In the wake of a World Health Assembly that became a focus of intense activist and social media attention over a WHO resolution on medicines price transparency, member states are now looking at new rules for shaping involvement of NGOs and other “non-state actors” at public WHO meetings.

On Wednesday, a proposal for revising procedures on the Involvement of Non-State Actors (NSAs) in meetings like the World Health Assembly (WHA) was the focus of an initial review at the 145^th WHO Executive Board (EB) session. The EB meeting of 34 member states regularly convenes on the heels of the annual WHA meeting, to plan agendas for the following year.

The WHO report, still under development, suggests the creation of a separate, annual “World Health Forum” to provide a dedicated venue for interactions between member states and non-state actors – while curtailing their formal involvement in the WHA somewhat. Currently some 214 such groups, including not only NGOs, but also philanthropies and the private sector, are officially recognised and entitled to speak as observers in governing body meetings such as the World Health Assembly.

“The increased interest reflected by the greater numbers of non-State actors participating and requests for interventions has not led to a more meaningful involvement,” says the WHO report.

“Dissatisfaction with the current system has been expressed by Member States, and echoed for different reasons in communications from non-State actors,” states the WHO review, which recommends options such as consolidating NSA positions into more streamlined statements at public meetings, along with the creation of a separate forum where actors could meet directly with member states.

“A World Health Forum could be organized along similar lines to the World Trade Organization’s Public Forum. Such a World Health Forum could be an annual stand-alone event in November each year, as with the Meetings of Interested Parties,” the WHO review suggests.

The EB debate over the role of NSAs followed expressions of dismay by some member states on the very prominent role certain activist groups played in the debate over the milestone resolution approved just the day before, to support greater price disclosure of medicines purchased by national health systems.

In the leadup to the final vote, the resolution was the focus of an intense NGO campaign during the Assembly, as well as heavy media coverage by national and international press, and social media.

NGO Activism and Media Coverage Rankles USA and Some European Member States

The raucous social media campaign clearly ruffled the feathers of some member states, including major health donors such as Germany and the United Kingdom, unaccustomed to being targeted for blocking medicines access. Both ultimately “disassociated” themselves from the resolution.

Speaking at yesterday’s Executive Board meeting, Germany complained that the intense media and social media attention had distracted negotiators and intruded into their deliberations.

“Some member states felt unease in the negotiations and were really concerned about being attacked from the outside, also through media campaigns from the outside. That’s something that needs to be addressed and reflected in the governance debate,” said the delegate from Germany, speaking at yesterday’s EB wrap-up on events at the World Health Assembly.

The United States, which supported passage of the resolution, albeit with a watered-down section on public disclosure of R&D costs, criticised the aggressive Twitter campaign waged by some NGOs or their supporters.

“We do value the role of diverse non-state actors informing discussions of WHO’s governing bodies… However, these efforts must respect the process,” said the US delegate speaking before yesterday’s EB, adding: “We denounce strongly the actions of some advocacy NGOs during the Assembly to intimidate member state delegates during the transparency negotiations.”

“This behaviour, including spreading false rumours and half-truths about internal negotiations, taking photos of our negotiators, and posting their names online, and firing off ridiculous poisoned tweets – that sort of behaviour, that is absolutely unacceptable,” said the US representative to the Executive Board, speaking at yesterday’s session.

Médecins Sans Frontières, one of the groups that was out front on the social media campaign, could not be reached today for comment. Another NGO that led an advocacy campaign for strong transparency measures in the resolution, Knowledge Ecology International (KEI), noted that, like it or not, rough and tumble social media activism is part of the new normal in politics – and that the sharpest comments on social media were not directly from the NGOs in the room at WHA.

“Curious that the US complained about Twitter; have they talked to their commander in chief?” quipped Thiru Balasubramaniam, of KEI, a major backer of the transparency of medicines markets.

“Much of the hard-hitting social media was coming from people not in the room, and not accredited. They were just following the debate online,” said KEI’s Washington director Jamie Love, adding that more public debate also helped air the issues and countries’ positions more transparently.

Member States, Not NGOs, Made the Difference

Ultimately, Love said, while NGOs may have publicised the issues, it was among member states where “feeling about transparency was deeper and broader than many diplomats thought they would be. They are used to no one caring much about what WHA does.”

Early on, the resolution was taken up as a project by the new Director General of the Italian Medicines Agency Luca Li Bassi, whose knowledge and interest is anchored by years of field experience working with multilateral and bilateral health and development groups, including the establishment of the first procurement systems for the Global Fund that supplies drugs to low- and middle-income countries for HIV/AIDs, Tuberculosis and Malaria.

“Luca was among the very first hires for the Global Fund and set up the systems for drug procurement that have made this a scandal-free operation, which is very impressive. I believe he began [at the] Global Fund in 2005. Before that, he worked in Swaziland, where he was working on procurement of HIV drugs,” remarked Love. “His extensive experience in Africa helped him in terms of working with Africa Group negotiators.”

The resolution concept was also readily taken up by the Italian Health Minister, Giulia Grillo, whose Five Star political movement had campaigned on health issues such as medicine prices. Greece, Spain and other central and southern European countries that are burdened by increasingly high drug costs were early co-sponsors, to be joined by other South-East Asian, African and Latin American states – where prices create higher barriers for patient access to life-saving treatments for cancer, diabetes and hepatitis.

Even so, the debate over non-state actors’ role in the WHA discussions and ensuing media coverage reflect some of the broader dilemmas that WHO member states will confront even more often in the coming years – posing a thicket of complex questions regarding how to balance public debate, NGO involvement and member state deliberations in the inner halls and outside of the WHA.

While WHO Director General Dr Tedros Adhanom Ghebreysus has spoken repeatedly about his interest in engaging civil society more deeply and directly with WHO, how to do that remains a challenge.

“We support WHO’s ambition to improve the meaningful, effective and efficient engagement of non-state actors in official relations with WHO and recognise that full Governing Bodies agendas drive the need to streamline statement processes,” said the Union for International Cancer Control, in a statement to EB about the proposals for changing the rules around NGO involvement at WHA. “We do however harbour grave concerns that the measures put forward in the report… could potentially undermine the ability of civil society organisations (CSO) to positively contribute to WHO’s work.”

South-East Asian and Latin American Member States Satisfied with Resolution Outcome

Meanwhile, not everyone seemed unhappy with the attention the transparency resolution received.

Brazil, speaking at the same EB meeting yesterday, lauded the “positive atmosphere and dialogue that prevailed during the 72^nd World Health Assembly.” Maria Nazareth Farani Azevêdo, Brazil’s Ambassador to the UN in Geneva, called passage of the resolution on transparency for costs and prices of medical products among the “much-needed initiatives and ground-breaking initiatives for this organization.”

Rajitha Senaratne of Sri Lanka, speaking on behalf of WHO member states in the South East Asia Region, expressed “sincere appreciation to all member states for adopting the resolution on improving transparency of markets for medicines, vaccines and other health products, proposed by 19 countries, including many countries from the SEARO region.” He called it a “key determinant for accessibility for those products.”

Image Credits: WHO.