WHO Future In Question; Debate Over Industry Representation

A seemingly overworked and impoverished World Health Organization opened its Executive Board session today with calls for reform amid deep concerns about its financial future. Meanwhile, dissension arose over an industry representative named by the WHO secretariat to a new research and development funding working group, sparking the WHO director general to cast doubt on the role of industry in such groups.

Also discussed was the sensitive topic of pandemic influenza virus access and benefit-sharing, with developing countries restating concerns that the new global approach will ensure they can obtain sufficient supplies of affordable treatments and vaccines.

Discussion is expected to occur as soon as tomorrow (Tuesday) on the WHO’s counterfeit medicines policy, despite the agenda item being reduced after a closed meeting on the issue was unable to be held in December. Concerned countries like India plan to use the agenda item to discuss the issue anyway, with concerns over issues like generics and pricing, according to sources.

WHO Director General Margaret Chan said in opening remarks that the United Nations agency is stretched thin due to a level of demands impacting its efficiency in some areas, and that far-reaching reform is needed. She also warned against big corporations’ influence on policies.

The 128th Executive Board session is taking place from 17-25 January. The rotating 34-government Executive Board is an advisory body which aims at giving effect “to the decisions and policies” of the annual May World Health Assembly (WHA). This session’s agenda includes discussions on pandemic influenza preparedness, public health, innovation and intellectual property rights, the WHO HIV/AIDS strategy, substandard medicines, and the future financing of the WHO.

In her remarks, Chan underlined the financial shortfall of the WHO, which some later said could range between US$200 and $600 million dollars in the biennium.

She also said the WHO issued its first report on neglected tropical diseases in 2010, and that the launch of the report was “accompanied by further commitments from the pharmaceutical industry to donate drugs in massive quantities,” as the very poor cannot afford drugs at any price.

Chan cited a new worrisome trend in the general public mistrust of vaccines. “Public perceptions about vaccine safety can be permanently altered by unfounded fears, to an extent that no amount of evidence can change,” she said.

Chan took aim at products that harm human health but are promoted by big businesses, making it difficult to make good public policy based on health concerns. The sectors and policies “that are driving the rise of non-communicable diseases are influenced by the actions of powerful industries and multinational corporations, like tobacco, alcohol, food corporations and the agribusiness giants,” she said, adding that “the objective of incorporating health concerns in all government policies, especially for controlling non-communicable diseases, faces some tough opponents.”

Chan also complained about the workload of the organisation, which operates at the behest of member states, and called for reform. “We are constantly asked to do more and more,” she said. “This has a limit. We are there.”

“WHO needs to change at the administrative, budgetary, and programmatic levels,” she added. “We do not need to change the constitution but we do need to undergo some far-reaching reforms.”

Possible Conflict of Interest in New Expert Group

During the last WHA in May 2010, a consultative expert working group on research and development financing and coordination was created. A previous group was shaded by concerns about lack of transparency and its final report did not meet the expectations of a number of member states (IPW, WHO, 21 May 2010).

According to an EB document, EB128_6 [pdf], following the May 2010 Assembly, the details of nominees were to be submitted to Chan through regional directors. The decision requested that Chan “establish a roster of experts comprising all the nominations submitted by the regional directors and to propose” a composition of the group to the EB for its approval, taking into account “regional representatives according to the composition of the EB, gender balance and diversity of expertise.” The list included in the document has 21 names chosen from 79 nominations sent by regional directors.

Among the 21 proposed individuals to be part of the working group, Switzerland proposed Paul Herrling, head of Novartis Institutes for Developing World Medical Research. The fact that a member of industry who could stand to directly gain from the outcome could be on the working group, prompted comments and reservations from some countries. The predecessor group was suspected of including members with a conflict of interest by some countries, and this year a declaration of possible conflicts by nominees was included. A document circulated [pdf] by non-governmental group Knowledge Ecology International suggests that Herrling previously submitted a proposal to the working group pitching his company’s services to address the problem of neglected diseases.

Bangladesh was first to raise the subject and said that a member of industry sitting on the working group was a major concern. The issue also was raised by Brazil, and especially by Thailand, which spoke as a non-member of the Board. Brazil said it would have appreciated Board members getting to see the full list of names and the CVs of the short-listed candidates.

Chan, who appeared to be near tears, said the secretariat “diligently” followed the process articulated by the WHA. She demanded to know from members – specifically Thailand – why it would be unacceptable to have a candidate with a pharmaceutical background in the working group and said that it would be naïve to think that all participants in such matters – even the WHO – have no vested interest.

Herrling brings “unique expertise” in this group, she said, and she did not see how “a group of this nature” could totally exclude people with rich experience in the pharma sector. If all people with a pharmaceutical background are unacceptable, in some working groups “we will have nobody,” she said. Two countries proposed that industry representatives such as Herrling should instead be invited to appear before the working group to offer their insights.

Chan’s remark about other working groups prompted commentary afterward among observers that it could be read as an admission that all working groups have conflicts of interest.

Canada and the European Union declared they were satisfied with the list as presented by the WHO. The United States said it disagreed with any assertion that last year’s working group was discredited, and that a number of countries had supported its outcome. It also called for the working group to respect its mandate and stay focussed on recommendations for R&D financing.

Before the opening of the agenda item, WHO said Ravindra Prasan Rannan-Eliya from Sri Lanka would be replaced by a candidate from India. India, whose nominee had been left off the working group initially, did not join in the criticism of the naming of a brand-name industry representative to the working group despite being an enormous generic drug producer.

Brazil asked that the agenda item remains open for further discussion between members about Herrling but at the end of today’s session it was unclear if the secretariat would keep the item open as there was discussion whether Brazil’s request came too late. The meeting chair had swiftly gavelled the agenda item closed after “seeing no objections” and citing the nearing end of translation services. Brazil shortly afterward raised a point of order to state a desire to keep the topic open for more discussion.

Several sources insisted afterward that the issue will be reopened again as soon as tomorrow. And a developed country official told Intellectual Property Watch that if Herrling were removed, it could lead to other nominees coming into question. One key nominee favoured by developing countries is Argentinian academic Carlos Correa, who is currently conducting research at the Geneva-based South Centre.

The People’s Health Movement issued a letter [pdf] to all Board members on its behalf and a number of “affiliated networks,” with comments on agenda items, including a concern about Herrling’s presence in the list. The NGO called for the appointment of Herrling to be disallowed on the basis that WHO’s conflict of interest policy would preclude the presence of an industry employee in a norm-setting forum.

Virus Sharing, Benefit Sharing discussed

Meanwhile, during discussion of the global pandemic policy, several countries called for the access and benefit sharing of viruses.

On pandemic influenza preparedness, some countries such as Burundi and Bangladesh brought up the new Convention on Biological Diversity protocol on access and benefit sharing as instrumental. The Nagoya Protocol on Access to Genetic Resources and the Fair and Equitable Sharing of Benefits Arising from their Utilization to the Convention on Biological Diversity, adopted in October will be open for signature in February.

Burundi said IP rights should not constitute a barrier to public health issues. Brazil called for the WHO and its members to listen to the voice of developing countries and said that it is mandatory to solve the issue of the production of enough vaccines for developing countries. The increase of vaccine manufacture capabilities in developing countries was supported by the US.

Several brand-name producing developed countries specified that the existing system – constructed by and for developed countries – should be built upon, a position that varies somewhat from hints at calls for a new system that would be centred around ensuring full equal sharing of benefits of pandemic vaccine research. It was noted that the current system developed a vaccine for H1N1 in record time, six months. But it was also noted that not every country could get the vaccine for their populations.

What to Cut at WHO?

At a packed off-site session on the future of the WHO hosted by the German mission, speakers and audience members hashed through the reality that WHO will need to make great cuts and rethink its work. The message appeared to be that WHO will need to identify its core functions and priorities.

One speaker said, “the default question at WHO is what are we going to cut,” and raised questions about how health and development fit together, plus whether it should be branching into areas such as food safety. Gaudenz Silberschmidt of the Swiss health ministry said WHO remains central to global health governance and gave an analysis of things that could be done quickly or over more time.

Devi Sridhar of the Oxford Global Health Governance project said newer groups like the Global Fund and GAVI might be attracting more resources from traditional funders of groups like the WHO because they feel they can have more control and gain more favourable outcomes from the work of those groups. She termed this notion “Trojan multilateralism” in which countries are increasingly involved multilaterally for their own gain.