Breakthroughs Blog: WHO

GHTC’s PQ Pulse interview series explores challenges in navigating the World Health Organization’s (WHO’s) prequalification (PQ) program with various stakeholders engaged in the regulatory ecosystem. In our second installment, we sat down with Dr. Iain Barton from Health 4 Development (H4D) and Vizuri Health Dynamics to discuss their experiences with the WHO PQ program in the African continent. H4D is a consultancy firm that specializes in African health system strengthening, market access, and scalable impact for regulatory harmonization across the continent. Vizuri Health Dynamics is an H4D-initiated organization that aims to ensure sustainable and equitable supply of high-quality, affordable medicines across the continent by fostering a competitive pharmaceutical manufacturing sector and empowering African manufacturers.In our interview, which has been lightly edited and condensed below, Dr. Barton discusses H4D and Vizuri’s vision for a harmonious African R&D ecosystem through aligned manufacturers and regulators.  GHTC: In our second installment of PQ Pulse, we’re sitting down with Dr. Iain Barton from H4D and Vizuri Health Dynamics to discuss his experience with WHO’s PQ process on the African continent.  I want to launch right into it and ask our first question. Can you briefly describe H4D and Vizuri’s engagement with the PQ process?Dr. Barton: Vizuri's engagement with the PQ process and the regulatory landscape is first around advocacy. This means bringing the messages of the national regulators and of third-party quality standard authorities to African manufacturers and helping them understand how to engage and how to qualify and position themselves within those spaces. We strive to prompt and help answer the questions: “What are the products? What are the processes? What are the industrial environmental impacts for manufacturers?” The second area of engagement with PQ connects back to national regulators and streamlining processes for WHO-listed authorities around maturity level 3 or 4 [Editor note: A WHO designation for countries with stable, well-functioning regulatory systems]. And so in the development of regulatory reliance structures, we strive to be cognizant of all that is happening, ensuring manufacturers are supported to do cross-border sales, for example, and that they know how to engage with regulators at each level. It’s a difficult and often uncertain space to navigate, and, therefore, the advocacy and education we bring and the enabling of manufacturers we do has probably been the most important role we’ve played around WHO’s PQ structure. GHTC: Yeah, so that's super helpful.GHTC: How has this engagement been shaped by being an African organization in Africa and thinking about the fact that the landscape is evolving and changing? And what are your thoughts on the evolution of that ecosystem?  Dr. Barton: Yes, lots is changing, it really is. It’s cool, it’s very exciting. But it is important that we ensure that everyone comes along on that journey of change. The emphasis on quality and safety is fundamental and must remain the cornerstone. Some things can’t change, and that emphasis on quality and safety is foundational.But it is also important to understand what is changing within the national regulators. Not only what is changing within their own structures, but within regional structures, within cross-regional collaborations around interregional reliance mechanisms, and then in the continental initiative of the African Medicines Agency (AMA) and what that means, both for our national regulators and the manufacturers working within those markets. If you look at the collaboration that is happening now between WHO PQ and national regulatory authorities (NRAs), AMA, and manufacturers, there's an incredible amount of energy going into creating alignment and transparent pathways for those NRAs to integrate with each other and within a much larger system. This is a significant step for African players in supporting not only integrated systems between Africa’s 54 countries but in their integration with the rest of the world. The common goal across stakeholders is to have vibrant African manufacturing capacity that is moderated and enabled by empowered and high-standard NRAs within the AMA structure that is overarching in standards and policy administration. You can start to see why Vizuri being here and acting as that translation layer is so important. The journey from 54 individual regulators to a harmonized, standardized, and reliant regulatory model across the continent is fundamental to achieving that end-vision of a vibrant industry, because it is vitally important to enable manufacturers to not only sell within their own country but also cross-regionally to neighboring countries and even out into the rest of the world. The other thing that’s interesting to watch is how digital tools and technology, in particular artificial intelligence (AI), are being used to expedite processes and create transparency. For example, we’re seeing AI being used to simplify registration application processes. And then also the use of digital tools, and in some cases conversations around blockchain, to ensure that dossiers submitted to this regulator are the same dossiers now submitted to that regulator. Regulatory reliance isn’t just a one-way street; it’s about ensuring the credibility of the applicant as well. So, technology becomes quite an important part in expediting and simplifying regulatory processes. It is important that we continue to accelerate that momentum to reform and enable African manufacturers to adapt to the regulatory landscape as it evolves. And to do this, we have to go together to find new opportunities for funding and collaboration to bring this to fruition. Our current reality is that for many procurements, the third-party regulator is the authority. But we must always live in a place where a third party is also trusted to ensure quality validation, to simplify trade, and to expedite access. There will always be a role for WHO PQ within the environment, I believe, because that trusted third party will fulfill that role across the world. But within Africa, it may diminish all the way to where AMA becomes the overarching validation authority. It’s going to be important that everybody is both willing and engaged in that evolution of the entire ecosystem. GHTC: There are so many exciting things happening and changing in the landscape with the AMA, the Africa Centres for Disease Control and Prevention, and other regional harmonization work for alignment between countries. How does that loop back to the global conversations that are happening or conversations happening in different geographies to ensure that PQ has a role to play? And what would the best-case scenario for what that looks like? Dr. Barton: Yeah, so the stringent regulatory authorities were a closed shop, and that was a method in a system that was completely unsustainable. Stringent regulatory authorities were used as the only means by which anyone could benchmark themselves. And for cross-border trade between regulators, that was the way in which things had to be done. WHO PQ changed that. But then it became another third-party certification process because the people who were paying for the product (i.e., the donors) demanded that third-party validation. As African regulators become recognized for their ability and the quality of their work and the enforcement that they’re able to provide around safety, quality, and efficacy, the need for third-party regulators diminishes. However, until the confirmation of the role of the AMA and the African Medicines Regulatory Harmonization program, third parties like WHO PQ will remain a means by which there’s validation between NRAs. There’s also a vital role to be played in developing trust around African-made products for consumers and practitioners. It’s not only funders that need to trust the product in the public health space—it’s everybody. Everybody always sees WHO PQ as being the way in which funders are able to have confidence in safety, quality, and efficacy. But even more vital as we build a vibrant industry on the continent is the confidence of patients that African-made products are of a high quality. That’s probably the biggest burden that rests on the AMA; over time, the AMA is to become the trusted authority that builds, provides, and maintains confidence across regulators to donors and professionals and, eventually, downstream to patients. GHTC: You’re reminding us of the end goal here to bring new technologies to the people who need them most—practitioners and patients—and the systems that allow them to do that. GHTC: If you had a magic wand that could change the system, influencing the PQ process specifically, what improvements would you make? Broadly speaking, thinking about the integration of AMA with other regulators, what other changes would you make? What would you hope to see five to ten years down the line? Dr. Barton: I guess the clear definition of roles and responsibilities is crucial and for everyone to confidently and assertively pursue perfection in each of their roles in trusted collaboration. For instance, if one looks at the role of AMA, there’s the role of enabling policies and guidelines and expediting the adoption of those policies and guidelines to countries and NRAs. There will always be a need for every product to be registered within each market, because only the local NRAs can hold manufacturers accountable for product quality and drive post-market surveillance and pharmacovigilance for the assurance of product safety in their country. We’re talking about building an accountable system. We want manufacturers in Africa who are accountable for the security of supply of commodities. We want manufacturers in Africa who are accountable for the quality of the product that is delivered to patients. For example, if you have a batch failure on a product that you procured from a manufacturer in China, what enforcement capacity does the national regulator in Malawi have? However, if the manufacturer in Kenya has a batch failure, they can be held accountable by the national regulators, regional regulators, and by the AMA.  And so, when you use that magic wand, the impact you have is different for every different player in the space. The magic comes in an industry that is accountable for security and supply and delivery.They are also accountable for the environmental consequences of their manufacturing processes. We want to see standards around the means of production, in terms of energy use, fossil fuel inputs, solvent utilization, waste management, and water contamination. That accountability can happen in a market that has regulators who are empowered, standards that are homogeneous, and people who invest in those businesses who can access markets across multiple countries, creating an economy of scale. That is the way we will build this vibrant industry. GHTC: That is a great answer, framing the localization agenda through the lens of accountability. Thank you for joining us today to share your perspectives and the work you do with H4D and Vizuri. 

For the first time, global leaders have come together to lay out a comprehensive plan for pandemic prevention, preparedness, and response. After over three years and 13 formal rounds of negotiations, member states of the World Health Organization (WHO) defied expectations and reached consensus on a Pandemic Agreement. The final draft of this legally binding instrument will lay the groundwork for stronger global cooperation and be a major catalyst for a more robust research ecosystem that ensures that the fruits of innovation are more equitably shared.  A win for multilateralism! This agreement is a major win for multilateralism. At times, there were reasons to think the negotiations might fail, including seemingly intractable disagreements between high-income and low- and middle-income countries on access and intellectual property issues. Then came the announcement in January that the United States intended to withdraw from WHO and would take no further part in the treaty talks. International cooperation has been tested, and it was important for the global health community to clear this hurdle.  While the text agreed upon in Geneva reflects compromise and not all negotiators’ ambitions were met, it represents important progress and lays the groundwork for action toward global readiness and equity in future health emergencies.  What’s in it for R&D? Efforts to accelerate the research and development (R&D) of vaccines, drugs, and other medical countermeasures were at the heart of the negotiations, and member states agreed to the following priorities: Promote technology transfer—which involves the transfer of scientific knowledge and know-how from one party to another to facilitate the broader production and availability of products—under “mutually agreed” terms. While this qualifier was disappointing to some low-income countries who had hoped for stronger commitments to help scale up local manufacturing of lifesaving medical countermeasures, it was ultimately a red line for wealthier countries, which prioritized preserving existing intellectual property frameworks.  In a historic first, the text obligates countries to attach conditions for access to publicly funded R&D contracts, a landmark step toward promoting equity. If implemented effectively, this means countries would be empowered to use contract enforcement measures to ensure public R&D spending ultimately results in products that reach patients. An agreement to promote post-clinical trial access to products for trial populations and for populations at risk in their communities, as well as commitments to support the transparent publication of clinical trials protocols and research results.  A framework for a new Pathogen Access and Benefits Sharing (PABS) system that grants companies access to scientific data, such as pathogen samples and genomic sequences, in return for more equitable sharing of drugs, vaccines, and diagnostics during a pandemic. Countries agreed that 20 percent of the vaccines, drugs, and diagnostics produced by participating manufacturers will be made available to the WHO for distribution. PABS wasn’t finalized during the negotiations and will now have to be fully developed through a new working group and added as a separate annex to the agreement. Establishment of a Global Supply Chain and Logistics Network to coordinate resource allocation, reduce access barriers, and mitigate the practice of hoarding of pandemic products through shared stockpiles. Beyond R&D, other key elements of the proposed agreement include a commitment to a “One Health” approach to pandemic prevention, efforts to strengthen national health systems, and the creation of a coordinating financial mechanism to support implementation of new obligations and capacity-strengthening measures.For a more detailed breakdown of the agreement, check out this briefer!Next steps: World Health Assembly and beyond After three years of intense negotiations and significant progress made toward aligning key provisions, critical procedural steps remain before the agreement can be formally adopted and implemented.   First, the text must be adopted by member states at the World Health Assembly later this month. There will then be an intergovernmental working group that will convene to hash out the details of the PABS system, likely over the course of the next year. Once the PABS annex has been finalized, at least 60 countries must ratify the treaty—in accordance with their own national laws and processes—in order for the Pandemic Agreement to become international law and enter into force. Finally, in order to support implementation and ensure enforcement and accountability, a “conference of parties” will be established to regularly review the agreement’s implementation.  The agreement has now reached an important milestone, but the work is not done. Leaders must carry it across the finish line later this month before committing to the task of ensuring its success through robust implementation. 

In 2001, I traveled to Ghana as a graduate student working on a US Agency for International Development-funded decentralization program. I arrived armed with materials on local governance best practices. But the mayors I met were focused on urgent public health issues: clean water, HIV/AIDS, tuberculosis, and malaria. That trip, meant to be an early lesson in governance, became my first and most personal education in global health. It also nearly killed me. I was taking mefloquine weekly to prevent malaria. Toward the end of our stay, my partner and I set off to explore the country. Somewhere along the way, I developed what I believed to be giardia. That infection likely compromised the absorption of the mefloquine and left me dangerously vulnerable. One night in the village of Kokrobite, I woke with a high fever and chills so intense I could barely stand. A local man saw me and immediately recognized it as malaria. He arranged for a taxi to take me back to Accra. Before I left, he handed me a small, crumpled packet labeled in Chinese characters. Inside was a blister pack of pills. The only word written in English on the package was artesunate. He told me it would help, and, in that moment, sick, scared, and weak, I took it. At the hospital, a blood smear confirmed that I had cerebral malaria caused by Plasmodium falciparum, the deadliest strain. Cerebral malaria can cause brain swelling, coma, and death. I drifted in and out of consciousness for days. At one point, hospital staff told my partner that there was nothing more they could do. I should “go home” and be “as comfortable as possible.”My partner worked relentlessly to get me on one of the next flights back to the United States. I was so sick that the airline nearly refused to let me board. Once we arrived home, I was seen right away by an infectious disease doctor at Johns Hopkins Hospital. After reviewing my labs and the herbal remedy package, he said plainly: this saved your life. The artesunate had bought me enough time to survive the journey and begin treatment. At the time, the World Health Organization had not yet formally endorsed artemisinin-based combination therapies (ACTs) as the global standard for P. falciparum malaria. That came in 2006. But the effectiveness of artesunate alone was already well known in many parts of the world. That medicine saved my life.I missed several weeks of school but made a full recovery. Without that drug and the help of my partner (now my husband) and friends in Accra, I wouldn’t be here today. More than two decades have passed, and we've made tremendous progress. Insecticide-treated bed nets, rapid diagnostic tests, and ACTs have saved millions of lives. Two malaria vaccines, RTS,S and R21/Matrix-M, have been approved. Long-acting monoclonal antibodies are showing promise as seasonal protection for children. Newer insecticide-treated nets help counter resistance. And researchers are exploring RNA-based therapeutics and single-dose cures.Many of these breakthroughs are being developed by members of the Global Health Technologies Coalition, where I now serve as Executive Director. These tools represent our best chance not just to control malaria but to end it.But progress is not guaranteed. Cuts to foreign assistance and global health research and development are already slowing the progress of innovations in the pipeline. Some promising tools may be delayed or abandoned. That means more children at risk, more untreated infections, and more drug-resistant strains emerging. The parasite has evolved before. It will do so again if we let it. And malaria is no longer a disease that happens mostly outside of the United States. In the past two years, locally acquired cases have been reported in Florida, Texas, and Maryland. Climate change, global travel, and changing mosquito habitats are making malaria a threat we can no longer treat as distant. I know how thin the line is between surviving this disease and not. For me, it’s not abstract. It’s the memory of a fevered body, the generosity of strangers, and a medicine in the right place at the right time. This World Malaria Day, I urge leaders and policymakers to stay the course. The science is moving forward. But science alone isn’t enough. If we don’t finish what we’ve started, we risk letting malaria surge back and take more lives with it. Science has given us the tools. The question now is whether we will act in time or let the disease outpace us once again. 

The World Health Organization’s (WHO’s) prequalification (PQ) program plays a critical role in certifying the quality, safety, and efficacy of medical products to expand access to health technologies in low- and middle-income countries (LMICs). In our PQ Pulse interview series, GHTC speaks with stakeholders involved in the PQ process about persistent challenges within this evolving regulatory ecosystem and potential reforms to promote equitable access to innovative medical products.  Our first guest is Pierre Hugo, Vice President of Market Dynamics and Global Supply Security at the Medicines for Malaria Venture (MMV), a nonprofit product development partnership working to advance accessible medicines to treat, prevent, and eliminate malaria. MMV works end-to-end along the research and development pipeline, developing novel products, engaging with regional regulatory bodies, and supporting local manufacturers.In our interview, which has been lightly edited and condensed below, Pierre discusses MMV’s experience navigating WHO PQ and his hopes for the future of the R&D ecosystem.Can you tell us about MMV and the unique role and perspective it brings to product development?We fill the gap and, by and large, are a risk mitigation tool as one of the product development partnerships, or PDPs, within the malaria space to discover, develop, and deliver malaria products. Regarding access, our key ethos is that no drug is a medicine until it's in the hands of the patient. It's all very good and well developing drugs, but if they aren't developed correctly or affordably for the target population and ultimately made available, it's a dead-end game. So, we try to ensure that in the last mile, or the death-mile, drugs are getting to the patients. WHO PQ and organizations like MMV play a very important role.Broadly speaking, how would you describe MMV's experience with engaging in the WHO PQ process?  We’ve got a number of products that are now WHO prequalified, working with our pharmaceutical partners. We see the whole PQ process as a critical mechanism to ensure that quality standards are adhered to and, ultimately, to make quality-assured products available in LMICs, where maybe those regulatory pathways are a little bit less mature. I think what's great to see is that the landscape is changing, with a lot more countries achieving WHO maturity-level 3 status [Editor note: a WHO designation for countries with stable, well-functioning regulatory systems]. Yes, there have been challenges. WHO has been very collaborative, the team has been engaging, and we are grateful for the support that WHO PQ provides.Looking forward, it's going to be critical to see how WHO PQ needs to evolve and change to further strengthen and work more closely with countries’ regulatory mechanisms or pathways.How do you see the regulatory landscape evolving in the coming years, including the potential role of the African Medicines Agency (AMA) and other regional bodies?  The AMA I think is the future; it's critical that it is a success. There's a fair amount of, I wouldn't say pessimism but [questions about] how long it will take for them to be up and running, simply because they just have so many different countries and regional regulatory systems.By and large, the East African collaborative registration or collaborative processes [The Eastern African collaborative registration process is a regional initiative that aims to facilitate the registration of medicines and medical products through a collaborative process, including joint assessments and mutual recognition of regulatory decisions] have been working to some success. There are other regional harmonization networks, but it takes time, and there is still a lot of work that is needed.How do you view recent reforms made to the PQ program? Overall, we are encouraged to see efforts that enable the fast-tracking of innovative product introduction. The new WHO framework for novel products [a reform implemented in 2024 to initiate parallel, rather than sequential, processes for recommending the use of novel products and evaluating them through PQ] is just entering its pilot phase. The new web portal [an online PQ application platform that will provide real-time information for applicants, regulators, and other stakeholders on the status of products in review] will give us greater transparency. The Coordinated Scientific Advice [a new procedure that allows product developers to engage with WHO early on to better understand the evidence that they will need to generate to support PQ review and generation of policy recommendations] should ensure that later review of the finished product is as streamlined as possible.There also needs to be some thought on how AMA will work with the European Medicines Agency, the US Food and Drug Administration, and WHO PQ to avoid complexity for local manufacturers.  If you had a hypothetical magic wand to wave to influence the program, what changes would you make?Something that is critical is to have clarity on timelines and the interaction between PQ and national regulatory bodies and lessons learned. Ultimately, what is the incentive for a manufacturer to go that extra mile to ensure that a product is quality approved [through PQ]? That's where the funders play a critical role in endorsing and supporting the process. Without that support, if you speak to a lot of the manufacturers, they say, “Well, there's no way I'll be going through the WHO PQ process. It's a major investment, and it's an additional long-term commitment that you need to make as a manufacturer.” So, ensuring that there is coordination between normative bodies, funders, procurement partners, and regulators is critical to ensure fast uptake of innovative products.The dream is to have a lot more quality-approved manufacturers in Africa, where over 95 percent of the patient population is. If you look at our new products coming down the line, like single-dose cures or long-acting injectables, greater upfront alignment is key, between WHO PQ and these stringent regulatory authorities, to offer clearer guidance in terms of what those regulatory expectations are for new products. We need to ensure that global procurement agencies, like the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President’s Malaria Initiative, or UNICEF, are working as closely as possible with AMA and with WHO PQ to ensure the rapid uptake of new qualified drugs.I would love to see harmonization between PQ and national regulatory authorities to fast-track important innovation and ensure that new quality-assured drugs get to market faster.Putting on your advocacy hat, where do we, as an advocacy community, need to put our energy in the next couple of years to make some of those improvements become reality?  To unleash the potential [of PQ], we need to simplify the processes for manufacturers, ensure procurement commitments for a clear return on investment, and provide continuous and sustained funding to support manufacturers to embark on the lengthy quality assurance process. If I look at the manufacturers, we did an extensive exercise with the Africa Centres for Disease Control and Prevention to identify manufacturers throughout the whole continent that would want to take malaria products forward to be WHO PQ’d. We only had about 50 manufacturers that were interested in taking part in this initiative [out of 400], so that's a very low number. I mean, we're talking small molecules, not vaccines, and you've got to ask yourself why? They obviously don't see a need to have products WHO PQ’d, which is, on the one hand, a problem. The Africa Centres for Disease Control and Prevention and MMV and other partners believe that the African manufacturing sector can take its place long term alongside manufacturers from India and China, who today supply the vast majority of public health medicines for malaria on the continent.Big Pharma, if anything, is disinvesting in Africa. So, having those in-Africa partners is critical within the malaria space and, obviously, not just for malaria, but for HIV and tuberculosis and so forth.So, I'm just thinking that if manufacturers are going down the WHO PQ route, it might be a really nice carrot to say, “Look, if you are applying for the WHO PQ process, this is a financial incentive in place.” That could be a really nice carrot to keep the Big Pharma guys in the game.