PHM-Exch> COVID-19 response exposes deep flaws in global health governance

[Claudio Schuftan]

*Von:* dlegge at phmovement.org


*COVID-19 response exposes deep flaws in global health governance*


David G Legge, Global Social Policy, 23 October 2020

https://doi.org/10.1177/1468018120966659



The global COVID-19 response exposes flaws at the heart of the prevailing
regime of global health governance (GHG): first, in the debates about fast
tracking the development of vaccines and medicines and, second, in the
extraordinary variations in national responses to the pandemic.

The World Health Assembly (WHA), the governing body of World Health
Organization (WHO), is a leading player in GHG. For many years, it has also
been a key site where geopolitical contradictions between the Global North
and the Global South are played out. The US withdrawal from WHO is the
latest initiative in a continuing campaign to marginalise WHO and in doing
so to marginalise the voices of developing countries since the Assembly is
the principal forum where they are able to participate in GHG.

Under the banner of so-called ‘WHO reform’, there has been continuing
pressure to transform the WHO from an intergovernmental body, where member
states have sovereignty, to a ‘multi-stakeholder public private
partnership’ model where transnational corporations and philanthropic
foundations are able take up (what they see as) their rightful seat at the
table.

The long-standing freeze on assessed contributions associated with tightly
earmarked voluntary contributions, implemented from the mid-1980s, was
imposed and has been maintained, with a view to restricting the influence
of the Global South over the work programme of WHO (Legge, 2015
<https://journals.sagepub.com/eprint/XRHSRYHCKDIZPGQDZFAZ/full>).

A slightly different theme, long embedded in the International Health
Regulations (IHRs), positions developing countries as a public health
threat to the rich world. This preoccupation with ‘protecting us from them’
is commonly articulated in the discourse of ‘global health security’. Over
the last 6 years, since the Ebola outbreak in 2014, there has been a
campaign of finger pointing around the failure of certain developing
countries to invest sufficiently in the ‘core capacities’ which the IHRs
require (laboratory capacity, public health surveillance, border control,
etc.).

In the context of COVID-19, WHO (Economic Times, 2020
<https://journals.sagepub.com/eprint/XRHSRYHCKDIZPGQDZFAZ/full>), civil
society organisations (MSF Access Campaign, 2020
<https://journals.sagepub.com/eprint/XRHSRYHCKDIZPGQDZFAZ/full>) and
Presidents Macron and Xi (in the WHA) have called for vaccines to be
regarded as global public goods, implying a shared obligation to mobilise
resources. The broader principle applies to global health security more
generally, whether for vaccines or ‘core capacities’ under the IHRs.

*The Access to Covid-19 Tools Accelerator*

The creation of the Access to Covid-19 Tools Accelerator (ACT-A or ‘the
Accelerator’) as the main global platform for fast tracking the development
of vaccines and medicines for COVID-19 (Global Collaboration, 2020
<https://journals.sagepub.com/eprint/XRHSRYHCKDIZPGQDZFAZ/full>) needs to
be understood in the light of these kinds of North–South tension. The
arrangements for fast-tracking medical products have important implications
for the reform or the defence of prevailing intellectual property laws and
the associated price barriers to accessing medicines more generally.

The Accelerator has four ‘pillars’ designed to mobilise and disburse
funding to accelerate the development of new diagnostics, medicines and
vaccines. The diagnostics, medicines and vaccine pillars aim to support
promising developments through a combination of direct grants and advance
purchase agreements which will help to share the financial risks associated
with the continuing development of products which have yet to be shown to
be effective. The fourth pillar promises to support health system
enhancements needed to facilitate access to these new products.

The vaccines pillar (led by Gavi, the Vaccines Alliance and CEPI, the
Coalition for Epidemic Preparedness Innovations) is structured around a
complex system of advance purchase agreements centred around the Covax
Facility as the main financing instrument (Gavi and CEPI, 2020a
<https://journals.sagepub.com/eprint/XRHSRYHCKDIZPGQDZFAZ/full>). Covax
will be funded through official development assistance from the donor
countries, through philanthropy (especially Gates and Wellcome) and through
the 10% down payments required of self-funded participating countries.

The Covax Facility will operate through two sets of ‘advanced purchase
agreements’ (APAs): one set of agreements between Gavi and (possibly 5–10)
vaccine suppliers, and another between Gavi and participating countries.
Different country agreements will be struck for ‘self-funded countries’
(upper-middle-income and high-income countries) and for ‘funded countries’
(low-income and lower-middle-income countries). Vaccine purchases for
‘funded countries’ will be financed through the facility.

The Covax facility will support procurement for the ‘high priority’
fractions of participating country populations (set at around 20% for
self-funded but less than that for funded countries) and will only operate
in the short to medium term. Once participating countries have been
supplied the agreed doses for their ‘high priority’ populations, supply
arrangements (prices, volumes and delivery dates) will revert to bilateral
arrangements between individual countries or purchasing consortia and the
vaccine suppliers.

Significant contradictions between the Global North and South are manifest
in the Accelerator. The Accelerator is created as a ‘multi-stakeholder
public private partnership’, with the Bill and Melinda Gates Foundation
centrally involved and the WHO cut out from any significant involvement in
its governance. Developing countries have not been consulted in the
development of the Accelerator and the WHA, where they do have a voice,
will have no role in its development.

Through the Accelerator, billions of dollars are being channelled to the
pharmaceutical industry with no conditionality regarding ongoing pricing
and no restrictions on the privatisation of the intellectual property
created under public financing. In relation to vaccines, for example, there
will be downwards pressures on prices for the priority populations (10–20%
of total) but market prices for the remaining 80–90% (Gavi and CEPI, 2020b
<https://journals.sagepub.com/eprint/XRHSRYHCKDIZPGQDZFAZ/full>).

Even while the Accelerator’s pillars are being erected, there has been a
flurry of APAs, outside the Accelerator arrangements, with Europe and the
United States buying up priority access to vaccines and medicines which are
still in development, foreshadowing consequent delays and barriers to
accessing such vaccines and medicines by developing countries.

For countries in the Global South, medicines and vaccines (purchased on
global markets) constitute a high proportion of total health expenditure
and high prices are a major barrier to ensuring universal health care. The
role of extreme intellectual property protection in supporting high prices,
and the hyper-profitability of the transnational pharmaceutical industry,
is a major concern for developing countries (Kanth, 2020
<https://journals.sagepub.com/eprint/XRHSRYHCKDIZPGQDZFAZ/full>).

In March 2020, Costa Rica launched a proposal for a global pool of rights
in the data, knowledge and technologies useful to the prevention, detection
and treatment of the coronavirus/COVID-19 pandemic. The concept was
supported by the Director General, by many countries of the Global South
and by the European Union and, in May, was adopted by the WHA, albeit in a
watered-down version (WHA, 2020
<https://journals.sagepub.com/eprint/XRHSRYHCKDIZPGQDZFAZ/full>). The
United Kingdom, United States and Switzerland led the opposition (Bosely,
2020 <https://journals.sagepub.com/eprint/XRHSRYHCKDIZPGQDZFAZ/full>) to
what is now the Covid Technology Access Pool (C-TAP) (WHA, 2020
<https://journals.sagepub.com/eprint/XRHSRYHCKDIZPGQDZFAZ/full>).

In some respects, this debate appears as Global North versus Global South.
However, there is also an axis of contention between the transnational
pharmaceutical corporations and the people (patients and taxpayers) from
whence their profits derive or who are unable to pay for their medicines
and vaccines.

The attack on multilateralism and the drive to transform GHG into the
public–private partnership model are elements of ‘WHO Reform’ which are
fiercely advanced by the junk food industry globally and any concessions
with respect to intellectual property would set precedents of much wider
significance, including for the agro-chemicals, software and global
entertainment industry. It is not just pharma but transnational capital
generally which is contending in this space.

These contradictions, international and economic, point to the policy
imperatives of strengthening the voice and the organisation, of the Global
South, and at the same time building a global constituency to control the
depredations of transnational capital.

However, an analysis structured solely at the global level is also too
limited. The COVID-19 pandemic has also brought into sharp relief the
structures and dynamics at the community and national levels which shape
people’s health. This has been particularly evident in the wide variations
of national response, from Vietnam and New Zealand to the United States and
Brazil.

*Managing the pandemic at the national level*

Managing the COVID-19 pandemic confronts inescapable tensions between
protecting public health and maintaining economic activity. Settings where
these tensions have been successfully managed have been characterised by

   - coherent leadership, addressing both objectives in accordance with
   science and humanity;
   - inclusive, consensus-building policy formation: including
   consensus-building around the curbing of economic activity while
   transmission is suppressed (and the logic and fairness of such curbs), and
   around the need for continued close surveillance and response capability
   after suppression (and until successful vaccination); and
   - social solidarity: including the solidarity expressed in individual
   compliance, solidarity in ensuring the protection of the vulnerable and the
   solidarity of welfare provision to cushion the burden of economic collapse.

The most shocking failures of national response have been characterised by

   - outright denial of the public health imperative and resistance to
   particular public health measures, leading to incoherence and inconsistency
   in the implementation and in the lifting of such measures;
   - intersectoral and intergovernmental conflict and buck passing, leading
   to lack of coordination and inconsistent implementation; and
   - lack of solidarity (unsafe individual behaviours, lack of protection
   for the vulnerable and lack of welfare support).

Clearly, the conditions for such chaos vary between countries. In general,
it seems that continuing conflict around the national COVID-19 response may
reflect a combination of business resistance, popular distrust and the
impossibility of lockdown and social distancing for many.

The WHO has done an outstanding job at the global level in convening expert
groups, providing technical guidance, procuring and distributing medical
commodities, working with news media, providing online education for health
professionals and policy officials and distilling complex issues into
meaningful slogans (solidarity, testing, human rights). The outstanding
failure at the global level has been the lack of member state
accountability, including for lack of transparency, chaotic national policy
making and failure to contain the epidemic.

There are limits to what the WHO Secretariat could do to strengthen member
state accountability but one strategy which could have been deployed would
be to collect, publish and analyse descriptive material regarding national
policy making, implementation and outcomes. It appears that the Independent
Panel for Pandemic Preparedness and Response (IPPR) appointed to evaluate
the world’s response to the COVID-19 pandemic will explore national
responses as well as that of the WHO Secretariat (WHO, 2020
<https://journals.sagepub.com/eprint/XRHSRYHCKDIZPGQDZFAZ/full>).

The significance of nation state accountability extends beyond the national
response to COVID-19. It is highly relevant also to global policy making
around the Accelerator and C-TAP and to the marginalisation of WHO in
favour of global public–private partnerships.

The accountability of governments to their people is a core value of
inclusive, informed and participatory democracy. Strengthening the
democratic accountability of governments for their role in global policy
making and for the implementation of national public health policies would
be a significant step to democratising GHG.

Funding
The author received no financial support for the research, authorship
and/or publication of this article.

References

Bosely, S (2020) Coronavirus outbreak: US and UK ‘lead push against global
patent pool for Covid-19 drugs’. The Guardian, 17 May. Available at:
https://www.theguardian.com/world/2020/may/17/us-and-uk-lead-push-against-global-patent-pool-for-covid-19-drugs
Google Scholar
<http://scholar.google.com/scholar_lookup?hl=en&publication_year=2020&author=S+Bosely&title=Coronavirus+outbreak%3A+US+and+UK+%E2%80%98lead+push+against+global+patent+pool+for+Covid-19+drugs%E2%80%99>
------------------------------

Economic Times (2020) Covid-19 vaccines must be recognised as ‘global
public health goods’: WHO. Economic Times, 23 May. Available at:
https://economictimes.indiatimes.com/news/international/world-news/covid-19-vaccines-must-be-recognised-as-as-global-public-health-goods-who/videoshow/75909811.cms?from=mdr
(accessed
24 July 2020).
Google Scholar
<http://scholar.google.com/scholar_lookup?hl=en&publication_year=2020&author=Economic+Times&title=Covid-19+vaccines+must+be+recognised+as+%E2%80%98global+public+health+goods%E2%80%99%3A+WHO>
------------------------------

Gavi and CEPI (2020a) Covax, the ACT-Accelerator vaccines pillar: Insuring
accelerated vaccine development and manufacture. Available at:
https://www.gavi.org/sites/default/files/document/2020/COVAX-Pillar-backgrounder_3.pdf
(accessed
22 July 2020).
Google Scholar
<http://scholar.google.com/scholar_lookup?hl=en&publication_year=2020&author=Gavi+and+CEPI&title=Covax%2C+the+ACT-Accelerator+vaccines+pillar%3A+Insuring+accelerated+vaccine+development+and+manufacture>
------------------------------

Gavi and CEPI (2020b) COVID-19 Vaccine Global Access (COVAX) Facility:
Preliminary technical design. Available at:
https://www.keionline.org/wp-content/uploads/COVAX-Facility-Preliminary-technical-design-061120-vF.pdf
(accessed
24 July 2020).
Google Scholar
<http://scholar.google.com/scholar_lookup?hl=en&publication_year=2020&author=Gavi+and+CEPI&title=COVID-19+Vaccine+Global+Access+%28COVAX%29+Facility%3A+Preliminary+technical+design>
------------------------------

Global Collaboration (2020) Commitment and call to action: Global
collaboration to accelerate new COVID-19 health technologies. Available at:
https://www.who.int/news-room/detail/24-04-2020-commitment-and-call-to-action-global-collaboration-to-accelerate-new-covid-19-health-technologies
(accessed
22 July 2020).
Google Scholar
<http://scholar.google.com/scholar_lookup?hl=en&publication_year=2020&author=Global+Collaboration&title=Commitment+and+call+to+action%3A+Global+collaboration+to+accelerate+new+COVID-19+health+technologies>
------------------------------

Kanth, DR (2020) COVID-19: South Concerned Over TRIPS Barrier to Access
Affordable Vaccines. TWN Info Service on Health Issues. Available at:
https://twn.my/title2/health.info/2020/hi200610.htm (accessed 24 July 2020).
Google Scholar
<http://scholar.google.com/scholar_lookup?hl=en&publication_year=2020&author=DR+Kanth&title=COVID-19%3A+South+Concerned+Over+TRIPS+Barrier+to+Access+Affordable+Vaccines>
------------------------------

Legge, DG (2015) WHO shackled: Donor control of the World Health
Organisation (Third World Resurgence No. 298/299). Available at:
http://www.twn.my/title2/resurgence/2015/298-299/cover01.htm (accessed 16
June 2020).
Google Scholar
<http://scholar.google.com/scholar_lookup?hl=en&publication_year=2015&author=DG+Legge&title=WHO+shackled%3A+Donor+control+of+the+World+Health+Organisation>
------------------------------

MSF Access Campaign (2020) Ahead of Gavi Board meeting, MSF calls on Gavi
to revise its global mechanism and demand pharma sell all COVID-19 vaccines
at cost. Available at:
https://msfaccess.org/ahead-gavi-board-meeting-msf-calls-gavi-revise-its-global-mechanism-and-demand-pharma-sell-all
(accessed
24 July 2020).
Google Scholar
<http://scholar.google.com/scholar_lookup?hl=en&publication_year=2020&author=MSF+Access+Campaign&title=Ahead+of+Gavi+Board+meeting%2C+MSF+calls+on+Gavi+to+revise+its+global+mechanism+and+demand+pharma+sell+all+COVID-19+vaccines+at+cost>
------------------------------

WHA (2020) COVID-19 response (WHA73.1). Available at:
https://apps.who.int/gb/ebwha/pdf_files/WHA73/A73_R1-en.pdf (accessed 24
July 2020).
Google Scholar
<http://scholar.google.com/scholar_lookup?hl=en&publication_year=2020&author=WHA&title=COVID-19+response+%28WHA73.1%29>
------------------------------

WHO (2020) Independent evaluation of global COVID-19 response. Available
at:
https://www.who.int/news-room/detail/09-07-2020-independent-evaluation-of-global-covid-19-response-announced
(accessed
22 July 2020).
Google Scholar
<http://scholar.google.com/scholar_lookup?hl=en&publication_year=2020&author=WHO&title=Independent+evaluation+of+global+COVID-19+response>
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