Breakthroughs Blog: UHC

With thousands of delegates dashing from one meeting to another in the frenetic New York streets, it was clear that the United Nations General Assembly (UNGA) was back in full swing this year. Given the three High-Level Meetings (HLMs) on global health, including pandemic preparedness, prevention, and response (PPPR); universal health coverage (UHC); and tuberculosis (TB), this was already set to be a major opportunity to reset coming out of the worst of the COVID-19 pandemic. Yet despite high ambitions, this year’s forum fell short of expectations, with many key issues, such as new agreements for sharing medical countermeasures (MCMs), accountability and enforcement mechanisms, or new funding commitments, being either punted to other forums or ignored. Innovation did feature strongly in all three HLMs, and despite the general disappointment, the research community was able to notch a few wins.A milestone in global pandemic preparednessThe UNGA HLM on PPPR marked a historic moment with the adoption of a political declaration. While nonbinding, this declaration carries significant symbolic weight, underscoring the global recognition that pandemic threats transcend mere health emergencies; they are existential threats that must be addressed with a whole-of-society approach. However, it was clear in the lead-up that the ambition had been severely curtailed and much of the text of the political declaration watered down. The meeting saw minimal participation from heads of state and inadequate representation from civil society. Many countries chose to focus on their past accomplishments in PPPR without articulating clear next steps or new commitments.Funding (or lack thereof) was another key theme of the week. The declaration emphasizes the importance of supporting sustainable and alternative financing mechanisms, as well as strengthening the capacity for innovation and production of MCMs. Specifically, it highlights the need to assist low- and middle-income countries (LMICs) by bolstering local production, technology transfer, and voluntary licensing. Support for the Pandemic Fund is noted, acknowledging the need for $10 billion to make the mechanism successful. Despite these encouraging commitments, the adopted declaration does not include specific new financial pledges for the Pandemic Fund nor targets that ensure the realization of the 100 Days Mission Plus, an initiative that would seek to develop and distribute MCMs within 100 days of an outbreak. Some were also hoping to see the declaration lay out some key principles or targets for a potential MCMs platform to succeed the Access to COVID-19 Tools Accelerator, which coordinated and oversaw the rollout of COVID-19 technologies to low-income countries. But while leaders emphasized the importance of achieving equitable access to essential tools in their statements, disappointingly, there was no mention of a platform in the final declaration text, and the idea was hardly mentioned by member states during debate. Instead, it was clear from the statements leaders made at the meeting that they are eyeing the ongoing processes in Geneva on a pandemic accord and reforms to the International Health Regulations (IHR) to resolve many of these issues—further increasing the stakes for the outcomes of these processes, which need to be aligned with each other and with the declaration.Lack of progress on UHC implementationThe UHC meeting began with the adoption of a nonbinding political declaration by member states. During the meeting, issues of equity and access took center stage. Various countries emphasized the importance of ensuring that health care and health products are accessible to all, regardless of income, and advocated for gender-inclusive health interventions.The role of R&D in achieving UHC emerged as another central theme. Many countries highlighted the need for local and regional production of vaccines, diagnostics, medicines, and other health technologies. Several member states stressed the importance of technology transfer to LMICs and the removal of barriers posed by intellectual property rights. Collaboration and innovation were identified as key drivers of improved global health outcomes. In alignment with the sentiments coming out of the previous day’s PPPR HLM, this reflects a growing recognition of the importance of regional and domestic capacity for health care production and innovation.The spotlight on R&D in the broader UHC context is an exciting step in the right direction, but like the PPPR HLM, the UHC discussions lacked targeted commitments. Member states focused on identifying gaps and areas of needed improvement, such as localized manufacturing of health technologies and increased investments, but largely failed to pledge new financing and other concrete commitments to fill these gaps.  TB commitments finally include tangible targetsThe week culminated with the TB HLM adopting a political declaration, setting forth targets and commitments for tackling TB. In the document, governments pledged to mobilize at least $22 billion annually by 2027, with a more substantial commitment of $35 billion annually by 2030 for TB prevention and treatment. Additionally, there was a commitment to mobilize an additional $5 billion a year by 2027 for TB research and innovation. These commitments are ambitious, especially given that governments have delivered less than half of the $13 billion they had committed to raise by 2022 during the 2018 HLM. Similarly, only half of the $2 billion pledged annually for TB R&D has materialized.While many in the TB community celebrated the adoption of the declaration, it is important to note that the document does not go as far as some advocates would have liked, particularly on equity and inclusiveness provisions, and others have expressed disappointment about the lack of engagement from heads of state. That said, the ambitious funding targets set forth in the declaration hold the potential to make a significant impact if they are met with concrete actions, accountability, and global leadership. Now, the challenge lies in holding governments accountable for their commitments by putting in place robust monitoring mechanisms to track progress.So where do we go from here? With all three political declarations adopted at the HLMs, the General Assembly must formally ratify them in the coming week, and there could still be fights ahead, as several member states lodged objections ahead of the summit. The UNGA HLMs shed light on the global community's priorities on PPPR, UHC, and TB but also gave insight on the lack of concrete commitments from member states. Heads of state were disappointingly underrepresented in all three. Statements from ministers were verbose on gaps and needs but short on commitments and implementation.Zooming out to the broader ecosystem, it is reassuring to see alignment between multilateral bodies, such as the G7’s promise to foster innovative technologies for TB and other diseases, acknowledging the need for advancements in this critical area. In fact, one of the major concrete announcements of the week was the government of Japan launching its Impact Investment Initiative for Global Health (Triple I for GH), a new G7 initiative that seeks to align private and nonprofit stakeholders around best practices for impact investment in global health. Finally, the G20 also reaffirmed its commitment to combat TB and other diseases and to support the interim MCMs platform under development by WHO.While the HLMs were significant milestones, the true test lies in the implementation of commitments. With the political declarations being nonbinding, it is now up to other multilateral bodies to pick up the baton and ensure targets are established, commitments are made, and leaders deliver on implementation. Looking ahead, the deliberations around the pandemic accord will next take center stage through the intergovernmental negotiating body on the pandemic accord, with the process set to conclude by next year. Several member states hope this will serve as a vehicle to advance discussions on the development and access to MCMs. Similarly, IHR reforms offer a chance to advance key elements of the PPPR agenda, such as data sharing and other core capacities.  The G7 and G20 will also need to play a bigger role in financing all these ambitions.The HLMs ultimately served as a good reset moment to reemphasize the importance of these global health priorities, but it is now up to other forums and national governments to work collaboratively to translate pledges into action.

The health ministers of G20 nations concluded their annual meeting last weekend with the adoption of an “outcome document” that includes welcome commitments to advance the research and development (R&D) of health products. While normally such a ministerial-level meeting would end with the release of a formal consensus communique, broader geopolitics derailed this process, with Russia and China opposing the inclusion of language condemning the Russian war of aggression against Ukraine. Below we break down what R&D commitments are included in the outcome document, why it matters, and where conversations are expected to go from here. What’s in the declaration? At the highest level, G20 nations made commitments to strengthen the global health architecture and “build more resilient, equitable, sustainable and inclusive health systems equipped to address ongoing global health challenges and future public health emergencies with equitable access to safe, effective, quality-assured and affordable vaccines, therapeutics, diagnostics, and other medical countermeasures.” They also reaffirmed their commitment to ending the epidemics of AIDS, tuberculosis, and malaria; achieving polio eradication; advancing universal health coverage (UHC) and the Sustainable Development Goals (SDGs); and tackling antimicrobial resistance (AMR). On the latter issue of AMR, the ministers vowed to strengthen R&D for AMR and further the development of novel antimicrobials. They welcomed the work of various international initiatives and GHTC members including the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) and the Global Antibiotic Research and Development Partnership (GARDP) and voiced continued support for the Global AMR R&D Hub, which was established under the German G20 presidency to promote AMR R&D coordination. On the broader issue of R&D for pandemic prevention, preparedness, and response (PPPR), G20 leaders agreed to support a World Health Organization (WHO)-led consultative process to develop an interim (and potentially later permanent) medical countermeasures (MCMs) mechanism to coordinate the end-to-end R&D, manufacturing, procurement, and equitable delivery of MCMs during health emergencies. They advised that such a mechanism should consider a “network of networks” approach, building off existing international and regional partnerships, and should be coherent with the outcomes of ongoing efforts to amend the International Health Regulations (IHR) and advance a binding pandemic instrument. Additionally, the ministers underscored the need to strengthen local and regional R&D networks and manufacturing capabilities, especially in low- and middle-income countries, as well as voiced support for what many call the “100 Days Mission” to develop and make available safe and effective vaccines, therapeutics, and diagnostics within 100 days of the identification of a pandemic or epidemic threat. They also noted the importance of public-private R&D partnerships—calling out the contributions of GHTC members the Coalition for Epidemic Preparedness Innovations (CEPI), Medicines Patent Pool (MPP), and FIND—and technology transfer and knowledge sharing “on voluntary and mutually agreed terms.”Why it matters?  G20 nations currently conduct and fund the majority of the world’s health R&D. Thus, it is great to see G20 leaders reaffirm the importance of R&D to achieving UHC, SDGs, and PPPR and demonstrate political will to accelerate R&D efforts. However, the outcome document is short on specifics as to how G20 countries intend to operationalize their many promises, and it disappointingly includes no new funding targets or commitments.  Additionally, going into this year’s G20 cycle, many observers and health advocates also expected that the G20 under the Indian presidency would play a more active role in envisioning and detailing a specific proposal for the creation of an end-to-end MCMs mechanism or platform to succeed and build upon the Access to COVID-19 Tools Accelerator. Instead, the G20 simply promised to support a WHO-led consultative process to design an interim mechanism and punted it to the International Negotiating Body (INB) process for a pandemic instrument to determine the prospects for a permanent MCMs platform. What’s next? With G20 nations offering few specifics on a vision to reimagine the global health architecture and advance an MCMs platform, the focal point for change is now squarely within the separate but interrelated processes now underway to amend the IHR, advance a pandemic accord that will create a more comprehensive framework for how countries will prevent and respond to outbreaks, and design an interim MCMs platform. While these processes have been ongoing, the deliberations have been stymied as countries struggle to reach consensus around thorny R&D topics like access and benefit sharing, with some pushing for more aggressive legally binding commitments for transparency, conditions on public R&D funding, patent waivers, and new supply chain mechanisms for ensuring low- and middle-income countries access to medical countermeasures. Questions remain on the full scope of some of the processes, and how they will delineate which issues will be tackled where and with the target date of May 2024 for the adoption of an instrument rapidly approaching and the INB and IHR processes largely behind schedule, it remains to be seen what tangible changes for R&D can be realized. While it is impossible to know what exactly what the future of these negotiations hold, GHTC promises to continue to watch, weigh in, and report back in the months ahead as these interrelated processes unfold. Stay tuned! 

As is tradition, the World Health Organization (WHO) Executive Board (EB) kicked off what promises to be another packed multilateral calendar. While much has remained the same, this year’s forum also ushered in noteworthy shifts in deliberations, dynamics, and dialogue that advocates should be aware of. Here are GHTC’s top takeaways from the week: 1. EB shrinks space for civil society engagement. As civil society delegates entered the halls of WHO for the EB for the first time since 2020, they were confronted with a harsh reality: The ability for non-state actors to meaningfully participate in these meetings is at an all-time low. New protocols had been introduced limiting delegation size and physical and structural changes put in place that left civil society literally on the outside looking in. Gone are the days when civil society could be physically present in the assembly room to follow the proceedings. Instead, advocates were relegated to a small, hot, and stuffy overflow room, more akin to a small press room, located far away from the official proceedings, hampering their ability to connect with officials and country delegates, which is often the most valuable part of the week. As EB participation and the number of agenda items have ballooned, WHO has also imposed new constraints on civil society statements, which have hit non-state actors particularly hard. WHO has tried to force civil society organizations to come together and develop single constituency statements for certain agenda items, a challenge that often further dilutes specific technical feedback from a diverse set of voices as various WHO-accredited institutions try to reconcile diverging views into a single, cohesive communication. Individual interventions are now reduced to just one minute, and they must be uploaded to a WHO database prior to the start of that agenda item. Apart from the challenge of distilling feedback and technical input down to around 100 words, the requirement to upload in advance prohibits advocates from rebutting issues that arise during debate or meaningfully influencing the decision making in real time. Other United Nations (UN) agencies, such as the World Trade Organization and the World Intellectual Property Organization have far more robust and meaningful civil society engagement processes that could serve as better models for WHO to emulate. 2. Debate on WHO’s work in health emergencies goes into the next round. Global politics tend to spill over into the parliamentary debates at EB, and this year was no different with the war in Ukraine creating serious tension between western allies and Russia. Much of the debate surrounding WHO’s role in health emergencies was derailed by several testy back-and-forths between delegations, leading to disruptions and little progress on key agenda items. A new ten-point proposal from WHO Director-General Dr. Tedros Adhanom Ghebreyesus to improve preparedness and response to health emergencies also received mixed reviews from WHO member states, with many warning the WHO secretariat not to move ahead of member states and the already ongoing processes to amend the International Health Regulations and negotiate a pandemic accord.  The latter did make waves at this EB, as the WHO Intergovernmental Negotiating Body (INB) published a “zero-draft,” that included a few surprises. The draft features some strong, equity-focused language, as well as calls for building and strengthening country regulatory, manufacturing, and innovative research and development (R&D) capacities for pandemic-related products. Surprisingly, it also features numerous callouts and provisions focused on intellectual property, including incentivizing relevant transfers of technology and know-how, forcing manufacturers that receive public funding to disclose prices for pandemic-related products, and time-bound waivers on medical countermeasures that can accelerate or scale up manufacturing, signaling the key battlegrounds for upcoming negotiations.  The biggest stunner, though, is a brand-new section focused on creating a new WHO Pathogen Access and Benefit-Sharing System (the “PABS System”) that would collect and equitably distribute a portion of all globally produced vaccines and other medical products during pandemics. According to the draft, 10 percent of total global production of pandemic products would be allocated to WHO, with half donated and half bought at an “accessible” price. Now, deliberations on the specific provisions will begin in earnest ahead of the World Health Assembly (WHA) in May, with the INB hosting two meetings in the next few months to debate individual chapters of the draft.  3. Implementation of the clinical trials resolution enters its next phase as member states argue about scope. Member states also debated the implementation of last year’s clinical trials resolution during the session on global health emergencies. Delegates noted the progress WHO had made over the past year in leading consultations and mapping the current clinical trial networks landscape. A few countries underscored the importance of inclusiveness and equity and called for greater technical support from WHO. On the contrary, in response to a WHO proposal to develop a complementary self-assessment tool to measure the maturity of the clinical trial ecosystem at national and international levels, the United States and United Kingdom instead urged the WHO secretariat to keep its focus limited to the scope of the actual resolution until more progress is achieved. The WHO is now set to move forward with a process to develop draft guidelines for clinical trials, with the help of experts and member states, that is expected to be in place by WHA. 4. Universal health coverage (UHC) reemerges as a priority from COVID-19 slumber. In 2019, UHC was the “it” topic of global health. It featured prominently on the agenda of WHO meetings and the UN held a high-level meeting on the subject to advance a new framework to achieve the Sustainable Development Goals. Then came the pandemic, and focus and attention on the topic slipped. This year, UHC is back on the map, having featured heavily at this year's EB.  During the broader discussion on UHC, WHO member states highlighted the importance of primary health care and health system strengthening, as well as considered and ultimately passed a resolution on strengthening diagnostics capacity. The resolution urges member states to address a range of diagnostic issues, including increasing local production, streamlining regulatory approaches, and addressing access barriers. It also calls for greater investment in diagnostic R&D and more systemic funding of capacity-building infrastructure for diagnostics, as well as urges WHO to enact specific technical changes to facilitate and catalyze diagnostic development.  The next couple of months will continue to deliver multilateral developments at a breakneck pace, and given the interlinkages between the many multilateral processes underway, it will be vital for advocates to understand the full landscape of possible changes to the global health architecture. While the dynamics may be shifting, it is encouraging to see that the research agenda is present throughout these different dialogues, both in Geneva and beyond. 

Last week, the world waited with bated breath to see whether G20 health ministers would seize the moment at their annual summit to take bold and necessary action to end the pandemic, build the global health architecture for the future, and recommit to health priorities that have taken a back seat during the past two years.The answer was rather muddled. The G20 health ministers did agree on several key principles and high-level priorities, many of which were positive, but their health declaration stopped short of providing a clear road map to translate these ambitions into concrete actions. Advocates were particularly disappointed in the lack of immediate actions, including calls for specific financial commitments, to address the shameful inequities in rollout and ongoing acute needs for COVID-19 vaccines and other tools.While the G20 didn’t provide much specificity regarding new pledges, it did highlight the importance of research and development (R&D) in all aspects of global health, including bolstering pandemic preparedness, combatting antimicrobial resistance (AMR), achieving universal health coverage (UHC), and strengthening digital health. As discussions in other forums such as the United Nations (UN) General Assembly, the World Health Organization (WHO), and the Global Health Security Agenda ramp up, G20 leaders have set the framework from which to build concrete reforms to the international system.Putting R&D at the core of the agenda This year’s G20 health declaration included strong language on R&D throughout. In discussing the Access to COVID-19 Tools Accelerator, pandemic preparedness initiatives, and reinvestment in key programs to achieve the Sustainable Development Goals (SDGs) and UHC, G20 leaders put R&D front and center. One particularly encouraging sign was the explicit callout from health ministers acknowledging R&D as a central pillar of pandemic preparedness, something that was notably absent in global health security frameworks, including the International Health Regulations, prior to the start of the pandemic. The COVID-19 crisis has exposed the need to enshrine greater global governance and coordination of R&D into the global health security architecture. The mention by G20 health leaders acknowledges a political shift on the issue and increases the prospects that R&D coordination and governance provisions will be integrated into a potential pandemic treaty and other WHO reform discussions in the coming months. The G20 health declaration also underlined the continued commitment toward combatting AMR, including by developing new safe and effective antimicrobials and sustaining reliable supply and production of existing antimicrobials. For the past few years, the agenda for the G20 has consistently included AMR with a focus on multidrug-resistant tuberculosis (TB), which is estimated to account for one-third of all AMR-related deaths globally. Leaders recognized that sustainable and robust resources for TB R&D are needed to accelerate development of new tools and deliver on previous commitments from the G20 and the UN high-level panels on TB, AMR, and UHC.Health ministers underscored the need to strengthen the resilience of supply chains; increase and diversify global, local, and regional vaccine manufacturing capacity; and build expertise for low- and middle-income countries (LMICs). Acknowledging that equitable access to medical countermeasures continues to be a major challenge, global leaders recognized the need to develop more balanced systems and infrastructure that provide greater coverage and capacity in LMICs. G20 leaders also reiterated that while vaccines have been at the top of everyone’s agenda, we must ensure that all countermeasures, especially therapeutics including oxygen therapies and diagnostics, are reprioritized as key elements of global response efforts and that the pipeline for new countermeasures continues to receive investments. Given the accelerated development of new diagnostic tools and the scale of testing needed for COVID-19, it was a positive development that G20 nations acknowledged that the introduction of testing capabilities should also be leveraged for other infectious diseases including TB, malaria, and HIV. To achieve the SDGs by 2030, the systems that are being built to respond to the pandemic must also serve to strengthen health systems overall and help in the fight against other disease threats.Where do we go from here?G20 health ministers reaffirmed their commitment to global solidarity, including by working toward equitable distribution of vaccines and supporting WHO’s goal of vaccinating 40 percent of the global population by the end of 2021. Despite this, no specific pledges were made to provide additional funding to the Access to COVID-19 Tools Accelerator, nor did leaders commit to increase vaccine dose sharing to address the acute needs of LMICs.The lack of specific targets or road maps for how to achieve the outlined principles and new investment pledges by G20 countries means that leaders must now work out how to operationalize these ideas in other multilateral meetings this fall. Many advocates are now pinning their hopes on the Biden administration’s call to convene heads of state at a Global COVID-19 Summit next week on the sidelines of the UN General Assembly and looking for tangible actions during the G20 Joint Health and Finance Ministers’ Meeting or World Health Assembly deliberations on a new pandemic treaty or framework convention.These forums will now have to pick up the baton, since we need global governance to be more inclusive, equitable, and accountable. This G20 health ministers’ declaration was a step in the right direction, as it set a framework for improving global health R&D coordination and governance, but it put the onus on other forums to follow through with concrete actions. Global leaders must now seize the moment and deliver on their promises.