Hi,

We are happy to be presenting the tenth edition of this newsletter. It feels like a small but happy milestone. Thank you for reading us.

Few weeks in 2020 have been as significant as this one.

The repercussions of what happens in America, will not only be felt in the country grappling with the pandemic, but also in places such as Yemen; in homes and clinics negotiating women’s reproductive choices; of course, in Geneva. Already, international organizations such as the WHO and the WTO have been impacted by recent directions taken by American foreign policy. But astute observers believe that for some of the issues that take shape in Geneva whether its reform of the WTO or issues concerning drug pricing (to an extent), American diplomacy is near-agnostic to the administration in the capital. So lets say the “markets” had somewhat priced in this uncertainty. The impact of the American elections on global health will continue to be deciphered in the coming months.

Our story this week, an exclusive, on a new proposal by U.S. and Brazil on WHO’s roadmap on governance reforms. At the cusp of a potentially new administration in the U.S., what does it mean for WHO?

This week, exceptionally, we also have another story for you, laying out the legalese around the first ever virtual World Health Assembly. This briefing we believe, it is important to understand the hows and whys of these governance matters.

In other news, we are also delighted to announce that we have won a small but important grant from the European Journalism Center. It gives us the much needed breathing space to meet our immediate costs. We are happy and encouraged by this recognition.

Finally, do consider supporting us. Paying for content that informs you, will keep this going. Your financial contributions will continue to enable us to raise questions and add to the diversity of perspectives in global health reporting. I also urge you to share our work with colleagues who work in global health, who you think will benefit from reading us, and those who could further inform and contribute to our work!

Share, source and support us.

Best,

Priti

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

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1. Story of the week

THE U.S. & BRAZIL TEAM UP TO MAP W.H.O. REFORM

The U.S. and Brazil have teamed up to lay out a governance reform proposal for WHO in the context of the urgencies that COVID-19 has wrought upon. The timing of such a proposal is bemusing given the uncertainties around American engagement at WHO.

It is expected that this proposal, along with others, will be discussed at the margins of the upcoming World Health Assembly next week, Zsuzsanna Jakab, Deputy Director-General, World Health Organization said at an event today.

While there are some convergences with the earlier proposal put forth by Germany and France (such as on independent access to outbreak areas), on certain issues including on funding for WHO emergencies programme or greater transparency for the workings of the IHR Emergency Committees, or “delinking” travel from trade restrictions during health emergencies, for example, there are some new approaches.

In a document titled, “Reviewing COVID-19 Response and Strengthening the WHO’s Global Emergency Preparedness and Response,” it sets out a roadmap for WHO.

“…this roadmap sets out areas where we believe there is an opportunity to strengthen the WHO by increasing accountability and its ability to be impartial and objective, improve transparency and its overall effectiveness, by providing it with a more comprehensive set of tools that are fit-for-purpose to address new and emerging threats….,” according to the document, seen by Geneva Health Files.

The proposal is divided into areas for short term progress under existing mandates and areas for medium and longer term action.  

PROPOSED SHORT TERM ACTIONS

As has been discussed over the last few months, the proposal suggests that WHO consider a new designation -- the Intermediate Public Health Alert (IPHA) or “amber light” for the declarations of Public Health Emergency of International Concern (PHEIC). 

The document says, that WHO must issue updated guidance for itself, Member States and non-state actors building on the existing provisions in the IHR framework.  

“Increased objectivity and impartiality of WHO, including the membership and scope of an EC, tailoring each to a given outbreak and adapting as needed, over the course of each event as new evidence emerges provide a pathway to an improved EC. Additionally, more transparent public accounting of proceedings is important to understand decision making around PHEICs. The ECs should hold additional meetings, including if requested by an appropriate number of Member States, and be responsive to Member States’ inquiries. Providing written summaries of the discussion in all EC meetings would help build confidence.”

Greater transparency on emergency committee meetings are significant. (See below our analysis on this.)

In addition, the proposal also asks WHO and World bank to beef up processes around Independent Oversight and Advisory Committee (IOAC) and Global Preparedness Monitoring Board (GPMB) asking them to “review and secure their permanent mandates, terms of reference, defined scope of activities and sufficient resourcing.”

It also seeks ways to empower the Chief Scientist’s Office with sufficient budget and staffing, and “make global expertise available to all levels of WHO.”

The proposal also has language on access to medical products in the context of the pandemic. But it is not sufficiently clear in the proposal itself, on how access to medical products can be streamlined.

“Once COVID-19 countermeasures are developed, all countries must benefit from equitable access. Based on the experiences with access to medical products for COVID-19, strategies for medical countermeasures for future pandemics could be developed,” the document says.

“MEDIUM TO LONGER TERM ACTION”

The proposal suggests an overall approach to revamping health security including addressing matters on compliance to IHR, on preparedness, detection and response.

“…we propose consideration of a universal review mechanism for IHR compliance, to encourage countries to view preparedness as fundamental to national and health security as well as incentivize fulfillment of IHR obligations,” according to the proposal.

The U.S. and Brazil, adopt a strong position on accountability and oversight in the context of health security, also hinting at a wider role for “other global health partners and the public”.

The proposal says,“…Especially for public health risks with the potential to spread globally, we need to consider how best to strengthen Member State reporting to WHO, and empower WHO leadership to articulate Member States’ responsibilities in an impartial and objective manner when they are not meeting obligations.”

On the somewhat contentious matter of access to outbreak areas, it asks the independent review panel “to consider mechanisms to facilitate more rapid access to outbreak areas for WHO-led response teams to the extent required for a robust public health response, including in the assessment phase…” It argues that such access is crucial to the early containment of outbreaks, and therefore recommendations should include “ways to empower the DG to report and incentivize Member State compliance”

The proposal underscores the need to de-link travel from trade restrictions under emergency conditions in order to minimize economic impacts while maximizing public health measures.

“Ensuring open and safe global transportation routes and securing supply chains to allow delivery of essential products, guaranteeing humanitarian aid access to people in need and continued travel for responders are necessary,” the proposal says.

It asks WHO to work on an evidence-based process in conjunction with relevant organizations “to develop recommendations on the appropriate role of domestic and international travel restrictions within a suite of preparedness and response interventions…”

Pitching in support for the crucial WHO’s emergencies programme by initiating budget reforms, to make it sustainable, the proposal says “The WHO Solidarity Fund and the WHO Foundation are helpful in broadening the donor base, but any new funding sources need Member State oversight.” This is significant and can be read as an effort to have a great say in who controls the financial resources for the emergencies work.

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2. Briefing: World Health Assembly

THE WORLD HEALTH ASSEMBLY DURING A LOCKDOWN

The 73rd World Health Assembly resumes virtually next week at a time when large parts of Europe including Switzerland are locked down. What’s more the Director General of WHO, Tedros Adhanom Ghebreyesus is currently in self-quarantine after coming in contact with COVID-19 confirmed case. It is as somber a milieu that one could be faced with, when 194 countries come together to work through health challenges in the midst of this pandemic.

And yet, despite the limitations, a fairly productive week awaits the global health community. It is understood countries continue to discuss with WHO on the ways of engagement including special rules, for the forthcoming assembly, given the particular circumstances as a result of the pandemic.

WHO is planning on having a full assembly including three kinds of meetings as is usual - Committee A, Committee B and the general committee. The virtual format will be a test of how WHO and members will juggle through these various meetings, experts say.

The Director-General is also expected to announce a new framework for “Universal Health Review” (a proposal by Benin) at the Assembly next week, Zsuzsanna Jakab, Deputy Director-General, World Health Organization said at an event today.

PROCEDURES AROUND A VIRTUAL ASSEMBLY

The immediate local circumstances have had a physical impact on the proceedings in the run up to the Assembly scheduled to take place next week 9th-14th November 2020.

It appears not all member states are aware of what to expect from the Assembly and believe that the current situation has contributed for inadequate transparency and consultations in the proceedings around the Assembly.

The Assembly is expected to be in a fully virtual format. This is different from May 2020, where it was a hybrid format with a  mix of online and in-person consultations among member states.

A decision adopted by WHO Executive Board (EB 147/8) recognized that the possibility of limitations to physical meetings over the coming months that could impact the Executive Board meeting in early 2021 and the 74the World Health Assembly in May 2021. It empowers the Executive Board “Officers of the Board, in consultation with the Director-General” to make adjustments to the arrangements for these governing bodies meetings. (Also keep in mind that there have been calls for making the EB a more meaningful governance body able to set the agenda more effectively.)

It reads thus:

The Executive Board decided that in the event that limitations to physical meetings preclude the holding of the Seventy-fourth World Health Assembly, the 148th session of the Executive Board and the thirty-third and thirty-fourth meetings of the Programme, Budget and Administration Committee of the Executive Board in 2021 as envisaged, adjustments to the arrangements for these governing bodies meetings should be made by the Executive Board or, exceptionally, by the Officers of the Board, in consultation with the Director-General.

In terms of procedure, the pandemic has inevitably impeded the usual consultations by member states. In May 2020, the Assembly had already adopted a written silence procedure.  This allowed for decisions for approval by the Assembly as having tacit approval from member states, unless, countries broke the silence procedure on particular proposals, by submitting written objections to proposals within a limited time frame. (It is understood that about 20 decisions have been adopted in this manner)

Typically, the silence procedure follows formal and informal consultations on various proposals between countries. (Some civil society stakeholders believe that it is contributes to opacity in discussions between countries and other actors.)

On the closure of the Assembly, the decision said,

The Seventy-third World Health Assembly having considered the report on the closure of the Health Assembly, written silence procedure, decided: (1) to adopt the written silence procedure set out in the Annex to this decision;

(2) to suspend Rule 49 of the Rules of Procedure of the World Health Assembly in respect of the deadline for introduction of formal proposals for the purposes of paragraph 1 of the written silence procedure.

Paragraph 1 of the Written Silence Procedure discusses how the procedure will apply to proposals brought by member states. It reads thus:

1.       Following the suspension of the Seventy-third World Health Assembly session and pending its resumption, the following written silence procedure will apply in respect of any proposal that the President of the Health Assembly determines, following informal consultations or because the proposal was recommended by the Executive Board for adoption, is suitable for adoption without further discussion by the Health Assembly.

As per Rule 49 of The Rules of Procedure for WHA, mentioned above:

CONDUCT OF BUSINESS AT PLENARY MEETINGS

Rule 49

Formal proposals relating to items of the agenda should be introduced at least 15 days before the opening of a regular session of the Health Assembly and may, in any event, be introduced not later than the first day of a regular session of the Health Assembly and no later than two days before the opening of a special session. All such proposals shall be referred to the committee to which the item of the agenda has been allocated, except if the item is considered directly in a plenary meeting.

As per special procedures adopted to regulate the conduct of the de minimis Assembly session in May 2020, it was decided that “The first day of the resumed session of the Health Assembly shall be regarded as the first day of the session for the purposes of Rule 49, by which date formal proposals relating to items of the agenda may be introduced.”

Gian Luca Burci, Adjunct Professor, International Law; Academic Advisor, Global Health Centre and former legal counsel for WHO, clarified at an event today, that special procedures have to be adopted for the virtual assembly next week.

It seems that there are concerns on the feasibility of conducting a roll-call of countries if a vote is needed on some of the political issues such as Taiwan and Palestine, Jakab of WHO said.

Finally, it seems that unlike before, delegations will have limited and specified opportunities to make interventions. (Each country will have only limited number of opportunities to participate per “pillar”, observers said.)

Image Credit: Markus Winkler, Pexels

DECISIONS MADE

In early August 2020, WHO published a list of decisions proposed to the World Health Assembly in May, which were adopted by member states using the "Written Silence Procedure". (An earlier decision states that the adopted proposals will be referred to the Health Assembly at its resumed session for information only.)

The proposals relate to: strengthening global immunization efforts; cervical cancer prevention and control; a global strategy for tuberculosis research and innovation; eye care - including preventing vision impairment and blindness; strengthening efforts on food safety, a global strategy and plan of action on public health, innovation and intellectual property; a decade of healthy ageing; and influenza preparedness, WHO has said.

BETTER NON-STATE ACTOR REPRESENTATION?

Stakeholders in civil society have been some what assuaged that they will be allowed to formally present oral and written statements at the Assembly, unlike at the recently concluded Executive Board meeting in October 2020. In a letter to non-state actors in official relations with WHO, the secretariat said “Considering the specific arrangements set for the Seventy-third World Health Assembly, Non-State actors in official relations with WHO that have registered to participate may request to make statements through a dedicated video connection, during the meetings of Committee A and/or B of the World Health Assembly, under a technical item in which the non-State actor has a particular interest.” (Only statements presented orally at the invitation of the Chairperson will be considered in WHO’s official records, the letter clarified.)

WHAT TO EXPECT?

Given the on-going changes in geopolitics including a potentially new administration in the U.S. (votes were still being counted when this story went to print), the implications of how this plays out at the World Heath Assembly, will be interesting to see.

In parallel, discussions on WHO reform are gathering steam, including a new proposal by U.S. and Brazil, as reported above. WHO has asked member states to come together with their proposals to build on existing WHO reform processes, top officials said. These reform proposals are expected to come up at the margins of the assembly.

Will we see a repeat of the recent Executive Board, where countries sought greater transparency and consultations on new governance mechanisms? Watch this space for more.

(This story was slightly edited post-publication to improve readability)

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2. What we found interesting this week:

I. IHR EMERGENCY COMMITTEE MEETING ON COVID-19

The emergency committee meetings at WHO have assumed more importance that before, given also its impact on geopolitics.

The IHR Emergency Commitee on the pandemic met on 29th October, 2020 to take stock of the evolution of COVID-19.

Director-General WHO, Tedros determined that the COVID-19 pandemic continues to constitute a PHEIC. “He [DG] accepted the advice of the Committee to WHO and issued the Committee’s advice to States Parties as Temporary Recommendations under the IHR (2005),” WHO said in a statement

Read full the Statement on the fifth meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic

Some excerpts we found interesting:

Recommendations to WHO Secretariat:

On Research 
Continue to convene multi-disciplinary experts to agree on consistent language for and to further explain: all potential modes of transmission and virulence of SARS-CoV-2; severity risk factors and epidemiology of COVID-19; and the striking diversity of the pandemic dynamics globally.

Continue intersectoral collaborations to understand the origin of SARS-CoV-2, the role/impact of animals, and provide regular updates on international research findings. 

Continue to work with partners to refine mathematical models that can inform policy decisions on how best to mitigate the effects of the pandemic.

Temporary Recommendations to State Parties:

On Research

Conduct research and share information on transmission, including role of aerosols; presence and potential impact of SARS-CoV-2 in animal populations; and potential sources of contamination (such as frozen products) to mitigate potential risks through preventative measures and international cooperation.

(IHR EMERGENCY COMMITTEE ON COVID-19)

As our story today on the American-Brazil reform proposal highlights, countries are pushing for greater transparency in the workings of these committees.

We flag this New York Times article that discusses how the Emergency Committee meeting in January 2020 had unfolded:

 NYT: In hunt for virus source, WHO let China take charge

“What was not publicly known, though, was that the committee’s Jan. 23 decision followed intense lobbying, notably by China, according to diplomats and health officials. Committee members are international experts largely insulated from influence. But in Geneva, China’s ambassador made it clear that his country would view an emergency declaration as a vote of no confidence.”

New York Times

(BEHIND THE CURVE - This series of articles examines the missteps, misunderstandings and missed warning signals that allowed Covid-19 to spread around the world.)

Like a forensic investigation, the story goes after the narratives on the origins of the virus - a key issue that will continue to stick out in the months and years to come.

Questions on the issue of the origins of the virus routinely come up at the weekly WHO press briefings - as it did last week.

DG Tedros said on 30th October, that a group of international experts had their first virtual meeting with their Chinese counterparts.

An intrepid journalist, immediately seized upon the “virtual” nature of the meeting and asked if a team will actually go to China. Dr Mike Ryan, head of WHO’s emergencies programme made strong statements that the investigations will be driven by science and not politics. He also said that investigations around MERS and SARS had taken months and even years for a fully fledged investigation.

“We seek full scale, prolonged, sustained, comprehensive set of scientific investigations in China and in other countries….we need the best answers, not just any answer to satisfy the political needs of speed and investigation…We are scientists, we need the best possible scientific outcome, because it is very important that we know the truth…. to seek answers for the populations we serve”.

Dr Mike Ryan, WHO Emergencies Programme Chief

The Times story has articulated this interestingly: “The search for the virus’s origins is a study in the compromises the W.H.O. has made.”

It goes on to add:

“…What the team members did not know was that they would not be allowed to investigate the source at all. Despite Dr. Ryan’s pronouncements, and over the advice of its emergency committee, the organization’s leadership had quietly negotiated terms that sidelined its own experts. They would not question China’s initial response or even visit the live-animal market in the city of Wuhan where the outbreak seemed to have originated...”

Not everyone agrees with the NYT headline though:

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3. We are also watching:

• WTO’S General Council meeting: 9 November 2020

  The appointment of Ngozi Okonjo-Iweala for WTO’s top job will be discussed at the meeting. It is not clear if the appointment will be approved assuming full consensus will have been negotiated by then, or whether the process will be stalled till a new American president assumes office in January 2021.

  (The General Council is the WTO's highest decision making body comprising of all member countries, apart from the Ministerial Conference which normally meets every two years.)

  See WTO statement on the developments from last week: Members indicate strong preference for Ngozi Okonjo-Iweala as DG but US objects

  In a story last week, Bloomberg predicted, “…the possibility of months of gridlock over the selection process and more diplomatic friction with trading partners like the European Union….”

  The Bloomberg story also said:

  If former Vice President Joe Biden wins, it is likely WTO members will postpone the meeting until after the inauguration on Jan. 20, according to sources familiar with the matter. Even then, it might be several months after Biden takes office before the Senate could confirm a Trade Representative who would craft U.S. positions at the WTO.

  U.S. Sows WTO Turmoil by Vetoing Front-Runner for Top Job: Bloomberg

• The ACT Accelerator Facilitation Council met this week.

  We are waiting to know more! A revised investment case for the Accelerator is expected to be released soon.

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