The ACT Accelerator Independent Review: A Missed Opportunity?

Newsletter Edition #97 [The Weekly Primer]

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An ostensibly independent review of the ACT Accelerator, published last week, has been unable to find an accountability mechanism within this multi-institution structure that was set up to respond to the pandemic. This is not surprising, as others and we have argued in these pages numerous times before, that no one will be held responsible for a botched international response to the pandemic.

Read our brief assessment on this today.

You may want to sign up and read this exclusive from last week: Review of International Health Regulations Makes Space in Treaty Talks; and The “Subtle Shift" in TRIPS Waiver Debate.

Also check out our thread on the COVAX Facility, all our stories on the evolution of this mechanism over the last 18 months.

Until next!



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  • WHO: ACT-Accelerator Strategic Review

    The much-awaited review of the ACT Accelerator was published last week. Unfortunately, it does not meet expectations, partly because the scope of the review was limited by design, and also because it toes the official line of the sponsors of ACT-A. This is a missed opportunity to take a hard look at the ACT-A processes and take lessons for the future. It is, of course, no coincidence, that in parallel, the longevity of the ACT A is being considered in other forums including informally, at the Working Group on strengthening WHO preparedness and response to health emergencies (WGPR).

    But nevertheless, the independent review conducted by Dalberg does assess some of the limitations of the ACT-A.

    The review covers four aspects: scope and objectives; operating model; financing; and the broader ecosystem.

    Dalberg says:

    “this Strategy Review was designed to understand ACT-A’s progress to-date, with a focus on identifying changes that could make it more effective in the short term….However, the main emphasis of the review was not on assessing impact, but rather on identifying changes that could have a positive impact in the coming 12-18 months.”

    It acknowledges that the ACT-A was set up as a voluntary partnership without new entities or legal structures. “This approach de-facto relied on existing partner systems and governance structures to provide accountability.”

    Yes, it was “voluntary” for the partners, but global governance experts have pointed out, the mechanism effectively reduced WHO to a coordinating hub, instead of being the leader of the international response to the pandemic. Not so voluntary for WHO, in our view.

    It further adds:

    “The Review was not focused on evaluating results, performing an audit, nor providing an impact assessment. Rather, it considered perspectives on ACT-A and its Pillars’ achievements to date to the extent that these can inform learnings on what has worked well and where there is room for improvement. It also considered the extent to which ACT-A is focused on addressing the most pressing needs within its scope today.”

    But why not? What the world needed now was an audit and to assess impact of this giant mechanism.

    Despite the staid nature of its language, it makes for fascinating reading on policy-making by a diffused set of actors in the midst of a raging pandemic.

    Consider this about oxygen supplies:

    “In the first quarter of 2021, many L/MICs saw severe oxygen shortages,34 and many external groups called on ACT-A to more actively manage oxygen. In the updated Strategy and Budget presented in February 2021 oxygen had been moved under Therapeutics and by the end of the month the Emergency Oxygen Taskforce had been formed together with key CSO groups. There was consensus amongst interviewees that, as a life-saving treatment which also works well in combination with dexamethasone, oxygen fit better under the mandate of Therapeutics.”

    On the Therapeutics Pillar it cautions:

    “….stakeholders stressed the importance of market readiness work in preparation for new treatments. Unlike COVAX, the Therapeutics Pillar does not yet have a clearly articulated procurement structure to supply countries or to negotiate contracts. The Pillar is also yet to engage in Advance Market Commitments, which external stakeholders noted put the Pillar at risk of becoming non-competitive against national bilateral deals. They expressed concern that, without rapid pre-emptive action, the Pillar could face similar challenges to COVAX in ensuring sufficient supply for L/MICs if new effective treatments are discovered. Existing advanced market purchases of Molnupiravir (an anti-viral in Phase 3 clinical trials which is hoped to treat mild to moderate COVID-19) by the USA were noted as examples of this risk.”

    On the vaccines pillar, the review carefully sticks to officialese, despite the rising chorus on the failure of COVAX. But admits:

    “…COVAX had aimed to mitigate such behaviour by including self-financing participants to work through the Facility. Instead, HICs not only joined COVAX as self-financing participants but also secured direct access to early doses, before COVAX had raised sufficient funds from those same countries to cover its own procurement and could enter into contracts to lock in doses for lower-income participants.”

    On the Diagnostics Pillar, the review says that the ACT-A was able to meet targets on expanding lab infrastructure and increasing testing capacity. It also notes that early breakthroughs in rapid testing led to faster market shaping and deployment. But it also adds:  

    “The Diagnostics Pillar is currently not on track to reach its procurement goals, and the goals themselves require additional contextualization to describe their intended impact. The Diagnostics  Pillar set the original target of making 500 million tests accessible to L/MICs by mid-2021. It extended this in April 2021 to a cumulative total of 900 million tests procured for L/MICs by the end  of 2021. The Pillar missed its mid-year goal, having procured over 84 million PCR and Ag RDTs for  L/MICs by 30 June 202115—only 16% of the way to their mid-year target.”

    The review is most revealing on the Health Systems Connector which has not received as much attention as it should have. (We too are guilty of not probing this)

    “..Debate and tension over the appropriate mandate for HSC, often described as a trade-off between emergency response and health systems strengthening, impeded progress and impact. Stakeholders expressed concern that HSC held disjointed workstreams from the start which lacked a natural synergy. A key conflict was on whether HSC should take a humanitarian or development lens to health systems. This was captured as the tension between emergency response (commodities delivery and country readiness to absorb tools) and health systems strengthening (broader systems building). Internal early discussion documents noted these tensions and risks within HSC’s scope from the outset, specifically noting differing perspectives around the challenge of focusing on COVID-19 response versus wider health systems work. What could be feasibly achieved within budget constraints was also a factor in these debates…”

    On the overall ACT-A structure, the review acknowledges:

    “the absence of a central programmatic direction-setting and coordinating function poses risks of gaps and incoherence in ACT-A’s activities…”

    It also notes: “Donor country voices and perspectives tend to dominate L/MICs’ contributions, posing risks of developing solutions that are not truly responsive to recipient countries’ needs.” On representation and participation, it says “Insufficient inclusion and meaningful engagement of LMICs, regional bodies, CSOs, and community representatives.”

    “The eight co-convening agencies are WHO, Gavi, CEPI, Unitaid, Wellcome, the World Bank Group, the Global Fund, and FIND, with additional key partners of Bill & Melinda Gates Foundation and UNICEF. These are supported by a host of other partners at pillar and implementation level. In addition, key industry representatives are included, such as International Federation of Pharmaceutical Manufacturers & Associations (IPFMA), International Generic and Biosimilar Medicines Association (IGBA), and Developing Countries Vaccine Manufacturers Network (DCVMN). Civil society is also represented at the ACT-A and Pillar levels, with a range of organisations active across the partnership on behalf of diverse constituencies,” the report says.

    The ACT-A is likely to continue beyond 2022 and might become a permanent structure despite its limitations on financing and inherent governance challenges. At this point, it is difficult to envision whether WHO member states will have any role in reforming it.






  • The COP26 Special Report, “The Health Argument for Climate Action”: 11 October

  • Release of the 2021 Global Tuberculosis Report: 14 October

  • WTO Informal TRIPS Council Meeting: 13 October


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