WHA 2019 Top Issues: Budget, UHC, Access To Medicines, Emergencies, Environment

This year’s World Health Assembly will provide perhaps the best measure to date of the World Health Organization director-general’s policies since taking office nearly two years ago. But it will also reflect changing times for country relationships and for the state of global health.

The 72nd annual World Health Assembly (WHA) of member states will take place from 20-28 May. Documents for the Assembly are available here.

The preliminary agenda and other details of the meeting including member state side events are available in the Preliminary Journal of the Assembly dated 2 May. There are links to some 50 progress reports, strategy plans and updates that will contribute to the meeting of WHO’s 194 member states. Events organized by non-state actors are listed here.

The WHA will take on a wide range of topics in a short time, including universal health coverage, the next two-year budget, organizational reform and a host of staffing and internal issues, access to medicines, emergencies and pandemics, environment and health, antimicrobial resistance, and actions on a variety of diseases such as polio, tuberculosis, and non-communicable diseases. Below is a look at some of the issues ahead.

World Health Assembly, 20-26 May 2018, Geneva, Switzerland. Photo: WHO/Antoine Tardy

Universal Health Coverage

Considered a theme of this year’s WHA and a core component of the director-general’s platform, and with a high-level meeting slated for September at the United Nations, universal health coverage will be the highlight for health ministers and delegation heads at the outset of this Assembly, with a focus on inclusion (‘leaving no one behind’), according to sources. But after that, it may recede into the day-to-day work of the week, as this Assembly is not expected to negotiate on the issue.

WHO members approved a resolution on the high-level meeting (HPW, Universal Health Coverage, 5 February 2019) at the last WHO Executive Board meeting, in January, and unless a member tries to reopen it at the WHA, it should head on to negotiators in New York, who are rumoured to be starting work as soon as this week. The EB approved three resolutions on UHC: EB144R.10 (on preparation for the high-level meeting), EB144.R9, and EB144.R4. The resolutions set out a series of suggestions and commitments related to funding and emphasis on healthcare by member states.

There are three reports under the universal health coverage (UHC) agenda item at the WHA relating to these three areas: A72/12 (on primary health care), A72/13 (on community health workers delivering primary health care), and A72/14 (preparation for the high-level meeting of the UN General Assembly on universal health coverage). The Assembly is invited to take note of report A72/14 and to approve all three resolutions.

Swiss Global Health Ambassador Nora Kronig told Health Policy Watch: “I do think [UHC] is at the core of health and it’s at the core of our societies in terms of social contract that we put into place in terms of protecting the population in its access to health. You have public systems where you make sure the public has access to health which has the right quality level and being able to pay for it. It should be the case everywhere and in every situation.”

“It’s really a matter of responsibility of the state toward its population to make sure we have sustainable healthcare systems in place,” she said. “It is of course a different situation depending on the level of income the country has, and I think there’s still a lot of work to do through the development lens to make sure it’s universally so, but I think in the end it really goes to the core of making sure that the people get access to health when they’re sick to get treated.”

Related to universal health coverage, Dykki Settle with PATH’s Center of Digital and Data Excellence told Health Policy Watch: “It’s an exciting time for primary healthcare (PHC) and digital health. PHC is the foundation of strong health systems, and the first step in achieving universal health coverage and establishing health as a basic human right. However, most of the world’s population lack access to essential health services. Harnessing real-time, high-quality data for PHC through the application of digital technologies can help governments take more immediate and informed action on PHC programs, workforce, and financing to overcome this challenge.”

“With the essential support of the WHO and its member states, we are realizing the promise of digital health and working together to accelerate digital transformation,” he said. “We look forward to building on our shared digital and data agenda with global and government partners and stakeholders at this year’s World Health Assembly.”

PATH’s delegation to the WHA will include its President and CEO, Steve Davis, and other leaders that span PATH’s expertise in digital health, research and development innovation, and essential medicines, among others.

Everyone generally agrees UHC is needed, Rebecca Perl, Vice President, Partnerships and Initiatives, Policy, Advocacy and Communication at Vital Strategies, told Health Policy Watch, but they haven’t truly grappled with how to pay for it. One idea noted by Perl is to look to domestic resources to help pay, such as through taxes on unhealthy commodities. Taxes are a win-win, she said, as they reduce the burden of chronic disease and provide funds for governments to use for public health, prevention and universal health coverage.

WHO Director-General Tedros Adhanom Ghebreyesus speaking at WHA 71 in May, 2018. Photo: WHO

Budget, Transformation

When WHO Director-General Tedros Adhanom Ghebreyesus took office in July 2017, he ushered in an ambitious new program for the agency, the General Program of Work (GPW13) for 2019-2023, which was approved by the 2018 Health Assembly.

In March, he announced “the most wide-ranging reforms in [WHO] history,” changing its structure and orientation, in line with “Triple Billion” targets under the next five-year strategic plan. Those targets are “one billion more people benefitting from universal health coverage; one billion more people better protected from health emergencies; and one billion more people enjoying better health and well-being.”

This year, in the first budget of his administration, Dr Tedros has asked member states to raise the ceiling on how much WHO can spend by 8% for the period 2020-2021.

It has been noted that member states are not being asked to approve a budget increase of 8%, but rather to approve that increase in the “envelope”, the level to which WHO is allowed to increase its spending if it is able to raise the funds.

The 8% increase would be for voluntary funds, made up by contributions by governments above their obligatory levels, and from other sources such as philanthropy. Within those voluntary funds, some are earmarked by the donor for specific projects and some are made available for WHO to put them to greatest need.

In addition, member states at the Assembly will decide whether to increase the level of assessed, obligatory contributions they pay to be members of the organization. Sources said is unlikely to change this year. The scale of assessed contributions is set every three years in New York, but WHO members can decide to increase or decrease overall. For instance, if they decided to increase obligatory contributions by 10%, this would be a 10% increase across the scale set in New York, with larger economies paying more.

“Budgetary decisions are very important because it should be a moment where member states agree on the means that they allowed the organization to work with in a strategic way,” Swiss Global Health Ambassador Kronig told Health Policy Watch. “It’s one thing to have strong operational, strategic goals, but then it’s all about making them become reality, and for that you need resources, and you need to allocate them well.”

Public Health Emergencies

The area of public health emergencies is high profile due in particular to the rise of Ebola in the Democratic Republic of the Congo (DRC), but the Assembly does not have a resolution on emergencies to negotiate. There are reports to consider, however, plus the activity in DRC, all of which could stir discussion about the WHO Health Emergencies Program. The three reports on the WHA agenda are:

Public health emergencies: preparedness and response
Report of the Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme

Public health emergencies: preparedness and response
WHO’s work in health emergencies

Public health emergencies: preparedness and response
International Health Regulations (2005)
Annual report on the implementation of the International Health Regulations (2005)

On the second and third, A72/7 and A72/8, the Assembly is asked to take note of the reports.

The first report, A72/6, of the Independent Oversight and Advisory Committee (IOAC), which was established in 2015, was made public on 7 May, and raises a host of recommendations aimed at addressing gaps and shortcomings it identified. In its conclusion, it states: “The IOAC commends WHO’s reaffirmed commitment to ending the [Ebola] outbreak. However, the IOAC is very concerned about funding gaps and staff exhaustion due to prolonged operations in a highly insecure and complex setting.”

On the same day as the IOAC report, 7 May, the WHO announced a new strategy for dealing with Ebola in DRC, effectively thwarting rising concerns after its decision last month not to invoke international emergency status for the situation.

Amanda McClelland, Senior Vice President of Preventing Epidemics, Resolve to Save Lives, Vital Strategies, said: “The issues that will likely dominate discussion around epidemic preparedness and response at WHA will depend in part upon the progress WHO and partners make in the DRC. If security continues to be a problem, there will be a focus on how we respond to high-risk events in countries where this is an issue. If community engagement isn’t under control and they haven’t been able to gain the trust of communities, the social science aspect of responding to epidemics will come up and be quite a strong topic of discussion. And there is a risk that Ebola could become a multi-country event by mid-May, which might heighten debate around past PHEIC decisions (public health emergency of international concern, such as due to an epidemic), and query the exact purpose of the PHEIC.”

More than 111 000 people have been vaccinated in the DRC since the outbreak was declared in August 2018. Photo: WHO/J. D. Kannah

Pandemic Influenza Preparedness (PIP), Nagoya Protocol

In a related issue to health emergencies, the Board is expected to discuss the functioning of the WHO Pandemic Influenza Framework, with a report on progress in A72/21, as well as the controversial issue of access to influenza viruses under the Nagoya Protocol on Access to Genetic Resources and the Fair and Equitable Sharing of Benefits Arising from their Utilization to the Convention on Biological Diversity.

The WHO Executive Board in January was unable to agree on the way forward on questions of access to influenza viruses as countries are increasingly implementing the Nagoya Protocol regulating the sharing of genetic resources. The Board requested informal discussions be held in the lead-up to the Assembly.

In looking at the public health implications of implementation of the Nagoya Protocol, member states have been presented with a report, A72/32, by the WHO secretariat, which is moving the issue forward despite concerns raised by some member states at the January Board meeting.

The secretariat report before the WHA promotes the secretariat’s work and progress but contains little mention of risks or the delay to the flu vaccines to be needed later this year. The secretariat pulled an unusual move at the Board meeting to push the issue ahead.

But concerns may be raised again in discussion at the Assembly, especially as delays to flu vaccines may be occurring.

Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), in a statement to Health Policy Watch said the pharma industry group is “closely following the agenda item on ‘Pandemic Influenza Preparedness Framework for the sharing of influenza viruses and access to vaccines and other benefits’.”

“There are increasing examples of delayed virus sharing as countries seek to implement Nagoya Protocol,” Cueni said. “We urgently need WHO and member states to work with stakeholders to prevent delays in virus sharing to avoid compromising global public health security and emergency response.”

Polio Eradication and Transition

Intensive efforts in recent years have all but eliminated polio, except for three hard-to-reach conflict regions (in Afghanistan, Nigeria and Pakistan). Meanwhile, WHO is transitioning away from the enormous portion of its resources that have been put to polio eradication in these years, in a way aimed at retaining the best aspects of the health systems it has developed.

Reaching the last mile is the hardest and most expensive because of the difficulty in reaching the last people to vaccinate, but also because truly eradicating it is complex, sources noted. A challenge is to absorb the polio budget and activities into the general WHO budget, retaining the essential functions, a source noted.

The January Executive Board took note of the two reports (on eradication and transition) and sent them on to the Assembly. Document A72/9 on eradication updates on efforts and highlights the need for continued funding through the 2019-2023 period, for which about $3 billion is still being sought, according to the document. The document A72/10 on transition does not appear to be publicly available yet.

Access to Medicines and Vaccines

One of the potentially hottest issues of the WHA, the high price of new medicines and vaccines has hit the mainstream worldwide, and many countries rich and poor are looking at how to reduce its burden on their health budgets.

The WHO Executive Board in January held a lengthy debate – with more than 60 interventions – on a roadmap for access to medicines, and now it is before the WHA. But in the meantime, a draft resolution on drug price and R&D cost transparency put forward by Italy has attracted all of the attention. The Italian proposal captured backing from at least 10 other governments before running into a group of developed countries seeking to delay discussion on it until next year. The Italian resolution has been the subject of informal consultations this week.

The Italian proposal is due to come up under the agenda item 11.7 on Access to medicines and vaccines. It has generated significant discussion and may be overshadowing the focus on the WHO roadmap on access to medicines, vaccines and other health products, 2019–2023, document A/72/17, a 46-page report and annex from the director-general dated 4 April. The roadmap also includes language on transparency, as well as issues such as flexibilities under the World Trade Organization Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), and the delinkage of product pricing from the cost of research and development. The roadmap sets activity in line with the WHO General Programme of Work to 2023.

The action on the roadmap is for the Assembly to take note of the report and roadmap.

Swiss Global Health Ambassador Kronig told Health Policy Watch: “I think that we all have an interest in transparency, and from a Swiss perspective, we have a law in which every citizen of Switzerland can ask to have access to any public document within the administration.” But even the Swiss law has some exceptions, she said, such as for critical foreign policy matters or private data.

“I think what’s important in the discussion around the Italian resolution is first of all to bring it back in a broad sense of access to medicines in a holistic approach and not look in detail at only one aspect but to take the whole supply and demand aspects into account,” she said. And on transparency, there is the “aspirational aspect” of transparency and the pragmatic implementation involving a mix of full transparency and exceptions.

“[P]rice transparency is something we’re very supportive of because it’s the way we work, and we are the only ones who are actually fully transparent, and we do think it is very important for member states to work together to go in that direction because we are fully convinced that we will all profit from that,” Kronig said. “But at the same time, it is always something that is difficult to accommodate nationally since we are the only ones who don’t do any secret deals to an extent we may be losing in that situation and should think on doing that to a certain extent. We don’t have a price that is published and then a real, secret price, we only have one price.”

And on the other issues in the Italian proposal, “we have question marks, is it a good thing, is it a bad thing?” she said. “For instance, on being transparent on R&D costs, is it really going to help to get to better access to medicines. We will be asking all those questions.”

Related issues may be discussion of the WHO Essential Medicines Program, an important cancer drug pricing report by WHO corresponding to its Fair Pricing Forum that brings actors from across the spectrum together in an informal way to discuss the issues.

Health, Environment and Climate Change

Another high-profile agenda item for the WHA is the WHO draft global strategy on health, environment, and climate change, A72/15, and a draft action plan, A72/16, for small island developing states particularly vulnerable to climate change.

The draft strategy received broad support at the January Executive Board meeting.

The draft strategy includes six core functions grouped in three themes: “(a) leadership and policies; (b) evidence synthesis and advocacy, including the Organization’s normative function, development of tools, monitoring of implementation and shaping the research agenda that will support public goods for health; and (c) provision of direct country support.”

Tropical Cyclone Idai made landfall in mid-March, bringing heavy rains and flooding to Mozambique, Zimbabwe and Malawi, affecting a total of 1.6 million people in the three countries. Photo: WHO

Other Issues

There is a range of other equally important issues on this year’s WHA agenda, including follow-ups on several high-level efforts at the UN-wide level. These include implementation of UN 2030 Agenda for Sustainable Development, and follow-up to UN General Assembly high-level meetings on antimicrobial resistance, non-communicable diseases, and tuberculosis.

Still other critical issues are human resources, patient safety, substandard and falsified medical products, smallpox, a global strategy on the health of refugees and migrants, a global strategy for women’s, children’s and adolescent’s health, and many others. An effort to get WHO to revise its guidelines on biosimilars may come up as well.

Separately, there has been discussion around Taiwan’s effort to be allowed to participate at the WHO as its own country and not under China.

More on UHC

Commenting on UHC, Vital Strategies’ Perl cited the Philippines as an example of a country that has successfully used “sin taxes” on tobacco and alcohol to finance universal healthcare programs. Jeremias Paul, who was Undersecretary (Vice Minister level) of the Domestic Finance Group of the Department of Finance in the Philippines now works for WHO. Much of this was highlighted in a recent report “Health Taxes to Save Lives,” from the Task Force on Fiscal Policy for Health, which is co-chaired by WHO Global Ambassador Michael Bloomberg and former US Treasury Secretary Lawrence H. Summers. Analysis conducted for the task force estimated that over 50 million premature deaths could be prevented if countries implemented excise tax increases large enough to raise the product prices of tobacco, alcohol and sugary beverages by 50 percent over the next 50 years.

Another possible source of funding, she said, is to look for cross-pollination with what is already being funded, as some budgets address chronic disease comorbidities such as TB and HIV. Separately, Perl mentioned that air pollution and mental health are two areas that are getting more attention and have now made it onto the WHA agenda. From a non-communicable diseases standpoint, WHO previously used a 4×4 model, 4 leading drivers – tobacco, unhealthy diet, lack of physical activity, and alcohol, and 4 leading diseases – ones killing 70% of people today – cancer, diabetes, heart and lung disease. This will be the first WHA since UN member states voted at the High-Level Meeting on NCDs last September to adopt mental health and air pollution in the expansion from the “4×4” to the “5×5” NCD agenda, she noted. This was approved by the Executive Board in January and now will have to be fleshed out with policy recommendations such as “best buys”, which are WHO priority policies that offer high impact and low cost to implement in low- and middle-income countries. A 2017 WHO report on “best buys” is here.

And she raised ongoing concern about commercial influence on health policy, such as voluntary guidelines for alcohol and other food industry strategies that evidence has shown do not reduce NCDs, for instance. She gave an example of a successful program in Chile that required prominent black labels for products carrying high levels of salt, sugar, and fat. Companies reacted by lowering the amount of these ingredients in their products in order to avoid the negative labelling. But on food policy, she noted that WHO best buys do not really address sugar-sweetened drinks after some countries objected. “We really don’t want to see this,” said Perl. “We want policy before vested interests.”

A number of policy packages are available to guide government efforts to reduce NCDs, Perl noted, including: MPOWER to reduce tobacco use; REPLACE, a six-step action package for the global elimination of industrially-produced trans fats from the food supply; SAFER, an initiative and technical package outlining five high-impact strategies that can help governments to reduce the harmful use of alcohol and related health, social and economic consequences; SHAKE, which is aimed at sodium reduction; and HEARTS, which outlines a strategic and practical approach to reducing deaths from cardiovascular disease. Vital Strategies provides support to help governments implement these initiatives, in addition to work in areas such as obesity prevention, road safety and environmental health.

Vital Strategies also published a report called Hazy Perceptions, which details public perceptions about air quality based upon discourse in the media and on social media.

IFPMA’s Cueni said a top priority for IFPMA is “to support the positive momentum for accelerating progress towards Universal Health Coverage and the preparations for United Nations high-level meeting (UNHLM) on UHC in September. We see UHC as the foundation for a healthier, more sustainable future for all.”

Another priority issue for IFPMA, he said, is the agenda item on access to medicines and vaccines. “Improving access can only be achieved through collaboration, investment in strengthening health systems including regulatory systems, reducing financial hardship and out of pocket expense for patients, while supporting innovation that delivers breakthrough treatments,” he said. “We are encouraged by the direction of the ‘Access to Medicines and Vaccines Roadmap’ towards a pragmatic approach to focus on a set of specific, measurable priorities where there is widespread international consensus. However, we are concerned about the draft ‘transparency’ resolution; if adopted as stands, would divert attention and resources away from finding sustainable solutions to access and may have unintended consequences of creating additional barriers to availability and access to health products.”

Image Credits: Photo: WHO/Antoine Tardy, WHO/Antoine Tardy, WHO, WHO/J. D. Kannah.

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