WHO’s 144 Executive Board Meeting: what to watch out for

Although appearing dry on the face of it, this is the first budget developed by Dr Tedros’ office. It sets out a vision for how WHO intends to implement the ‘triple billion’ targets contained in the 13 General Programme of Work as part of the organisational shift towards prioritising impacts in countries over outputs. In line with this, the Secretariat have developed several outcomes under each target. Some of the most relevant for cancer are:

• Achieving universal health coverage (UHC)  – including improved access to quality essential health services, reducing financial hardship and improved access to essential medicines, vaccines, diagnostics and devices for primary health care (PHC).
• Promoting healthier populations – with particular emphasis on reducing risk factors through multisectoral action and the social determinants of health.
• More effective WHO – with a strong focus on improving health data and implementation research.
• Area of emphasis on NCDs and promoting mental health – which includes the flagship cervical cancer elimination programme.

This agenda item also includes the WHO’s Impact Framework (EB144/7) which sets out overarching measures for health life expectancy, indices for each of the triple billion targets and a set of programme targets. It is particularly interesting as the UHC index includes coverage indicators for childhood leukaemia, breast, cervical, colorectal and uterine cancers, although there are concerns about the availability of data for these.

The agenda item also includes a short report from the Director General on his plan to improve value for money in the WHO (EB144/6).

Notes on the discussion 

This item was discussed on 25th January and many Member States requested further information on the operationalisation of the budget, particularly relating to the shortfall in funding for NCDs, the increased demands for normative and technical guidance and how this will support increased work at country-level. During the discussions the WHO Director General also re-iterated his calls for Member States to give money to the WHO without earmarks. 

This agenda item is a biennial report from the WHO Director General, looking at progress made towards Sustainable Development Goal (SDG) 3, including progress in tacking NCDs and rolling out UHC. The second half of the report shares progress on implementing the WHA resolution on health in the 2030 Agenda (WHA69.11), including the development of the Global Action Plan for health lives and well-being for all, which aims to improve coordination between different international agencies and organisation working on global health. We understand that the plan will be open for consultation later this year.

Key points for the cancer community are:

• Focus on the need to build strong health systems, and that weak systems are blocking progress.
• Recognition that progress is being made on NCDs, but that improvements for some disease groups (notably cardiovascular diseases) are masking an increase in the burden of cancer globally.
• Palliative care is included within the document as a key component of UHC.
• Discussion about the level of catastrophic health spending, despite limited data globally.
• Development of Global Action Plan on SDG to provide a joint framework for cooperation. We need to ensure that cancer and NCDs are not forgotten as they were in the first draft. This plan is due to be finalised and present in September 2019.

Read UICC’s joint statement on the 2030 Agenda here.

This agenda item includes three documents, the first of which looks at Primary Health Care (PHC) as a mechanism to move towards UHC (EB144/12) and the Astana declaration. From a cancer perspective, some key elements of the report are:

• Recognition that the burden of disease is moving increasingly towards chronic conditions, including cancer.
• Highlighting that PHC provides a framework to build health services around the needs of patients, which will be particularly important to support patients with multiple conditions and address some of the broader determinants of health.

The EB will be asked to note the report and discuss how the Astana Declaration can be used moving forwards, including during preparations for the UN High-Level Meeting (HLM) on UHC. Read UICC’s joint statement on PHC and UHC here.

The second document looks at the opportunities and challenges of community health workers in advancing the development PHC (EB144/13).

The third document up for discussion here is on preparations for the UN HLM on UHC (EB144/14). The first half of the report provides an overview of the role of UHC and current burden of catastrophic spending and impoverishment from health spending, while the second halffocuses on preparations for the meeting. Key points for cancer are:

• Delivering UHC is both a goal and a mechanism for supporting progress across the SDGs.
• Important that WHO metrics include service coverage and financial hardship, as the latter is missing from the SDG indicators.
• Need for strong investment in health systems that focuses on meeting the needs of patients, rather than investing in disease siloes. This better recognises of the importance of cross-cutting services like health education for signs, symptoms and risk factors, health data systems (including cancer registries), diagnostics and imaging, surgery, palliative care and systems to improve access to medicines and vaccines.

Read UICC’s statement on the preparations for the High-level Meeting on UHC here.

Notes on the discussions 

During the discussions a number of countries recognise the importance of PHC within their current health systems and as a mechanism for helping to deliver UHC. Several countries highlighted the importance of building strong health systems that can detect and diagnose and NCDs early, but the discussion around referral through to treatment and secondary and tertiary facilities was limited. The report was noted.

Many countries also welcomed the Director General’s report on preparations for the High-level Meeting; however the accompanying resolution was subject to intensive negotiations, which reached a consensus on the final day of the EB. These negotiations highlighted key topics for the upcoming negotiations around the Political Declaration on UHC, notably including TRIPs flexibilities and sexual and reproductive health. The report was noted and the resolution was adopted.

This agenda item contains two documents, the first is a report on the draft roadmap for access to medicines, vaccines and other health products (2019-2023) (EB144/17). The report, issued by the Director General, provides an overview of how the roadmap was developed and asks Member States to provide guidance ahead of it being presented to the World Health Assembly in May. The roadmap tackles various barriers to access, including lack of regulatory and health systems capacity, weak supply chains, shortages and affordability, and proposes some approaches.

The second document is a specific report on access to cancer medicines following on from the 2017 cancer resolution (WHA70.12). The report provides an executive summary of the full technical report on the ‘pricing on cancer medicines and its impacts’. It explores the benefits and risks, industry approaches to pricing, relationships across the value chain and their impact on price, availability, affordability and research and development (R&D). As requested, WHO has drawn this together and generated several policy options to improve affordability and availability, contained in Annex 1.

Key messages from the report are:

• Strategies to improve access to cancer medicines should be considered holistically as part of strategies to strengthen health systems. The report stresses that the benefits of improving access to cancer medicines is not achieved at the expense of essential health care products and services for other disease areas.
• Existing approaches to managing the prices of cancer medicines have not resulted in outcomes that meet policy and economic objectives, impairing the ability of health systems to meet the needs of patients.
• Overall, the report suggests that the costs of R&D and production may bear little or no relationship to how cancer medicine prices are set. This is problematic given the financial support provided for initial research by public/ non-profit bodies.
• This also undermines concerns that lowering cancer medicine prices might impair future research and development, for example for every US$1 put into R&D the average income return was US$14.50 (range US$3.30 to US$55.10).
• Non-transparent medicine prices raise problems for good governance, accountability and access to medicines, while there is some evidence which suggests that improving price transparency leads to lower prices and expenditure outcomes. 
• Evidence suggests that many targeted therapies approved in the last few years have not improved length or quality of life, but focus instead on short-term/surrogate measures like tumour size, making it more complicated for governments to rationally select the most effective therapies.
• Although, existing data on medicines shortages are not robust, disruption in the supply chain is a reality. Shortages of cancer medicines are probably due to problems related to quality and low market attractiveness rather than due to lack of financial incentives to ensure the ongoing supply of lower-priced medicine.   

Read UICC’s joint statements on the medicines and vaccines roadmap and access to cancer medicines here. 

Notes on the discussion 

The discussions on the roadmap to access highlighted the current impact of poor access and welcomed the roadmap as a way forward. Many Member States stressed the importance of the normative work that WHO is undertaking to address this and asked how WHO intends to take the roadmap forwards to implementation, recognising the need for further technical support. The WHO will continue to work on the roadmap ahead of the World Health Assembly in May.

The majority of EB members and other Member States from all regions welcomed the report on cancer medicines, with many representatives focussing on price and cost transparency. While a number of Member States raised objections to the methodology of the report’s preparation and some of the recommendations, many more asked how the WHO intends to operationalise the report as part of stronger international collaboration on the topic. The EB noted the report.

Following on from the HLM on NCDs in September last year, this agenda item (EB144/20) reviews how WHO can support Member States to fulfil commitments made in New York in 2011, 2014 and 2018. It highlights several actions that the WHO will take, including:

• A delivery plan to meet the rapidly increasing demand for technical assistance for NCDs requested by Member States
• Identification of a subset of ‘NCD accelerators’ from the ‘Best Buys and other recommended actions’, which will be presented at the WHA this year.
• Fast-tracking flagship programmes, including cervical cancer elimination
• An update to the current scientific knowledge on fiscal measures, contained in Appendix 2 
• Dialogues with different private sector groups including pharmaceutical manufacturers, the alcohol industry, food and non-alcoholic beverage industries and sports industries.
• Development of new indicators for a scorecard on NCD progress, which will be submitted as part of reparations for the next HLM on NCDs in 2025.

The second document under this agenda item contains the workplan for the WHO Global Coordination Mechanism on NCDs (EB144/20 Add.1).

The joint statement from World Cancer Research Fund International supported by UICC, the NCD Alliance and World Health Federation will be available soon here. 

Notes on the discussion 

In addition to the report put forward by the WHO Director General, EB Member States developed a decision document which aims to help shape follow-up to the meeting over the years to come. Key elements from the decision document includes:

• Extending the current WHO global action plans on NCDs and mental health from 2020 to 2030, aligning it with the SDG 2030 agenda
• Requesting the Director-General to propose updates to the appendices of the global action plans on NCDs and mental health, in consultation with Member States and stakeholders, including a list of effective policy interventions to promote mental health and wellbeing and reduce premature deaths from air pollution
• Increase in the technical support for Member States to integrate prevention and control into primary health services and improve NCD surveillance
• Requests a report on progress against the global strategy to reduce the harmful use of alcohol and ways forward, to be submitted in 2020
• Requests the development of a report in 2021 on positive examples of multisectoral action (including measure to address the social, economic and environmental determinants, incorporating health literacy, education and social media programmes).

The report (EB144/28) looks at the burden and status of cervical cancer services work to date, and proposes three accelerators for action to facilitate elimination. These are HPV vaccination, screening with HPV DNA test linked to timely treatment, and technical assistance to scale up integrated diagnosis, surgery, radiotherapy, systemic therapy and palliative care.

The report emphasises that elimination is feasible in all countries, however, reaching this elimination goal will need high coverage of services and multi-decade commitments from governments. Therefore we need all countries to consider their response and take action.

A decision (rather than a resolution) at EB in 2019 enables the Secretariat to move more quickly to Member State consultation on the emerging global strategy/action plan, with a view to approval and launch of the strategy at the World Health Assembly in 2020.

Actions that UICC members can take are:

• Reach out to the WHO regional offices to ensure that you know when the consultation is taking place and are able to attend.
• Work with other stakeholders (child, women’s health, HIV) to provide focused input relevant for your country needs.
• Provide feedback to the Geneva team.

UICC has included the call for a global online consultation to ensure opportunities to input for all civil society organisations. Our key ask, aligned with the focus on universal health coverage in 2019, is for equity in access to cervical cancer prevention and control services with adequate social protection measures. Add your name to our petition to show global support for the call to eliminate cervical cancer.

The agenda item has strong support from 41 countries: Australia, Brazil, Canada, Colombia, Ecuador, the European Union Member States, India, Kenya, Monaco, New Zealand, Republic of Korea, Sri Lanka, Ukraine, United States and Uruguay.

Read UICC's joint statement on cervical cancer elimination here.