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Hi,

Late one evening this week, missions of some countries shared photos of diplomats staring down at a computer with a palpable sense of excitement. The buzz was around countries reaching an unexpected consensus on agreeing to a gradual increase in their contributions to WHO that would, to an extent, make its financing more predictable and sustainable.

In the more than 2 years since the pandemic began, this is one of the first and surest signs, that countries are indeed taking concrete lessons from the crisis to address not only health emergencies, but the overall strengthening of WHO. One could argue that this is potentially even more historic than countries’ consensus for a new instrument to govern preparedness and response to pandemics.

I would even say that it is as landmark a decision as the election of the first African Director-General of WHO. Symbols are significant. They communicate a shift, no matter the scale.

While an increase in contributions of about US $1.2 billion over a period of a few years, will not stop the splintering of global health governance, it might help WHO stand its ground in the medium term. (Major global health actors will collectively raise US $50 billion this year.)

In one stroke, countries might have pulled back WHO from the brink of irrelevance in a fast-evolving architecture of global health. We reported last week that countries’ commitment on WHO finances was a temperature check on their seriousness. We had suggested that countries may not be serious enough in bolstering WHO when it mattered the most. We are happy to be proven wrong!

But as always, the devil will be in the details. We are told big donor states will get their pound of flesh one way or another. Read our update in this edition.

Check out our thread that comprises all our stories on WHO financing over the last 18 months. My gratitude to all our sources who took the time to explain the nuances in financing and the politics of it over many months.

Consider becoming subscribers, or making contributions, so we are able to track important, technical, policy matters such as these in a dedicated and consistent manner.

Thank you for you engagement.

Best,

Priti

p.s. In case you missed our exclusive from earlier this week: Pfizer Allegedly Pressured UNICEF to Keep Secret, Pricing for Anti-Viral Treatment Paxlovid. UNICEF Yielded.

Feel free to write to us: patnaik.reporting@gmail.com or genevahealthfiles@protonmail.com; Follow us on Twitter: @filesgeneva

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I. POLICY UPDATES

Member States Pull Back WHO from the Brink of Irrelevance, Reach Consensus to Pay More in Dues.

Barely hours before the proceedings came to a close, member states reached a consensus at the final meeting of the Working Group on Sustainable Financing, agreeing in principle for an increase in their contributions to WHO, diplomats told Geneva Health Files.

The road to consensus on this proposal was not without bumps. And compromises had to be made.

A consistent diplomatic effort, and public pressure might have contributed to the break in opposition by some Latin American countries to this much-debated proposal, sources say.

As we had reported earlier, despite an overwhelming support for an increase in assessed contributions (ACs) from most parts of the world, several countries from Latin America continued to express reservations on an increase in contributions, a key sticking point in the overall efforts to make WHO’s finances more sustainable and predictable.

The turning point really came when the U.S. came on board supporting an increase in ACs, albeit, with conditionalities couched in the language of greater compliance, accountability and transparency.

“Without the U.S., it would have been difficult to get other countries on board,” a diplomatic source familiar with proceedings told us.

The source indicated that a key reason for the change in the American position might have been the recent trip under taken by DG Tedros to the U.S. “It seems Dr Tedros turned on the charm offensive, and possibly agreed to whatever was asked”, a developing country diplomat suggested.

INTERLINKING THE INCREASE IN CONTRIBUTIONS TO GOVERNANCE REFORMS

It is understood that countries discussed at length on the question of interlinking governance reforms to any increase in their contributions to WHO.

There have been efforts to “itemize” any potential expenditure in a bid to pursue efficiency and accountability by having strict implementation plans. This, however is being seen as a backdoor method to earmarking contributions. “With so many conditions on how an increase in contributions will be implemented, it will leave the secretariat with very little flexibility in allocating resources flexibly”, a source cautioned.

The source cited a comparison: “the US government has given Gavi – The Vaccine Alliance nearly US $ 2 billion. And while contributing to WHO, they seek to put in conditions for a fraction of that investment”

One diplomat suggested that the push towards accountability and efficiency, although worthy, is essentially an effort to convince Parliamentarians at the national level to sign on increased contributions to WHO.

For one, management level changes are to be expected. At the cusp of the re-election of DG Tedros, a perfect opportunity is presented to powerful donors. (See Health Policy Watch: Senior WHO Leadership Reshuffle Expected after Member States Agree on New Financing Formula for Global Health Agency)

Some expect that this increase will mean big donor states will push to recruit more senior officials from their own countries into WHO’s leadership roles.

“There is no such thing as a free lunch”, a diplomat from a developed country told us.

Another diplomat from a developing country asked, “how many more people from donor countries do they want at the senior levels of WHO?”

Others have already pointed out that the increased and outsized role of the US and US foundations such as the Bill & Melinda Gates Foundation, in the WHO particularly in the Tedros administration.

ON THE REACHING THE 50% TARGET OF FUNDING BASE SEGMENT OF WHO BUDGET WITH ACs

The increase in contributions to WHO as per this latest agreement will be modest given the organization’s true need.

After all the Independent Panel for Pandemic Preparedness and Response had suggested that “The work of the organisation to be fully financed through a member fee, the assessed contributions,” or “The major part of the base/core budget – 2/3 – to be financed through assessed contributions equal to a doubling of the present level”.

The working group recommendations stops short at 50% of base segment of the Programme budget to be financed by ACs.

However, reaching consensus on increasing their dues to WHO is without doubt a big political win, especially given the overall shrinking space for investments in health in the context of a prevailing war in Ukraine, among other stresses.

QUANTUM OF THE INCREASE IN CONTRIBUTIONS

Sources suggest that in practice, hwoever, the actual increase may be less than the 50% goal. There is more than meets the eye.

Diplomats told us that, realistically, the best-case scenario will perhaps be meeting 35% of the base budget with ACs over a period of the next few years, despite the ostensible goal towards 50%.

(No doubt countries will expect WHO to do more in the coming years.)

“I do not expect that we can comfortably meet the target of 50% of the base segment, especially as the programme budget will surely grow six or eight years from now,” a diplomat closely involved in the discussions in the working group told us.

The reason for this is the fact that negotiations did not take into consideration the impact of inflation, they said.

In addition, by tying the commitments to the base segment of the Programme budget 2022–2023, the goal of 50% is pegged to this absolute number. This means that even as the programme budget will increase 6-8 years from now, the level of assessed contribution will remain pegged to the current baseline of 2022-2023.

The absolute numbers of such an increase is unclear pending the final report of the working group to the WHA next month.

But we bring some estimates to you with help of our sources:

The approved base segment of the budget for biennium 2022-2023 stands at US$ 2 182 million. The goal of reaching 50% of this number, would translate to about US $ 1091 million per year.
Total assessed contributions in 2022-2023 stand at US $ 957 million, or about 16% of the total Programme budget, or 22% of the current base segment of the budget.
The current base budget is US $ 4.4 billion for 2 years during 2022/2023. (WHO budget is biennial). The aspiration is to reach 50% of this base budget by 2028/2029 [or latest by 2030/2031]. This would be US $2.2 billion for over the two-year budget period, WHO financing experts patiently explained to us.
The current ACs stand at about $ 1 billion (approx. US $ 957 million) for the two year period. Therefore the total AC increase between 2024/2025 to 2028/2029 is about $ 1.2 Billion: this is the difference between the goal of reaching US $2.2 billion in assessed contributions in the future over the existing level of $ 1 billion in ACs. This translates into US $ 600 million per year.

DG Tedros in his speech this week at the working group’s meeting urged countries to consider the proposal to increase assessed contributions to cover at least 50% of the base segment, calling it “a game changer.”

“This means that by 2028-2029, WHO would see an increase of roughly US$ 600 million a year in its most sustainable and predictable source of income,” Tedros told countries.

Sources suggested that a significant part of the increase in contributions will go towards meeting costs at country level.

(This is made it harder for Latin American countries to oppose the increase, given that their contribution to WHO, was a fraction of the budget at the country level, in the case of some member states, diplomats pointed out. For some countries, their contributions to WHO might double, but over a very small base.)

(See here document: Deliberations of the Bureau of the Working Group on Sustainable Financing on options for an Increase in assessed contributions)

THE DURATION OF IMPLEMENTATION

Another key matter of disagreement between countries was the duration of implementation of the increase. The bureau suggested an increase in ACs to account for 50% of the base segment of the budget to be implemented over a period of six years. This now likely stands at eight years, stretching this exercise till 2030-2031. It is learned that some Asian countries were keen on a longer implementation period.

A major compromise, some suggest, is the quantum of increase in ACs in the first installment of such an increase. It was initially envisioned an increase of 20% when the decision will be implemented starting 2024-2025. This is now articulated with some ambiguity to suggest that any such first increase “cannot exceed 20%”, meaning that a potential first increase could be below this level, sources familiar with the discussions explained to us.

The other spanner in the works suggested by some WHO member states from Latin America included making an increase in assessed contributions, conditional upon the recommendations of a proposed task group on financing and governance. One of the recommendations of the bureau includes a task group on strengthening WHO budgetary, programmatic and financing governance. This new task group is expected to “analyse challenges in governance for transparency, efficiency, accountability and compliance”, we reported last week.

But making such a link would make an increase in ACs vulnerable to future negotiations yet again, diplomats feared. It is understood that eventually these opposing countries were persuaded away from insisting on such conditions.

NEXT STEPS

The working group will submit its recommendations to the World Health Assembly. Given the consensus among members states, these recommendations including the increase in ACs is expected to be adopted.

While the move towards an increase in ACs is being seen as a positive development across the board, developing countries are also cautious about what this will mean in practice. It emerged during the deliberations that a reduction in voluntary contributions to WHO by big donor states is to be expected, to make up for an increase in assessed contributions. It is understood that some major donor states had already made it obvious during negotiations.

Irrespective, this is significant, given the legal nature of assessed contributions, that commit all member states to finance WHO.

DG Tedros cited the soon to be published WHO Investment Case, that calculates the benefits from investing in WHO over the next ten years. Investment in WHO produces an economic return of 35 US dollars for every 1 US dollar invested.

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OTHER UPDATES

II. PODCAST CORNER

“Discoveries from vaccine implementation”

On the heels of #WorldMalariaDay

Global Health Matters podcast episode 8:

WHO’s recent recommendation to widely use the first ever malaria vaccine, RTS,S, was based on evidence generated from a pilot vaccine implementation programme in Ghana, Kenya and Malawi. This is an excellent example of how evidence based on implementation research tells us whether health interventions, such as vaccines, will be effective in real life beyond clinical trials. In this Global Health Matters podcast episode, host Garry Aslanyan speaks with Margaret Gyapong of the University of Health and Allied Sciences in Ghana, who shares her first-hand experiences and learnings from the malaria vaccine pilot.

Listen here

Garry Aslanyan is the host and moderator of the Global Health Matters podcast. You can contact him at: aslanyang@who.int

This podcast promotion is sponsored by the Global Health Matters podcast.

If you wish to promote relevant information for readers of Geneva Health Files, for a modest fee, get in touch with us at patnaik.reporting@gmail.com.

III. WHAT WE FOUND INTERESTING

My new colleague Megha Kaveri, has put this together for you:

NEWS:

Moderna investors reject proposal to transfer vaccine tech: Financial Times
The Drive to Vaccinate the World Against Covid Is Losing Steam - New York Times
Pharma shells out more than $300K to brother of top Biden aide in 3 months - Endpoints News
'Betrayal of public trust': Pfizer under fire for resisting Paxlovid compulsory license - Fierce Pharma
The health–environment nexus: global negotiations at a crossroads - The Lancet
The judge who tossed mask mandate misunderstood public health law, legal experts say - NPR
Omicron splinters into fast-spreading lineages, highlighting coronavirus’s evolution - STAT News
Scientists urge China to replace its faltering Covid vaccines - Financial Times
Covid hasn’t given up all its secrets. Here are 6 mysteries experts hope to unravel - STAT News
How much blame for global vaccine inequity should the WTO bear? - Quartz
WTO Vaccine Deal Looks Long on Good Intent, Short on Support - Bloomberg
Are new Omicron subvariants a threat? Here’s how scientists are keeping watch - Nature
Save America’s Patent System - New York Times
‘An undebatable political decision’: Why China refuses to end its harsh lockdowns - Science
India’s drug regulator has ignored red alerts on Covaxin, imperiling millions of lives - STAT News
Disrupting Global Health: From Allyship To Collective Liberation - Forbes
Moderna’s patents stand in way of mRNA vaccine hub’s grand vision - Devex
Moderna’s profits show why Big Pharma can’t meet our health needs: Al Jazeera
WHO recommends Pfizer's COVID-19 pill, but poor nations may lack access - Devex
With 200M unused doses, AstraZeneca's COVID vaccine partner Serum Institute halts production - Fierce Pharma
Men — especially from rich countries — still fill the boards of global health groups - NPR
The Dilemma of Vaccine ‘Charity’ vs Building Africa’s Production Capacity - Health Policy Watch
Inequity has marred the fight against Covid-19. This must stop - Indian Express
COVID-19 testing sees massive decline, leaving countries vulnerable - Devex
In WHO v. Health Ministry Over COVID Deaths Data, Whom Should We Trust? The Wire

JOURNALS/REPORTS:

What is the impact of intellectual property rules on access to medicines? A systematic review - Globalization and Health
Saving Ukrainian Lives during the Russian War: Ukraine Must Waive IP Rights under Article 73 TRIPS to Provide Access to Essential Medicines - SSRN
How to identify epistemic injustice in global health research funding practices:
a decolonial guide: BMJ Global Health
Activists’ Guide for a Healthier World: Global Health Watch 6: Speaking of Medicine and Health, the PLOS medical and health journals’ blog.

IV. WHAT WE ARE WATCHING

ACT-A Facilitation Council meeting: 26 April
Working Group on Sustainable Financing: 25-27 April
Informal consultations on the Standing Committee on Health Emergency Prevention, Preparedness and Response (organized by Austria): 29 April
Informal consultation on clinical trials (organized by the United Kingdom and Argentina): 29 April
Informal consultations related to amending the IHR (2005), (organized by United States of America): 3 May
Ninth Working Group on Strengthening WHO Preparedness and Response to Health Emergencies: 4-6 May

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Geneva Health Files

Member States Pull Back WHO from the Brink of…