Upholding the World Health Organization

Global Health Policy Undervalued

As public health policy-making remains mainly a national competence under Euro­pean legislation, the EU can coordinate and complement the policies of member states. The Union’s global health policy-making lacked visibility in recent decades, although the EU is traditionally a promoter of effec­tive multilateralism. With its Council Con­clusions on global health, adopted in 2010, the EU committed itself to stronger global health governance – including support­ing WHO and the United Nations (UN) sys­tem – focusing on Universal Health Cover­age, strengthening health systems, as well as recognising the need for a “Health in All Policies” approach, including in the EU’s external actions. However, the Conclusions never received the strong backing of health, development, and foreign ministries of EU member states, as the EU was primarily seen as a development actor rather than a strategic agent in global health. Thus, EU member states decided in an incoherent way on how large a budget that they and the European Commission would make available for international health priorities, initiatives, and institutions such as WHO. Before the COVID-19 pandemic, global health was not a priority on the European political agenda, and both the health and international development cooperation man­date was reclaimed by EU member states; with some exceptions being issues in fashion, such as anti-microbial resist­ance and digital health.

COVID-19: The EU’s Wake-up Call to Global Health?

The EU has been struggling to respond to the COVID-19 pandemic, as member states primarily followed a national response at the beginning. European and international cooperation were initially placed on the back burner with the introduction of ex­port restrictions on protective equipment such as masks and gloves. Aside from the reluc­tance of member states to cooperate, the lack of resources and authority of the Euro­pean Centre for Disease Prevention and Con­trol (ECDC) has hampered a har­monised, evidence-based approach with­in Europe, and it has impeded the ECDC from pro­actively engaging in global health policies.

Gradually, a more “Europeanised” effort is now evolving to shore up the effectiveness of Europe’s public health response within the EU as well as in its multilateral commitments to bolster global health. Euro­pean governments have started to realise that a joint approach is necessary to recover from the pandemic and the socio-economic crises that will follow. In her State of the Union address, Commission President Ursula von der Leyen called for a European Health Union. She announced plans to bolster the ECDC and the European Medi­cines Agency. An expansion of EU competence in the field of health is to be dis­cussed in the Conference on the Future of Europe, which the European Commission will organise in 2021. She also announced the establishment of a European Biomedi­cal Advanced Research and Development Authority (EU BARDA) to enhance Europe’s capacity to respond to cross-border threats.

Unfortunately, it is not clear if EU member states also support these ambitions. A pro­posal for the EU health budget (2021–2027) to be increased to 25 times its current size was largely undone by member states deciding to reduce the overall amount of the EU budget. A strong European investment in health systems and monitoring would have made global EU efforts in sup­porting the resilience of health systems and crisis preparedness more credible. Budgetary lines for global health policies for inter­nation­al cooperation have not been intro­duced or bolstered yet, which makes the future fi­nanc­ing of ambitious EU global health policies in the upcoming EU budget chal­lenging.

The Commission and EU member states were more united in February 2020, when they decided to uphold the international health order by activating financial support for WHO early on. During the pandemic, WHO has moved to the centre of information provision regarding the spread of the disease and the required public health responses. After harshly attacking WHO and accusing the organisation of being too China-friendly, the US administration announced in July 2020 that it would be pulling out of WHO. There are now in­creased expectations for the EU to fill finan­cial as well as leadership gaps. EU member states such as Germany and France have already stepped in, with the former pledg­ing an unprecedented €500 million to WHO for 2020. France has committed an addi­tion­al €50 million to WHO as well as a €90 million commitment towards founding a new WHO Academy.

Formal EU and WHO Cooperation

The relationship between WHO and the EU is based on an exchange of letters dating back to 1972. The EU–WHO cooperation is modelled on the work done by WHO and the EU on the global, regional, and national levels. Firstly, the EU and WHO Headquarters in Geneva interact through designated staff in the EU delegation and via Senior Of­ficial Meetings. Both are mostly concerned with global issues. Secondly, the European Commission as well as the ECDC have a prac­tical partnership with the WHO Regional Office for Europe (WHO EURO) in Copen­hagen, which is primarily focused on topics concerning the European region. Thirdly, the EU cooperates through its delegations with WHO country offices at the national level worldwide.

The coordination among EU member states on WHO matters has been prepared by the EU delegation in Geneva since 2010. Despite some initial questions on legitimacy and trust, it is now clearly in the driving seat to bring across a common EU position between European countries on key issues. It is backed by the European Commissions’ Directorate-General for Health and Food Safety (DG SANTE) and the EEAS. However, the EU only has an observer status, as only nation-states can join WHO. This prevents the Union from fully participating in WHO governing body meetings. Hitherto, the EU has not made any attempts to change this. However, with the current global climate of retreat from multilateralism, there might be a window of opportunity for the EU to upgrade its status as well as that of other regional economic integration organisations.

Despite various levels and areas of co­operation and the EU’s observer status in WHO’s governing bodies, the EU and WHO partnership still feels shaky and less clari­fied than it is for other partnerships between EU and UN institutions. The EU has, for instance, pushed for an enhanced observer status within the UN General Assembly (UNGA) that gives the Union, among others, the right to speak early in the debate of the UNGA and to be invited to the general debate. Furthermore, WHO is primarily considered a development organi­sation for public health standard-setting outside the EU. The COVID-19 pandemic may change this misconception for the better, since all countries are dependent on WHO recommendations, followed by many – but not all – EU member states.

The political support and increased joint action could strategically strengthen EU–WHO cooperation at all levels by building on existing collaboration and partnership models (Figure 1). Three aspects are critical in the EU’s web of relations with WHO. Firstly, the European Commission does not have formal partnerships with regional WHO offices aside from WHO EURO, which could enable the EU to engage in global health diplomacy within and outside the European region. Secondly, the cooperation with WHO EURO seems to be primarily focused on European issues, which is un­der­standable. However, the next programmatic partnership between WHO EURO and the European Commission might therefore focus on global priorities that are equally important to both parties, such as projects about the environment and health, gender equity, and the commercial determinants of health. Thirdly, collaborative efforts between EU delegations with WHO country offices could be made more visible, coordi­nated, and harmonised through shared learn­ing and training sessions.

The EU As a Geopolitical Actor in Global Health

Commission President von der Leyen has expressed a willingness of the Commission to become more geopolitical, which could imply a more proactive and instrumental approach to multilateral organisations, but it also bears the risk of implying an EU‑first bias. So far in the COVID-19 crisis, the EU has responded to the challenge of pro­viding equitable access to vaccines, thera­peutics, and diagnostics in three inter­national fora.

Firstly, in early May 2020, the EU organ­ised an international pledging conference to raise funds for the development of vac­cines, therapeutics, and diagnostics. Later, a second conference was organised. These conferences can be regarded as a double-edged sword: On one side, they provide sup­port for WHO’s goal to develop vaccines, therapeutics, and diagnostics as global pub­lic goods – goods that should benefit every­one equally. According to von der Leyen, the intention is not to distribute these exclu­sively among EU member states, but to make them available and affordable worldwide. On the other side, the confer­ences position the European Commission and the EU as leaders for COVID-19 soli­darity, thereby sidelining WHO as the main platform for global coordination on inter­national health priorities.

The EU pledging conferences are an exam­ple of “fast multilateralism”, but their focus is only on the development of vac­cines, therapeutics, and diagnostics for one infectious pandemic disease, leaving other pressing health challenges neglected. Ques­tions remain as to how more structural in­vestment in and with WHO can be created to sustain global health multilateralism and cre­ate a sustainable impact on people’s health.

Secondly, in the first ever virtual World Health Assembly (WHA) – the highest decision-making forum of WHO’s member states – the EU led the development of the main resolution, which focused exclusively on the response to the COVID-19 outbreak. Multilateral support for this resolution came from China and the EU leadership, but not from Russia, the United States, or India – with the latter having a large phar­ma­ceu­tical sector. The resolution includes four main features: the request for a broad UN response; a call to WHO member states to respect the International Health Regulations, the internationally binding set of rules to prevent, detect, and respond to in­fectious diseases; a call to international organisations to create a voluntary patent pool for the development of a COVID-19 vaccine to ensure affordable access for all; and the request for WHO to establish an impartial, independent, and comprehensive evaluation of the coordinated international health response to COVID-19.

The remuneration of pharmaceuticals is regulated by international patent law. However, since the global and simultaneous demand for COVID-19 diagnostics, vaccines, and therapeutics is so high, conventional patent licensing could make rapid development and large-scale production difficult, which therefore could delay access and distribution of a vaccine. According to the reso­lution, a COVID-19 technology access pool should be the mechanism to remedy this challenge, ideally based on best prac­tices; one example is the UNITAID-estab­lished and supported Medicines Patent Pool.

However, the devil will be in the details, because the implementation of a patent pool requires internationally recognised Trade-Related Aspects of Intellectual Prop­erty Rights (TRIPS) flexibilities by the EU and its member states. These flexibilities are not discussed at WHO, but at the World Trade Organization TRIPS Council, where South Africa recently pushed for initiating a resolution with the aim of simplifying the requirements for TRIPS flexibilities, including compulsory licensing of COVID-19 diagnostics, therapeutics, and vaccines. This was proposed in order to legally guar­antee access to diagnostics, therapeutics, and vaccines for COVID-19 as a global pub­lic good, including in low-income countries. The compulsory licensing of medical prod­ucts from pharmaceutical and biotech com­panies can better protect public health and secure access to essential technologies. How­ever, major pharma-producing coun­tries, including from the EU, prioritise voluntary licensing and stress that the cur­rent mar­ket-based system suffices to guar­antee access in low- and middle-income countries.

There seems to be a contradiction be­tween the EU’s desire for global vaccine ac­cessibility and EU member states’ com­mer­cial interests and political will to pro­tect patents, since a lifting of patent restric­tions could create a potential precedent for other vaccines and medicines. EU member states prefer to keep control over the licens­ing of new medical products, and therefore they opt for voluntary licensing via a patent pool. In theory, this could still allow global access, but the international experience with gaining access to medicines for other diseases, such as HIV/AIDS and hepatitis C, would indicate otherwise. The COVID-19 pan­demic could potentially provide the momentum for reforming the governance of TRIPS flexibilities, which could have implications on whether universal access to medical products is allowed. The EU would benefit from this in the long term when con­sidering both the economic and public health perspectives.

Thirdly, WHO and the European Commis­sion co-host an “Access to COVID-19 Tools accelerator” Facilitation Council (COVAX facility), a new multi-stakeholder platform that is intended to guide key strategic, policy, and financial issues during the development of new COVID-19 diagnostics, therapeutics, and vaccines – with commit­ments by over 180 WHO member states. Still, parallel bilateral initiatives, such as advanced market commitments between the EU and pharmaceutical and biotech companies to secure doses of vaccines for European populations, might run against efforts within the COVAX facility to provide affordable vaccines for all, especially in low- and middle-income countries. However, the EU is now willing to engage in the COVAX facility after having advised its member states to not buy vaccines through COVAX earlier.

What is still missing is an outspoken stance on how WHO should function with­in the plethora of global health arrange­ments (World Bank, GAVI, Global Fund, etc.) – vis-à-vis other powerful stakeholders such as philanthropic institutes and the phar­maceutical industry – as an independ­ent watchdog during infectious disease out­breaks (e.g. exposing cover-ups by states where an outbreak has started), as well as what its topics of focus should be and what organisational structure would be most adequate. In the lead-up to the announcement about the US withdrawal from WHO in July 2021, Germany and France allegedly were discussing WHO reform with the US administration, which points to a recognition of the need for changes to the current set-up. However, it is not clear which av­enues of reform the European Commission and EU member states prefer. By intensify­ing cooperation with WHO, the European position on reform and the WHO reform process itself could be accelerated; despite WHO’s limitations, the pandemic has illus­trated perhaps more than ever how much the organisation is needed. A non-paper presented by Germany and France gives some clues about the felt need for increased funding and a strengthening of the early warning and monitoring systems during epidemics and pandemics. But other issues, such as the regional structure of WHO and its norm-setting function as well as global health aid and advice to developing coun­tries, were not addressed.

Future Choices for the EU on Global Health

As the COVID-19 pandemic enters a pro­longed phase, the EU and its member states are in the position to jointly contain the virus and begin to structurally recover by investing in the development of strong and resilient public health systems. To become a reliable and capable partner for WHO and beyond, the EU could strengthen its capac­ities in the following areas.

Firstly, the EU could update its Council Conclusions on global health. A new, co­herent EU global health strategy should focus on facilitating resilient health systems that are rooted in sustainable development as well as the right to health, in addition to being prepared for external shocks such as health security risks and consequences of climate change. A new global health strat­egy should offer a broad, more geopolitical, European perspective. Elements that could be included are references to the Union’s values (access to health, equality, democracy, accountability); links to the Sustainable Development Goals (SDGs); a health focus in all policies; a bolstering of the implemen­tation of the International Health Regu­lations; as well as reference to the EU’s strategic autonomy with regard to medical supplies and medicines (see also Kickbusch and Franz).

New Council Conclusions should be accom­panied by a concrete roadmap and monitoring mechanisms in order to be effec­tive and transparent. Most important is that they be developed and owned by health, development, and foreign policy actors of the EU member states and insti­tutions. Without their commitment, a recur­rence of the 2010 Council Conclusions may happen when COVID-19 is behind us.

Secondly, the EU needs to establish stra­tegic global health capacities within EU institutions and across different sectors – including trade, energy, and the European Semester of economic and fiscal policy coordination – followed by a clear man­date and solid financial global health resources. A strategic unit with financial, personnel, and thematic resources needs to be created within the EEAS that would have the mandate to coordinate several directo­rates on global health matters. One Com­mis­sioner should clearly be responsible on global health vis-à-vis the European Parlia­ment, the European Council, and individual member states. This could either be the High Representative or the Health Commissioner. The unit in the EEAS would have to collaborate closely with experts from the Commissions’ DG SANTE and could liaise with WHO and other multilateral partners more strategically. Moreover, it could also have a specific global health diplomacy func­tion as well as active collaboration with EU delegations contributing to its for­eign policy.

Thirdly, the EU could strengthen its health competences domestically to be stronger abroad. Giving attention to, and linking, both the internal and external health dimensions of European policy, the EU could promote the internal strengthening of EU global and public health policy. The programme EU4Health 2021–2027, whose eventual budgetary allocation is still uncertain, should enhance European com­petences and coordination by boosting the EU’s preparedness for major cross-border health threats, strengthening health sys­tems across the EU in an equitable way, as well as providing agreement on a common vaccine policy. To complement this, the ECDC could be strengthened and given a more prominent role and mandate in the EU’s global health policy-making. It is im­perative for the EU to become more stra­te­gically autonomous with regard to medi­cal supplies, but this should not be to the detri­ment of global solidarity.

Fourthly, the COVID-19 pandemic has also shown that EU member states have to act more coherently and in concert with EU institutions as well as during exchanges with civil society actors to avoid duplicating and contradicting (global) health policies. Therefore, a space for communication, co­ordination, and collaboration between EU institutions, EU member states, the Euro­pean Parliament, and civil society actors has to be created in order to enhance the EU and member states’ abilities to perform more coherently on the international stage and within international partnerships, such as with WHO. The Global Health Policy Forum could be revived and upgraded for this purpose by broadening its functions as well as expanding membership to include the Council, the Parliament (aside from the Commission), the EEAS, and civil society actors.

Lastly, the EU needs to establish a stra­tegic global health budget to pursue an ambitious agenda that is financially backed. The various budgetary channels that are supporting global health policies should be harmonised, or at least mapped. This would offer an overview of European financial resources for global health, making them transparent for the European public and helping with the strategic decision-making as to which partnerships should be finan­cially supported, depending on the global health issue. Support for WHO could then be much more targeted and in coherence with other partnerships.

Recommendations

To strengthen and deepen its cooperation with WHO, the EU needs to increase its work in the following areas:

• Upgrade the EU’s status at WHO: The European Commission and EU member states should jointly ask for an upgrading of the EU’s status with WHO to increase the EU’s visibility as a powerful unified actor and to enable it to speak with one voice. This could be done either through a resolution, a special agreement, or by strengthening WHO’s representation at the EU in Brussels, which is already work­ing not only on a European but on a global mandate. In a first step, the EU could strengthen the partnership by so­lidi­fying the cooperation within a Memorandum of Understanding that replaces the exchanging of letters. More and well-coordinated meetings need to take place between senior representatives of WHO, the European Commission, and the EEAS. Consideration could be given to including representatives of EU member states to keep them engaged.

• Extend the EU’s cooperation with WHO regional offices: A new roadmap for the partnership between WHO EURO and the European Commission is current­ly in the making. Now is the time for EU member states to have a strategic debate on WHO EURO and its future rela­tions with the EU. New priorities and programmes should be aligned with achiev­ing the SDGs – in Europe and globally. In line with the EU’s Green Deal objectives, projects with WHO promoting environment and health could equally pave the way for new areas of cooperation. A solid monitoring mechanism for the new five-year plan is key to creating a sustainable impact as well as account­ing for joint actions. The establishment of formal relations with WHO regional offices outside of Europe, such as WHO AFRO, would put EU efforts at the coun­try level within a broader synergistic and strategic approach.

• Increase and sustain WHO’s budget: WHO’s financing is mainly based on in­dividual donor interests, leaving WHO highly dependent and vulnerable to the top 15 donors, which contribute more than 80 per cent of all voluntary contributions. An increase of assessed and core voluntary contributions, as demanded by many experts as well as governments, is necessary to ensure WHO’s ability to act on its core functions. Financially, the an­nounced US withdrawal could be partly compensated for by the EU, but the EU should also work for sustainable financ­ing and reform of WHO, including en­suring autonomy and the global public legiti­macy of the organisation. Sustain­able and long-term predictable financing leads to sustainable human resources planning with staff that can implement reforms and deliver what is demanded of WHO.

• Consider WHO recommendations and the results of the Independent Panel for Pandemic Preparedness and Response (IPPR): A high level of political support for WHO can be shown by applying WHO norms and standards at home as well as in international global arrange­ments. This should include unequivocal financial support by the EU and its mem­ber states for – as well as the commitment to – WHO’s COVAX facility. WHO’s role in global health can also be strength­ened by referring to and pro­moting WHO’s role as the supreme glo­bal health authority. Based on the WHA resolution, WHO has established the IPPR, which evalu­ates the global COVID-19 response. This initiative is strongly supported by the EU and its member states and can, as an indirect effect, po­ten­tially defuse some of the geopolitical tensions around the global governance of the COVID-19 pan­demic. The IPPR was launched in July 2020 and is co-chaired by former Prime Minister of New Zealand Helen Clark and former President of Liberia Ellen Johnson Sirleaf. An interim report to the WHA is expected in Novem­ber 2020. European countries need to properly consider the results of the in­dependent evaluation and further strength­en the autonomy of WHO.

• Lead the WHO reform debates: The EU should have the ambition to reshape multilateral global health structures while establishing WHO at the centre. The EU should provide voice and leadership in an institutional and legitimate reform process of WHO, which was slow and ineffective before the COVID-19 pan­demic. The German–French non-paper already provides relevant proposals.

• Develop a new EU global health strat­egy that addresses WHO reform and is backed by health, development, and foreign affairs stakeholders from EU institutions and member states. Such a global health strategy should include issues regarding WHO’s raison d’être, its current organisational structure, areas of focus, and independence during out­breaks of infectious diseases. It should also make choices about, or create a bal­ance between, the EU’s desire to uphold multilateral arrangements and simul­taneously become more strategically autonomous.

A renewed partnership between the EU and WHO during the COVID-19 pandemic – despite nationalistic trends and geopolitical tensions – offers a glimmer of hope. The EU should seize on this opportunity but not outshine WHO, as collective efforts are need­ed more than ever to secure global pub­lic goods and uphold the international health order.