE AMENDMENT TO THE IHR
One of the stickiest points of disagreement between member states has been – the resolution on amending a provision in the IHR that seek to reduce the timeline to reject or reserve an amendment from 18 months to 10 months. It further suggests that amendments must come into force within 12 months. This period currently stands at 24 months. (See our analysis from last week on why this is significant.)
Spearheaded by the US, the discussions leading up to the Assembly were several months long, mostly in informal consultations. And yet, negotiations on the resolution – “Strengthening WHO preparedness for and response to health emergencies: Proposal for amendments to the International Health Regulations (2005)” - went down to the wire. The African Union and Iran, among others, expressed concerns on content and process of the resolution. This forced, Hiroki Nakatani of Japan, the chair of the Committee A, at the WHA, to announce structured informal consultations in order to find a consensus on the matter. Iran repeatedly urged the chair to indicate a process for discussions.
By the time this story went to print, the Assembly had not yet approved the resolution. Sources told us that consensus had been reached and it is expected to be approved by the Assembly later today. (This story will be updated accordingly)
Developing country delegates were divided on the resolution. While many were circumspect on fast-tracking the process of amending IHR, they were nonetheless committed to strengthening the IHR.
“I think some countries are suspicious of the implications of the resolution, just because it was proposed by the US. But I do not see what the problem is”, a developing country diplomat told us on the sidelines of the Assembly.
Some others who were concerned about the resolution, noted that while they were in favor of amending the IHR, they were unsure about the implications of the amendment in their national frameworks. “We have to fully understand this, before approving it”. Others were displeased with the mention of “consensus” in the draft resolution. “There has been no consensus on this, and yet the resolution seems to suggest that there is.”
The draft resolution (May 24, 2022) had read:
“Noting Member State consensus to reduce the period for entry into force of amendments to the International Health Regulations (2005) as set out in Article 59, and to make technical adjustments to Article 59 and related Articles of the instrument, to ensure coherence and consistency;”
An updated version, published today, dated May 27, 2022 published here, deletes the paragraph above and has a new paragraph:
“PP5 Recalling that Member States decided to establish the Working Group on IHR amendments (WGIHR), through the Working group on strengthening WHO preparedness and response to health emergencies (WGPR), to discuss targeted amendments to address specific and clearly identified issues, challenges, including equity, technological or other developments, or gaps that could not effectively be addressed otherwise but are critical to supporting effective implementation and compliance of the International Health Regulations (2005), and their universal application for the protection of all people of the world from the international spread of disease in an equitable manner…”
As reported earlier, some experts have expressed caution on the implications of the amendments of the related articles, that have been described as “technical adjustments.”
But if indeed the U.S. manages to get the first amendment approved by the Assembly, it will be seen as a win for the country that has clearly favored the IHR route over the treaty approach, in framing new rules for governing health emergencies.
On proposing amendments to the IHR, Loyce Pace, US Assistant Secretary for Global Affairs at the Department of Health and Human Services, told reporters in a briefing in Geneva earlier this week, “It absolutely doesn’t take away any sovereignty from any one nation and in fact all of these amendments are done in the spirit of international norms and laws including national laws and legislation. And in fact, it's really just meant to open up the opportunities for transparency and action, especially when people were so rightfully critical of the response early on, pointing to instances where maybe that information did not [get] treated, frankly, and perhaps where various actors weren’t held accountable as they should have been.”
If adopted at WHA 75 later today, such an amendment to Article 59 could come into force at WHA 77. And any subsequent amendments to the IHR that will be decided by member states in the course of the next two years, will be adopted under the revised timeline, experts explained. This means, that any new proposed amendments that could be adopted at WHA 77 (in 2024), will come into force a year sooner than what current provisions state. So, any new amendments can take effect by WHA 78 (in 2025) instead of WHA 79 (in 2026), saving one year.
This is important because it would mean that IHR amendments that will be negotiated over the next year or two, will come into force in 2024. This process will run in parallel to the negotiations for a new pandemic accord at the Intergovernmental Negotiating Body.
SUGGESTED AMENDMENT COULD STILL BE OPPOSED (Art.59 IHR)
Even as suspense on this resolution continued, with one day left for the closure of the Assembly, Geneva-based sources suggested that some member states could oppose the resolution. Some suggest that some countries may decide to potentially “reject” such an amendment in the future, even if the resolution itself may be adopted.
Once a decision of the assembly is adopted in accordance with the Article 22 of the constitution the amendment will come in to force, except for those member states which reject it, a global health legal expert said.
So even if some countries reject the amendment, the amendment will go through, once adopted by the Assembly, in 24 months. The amendment will apply to all countries which do not reject it, and for those who reject it, current terms will apply, the expert clarified.
But if member states disagree on the very first amendment they have considered, this could set the tone for the entire process of amending the IHR. Experts caution that if countries differ or do not agree on the usefulness of other substantive amendments that will be suggested in the coming months, it could result in a varied “landscape” of substantive obligations, where countries end up choosing which amendments would apply to them. “This is why a firm consensus in adopting this and future amendments is so important,” the legal expert said.
Some countries have cautioned against re-opening the entire instrument. However, experts also say that member states are free to add new provisions, expand the scope of the IHR, as was the case following the SARS crisis, that saw extensive changes to the IHR in 2005, observers say.
DEVELOPING COUNTRIES ON IHR AMENDMENTS:
Earlier in the week, Botswana, on behalf of the 47 Member States of the WHO Africa Region, had said at the Assembly:
“Regarding the proposed amendments under this Agenda item, the African region hereby reiterates its position regarding the IHR (2005) Amendment which include: the need to undertake limited targeted amendment of the IHR (2005) to maintain its integrity and ensure the gains achieved in core capacities and other provisions are not lost. The amendments need to be considered as a holistic package, and the process should be transparent, inclusive, credible and consensual and with full respect to the sovereignty of Member States, while pursuing our collective action. The African region shares the view that the process should not be fast tracked by the amendments of article 59 or the technical adjustment amendment of Articles 55, 61, 62 and 63 at this Health Assembly.”
It also added that African countries are undertaking extensive and necessary consultations at the national and regional levels on the proposed amendments from all Member States.
In its statement, India said:
“India believes that amendments in IHR should be a member state driven process through meaningful consultations. The texts proposed for amendments must be negotiated by the member States, and not by expert groups alone through a consensus process.
Certain proposals which propose a substantial change by extending the process relating to objection and acceptance of reservation under Article 62 to IHR as early harvesting needs further detailed discussion. India proposes that any mechanism for amendment of IHR should be based on consideration of all proposals from various Member States together, in order to make the process holistic, comprehensive, inclusive and efficient.”
FINAL REPORT: WORKING GROUP ON PREPAREDNESS AND RESPONSE TO HEALTH EMERGENCIES
Yet another bone of contention for member states was the adoption of the final report of the Working Group on Preparedness and Response to Health Emergencies (WGPR). In a late-night session, the Assembly adopted the report, with the decision to continue with the WGPR with a revised mandate and name it as the “Working Group on IHR amendments” [WGIHR] “to work exclusively on consideration of proposed IHR targeted amendments”. The decision requires the DG to convene the first meeting of the WGIHR no later than 15 November 2022. It also requests the DG to convene an IHR Review Committee, before 1 October 2022 at the latest.
There is understanding that there is no consensus yet on the “possible actions considered by the WGPR” as described in the report. Observers suggested that the recommendations were watered down to “possible actions”. (See TWN, on how this final report came about: EU says “no” to equity in Health Emergencies in the WGPR Recommendations)
One of the most politically significant decisions at the Assembly has been the adoption of recommendations, based on the final report of the sustainable financing working group. There was much fanfare in the proceedings, marking the decision as a moment that strengthens WHO financing to an extent.
A report from the Programme, Budget and Administration Committee (PBAC) of the Executive Board to the Assembly said:
“It expressed support for the recommendations, including the proposal to increase assessed contributions incrementally, with the aspiration to have them cover an amount equal to 50% of the approved base budget for the biennium 2022–2023 by the time of the biennium 2030–2031, and if possible, by the biennium 2028–2029.
It also expressed support for the establishment of an agile Member State task group on strengthening WHO’s budgetary, programmatic and financing governance, noting that governance reform went hand in hand with measures to improve financial sustainability.”
The PBAC held its meeting 18-20 May, 2022 and the 151st Executive Board meeting is scheduled for May 30, 2022. The establishment of the task group on financing and governance will be considered by the EB next week.
But sources alerted us to the language around the increase in assessed contributions – “the proposal to increase assessed contributions incrementally, with the aspiration to have them cover an amount equal to 50% of the approved base budget for the biennium 2022–2023..”
The word “aspire/aspiration” indicates that member states are not mandated to carry out such a proposal. Member states may reject an increase to meet to 50% of the approved base budget, legal experts suggested. Concerns remain that large Latin American and Asian countries remain non-committed to an increase in assessed contributions, sources said.
Diplomats also clarified that only a decision by an appropriations committee at the time of the new budget in 2023 could potentially be legally binding, to enable an increase in assessed contributions.
Some member states believed that a strict implementation plan as discussed in the report, would tie the hands of the secretariat. But officials familiar with the negotiations within the working group indicated that many donor member states were in favor of keeping a tight check on how any increase in assessed contributions will be spent.
Diplomats also suggested that while some countries are cautious about ensuring WHO’s work to be free from donor influences, these same countries were not shy of relying on voluntary contributions or using replenishment mechanisms to shore up WHO finances in lieu of a meaningful increase in ACs.
In a statement, Bangladesh said, “For many developing countries, due to their resource and capacity constraints, it is not easy to affirm the AC increase. The Covid 19 pandemic has deepened their challenges. The strengthening of the WHO is required more than ever for optimum deliverables in the developing countries.”
The Assembly also saw an adoption of an important resolution on Strengthening clinical trials to provide high-quality evidence on health interventions and to improve research quality and coordination.
Several member states including Bangladesh, and others said in their statements that the consultations on the resolution were poorly attended. Some of the smaller delegations were simply not able to participate in the discussions owing to multiple tracks of negotiations on other matters.
THE RE-ELECTION OF DG TEDROS
In a secret ballot, WHO member states re-elected Tedros Adhanom Ghebreyesus for a second and final term. The DG has been seen internally, among staff, as a war-time general for leading on the pandemic of COVID-19 from the front. His consistent pressure on the industry to address inequities in the access to medicines, and his unequivocal support for the TRIPS Waiver proposal at the WTO, has drawn both praise and criticism.
At the cusp of his re-election for term of five years, it surfaced that UN rapporteurs believe that WHO failed DRC sexual abuse victims. In a damning story, Devex reported: “The WHO had an “inadequate response” to allegations of sexual exploitation and abuse during an Ebola outbreak in the Democratic Republic of Congo, based on publicly available information and intelligence received by a team of United Nations rapporteurs.”
The IOAC said in its report to the Assembly: “The IOAC identifies internal power dynamics as a persistent obstacle to clarifying accountabilities and the lines of authority between the WHE Programme and wider Organization, as well as between the three levels of the Organization. ….The IOAC reiterates its outstanding recommendation from one year ago on the urgent need to update the current version of the Emergency Response Framework to clarify explicit roles and responsibilities, accountabilities and lines of authority across regional and country offices and headquarters, including for security management and PRSEAH [Preventing and Responding to Sexual Exploitation, Abuse and Harassment]”
CSOs AT WHO
Some civil society organizations were not happy with their reduced and haphazard participation at the WHA. “We work hard to fight for WHO, but we are not treated very fairly by the organization”, suggesting the way some discussions proceeded at the Assembly specifically on the discussions on health emergencies (WGPR agenda item). Many CSOs cannot afford to travel to Geneva, and if their video statements are not even shown at the Assembly they have no way of making their presence felt, one activist told us.
The Global Health Watch was also released on the sidelines of the WHA. Read an introduction to the report here.
* Correction: In an earlier version of the story we reported that “If sufficient number of countries reject the amendment, such an amendment may not go through, legal experts suggest.” We are told that this is an incorrect interpretation. We have now removed this sentence and further explained the potential consequence if an amendment to the IHR is rejected by a member state. (May 27, 2022, 19:00 hours)
** The IHR amendments resolution was subsequently adopted by Committee A of the WHA on May 27, 2022, 20:30 hours
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