Breakthroughs Blog: United Nations

It has been nearly eight years since antimicrobial resistance (AMR) gained political attention at the highest levels. At the United Nations (UN) High-Level Meeting (HLM) on AMR in 2016, countries vowed to take a coordinated approach to address the root causes of AMR. Now, close to a decade later, progress has been uneven at best. While many countries have tried to tackle the issue by developing their own national action plans, fewer than a fifth of these plans are funded or implemented. And while annual global funding for antibiotic research and development (R&D) increased by 25 percent since 2017, access remains a challenge, as many new antibiotics never get registered and remain unaffordable in low- and middle-income countries (LMICs).On September 26, the UN is hosting a second HLM, aimed at accelerating multisectoral global, regional, and national action to address AMR. Will this be the moment where key global decision-makers generate lasting political momentum to make meaningful progress addressing this silent pandemic?Renewed sense of urgency to address AMR and invest in R&DThe upcoming meeting will occur amid a sense of renewed urgency around addressing AMR. A recent Lancet report highlights that drug-resistant pathogens could cause more than 39 million deaths over the next 25 years, forecasting that AMR deaths will increase steadily in the coming decades if remediation measures are not in place.A study by the Global Research on Antimicrobial Resistance Project predicts that AMR mortality will increase by 70 percent by 2050 and notes that the most impactful way to prevent this outcome is through improving access to effective antibiotics, particularly in LMICs, where the burden of disease continues to be the greatest. The study also suggests that the traditional model of drug development may not be sustainable for antibiotics, as most new products never reach key populations in LMICs because they are not able to overcome regulatory challenges and remain too expensive. Unless access and affordability are assured, the global mortality burden from resistant bacterial infections will continue unabated. Ensuring there are political commitments to strengthen the AMR R&D ecosystem will be crucial in realizing progress.2024: The year of AMR?The good news is that, in many ways, 2024 has already been the year of AMR. In May, the World Health Organization (WHO) delegates approved a resolution to accelerate national and global responses on AMR, with many of them highlighting it as a crucial building block for the HLM this fall.The resolution welcomes WHO’s strategic and operational priorities to address drug-resistant bacterial infections in the human health sector, including strengthening R&D to support the creation of new tools to combat AMR and replenish the shockingly waning pipeline.AMR has also continued to feature in G7 and G20 discussions, and member states are largely expected to include provisions focused on combating the silent pandemic in political outcome documents later this fall, including recognizing the need for new investments in research and greater support to initiatives like the Global AMR R&D Hub.Political declaration: Commitments on a path forwardSo, what constitutes success for the HLM on AMR? Much of it comes down to the commitments and pledges made in the political declaration that will be adopted by delegates. The good news is that the final draft includes some strong targets, including one to reduce global deaths from bacterial AMR by ten percent by 2030. Countries are also pledging to develop their national action plans by 2030, of which 60 percent would need to be adequately funded by the deadline (compared to the roughly 20 percent which are to date).Perhaps most notable though is the request for the Quadripartite—which is comprised of WHO, the World Organization for Animal Health, the UN Food and Agriculture Organization, and the UN Environment Programme—to establish an Independent Panel on Evidence for Action. The panel would serve a key function by supporting member states’ decision-making with regular guidance on the trends of science, data, and evidence across AMR-related sectors.R&D is also a central pillar in the declaration, with member states recognizing the need for increased public-health-driven R&D and the role of public-private partnerships like the Global Antibiotic Research & Development Partnership and the Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator. The text encourages the use of push and pull incentives to spur R&D while ensuring mechanisms are in place for equitable access. Countries are called upon to develop and incentivize the adoption of manufacturing standards, promote the transfer of technology and know-how, encourage research, and undertake measures to address the growing shortage of researchers and medical specialists.It is worth celebrating the inclusion of several numeric targets, as many past political outcome documents coming out of UN health-focused high-level meetings did not feature such specific and explicit provisions and pledges. However, while the political declaration offers a good framework for making bigger shifts in the fight against the silent pandemic and ensuring a more explicit focus on equitable access to health technologies to fight AMR, additional funding and research targets would have led to an even stronger outcome, as targets lead to better transparency and accountability.What’s next?Member states are largely expected to adopt the political declaration on Thursday without much controversy. The question is: what’s next? There will certainly be opportunities to further advance the work on AMR in other forums, such as the G7 and G20, as well as at the AMR ministerial in Saudi Arabia in November. The AMR political declaration includes a commitment by countries to raise $100 million to aid implementation of national action plans, and follow-through on the principles and targets will be key in the months (and years) ahead, especially with the next AMR meeting not scheduled until 2029. The 79th UN General Assembly will be a pivotal moment to garner the high-level political commitment needed to ensure sustained focus on the ongoing challenges around AMR and to shift from dialogue to action to combat the silent pandemic.

Last week, rain clouds gathered over Geneva as delegates from all over the world completed their annual pilgrimage to the World Health Assembly (WHA), the World Health Organization’s (WHO’s) annual forum for the 194 member states. The somber background reflected the mood heading into the meeting, as many were expecting this year’s gathering to be a washout. A visibly weary WHO Director-General Dr. Tedros Adhanom Ghebreyesus expressed his disappointment on the opening day that negotiations on a pandemic accord had not been completed in time for a WHA vote. Representatives also expected contentious fights over sexual and reproductive health and geopolitical conflicts, such as the ones in Ukraine and Gaza, to spill over into the proceedings, freezing debate and derailing possible progress on agenda items ranging from climate and health to universal health coverage. Yet, despite some serious bumps in the road, WHA also showcased that any multilateral system obituary is premature and that multilateralism can still deliver the necessary change we need to advance the global health agenda.   WHA approves new IHR amendments, resets timeline for pandemic agreement negotiationsAll eyes were on whether member states could come together to finalize the negotiations around the pandemic accord, a proposed convention to address some of the shortcomings exposed during the COVID-19 pandemic, as well as amendments to the International Health Regulations (IHR), an existing framework that codifies member state and WHO responsibilities in preparing for and responding to a public health emergency.  Heading into WHA, many stakeholders waited with bated breath to see if member states could bring both these processes across the finish line. Unfortunately, despite two long years of grueling negotiations, countries were unable to forge sufficient consensus to approve the pandemic accord. Instead, countries agreed to extend the mandate of the intergovernmental negotiating body, which coordinates the deliberation process for another year, providing additional time to reach compromises around the most contentious issues (financing, technology transfer—the process by which knowledge is transferred from the originator of a technology to other manufacturers to support the diffusion of health technologies into additional markets—, and a proposed access- and benefit-sharing system, which would pair commitments by countries around the sharing of pathogen samples and sequencing data with commitments from manufacturers to set aside a dedicated portion of their products for equitable distribution during health emergencies).  Nonetheless, member states notched a desperately needed win in reaching consensus on amendments to the IHR, achieving an agreement in the final hours of WHA. The consensus takes on added significance given that country representatives were not only in a race against time but also against fast-eroding trust in multilateralism, which was deeply fractured by the pandemic and subsequent geopolitical conflicts. The amendments to these technical rules, last revised in 2005 following the SARS outbreak, represent the first significant change in international law in the aftermath of the COVID-19 pandemic. While there were many changes to the IHR, one that stands out the most is that the added provisions include a commitment to solidarity and equity on strengthening access to medical products and to financing, including specific text that directs countries to promote research and development (R&D) and strengthen local production of quality, safe, and effective relevant health products. The previous IHR did not include any mention of R&D or the need to ensure equitable access to new tools.   WHA reinvigorates maternal and child health agenda  Progress was also made on a couple of other fronts in Geneva. Alarmed by the stagnation of progress in reducing maternal and child mortality, member states passed a critical resolution committing to specific actions to prevent the deaths of women, babies, and children.The resolution, led by Somalia and other cosponsors, commits countries to tackle the leading causes of maternal and child deaths, particularly in the hardest-hit nations. In it, countries agreed to improve access to maternal health services, including sexual and reproductive services, and comprehensive child health services through stronger primary health care and expanded access to emergency services. It also urges countries to develop and invest in tools that enable access to essential quality medicines for pregnant women, lactating women, mothers, and newborns and calls on WHO to strengthen and expand collaborative efforts, such as those promoted by WHO technical departments and the Global Accelerator for Pediatric formulations, or GAP-f, network, for facilitating better access to medicines for children. The WHA resolution marks WHO’s first significant action on maternal mortality in nearly a decade, following the adoption of the Global Strategy for Women’s, Children’s and Adolescents’ Health in 2015. Antimicrobial resistance in the spotlight  Antimicrobial resistance (AMR) also was in the spotlight in Geneva. With the United Nations High-Level Meeting (UN HLM) on AMR taking place in New York in September and a high-level ministerial meeting in Saudi Arabia in November, this year has been supercharged with attention on the issue, with WHA featuring numerous AMR events, roundtables, and initiatives.  Delegates approved a resolution to accelerate national and global responses on AMR, with many of them highlighting it as a crucial building block for the meetings in the fall. The resolution welcomes WHO’s strategic and operational priorities to address drug-resistant bacterial infections in the human health sector, which include prevention of infections; universal access to affordable, quality diagnosis and appropriate treatment of infections; strategic information, science and innovation; and effective governance and financing of the human health sector response to AMR.  The resolution also calls on member states to support investments in R&D for new tools to combat AMR and replenish the shockingly waning pipeline, to strengthen the capacities and standards of laboratories, and to participate in the WHO’s Global Antimicrobial Resistance and Use Surveillance System, or GLASS.While WHA did ultimately feature some contentious moments, especially around the geopolitics of Ukraine and Gaza, and major pushback on sexual and reproductive health, the latter almost derailing the adoption of several key decisions, the wins on IHR, maternal and child health, and AMR will have reverberations beyond WHA. Delegates hope that these wins will provide the necessary momentum to continue to make progress on the pandemic accord and at the UN HLM on AMR in the fall.  

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.

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.