What is happening at the 77th World Health Assembly- 2024? ......And an Introduction to the WHO Tracker

Seventy-sixth World Health Assembly, Geneva, Switzerland, 21 - 30 May 2023

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By Prof. T. Sundararaman Conversations on Health Policy May 24, 2024

What is happening at the 77th World Health Assembly- 2024?

......And an Introduction to the WHO Tracker

Dr. T. Sundararaman

Every year in the last week of May, the representatives of 194 countries who are the Member States of World Health Organization (WHO) meet at Geneva in the World Health Assembly (WHA) to endorse a number of reports and adopt a number of resolutions. Considering the high prevalence of international meetings that amount to little more than discussions without subsequent action, it might be alluring to overlook the importance of the annual WHA. But that would be a mistake.

The WHO is the pre-eminent organization in setting the agenda at the global level. But unlike in other sectors, WHO reports and resolutions influences the technical and administrative design of health interventions across most countries- but especially across all low- and middle-income countries (LMICs). Take for example an agenda like Universal Health Coverage. In 2005, it was not a term in use. In 2010 it was being hailed as the biggest innovation of the 21^st century and all countries sworn allegiance to achieving it. Alternatively, on a more detailed level, after the WHO introduced the DOTS strategy, every nation pledged its support, hailing it as the most significant development in tuberculosis management. A few years later, DOTS became DOTS plus and a few years later when the End TB strategy was announced DOTS was “denounced” and a slew of new strategies followed. So, it has been the same for HIV, Malaria, Neglected Tropical Diseases, Non-communicable diseases, mental health and so on and forth. Within one to three years of WHO adopting a strategy or operational design, almost all countries modify their respective strategies to conform. There is no parallel for this in say the education sector, or in natural resource management, or in energy sector etc. And this is despite the fact, that most commitments in the WHA are not binding commitments.

To a significant degree, the WHO’s role in setting agendas is well endorsed, and there’s a necessity to safeguard this role, especially when it faces criticism from global financial institutions and specific high-income nations, notably the USA, which tends to be particularly assertive in its opposition.. The annual WHA is the highest governance institution of the WHO. The WHO is an inter-governmental representative body operating on the principle of one country one vote, unlike almost all other global health and financial institutions. Its democratic essence has been significantly undermined since the mid-eighties, as its funding, previously derived predominantly from a mandatory and equitable cess levied on member states—amounting to over 80% of its budget—now constitutes only around 22% of its total budget. . The rest of the budget flows from bilateral donors whose funds come with specific obligations. Nevertheless, partly due to past tradition and partly due to the role required of it, the functioning of the WHO is more democratic and this character requires to be defended and expanded. But keeping it that way is a challenge. WHO’s actions are usually a negotiation between what it must do to satisfy its main bilateral donors, which are select high-income countries and corporate philanthropies like Bill and Melinda Gates Foundation, and what it must do to honour its Health For All mandate. The two are often not aligned.

Given this reality, when it comes to both setting the agenda at WHO or adopting and adapting the agenda that has been set to national priorities, LMICs need to exercise considerable informed judgement of their own. However, few LMICs can have all the expertise and capacity that is required for agenda-setting across such a wide variety of technical topics. It is crucial for professional, academic, and civil society organizations to offer impartial critical assessments of draft resolutions, identifying instances where the interests of high-income nations and corporates exert undue influence or compromise equity, justice, and the appropriateness of decisions for the needs of populations in LMICs.

One of the most important sources of independent analysis of the reports and resolutions that are placed before WHA and the preceding executive board meeting is the WHO Tracker. The WHO Tracker is a digital platform created by the Peoples Health Movements as part of its WHO Watch programme. The key objective of the WHO Watch programme is to enable efforts towards democratizing global health governance and is done in alliance with Medicus Mundi International and the Third World Network. The WHO Tracker provides informed commentaries on the agenda and activities not only of WHO but also of the United Nations General Assembly sessions on health, the World Trade Organization and other international meets.

Every year a week before the World Health Assembly goes into session the WHO Tracker publishes a commentary that covers all important agenda items. This Commentary is produced through PHM’s team of policy analysts in consultation with a global network of consultants. The commentary is designed to be read in conjunction with the Secretariat’s documents; it does not duplicate the material covered in the official documents. The suite of item commentaries is a work in progress and as more agenda papers are tabled, comments follow. For some items the PHM commentary takes time to develop and may not be published in time.

What is invaluable about the WHO Tracker is that it not only publishes a comment on the agenda item, but that this comment includes a note on the context in which the agenda item is introduced and a background that provides linkages to earlier resolutions and PHM comments on that theme. And this archive of papers can extend back to over two decades. This is an invaluable resource for country representatives attending the WHA, for policy makers back home and for public health professionals and practitioners to understand how global policy influences national policies and vice versa. There is really no other equivalent source of information on global health policy.

This commentary is then circulated to all the country embassies in Geneva and across a large number of civil society networks. We know informally that many participants and even members of secretariat refer to these commentaries for purposes of formulating their organizational positions as well as a source of critical reflection.

We request readers to download the integrated commentary on the full agenda of WHA77; this is downloadable in English, French, Spanish and Arabic from the Tracker WHA77 page. You could navigate through the WHA77 Tracker page to the PHM comments and background papers on individual items. Those who would like to receive an Update Alert could subscribe to the Updater.

The Agenda Of The 77th World Health Assembly (May 27th - June 1st 2024) - Overview

1. Highlights of WHA77- Pandemic Treaty and Amendments to International Health Regulations. (agenda items 13.1 to 13.4)

In an earlier conversation, we had introduced the debates on the pandemic treaty and stand-off between the LMICs and the high-income nations. With LMICs, led by the African group of 47, refusing to yield, the International Negotiating Body tasked with designing the proposed pandemic ‘instrument’ (treaty, accord, agreement) appears unlikely to finalize a text for the Assembly to consider. South Africa is quoted (by GHF) as listing seven outstanding issues:

Process and the instrument under which the agreement will be adopted;
Technology transfer and intellectual property of pandemic related health products;
Pathogen access and benefit sharing system (PABS);
One Health Approach;
Institutional arrangements and Conference of the Parties (COP);
Financing of the Pandemic Agreement; and
No Fault Compensation.

Given the stand-off, the Assembly will either have to give the INB another six months and bring it to a special session, or adopt a framework agreement and leave the details to working groups or try to negotiate it during the assembly. Tracker documentation for this item (13.4) is here. The official report A77/10 is still not published. The PHM comment includes links to a range of recent reports regarding the INB process.

The Working Group on amendments to the International Health Regulations appears to be closer to producing a draft, but even this is not completed and WHA begins on Monday. The revisions are likely to be as follows:

Art 3 highlights equity and solidarity among states parties but without mention of equity and solidarity within countries;
There will be new provisions regarding ‘health products’ (includes a definition, reference to a dossier, requirement for WHO to facilitate access, and concern for supply chains);
An ongoing debate over voluntary vs mandatory compliance with various provisions;
New gradings of emergencies, including provision for early action alert, a public health emergency of international concern, and declaration of pandemic including a more detailed decision tree;
A new provision for a National IHR authority to be identified as well as the existing IHR focal points;
New provisions regarding communication, consultation, verification;
Creation of a new Implementation and Compliance Committee;
More explicit obligations regarding financial assistance including for core capacities, the possibility has been raised of a ‘dedicated’ financing mechanism.
Tracker documentation for this item (13.3) is here. The official report (A77/9) is still not published.

2. Agenda items on UHC and related issues ( agenda items 11.1 to 11.8 and 12)

Agenda 11.1 is a report on UHC as put forth in the executive board which acknowledges that progress on UHC is seriously off track to achieve its goals. PHM in its comments appreciates the candid admission of this failure but points out that his poor progress is across regions, it points to flawed strategies rather than merely being a problem of implementation. The comment indicates the directions of re-design required. Regarding the resolution establishing a committee to propose strategies for enhancing emergency, critical, and acute healthcare, it advocates for a broader scope to effectively tackle the underlying causes of the current deficiencies in this domain.

Agenda item 11.2 is on NCDs. Another candid admission, again welcome, but insufficient attention to where the strategy is failing. The PHM comments point out to the limitations of the 4*4 approach ( now 5*5) and of its expansion in cost-effective best buys. The challenge is that current designs of UHC are not fit for purpose and integration into comprehensive primary healthcare remains a challenge. An important additional resolution under this agenda item on increasing availability, ethical access and oversight of transplantation of human cells, tissues and organs. This is a new development and while PHM welcomes this, some urgent considerations to improve upon the current draft has, in consultation with experts in this area, been put forth in the PHM comment.

Agenda item 11.3.is titled Infection Prevention and Control, but largely deals with IPC only within health facilities. While the priority to this is welcome, its to work not as a stand-alone intervention but with its integration into facility wide health systems strengthening, HR policies and quality assurance would be required.

Agenda item 11.4 is on Immunization, 11.5 is on End TB strategy and 11.6 is on Neglected Tropical Diseases (NTDs) and 11.7 is on Maternal health and child mortality. These were already commented on during the EB meeting and these are reiterated here. Agenda item 11.8 is on Antimicrobial resistance and this agenda item gains importance since it is preparatory to a high level UN meeting on this theme later this year. The PHM comment welcomed what has been included but has highlighted a number of concerns that were not included and a number of more specific measures that should be indicated. Agenda 12 is on malaria. A common problem running across all these agenda items is an over-emphasis or reliance on the emergence of new technologies that will make the existing problems go away, and an under-statement of both social determinants and the need for community engagement. It is worth noting that across all these items the role of community health workers hardly gets mentioned, which is in contrast to what was the position in say 2019.

PHM comments also noted that some of these draft resolutions were contested at the Executive Board in January and were supposed to be negotiated and finalized before the Assembly. In several cases the obstacle to consensus was a concern about terms like ‘gender sensitive’ or ‘gender responsive’, ‘gender equality’ or ‘unsafe abortion’ or ‘sexual and reproductive health rights.” Iran had objected to such language as ‘non-consensual’ in an intervention during the Executive Board meeting in January.

There are also two agenda items on the end-game as regards poliomyelitis (14.4) which has turned into a never ending saga and another on the destruction of the last stocks of smallpox virus (14.5), where the PHM position would be important to note.

3. Agenda items on War, conflict and emergency services:

A number of agenda items related to the war in Palestine (14.1 and 20)and Ukraine (14.2) and on a global health and peace initiative (14.3). PHM comments on these have been posted in consultation with a number of PHM activists who are engaged in peace and health efforts in these regions. Some of these issues will see high degrees of polarization and sharp debates and for those working on these areas or even those who are concerned about the devastation wrought by war, the resolutions, the PHM comments and the record of discussions would be most informative.

4. Agenda items on the Social and Political Determinants:

In what is called Pillar 3 and refers to the strategy of one billion more people enjoying health and well being there are five agenda items a) social determinants of health: 15.1; b) maternal, infant and young child nutrition 15: 2 c) well-being and health promotion 15: 3 d) climate change and health 15: 4 and e)economics and health for all- 15.5. Given the very inter-disciplinary nature of PHM and given its grounding in the political economy of health, PHM comments on each of these five areas are highly informative and combative towards the main thrust of each of these declarations. It even calls for member states to vote down the resolution on well-being and health promotion. This is not surprising, because the challenges in this area arise from the current global economic, social and political order and are highly discriminatory, unequal and unfair to LMICs. Just as in the pandemic treaty negotiations, the LMICs have found their voice and refuse to be push-overs, there is a need for a similar understanding in each of these five topics. In the last of these economics and health for all, the general thrust is in a direction that PHM would welcome, but its limitation is that is all inspiration and exhortation with very little concrete action. But here, the push-back comes from former colonizing powers and current high-income nations. However, this is still better than the silences and distortions found in some of the other resolutions.. On the climate change and health issue the PHM comment had called for basing it on ‘common but differentiated responsibilities and respective capabilities” (CBDR-RC) approach. This call has been also raised by a number of other countries, but the developed nations are firmly resisting this- and it is uncertain as to what will finally pass.

In conclusion:

Public health especially global public health clearly is not a neutral technical terrain, but a highly contested political terrain. One could miss this sober reality if one went only by the very diplomatic and euphemistic terms and expressions in which global policy documents are written. In the nineties LMICs gave away many rights, especially in the trade arena and in structural adjustment, partly because they did not understand the implications of what they were signing away. As the pandemic negotiations show, that danger is less now. But still across all health themes, including such apparently technical topics like Neglected Tropical Diseases (NTDs), concerns remain as to whether these policies are prioritising profits for big pharma and other corporates over health equity and social justice.

Often the negotiations remain limited to the corporate interests, the interests of high income nations and the elite and business interests within developing nations. The most important stake-holder which is the community is absent in the negotiating table. To paraphrase Virchow, it falls on the public health professionals (and civil society activists) as “the natural attorneys of the poor” to raise the concerns related to equity and social justice. The PHM commentary is one essential tool that helps those interested in Health for All and health equity to unpack the language of these global policy drafts and bring some of these concerns and the possible alternative formulations into the poliicy discourse.

Item alerts and commentaries on WHA 77 agenda will continue to be issued by PHM in the next few days. The record of discussions that took place in the assembly would also put up in the WHO Tracker over the next few month. For those interested in global health policy and its impact on national policies, WHO Tracker is a huge resource, to scan the entire area and to follow up on issues which are of specific interest to them.

Note : This article is posted at the website rthresouces.in. For earlier commentries you could visit Conversations on Health Policy in the same website. Links to the WHO Tracker on the WHA77 Tracker page and its integrated commentry is repeated here.