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The World Health Organization celebrated its 70^th anniversary last month. Since the inception of the organisation, the world has changed, and so have its challenges. The global rise of non-communicable diseases is one example of those challenges, as well as the escalating prices of new medicines and chronic access issues in many countries. The annual World Health Assembly will open on 21 May with an ambitious new General Programme of Work for 2019-2023, which promises 1 billion more people under universal health coverage.

There are many issues on the Health Assembly agenda for countries to discuss that are of relevance to readers, such as access to medicines and vaccines, and influenza pandemic preparedness. Antimicrobial resistance – the rising global resistance to known antibiotics – however, is absent from the agenda this year as it is a “biennial” issue and will be dealt with again in 2019.

How the General Programme of Work will be financed is still not clear. Meanwhile, the United States, the United Kingdom, the Bill and Melinda Gates Foundation, the World Bank, and Gavi the Vaccine Alliance are the champions of voluntary contributions to the WHO.

The 71^st World Health Assembly (WHA) is taking place from 21 to 26 May. The provisional agenda is here [pdf].

The WHO Executive Board in January approved the proposed 13^th General Programme of Work (GPW13) 2019-2023, to be confirmed by the WHA. WHO Board members’ approval of GPW13 did not imply, however, the approval of the preliminary financial estimate (US$10 billion) provided by the WHO secretariat before the EB January meeting (IPW, WHO, 29 January 2018).

The Board also requested that the WHO secretariat finalise the “outstanding work on the Impact Framework, financial estimates and investment case for consideration of Member States prior to the Seventy-first World Health Assembly.” The investment case will be available after the Assembly, according to a WHO press officer.

Medicines Access, Technologies, Innovation

According to several sources, a major focus of the upcoming World Health Assembly (WHA) is the question of access to medicines. This issue has been gaining in importance, in particular since high income countries started facing difficulties in meeting their public health needs due to the high price of new medicines, and medicines shortages. The Netherlands has been active at the WHO in denouncing high prices and measures in free trade agreements going beyond the requirements of the World Trade Organization Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), the 1994 agreement which sets out global IP rules on medical products as well as exceptions to those rules for public health reasons.

Following a January Board decision, the WHA is expected to adopt a decision requesting the WHO to elaborate a roadmap report, in consultation with member states, outlining the programming of WHO’s work on access to medicines and vaccines (IPW, WHO, 25 January 2018). This roadmap is supposed to include activities, actions and deliverables for the period 2019 to 2023, and is expected to be submitted to the 72^nd WHA (2019), as explained in the WHA document [pdf].

The WHA also will consider for adoption a resolution agreed at the January Board meeting concerning 33 recommendations by an expert group that reviewed the 2008 WHO Global Strategy and Plan of Action on Public Heath, Innovation and Intellectual Property (GSPA – also called GSPOA) (IPW, WHO, 26 January 2018).

Three of those recommendations, specifically aimed at member states, include the question of transparency of the cost of research and development. According to the WHA document [pdf], the budget for the implementation of those 33 recommendations was estimated at US$31.5 million for the period 2018-2022, and the estimated budget for the implementation of the high-priority actions identified by the review panel would be US$16.3 million.

The 33 recommendations are laid out in an annex to the WHA document and the high priority actions are underlined. However, the proposed budget is not covered within existing resources, and additional resources have to be found.

The WHA will further consider a draft resolution [pdf] adopted at the January Board meeting concerning access to assistive technologies. The WHA document [pdf] relates that only one in 10 people in need have access to assistive products owing to high costs and a lack of financing, availability, awareness and trained personnel. For example, the document explains that 70 million people need a wheelchair but only 5 to 15 percent have access to one, and hearing aid production meets only 10 percent of global need, and 3 percent of the need in low-income countries.

According to the document, most research and development in the area of assistive technology “has focused only on assistive products and is specific to high-income contexts,” and “there is an urgent need for research and development to be driven by the needs of the diverse users and contexts around the globe.”

Global Vaccine Action Plan Still Needs Progress

The WHA is invited to note a report [pdf] containing the summary of an assessment of the 2011-2020 Global Vaccine Action Plan.

The Strategic Advisory Group of Experts (SAGE) on immunization assessed the action plan in 2017, and provided recommendations. The experts found that progress still remains too slow for most goals of the vaccine action plan to be reached by the end of the Decade of Vaccines in 2020.

Beyond conflicts, natural disasters, displacement and migration, factors such as growing levels of vaccine hesitancy and the rise in stockouts, primarily related to shortcomings in vaccine procurement and distribution, are impeding progress, the document says.

The experts provided a list of recommendations, including on technical capacity building, and vaccine supply and access.

The document also contains a summary of WHO activities to support member states. It includes topics such as advocacy, accountability, vaccines for new and re-emerging diseases, vaccine prequalification, and joint procurement.

According to the document, the WHO has been working with stakeholders, such as UNICEF, non-state actors, industry, and Gavi on several initiatives on procurement and access to affordable vaccines. Those include efforts to develop policies and programmes to enhance availability and affordability of supply, for example through the dialogue on fair pricing for medicines and vaccines.

The WHO also worked to collect data to inform policymakers on procurement choices, for example through the Vaccine Price, Product and Procurement initiative. The initiative is currently collecting information from 144 countries, according to the WHA document.

Voluntary Contributions: US, UK, Gates Heavyweights

According to a WHA document [pdf] displaying voluntary contributions, the United States is the biggest funder of the organisation. The contributions are divided into several categories, including contributions, specified contributions, and outbreak and crisis response.

For 2017, the largest contributors among countries are the US (US$401 million), the United Kingdom ($163m), Germany ($89m), Japan ($46m), Canada ($34m), Sweden ($27m), South Korea ($26m), and Pakistan ($22m – mostly on outbreak and crisis response). The European Commission donated close to US$82 million.

The Bill and Melinda Gates Foundation is by far the largest non-governmental funder, with US$324 million (the bulk of it under Special Programmes and Collaborative Arrangements), followed by the World Bank $(145m), Gavi the vaccine alliance ($133m), the Rotary Club ($62m), and a number of UN agencies, such as UNAIDS, an the UN Central Emergency Response Fund.

UN High Level Meeting on Non-Communicable Diseases

The UN General Assembly will hold a high-level meeting on 27 September 2018 “to undertake a comprehensive review of the prevention and control of non-communicable diseases,” according to the dedicated webpage.

The WHO is preparing for this high-level meeting and stated in the WHA document [pdf] that the global epidemic of premature deaths from non-communicable diseases is driven by several factors. These include: poverty leading to barriers in access to safe, quality, effective and affordable medicines; the impact of the globalisation of marketing and trade of products deleterious to health, such as tobacco, alcohol and unhealthy diets; and population ageing.

It is estimated that 15 million people died prematurely from non-communicable diseases in 2015, according to the document, and the burden “continues to rise disproportionately in low-income and lower-middle-income countries.”

The WHO established a WHO Independent High-Level Commission on Noncommunicable Diseases, which is expected to submit its report to the WHO Director General on 1 June 2018 with recommendations.

The WHA is invited to note the WHO report.

Snakebite, mHealth

At the January Board meeting, WHO members adopted a draft resolution [pdf] which is on the agenda of the WHA for formal adoption (IPW, WHO, 30 January 2018). The draft resolution recognises that snakebite envenoming has been “largely overlooked” by the global health community, and requests that WHO members assess the burden of snakebite, improve the availability, accessibility, and affordability of antivenoms to populations at risk, and promote the transfer of knowledge and technology between member states to improve the global availability of antivenoms.

And the WHA will be called to consider a report on “mHealth” (mobile health). According to the WHA document [pdf], “digital technologies are becoming an important resource for health services delivery and public health.”

With over 7 billion mobile telephone subscriptions across the world, 70 percent of which are in low or middle-income countries, mobile wireless technologies are particularly relevant, it says.

However, governments “have found it challenging to assess, scale up and integrate such solutions,” in part due to contributing factors such as the multiplicity of pilot projects with no clear plan or process for scale; and “the lack of a multisectoral approach within government – and also among donor agencies – especially engagement between ministries of health and ministries of information and communication technologies and recommended rules of engagement with mobile network operators and the private sector.”

According to the WHA document, WHO priorities include: supporting cross-sectoral collaboration and coordination between different UN agencies and other bodies; updating the Global Observatory for eHealth mechanism for data collection and reporting; and provide guidance and assessment frameworks on mHealth and digital innovations to help member states to select, adopt, manage and evaluate digital health solutions in order to aid good governance and investment decisions.

Pandemic Influenza Preparedness

Last year, the WHA took a decision [pdf[ (page 65) on the review of the WHO PIP Pandemic Influenza Preparedness (PIP) Framework for the sharing of influenza viruses and access to vaccines and other benefits. The WHO was requested to provide an in-depth analysis on a possible inclusion of seasonal influenza viruses into the PIP Framework, and on how to deal with virus genetic sequence data (virus genetic code) within the PIP Framework (IPW, WHO, 26 May 2017). The question whether genetic sequence data are included in the framework seems to be a matter of interpretation at the moment.

The WHO was also requested the External Auditor to perform an audit of PIP Partnership Contribution funds (funds paid by users of the WHO Global Influenza Surveillance and Response System [GISRS] to access influenza virus with pandemic potential). This audit was requested to make sure that the Financial Regulations of the WHO have been appropriately applied in the use of the funds, and that the information reported is accurate and reliable.

Furthermore, the WHO was to consult with the secretariat of the Convention on Biological Diversity, in particular on the Nagoya Protocol on Access to Genetic Resources and the Fair and Equitable Sharing of Benefits Arising from their Utilization.

According to the WHA document [pdf], the WHO secretariat has been working since May 2017 with the CBD, the UN Food and Agriculture Organization, and the World Organisation for Animal Health “to advance work relating to access to pathogens and the fair and equitable sharing of benefits in the interest of public health.”

The four secretariats are planning to hold a joint workshop in June 2018 to discuss and develop tools that could facilitate access to pathogens and sharing of benefits during public health emergencies, the document says. The WHA is expected to note the WHO secretariat report and approve a set of steps for further work.

In April 2018, an information session on GISRS was held for member states, representatives of the GISRS, members of the PIP Advisory Group, and “relevant stakeholders.” Several fact sheets were due to be published ahead of the session. Some of them were not available at that date. At press time, some are still missing, such as the fact sheet on genetic sequence data and databases, and the fact sheet on new technologies.

Another WHA document contains the report [pdf] by the Director General on the PIP Framework. According to the document, despite the fact that the Global Action Plan for Influenza Vaccines, which ended in 2016, led to the quadrupling of potential pandemic influenza vaccine production capacity (to 6.4 billion doses), global vaccine production remain insufficient. The WHA is asked to note the report.

Financial Reports, Some Countries Banned From Voting

The WHA is also expected to consider the WHO programmatic and financial reports for 2016-2017, including the audited financial statements for 2017 [pdf], and the financing of the Programme budget 2018-2019.

According to a WHA document [pdf] on the status of collection of assessed contributions by member states, as of 31 December 2017, unpaid contributions amounted to US$175.5 million.

Following Article 7 of the WHO Constitution, members who fail to meet their financial obligations to the WHO may see their voting privileges suspended. If by the time of the opening of the WHA Gambia, Grenada, and South Sudan are still in arrears in the payment of their contributions their voting privileges might be suspended as from the opening.

Three countries not respecting their commitments under special arrangements made for repayment of arrears might also be deprived of their voting privileges: Central African Republic, Ukraine, and Afghanistan.