New Pandemic Agreement: Pharma Wins, Developing World Loses, says AHF Global Public Health Institute

As the final Intergovernmental Negotiating Body (INB) meeting of the World Health Organization (WHO) Pandemic Agreement approaches, the AIDS Healthcare Foundation and the AHF Global Public Health Institute are voicing significant concerns about the April 16, 2024, Proposal for the WHO Pandemic Agreement.

This latest iteration of the text, which has been significantly watered down through the negotiation process, is filled with platitudes, anemic in obligations, and devoid of any accountability. Falling victim to least-common-denominator policymaking in Geneva, this text now lacks the requisite power to operationalize equity and achieve its intended objectives.

We express profound concern that developed nations have vehemently defended the private interest of pharmaceutical companies over the collective common interest of achieving global health security in a sustainable and equitable manner. Such disregard has been observed in the proposed compromise for the WHO Pathogen Access and Benefit-Sharing System (PABS), which the Lancet has described as not only "shameful, unjust, and inequitable" but also "ignorant."

Under the present terms of PABS, a mere 20% of pandemic-related health products are guaranteed to the WHO in the event of a pandemic. As the Lancet points out, such an arrangement will effectively leave 80% of crucial vaccines, treatments, and diagnostics "prey to the international scramble seen in COVID-19." Furthermore, such pandemic-related health products are now made available only in the event of a pandemic rather than upon the declaration of public health emergencies of international concern, as previously proposed. In addition, we consider that monetary financial contributions to PABS should not be "administered by WHO" but rather directed to existing global health financing mechanisms according to formulations agreed-upon in advance of the conclusion of negotiations.

Have we learned nothing from the COVID-19 Pandemic?

While the INB co-chairs, vice-chairs and some delegates have undoubtedly been working diligently to reach an agreement, a simple fact remains: equity will not be operationalized without effective mechanisms for accountability and enforcement.

Despite warnings by technical experts, the INB has persistently failed to incorporate tangible provisions for accountability and enforcement. In the current proposal, Article 8 language regarding Preparedness Monitoring and Functional Reviews has been withered to nothing; Article 19, Implementation and Support, contains no reporting or verification requirements; previously proposed mechanisms for an accountability committee have been deleted instead of strengthened, and the text now moves forward without any effective means for timely and accurate verification of party compliance.

Calls for strong mechanisms of accountability in the pandemic agreement are widespread but have not been heeded. They have been made by the United Nations General Assembly and prominent international bodies, including the Global Preparedness Monitoring Board (GPMB) and the Independent Panel for Pandemic Preparedness and Response (IPPPR). In addition to the GPMB and the IPPPR, the Panel for a Global Public Health Convention and Spark Street Advisors have also emphasized the critical need for independent monitoring.

The absence of any form of independent oversight is concerning because proven and practical experience confirms that relying solely on state self-reporting mechanisms does not work. Yes, instead of learning from the widespread delays and incomplete self-reporting experience of the International Health Regulations (IHR), the pandemic agreement promotes more of the same practices that have compromised global health security in the past. To ensure its objectivity and effectiveness, the agreement should, at minimum, consider establishing an independent oversight body that is "politically, financially, technically and operationally independent of the WHO and donors."

In addition to oversight, accountability also requires a clear enforcement framework with incentives and disincentives for compliance. The two major treaties under the authority of the WHO ? the Framework Convention on Tobacco Control and the IHR ? are described in the literature as "plagued by incomplete compliance." Incomplete compliance with the IHR, for example, "contributed to COVID-19 becoming a protracted global health pandemic."

Compliance, however, has largely been ignored by all parties and brushed under the rug throughout the negotiations. This is reflected in the current text, which does not mention the word compliance even once. To this end, we echo the concerns of the Panel for a Global Public Health Convention that the idea of a Compliance and Implementation Committee should not have been dropped from the text.

We also support the Panel's assessment that an independent and autonomous Conference of the Parties (CoP) is critical because pandemics are not just a health issue but a "societal and governmental priority" that requires a whole-of-government and whole-of-society approach. We are, thus, concerned that modifications to the proposed text, which now call for the WHO to function as the Secretariat for the entire agreement, undermine the independence of the CoP. We are also not clear how this agreement will secure the necessary financial resources to achieve its objectives.

To this end, we emphasize that member states should commit the necessary funding to establish a fit-for-purpose pandemic prevention, preparedness, and response architecture, taking into account the existing global health financing mechanisms. "One of the central failings of the IHR has been that its requirements for states to collaborate, including with respect to mobilizing financing, lacks specificity," and that "without benchmarks, formulas, or other such details" such "requirements have little real force." Here, the same mistakes are being repeated ? most notably through the lack of binding financial commitments in the letter of the agreement. Furthermore, the removal of language from Article 20, calling for the development of a five-year financial implementation strategy is a step backwards.

We also highlight that the current text misses the opportunity to effectively engage civil society and other non-government actors. The sole mention of civil society, in Article 17, is immediately followed by a caution regarding potential conflicts of interest, as if conflicts only arise when civil society is involved. Despite their critical contributions during the COVID-19 pandemic and numerous previous health crises, the voices of civil society remain marginalized in the decision-making processes of the WHO, the pandemic agreement negotiations and its implementation. Moving forward, this could be solved by weaving civil society in the fabric of the CoP to ensure its meaningful participation.

In the final stretch of negotiations, countries will be wise to remember how we got here, what needs to be accomplished through this pandemic agreement, and most importantly ? what the consequences will be if it fails. Hoarding of essential public health goods, and policies that tolerate corporate greed to take precedent over human lives should not be allowed anymore. We, therefore, urge that delegates heed the warnings of experts and take action to correct critical flaws in the proposed text. Empty handshakes in Geneva will not prevent another global health disaster, nor will it keep countries from trampling over each other when the next pandemic comes.

AIDS Healthcare Foundation (AHF), the largest global AIDS organization, currently provides medical care and/or services to over 1.9 million clients in 47 countries worldwide in the US, Africa, Latin America/Caribbean, the Asia/Pacific Region and Europe. To learn more about AHF, please visit our website: www.aidshealth.org, find us on Facebook: www.facebook.com/aidshealth and follow us on Twitter: @aidshealthcare and Instagram: @aidshealthcare

The AHF Global Public Health Institute is as a joint initiative of the AIDS Healthcare Foundation and the University of Miami created to engage in global public health policy analysis and research to generate objective evidence that can inform improvements in public health policy at the global, regional, national and local levels, particularly for infectious diseases. To learn more about the AHF Global Public Health Institute, visit https://ahfinstitute.org/.