The Pandemic Accord Needs Clear Commitments on Adequate & Fair Financing for Prevention Preparedness and Response [GUEST ESSAY]
Newsletter Edition #52 [Treaty Talks]
Hi,
COVID-19 has spawned immense private sector interest in global health - there is money to be made. And yet, is there enough money going round to improve financing Pandemic Preparedness and Response? A vital question that is yet to be effectively addressed in current global health negotiations on PPR.
Of the many promises that these deliberations hold, the commitments on financing could be a game-changer for not only trade-offs in these negotiations, but the very real impact it can have on capacity building and implementation of potential, new obligations in global health.
In today’s guest essay, scholars and activists raise critical questions on the urgency in matters of resources, on alignment, representation, and governance issues for effective PPR financing. We hope you find this timely and useful.
If you find our work valuable, become a paying subscriber. Tracking global health policy-making in Geneva is tough and expensive. Help us in raising important questions, and in keeping an ear to the ground. Readers paying for our work helps us meet our costs.
Until later. Watch out for our analyses on the discussions towards a Pandemic Agreement taking place in Geneva this week.
Best,
Priti
Feel free to write to us: patnaik.reporting@gmail.com or genevahealthfiles@protonmail.com; Follow us on Twitter: @filesgeneva
I. GUEST ESSAY
The Pandemic Accord Needs Clear Commitments on Adequate & Fair Financing for Prevention Preparedness and Response
By Simon Reid-Henry, Public Interest and Peace Research Institute Oslo; Koen Scholten (Global Health Advocate), Wemos; Khalil Elouardighi (Director, Think Equal), Equal International
Global health governance confronts two long-term problems. One of them is a growing fragmentation and misalignment of agendas and initiatives. The other is a problem of power, encompassing accountability, transparency, and meaningful voice. Inevitably the two problems are linked, and nowhere more so than when it comes to the financing of global health agendas. Each of these problems have intensified since the pandemic, as identified by numerous commissions and initiatives including the International Panel on Pandemic Preparedness and Response and the more recent Future of Global Health Initiatives process.
But where do the various recommendations that have emerged from these processes take us? The answer may be nowhere if the formal governmental and multilateral processes seeking a common approach to pandemic preparedness and response continue to underestimate the significance of an adequately and equitably financed post-COVID regime. This would be a victory for entrenched inequalities. But the challenge concerns not just the volume of the financing needed for effective PPR. It also concerns the quality of that financing and how it is governed.
Addressing the macro-challenges in global health financing
With the negotiations of the Intergovernmental Negotiating Body (INB) on the Pandemic Accord, underway we see four macro-challenges that need addressing within the financing component of those discussions if global health’s longstanding problems of fragmentation and power are to be addressed:
1. Discussions on the Pandemic Accord need very quickly to establish a viable set of principles and commitments regarding how countries will meet their obligations rather than a shopping list of options.
2. Global health leaders, including the WHO, need to clearly delineate and justify the relationship between any Pandemic Accord and the recently established Pandemic Fund, as well as other PPR initiatives.
3. Recognition is needed of the international cooperation required to solve rising debt burdens in LMICs, illicit financial flows and tax avoidance, all of which severely limit the domestic fiscal space of countries to invest in PPR.
4. A consistent approach to the principle of equity and inclusion, which is essential to ensuring an effective and international policy regime, is needed across all PPR agendas.
Starting with the need for clear and actionable commitments, first, as it has recently been underscored by the Independent Panel, the INB-led discussions are the world’s best chance of holding governments to account and ensuring that they fully understand each other’s pandemic responsibilities to better protect citizens from future pandemic threats and disastrous policy response.
It is astounding to us, as global health scholars and civil society representatives, that the Pandemic Accord discussions to date have not begun seriously to do this. Article 20 of the present International Negotiating Body (INB) text, where the matter of financing is taken up, manages to pack into its 503 words such generalities and obfuscations that, in their present form, look more likely to reinforce than to fundamentally address the challenge of securing adequate, equitable, and effective financing for pandemic preparedness and response.
It is critical that negotiators now move out of first gear on Article 20. Experience shows that very often in international negotiations it is financing that eventually trumps other considerations in the final reckoning of which policy priorities have impact within them. This is a lesson in which low- and middle-income countries have long been painfully aware. But it is something that fiscally constrained higher-income countries are also increasingly coming to understand, with health budgets deteriorating, and other global crises putting pressure on limited public revenue streams. In this light, a bold – but perhaps above all, lucid – financing vision is required for the Pandemic Accord. In its present state the proposal for Article 20 lacks a sufficiently coherent approach to effectively tackle future health emergencies, while its overly broad language provides little sense of direction or commitment.
Without spelling out ambitious aims or articulating a clear vision for financing PPR, the predictable result is that deeply entrenched systemic inequalities will remain unaddressed. The current proposal of establishing a Conference of Parties to identify a sustainable funding mechanism no later than 31 December 2026, for example, risks delaying these important discussions that should be taking place during the ongoing INB negotiations. It is essential that negotiators find ways to address this lacuna with new thinking about how best to finance the PPR initiatives that will operate under the Pandemic Accord umbrella in ways that are aligned, proportional, complimentary, sustainable and fair.
Alignment of financial mechanisms
This brings us to the second challenge. At present there has been no serious recognition of the elephant in the room in PPR discussions: namely how the avalanche of post-Covid pandemic instruments and processes will intersect. For example, what will be the future relationship between the World Bank’s newly established Pandemic Fund and the Pandemic Accord, which at the moment calls for both a “capacity development fund”, including annual monetary contributions by Parties to the WHO Pandemic Agreement”, and an “endowment” comprising voluntary monetary contributions from “sectors that benefit from international work to strengthen pandemic prevention, preparedness and response” and other voluntary donations, such as from philanthropic foundations, as part of its financing mechanism?
In our view, the usual negotiating mechanism of “constructed ambiguity” on this matter threatens to create little beyond loose normative commitments. This threatens to result in an Accord that is financially misaligned with other PPR initiatives and will result in diminished economies of scale. Moreover, the rapid establishment of the Pandemic Fund, with its own initial round of funding, has now created a degree of pathway dependency, where precedence constrains future decisions and policy options which cannot be ignored nor siloed away without profound fragmentation effects.
The implications of entrenched fragmentation within the Accord reach far beyond its relationship with the Pandemic Fund. The wider PPR governance and finance architecture also includes proposals for a new Medical Countermeasures Platform, a new International Pathogen Surveillance Network, and the revised International Health Regulations. All of which require financing. Although these new initiatives should theoretically connect to key negotiated articles within the Pandemic Accord, exactly how the Accord will act as an umbrella structure across, and in relation to, these other policy agendas remains under-specified, if not entirely absent. Again, this raises concern about how it will be possible to deliver coordinated, comprehensive, and cogent PPR as a global public good – particularly in a political environment with strong signs of “donor fatigue”.
Tackling domestic and international barriers for sustainable financing of PPPR
Thirdly, sustainable financing for PPR will require mobilizing domestic resources as well as additional international financing. However, fiscal capacity is often constrained by debt burdens (e.g. rising debt servicing costs), tax avoidance and evasion, and other illicit financial flows, particularly in low- and middle income countries. While the Accord itself need not comprehensively address these macroeconomic realities, it must better acknowledge such constraints. In our view, discussions on financing within the accord should therefore link much more explicitly to other processes tackling unmanageable debts (including debt cancellation), tax evasion, and financial outflows limiting domestic fiscal space.
If countries lack fiscal leeway, they cannot sufficiently strengthen their health systems – so the accord must recognize systemic economic barriers and connect with broader efforts enabling countries to sustainably mobilize adequate domestic financing. Simply ignoring these realities poses a serious risk to the needed investments in PPR.
Representation and governance
Fourthly, the existing and emerging PPR initiatives already suffer from legitimacy deficits. It is a common critique that the PPR agenda is “in democratic retrograde”: captured by the usual suspects without meaningful representation, particularly for lower and middle-income countries and by civil societies and communities. The lack of representation in the Access to Covid-19 Tools Accelerator (ACT-A) is well documented, impacting the delivery of COVID-19 tools. Despite these lessons and best practice across the global health architecture, civil society still had to advocate for their own representation and voting in the governance of the Pandemic Fund. At the INB, despite repeated calls from a broad range of stakeholders, participation remains limited. Such a lack of voice is disheartening on democratic and procedural grounds, since processes of coauthoring and ownership are key to promoting accountability, transparency, ownership, trust, compliance, and importantly, more effective, efficient, and equitable health outcomes.
The Pandemic Accord, a member state led process at the WHO, is at risk of similar failures if it ends up enshrining what is effectively the status quo, especially with regards to financing, into a binding agreement to be signed by member states. At present there is seemingly limited political desire to improve representation within PPR processes. Getting this wrong now will have acute legitimacy effects that will plague global health policy for generations.
Consequently, we argue that no effective PPR response will be possible unless and until these financing challenges are addressed, for which they need more explicit consideration within the democratic negotiation of these diverse elements within the pandemic accord discussions. We believe that the financing discussion within the INB process will become more and more significant as the deadline of May 2024 approaches and so it is important that country representatives and stakeholders come together now, in this seventh round, to address the question of what a fair and equitable approach to pandemic financing looks like across the board. We must address above all else, what core principles – such as those of all contributing, all benefiting, and all deciding, as proposed in a Global Public Investment framework – would allow countries to fairly determine the costs and shared burdens of financing future PPR commitments, and to see these principles in the final pandemic accord text.
A serious discussion now needs to take place. And for the next few months, Geneva is where that needs to happen.
Get in touch with authors: via Simon Reid-Henry: simrei@prio.org
Global health is everybody’s business. Help us probe the dynamics where science and politics interface with interests. Support investigative global health journalism.