Antimicrobial Resistance, Budget, Reform Raise Debate At WHO Executive Board

The World Health Organization Executive Board this week has addressed the relationship between the UN agency and its funders and lobbyists, examined the budget for the next biennium, and looked at the issue of the growing resistance of bacteria to antibiotics.

The 136^th session of the WHO Executive Board (EB) is taking place from 26 January to 3 February.

One of the issues described as key by a number of countries, private sector and civil society representatives during this session of the EB is the relationship with WHO with non-governmental actors, including donor foundations and industry. Work has been ongoing on a framework of engagement with “non-state actors”. A new draft of the framework [pdf] has been produced by WHO for the EB to take note of so it can be sent to the upcoming World Health Assembly in May for approval.

The framework is meant to address issues such as conflicts of interest and undue influence of non-state actors in the work of the WHO. Some member countries deem the framework to be adequate for adoption, while others, mainly developing countries, feel that additional work is needed and amendments made.

Argentina tabled a draft decision [pdf] at the beginning of the week asking that member states participate in the drafting of the framework (IPW, WHO, 26 January 2015).

Countries such as China, Iran, Suriname, Egypt, Panama, Gambia, Eritrea, Namibia, Uruguay for the Union of South American Nations (UNASUR), India, Thailand, and Bolivia, approved Argentina’s draft decision. A number of developed countries suggested that the framework should be adopted as it stands and further refined after it is tested in operation.

Today, an updated draft decision [pdf] (EB136/CONF./5 Rev.1) proposed by Argentina and resulting from a drafting group was released. In particular, the updated draft decision calls for member states to submit their specific proposals for amendments, inclusions or deletion of text from the draft framework. It also requests that those proposals be compiled and available to member states by 9 March, and an open-ended intergovernmental meeting be convened from 30 March – 1 April to discuss the textual proposals submitted by member states.

The International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) said, “Transparent engagement with all non-state actors should be linked to the concept of accountability by all. … Provisions in the Framework should be applied equally among all non-state actors, so that everybody’s interest can best serve the shared objective of making this world a healthier place.”

WHO Director General Margaret Chan underlined the large number of countries in favour of Argentina’s draft decision and suggested work on further improving the draft framework should start this week among member states. Argentina is to chair the meetings. The agenda item was left open for further consideration.

Antimicrobial Resistance

The growing resistance of bacteria to antibiotic treatments is gaining attention from public health authorities throughout the world. Affecting all countries, the threat of being deprived of efficient treatments against infectious diseases coupled with the lack of new medicines on the pipeline prompted the development of a draft global action plan [pdf] on antimicrobial resistance.

All countries which took the floor underlined the extent of the problem to not only public health but also from the standpoint of socio-economic consequences. Some described it as one of the biggest challenges to public health, and many as a matter of urgency.

Among the sources of bacterial resistance underlined by countries were self-medication, the illegal market for antibiotics, improper following of prescription, wide use of antibiotics in farming and in food production, and direct pollution from pharma production.

As an example of the discussion, Norway mentioned that the country’s fish farms have almost dropped use of antibiotics in lieu of vaccines, as a way to help reduce antibiotic resistance.

Developing countries remarked on the need for support in the surveillance and monitoring of the use of antibiotics, the need for regulation and capacity building, as well as sustainable health systems.

Several countries urged that prices of new antibiotics be de-linked from the cost of the research and development to make them.

India noted that the draft document did not give any assessment of the financial and other resources required to achieve the objectives of the action plan. “Surveillance mechanisms, lab capacities, health system strengthening, human resources, etc. need huge investments. We must address this issue, failing which our efforts may not give the desired results,” the delegate said in prepared remarks.

“It is also critical that prices of new antibiotics are delinked from R&D costs,” he added. “This is especially so, as new drugs should be available for the benefit of everyone,” he added. This was echoed by Thailand.

Pakistan also called for financial help to develop capacity of developing countries. Thailand remarked that WHO should facilitate the development of mechanisms for sustainable resources for developing countries and least-developed countries to deal with the issue.

The IFPMA said: “A combination of push-pull mechanisms, and other mechanisms to create market incentives, is needed. This could be pursued through dialogue around the development of market models that incentivize innovation and ensure sustainable research and development investments.”

In its statement, Médecins Sans Frontières (MSF, Doctors without Borders) said the global action plan is “an urgent first step towards addressing antibiotic resistance,” however, “with few antibiotics in the pipeline, MSF believes the solution to the current market failure in medical research for new antibiotics lies in de-linking the cost of research and development from the volumes of sales and revenues.”

“Public, private and philanthropic funders should embrace the concept of ‘de-linkage’, developing new products that are affordable for all,” MSF said.

According to the WHO, the Strategic and Technical Advisory Group on antimicrobial resistance is expected to meet on 24-25 February, and comments made by member states at the EB will be taken into consideration with the view to submit a revised document to the WHA.

Methods of Work of the Governing Bodies

WHO is revisiting the Methods of work of the governing bodies [pdf] as part as WHO overall reform. In particular, the proposed methods of work of the governing bodies include a section on side events to the WHA, which are increasing.

The document proposes several solutions, among which is to hold a one-day session in advance of the WHA for side events, to pass on the actual costs of organising side events to the organisers, and to introduce a limit on the number of side events.

Some delegations, such as Argentina, Panama and Turkey, remarked on the proposed limitation of side events and said it should not be too restrictive.

Other elements of the proposed methods of work relate to better management of the agenda, better management of sessions, and minimising the late submission of draft resolutions and decisions.

Medicus Mundi, a network of organisations working on international health cooperation and global health, warned about side events being financed by organisers and becoming promotional events showcasing some organisations.

Chan remarked on the need to change the behaviour of member states, in particular in the number of agenda items. She also said some 67 side events were organised last year and it was for countries to decide how to address the issue. The EB took note of the report.

Budget 2016/2017

The EB took note of the report on the 2014-2015 budget and examined the proposed budget 2016-2017 [pdf], which includes several proposed scenarios.

The first scenario is based on budget 2014-2015, keeping the total to US$4.171 billion, according to the budget document. The second scenario includes adjustments in staff costs and would result in a total budget of US$4.262 billion.

The EU remarked that the scenarios foresee a budget increase and asked how the WHO was envisaging financing it. Australia, Albania, the United Kingdom and France concurred.

A number of developing countries underlined the need to strengthen country offices, and to ensure technical support and coordination at country level. Some countries remarked on the shift of budget lines (increases and decreases) which they disapproved of.

Chan she said she hears the same issues every two years. In response to some countries remarking on budget cuts, for example on communicable diseases, she said priority-setting is a prerogative of member states, she said, “but it does not mean you will get everything you want.” This is because it is a consensus process, she said.

Behavioural change is needed both in the secretariat and in member states, said Chan. “Every resolution has a cost,” she said. “What goes up comes down,” she added, “something has to come down.”

Citing the open-ended working group suggested by a draft decision [pdf] put forward by Mexico and Panama on the overview of the WHO reform implementation, she said one meeting of such a working group can cost half a million dollars to the organisation. “Where am I going to cut?” she asked.

The Mexico and Panama draft decision proposed in particular that an open-ended working group on governance reform be established to review the progress made in the governance reform agenda.

On resolutions in general, she said implementation of agreed resolutions is often lacking, so much time is spent on passing resolutions and “yet you don’t implement them,” she said. “Are you efficient, are you effective?” she asked. “Please think about it. This is my advice to make us much lighter,” she said.

Also to be considered by the EB was the report [pdf] on the working group on strategic budget space allocation. In particular the working group was tasked to determine a new strategic resource allocation methodology.

Resource Allocation

The budget space allocation is divided into four segments: Country level technical cooperation (segment 1); provision of global and regional goods (segment 2); management and administration (segment 3); response to emergency events, such as outbreak and crisis response (segment 4).

A number of countries, such as China, Egypt, India, and Thailand, underlined the fact that they found the indicators were based on outdated or missing data, not reflecting the realities on the ground, calling for more allocation in segment 1. Some stressed the need for strong scientific evidence to establish indicators.

Belgium, as chair of the working group on the budget space allocation, defended the proposed methodology and said the working group spent two days to discuss only indicators. The delegate said the working group members come from all regions of the WHO: Mexico, Maldives, Malaysia, Egypt, Cameroon, and Belgium. Each indicator was discussed in depth and analysis was carried out and cross-checked with existing databases. He assured that the working group’s decisions were based on scientific evidence and in consensus with all regions present.

Chan commented on the amount of time considering the matter. But it is only a space, she said, “not even money.” “If no donor wants to give you money, that space is only a dream,” she said, and noted that many countries like to earmark the money they contribute. She commended the work of the working group and said no indicator will satisfy everybody.

This morning a draft decision [pdf] (EB136/CONF./11) proposed by the secretariat stated that the recommendation of the working group be applied on segments 2, 3 and 4. For segment 1, an allocation of budget space, applying the guiding principles of the new methodology, and taking into account comments made during the week is proposed. Meanwhile, the working group is expected to continue work to further develop operational segment 1, in particular on the choice of appropriate indicators and availability of data.

 

Image Credits: Flickr – NIAID