What to watch at this year's World Health Assembly

GENEVA — With Ebola back in the Democratic Republic of the Congo, this year’s World Health Assembly sees the threat of pandemic diseases and the fragility of global health security once again at the forefront of the global health leaders’ minds.

While the virus is endemic in DRC, this latest outbreak has raised particular concern after a patient was confirmed to have contracted the virus in one of the health zones in Mbandaka, a city of more than 1 million and a major port town next to the Congo river. Nine countries, including the Republic of Congo and the Central African Republic, are at high risk of transmission.

Still, experts say conditions on the ground do not yet constitute a public health emergency of international concern, given the “rapid and comprehensive” response of everyone involved.

Nevertheless, the aid community is on alert. As soon as it heard of the outbreak, the World Health Organization — which was harshly criticized for its handling of the recent Ebola outbreak that devastated West Africa — activated its restructured incident management system, sent experts to the site, and started working with partners on different levels of the response, including tracing and case management. Preparations are also underway for the deployment of an experimental Ebola vaccine, which WHO Director-General Tedros Adhanom Ghebreyesus told press would start on Sunday. DRC’s Health Ministry has reportedly said they will start on Monday, however.

In a demonstration of leadership, Tedros flew to DRC last weekend to see the frontline response himself, a move seen by some as unprecedented in WHO’s history.

In his opening press briefing for the 71st World Health Assembly on Friday, which was almost entirely about Ebola, Tedros spoke of his visit to Bikoro. He said that a few days following his trip, WHO was able to secure over $8 million in funding, out of the $26 million they’ve requested to address the outbreak.

But he emphasized that mobilizing political support is key to unlocking more funding.

“You can see a consensus saying: what happened in 2014 should not happen. That commitment will mobilize resources, and that’s what we want,” he said.

The focus Ebola is receiving against the backdrop of the organization’s most important annual meetings provides the U.N. aid agency an opportunity to showcase leadership and demonstrate that the reforms it has taken since the last outbreak are proving to be effective.

Improved confidence in the agency could have ripple effects on other agenda items at the weeklong meetings in Geneva. Member states will be evaluating funding for WHO’s Contingency Fund for Emergencies, which as of March 2018, had received “no new multi-year funding agreement,” and deciding the fate of the organization’s draft 13th General Programme of Work, which Tedros said is the “most important” action item at this year’s assembly.

Tedros aims for member states to endorse the GPW in this year’s assembly, allowing him to fast-track a process that traditionally takes at least two years.

But again, whether that confidence will translate to a fully funded GPW remains to be seen.

“We do remain encouraged by the emphasis on measurable goals, outcomes, and impact throughout the [GPW]. However, the aspirational plans versus the high-level financial estimate of $10.8 billion over five years of course I think will remain a key debate. This represents about $1.2 billion over the previous GPW, and consequently, while the strategy is promising, there will be discussion related to the feasibility of the proposal,” said Elisa Adelman, health officer from the Office of Health Systems and WHO liaison at the U.S. Agency for International Development, in a panel at the Center for Global Development last week ahead of WHA.

While the Ebola outbreak has spotlighted global health security at this year’s assembly, member states should be reminded that it’s not the only critical health issue — or issue more generally, for that matter — that will carry serious consequences if left unchecked.

Here are some of the key issues we’ll be following this week in Geneva.

Polio

Continued support for polio eradication efforts will be critical, even as member states discuss polio transition planning, and more so as they consider a post-certification strategy for the disease. Polio transmission continues to be a challenge in the only two countries where it remains endemic. There have been seven wild polio cases recorded in Afghanistan and one in Pakistan this year, according to Carol Pandak, director of PolioPlus at Rotary International, in a press briefing on Thursday about polio eradication efforts. In 2017, there were also vaccine-derived polio cases recorded in conflict-affected countries such as Syria and the DRC.

The Global Polio Eradication Initiative was able to raise an additional $1.2 billion for polio eradication efforts last year. But Michel Zaffran, director of polio eradication at WHO, admitted during a briefing on Thursday that as deadlines for polio eradication continue to be missed, additional resources will be needed.

“We have not yet gone back to our donors with indication of how much additional resources we will need because of having missed the 2017 deadline,” he said.

Kate Dodson, vice president for global health strategy at the U.N. Foundation, is anticipating important sideline conversations in Geneva this week with health ministers of the 16 polio priority countries on how to fulfil the goals of their transition plan, enhance the quality of those plans where there are gaps, and options for the future.

Tuberculosis

Tuberculosis is having its first-ever U.N. high-level meeting this year, and at WHA, member states will consider a draft multisectoral accountability framework aimed at accelerating progress to end TB. The framework allows for a review of member states’ commitments to end the disease, the identification of actions needed to reach that goal, and the monitoring and reporting mechanisms necessary to track progress.

Holding member states accountable to their commitments to end TB is crucial as incidence rises — including multidrug resistant cases — and millions of infections remain undetected.

As Sharonnan Lynch, HIV and TB policy adviser for Médecins Sans Frontières’ Access Campaign, told Devex in February: “What we cannot allow at the U.N. high-level meeting or the lead up to it is for governments simply to say they are committed to end TB, or that they promise to end TB by 2030, and that’s the end of it.”

Jamie Bay Nishi, director of the Global Health Technologies Coalition, particularly underscored the need for R&D investments in TB diagnostic tools and treatment, especially with the rise of MDR-TB. Diagnostics, she said, is often overlooked during discussion of disease areas. But she welcomed the initial essential diagnostics list that WHO came out with last week, which could be a potential game changer, helping smooth out regulatory bottlenecks that impede or slow uptake of some diagnostics in low-income settings.

NCDs

Noncommunicable diseases, responsible for the death of 40 million people annually, are receiving unprecedented attention at this year’s meetings. A fun run event — which Tedros himself participated in, along with two-time Olympic gold medalist long-distance runner Haile Gebrselassie — took place Sunday in Geneva as a kick off celebration to WHO’s 70th anniversary, but also to emphasize WHO’s commitment to promote better health for all. Lack of physical activity is a key risk factor for many NCDs, including cardiovascular diseases and diabetes.

A series of side events, both inside and outside the Palais des Nations, are focused on NCDs. On Saturday, Tedros also called for coordinated action to eliminate cervical cancer, a very often preventable disease that kills an estimated 270,000 women every year.

The increased attention paid to NCDs comes after years of the subject being sidelined at health conferences, and key questions remain as to how much of this year’s focus will translate to political and financial commitments. NCDs have been the topic of two high-level U.N. meetings, and a third one is set for September, but a considerable number of countries still have not fully developed their own NCD plans and targets. And as Devex reported earlier this year, NCDs, one of WHO’s most underfunded areas, have historically received little investment.

Access to medicine

Access to affordable and quality medicine was the subject of a heated debate at the executive board sessions in January. A particular point of contention was promoting transparency and understanding of R&D costs, and urging member states to dedicate 0.01 percent of their GDP to “basic and applied research relevant to the health needs of developing countries.”

In the end, these two points — as well as a third proposed recommendation that members take steps to prevent shortages of essential medicines — were left for further discussions.

This week, we’ll see if member states have the appetite to engage in another round of rigorous negotiations on these topics.

And on Friday, the delegation of Morocco and several member states are sponsoring an event at the Palais des Nations on overcoming monopolies on access to medicine.

Gender equality and diversity at WHO

WHO is inching closer to its goals of gender parity and equal geographic representation — but it still has a way to go, especially in terms of senior and leadership positions.

Tedros has made headlines in his first year as director-general after tipping the gender balance in his cabinet toward more women leaders. WHO’s latest human resources report also notes that the number of women in P4 grade positions and above at WHO has increased by 2.2 percent since January 2017.

But as of December 2017, women were still not equally represented in WHO country offices. Women accounted for 33 percent of staff in country offices, and of this, only 31 percent occupy director-level positions.

And then there’s the issue of regional leadership. On Saturday, WHO’s Eastern Mediterranean Regional Office held a special session to elect the regional office’s new director after Dr. Mahmoud Fikri, who was elected to the post in February 2017, died a few months after taking office.

The election was a test of Tedros’ call for more women representation in leadership positions across WHO. While still not representative, there were two women out of eight candidates on the list, a first in the region’s history, according to Women in Global Health, an organization championing more women in global health leadership. After having five men at the helm for 70 years, the organization and observers were hoping a woman would finally lead the regional office. But on Saturday, Dr. Ahmed Al-Mandhari of Oman was chosen by member states to lead the organization for the next five years.

Having women in leadership posts is only one of a list of items advocates want to see progress on within WHO. Others include gender mainstreaming across WHO program areas, budget for the aid agency’s gender-related efforts, and efforts to address issues of sexual harassment, abuse, and bullying across the organization, according to Roopa Dhatt, executive director of Women in Global Health.

The set of recommendations the WHO-CSO task team will be releasing on Tuesday evening will also include gender equity rights, Dhatt said.

Civil society engagement

Civil society actors have long been calling for more engagement and a place at the table as WHO drafts its policies. In the past year, they’ve seen increased engagement, with WHO setting up multiple civil society task forces and working groups to facilitate input into some of WHO’s programs, including on TB and NCDs. Tedros has also engaged civil society in consultation on the draft GPW.

Much of the engagement, however, is happening at the secretariat level. Loyce Pace, president and executive director of the Global Health Council, told Devex it remains to be seen how such levels of engagement will be implemented at the regional and country levels of WHO, which will be crucial as WHO heads toward boosting its country-level engagement under the draft GPW.

In addition, WHO’s framework of engagement with non-state actors — which include civil society and the private sector — that was adopted at the World Health Assembly in 2016 still has some conflict of interest safeguards to hash out. WHO staff have been tasked with coming up with details on this, with FENSA supposedly to be fully implemented this May. But the status is unclear.

Vince Chadwick contributed reporting.

Update, May 22, 2018: This article has been updated to reflect that the Global Polio Eradication Initiative raised an additional $1.2 billion for polio eradication last year.