Upholding the World Health Organization. Next Steps for the EU

NO. 47 OCTOBER 2020 Introduction

Upholding the World Health Organization Next Steps for the EU Susan Bergner, Remco van de Pas, Louise van Schaik and Maike Voss

Before the COVID-19 pandemic, the European Union (EU) was neither a strong promoter of global health nor a strong supporter of the World Health Organization (WHO). The Global Health Council Conclusions from 2010 were never comprehensively implemented and quickly forgotten. With the pandemic greatly affecting EU member states, the EU is increasingly interested in upholding multilateral cooperation in the global health field. Therefore, the EU should aim for an upgrading of the EU’s status in WHO, the establishment of a global health unit in the European External Action Service (EEAS), and an overhaul of the formal relationship between the European Commission and WHO.

The pandemic discloses the discrepancy The Union’s global health policy-making between the EU advocating for global access lacked visibility in recent decades, although to a COVID-19 vaccine while at the same the EU is traditionally a promoter of effec- time safeguarding its own access to it. Its tive multilateralism. With its Council Con- refusal to alter patent laws that serve to clusions on global health, adopted in 2010, protect the commercial and innovation in- the EU committed itself to stronger global terests of pharmaceutical companies based health governance – including support- in EU countries can equally be questioned ing WHO and the United Nations (UN) sys- on grounds of global solidarity. A revamped tem – focusing on Universal Health Cover- global health strategy is needed to over- age, strengthening health systems, as well come such issues and make the EU a reli- as recognising the need for a “Health in All able and capable partner on global health Policies” approach, including in the EU’s that gives WHO a central role. external actions. However, the Conclusions never received the strong backing of health, development, and foreign ministries of EU Global Health Policy Undervalued member states, as the EU was primarily seen as a development actor rather than a As public health policy-making remains strategic agent in global health. Thus, EU mainly a national competence under Euro- member states decided in an incoherent pean legislation, the EU can coordinate and way on how large a budget that they and complement the policies of member states. the European Commission would make

available for international health priorities, enhance Europe’s capacity to respond to initiatives, and institutions such as WHO. cross-border threats. Before the COVID-19 pandemic, global Unfortunately, it is not clear if EU mem- health was not a priority on the European ber states also support these ambitions. A political agenda, and both the health and proposal for the EU health budget (2021– international development cooperation 2027) to be increased to 25 times its current mandate was reclaimed by EU member size was largely undone by member states states; with some exceptions being issues deciding to reduce the overall amount of the in fashion, such as anti-microbial resist- EU budget. A strong European investment ance and digital health. in health systems and monitoring would have made global EU efforts in supporting the resilience of health systems and crisis COVID-19: The EU’s Wake-up Call preparedness more credible. Budgetary lines to Global Health? for global health policies for international cooperation have not been introduced or The EU has been struggling to respond to bolstered yet, which makes the future financ- the COVID-19 pandemic, as member states ing of ambitious EU global health policies primarily followed a national response at in the upcoming EU budget challenging. the beginning. European and international The Commission and EU member states cooperation were initially placed on the were more united in February 2020, when back burner with the introduction of ex- they decided to uphold the international port restrictions on protective equipment health order by activating financial support such as masks and gloves. Aside from the for WHO early on. During the pandemic, reluctance of member states to cooperate, WHO has moved to the centre of infor- the lack of resources and authority of the mation provision regarding the spread of European Centre for Disease Prevention the disease and the required public health and Control (ECDC) has hampered a har- responses. After harshly attacking WHO monised, evidence-based approach with- and accusing the organisation of being in Europe, and it has impeded the ECDC too China-friendly, the US administration from proactively engaging in global health announced in July 2020 that it would be policies. pulling out of WHO. There are now in- Gradually, a more “Europeanised” effort creased expectations for the EU to fill finan- is now evolving to shore up the effective- cial as well as leadership gaps. EU member ness of Europe’s public health response states such as Germany and France have within the EU as well as in its multilateral already stepped in, with the former pledg- commitments to bolster global health. Euro- ing an unprecedented €500 million to WHO pean governments have started to realise for 2020. France has committed an addi- that a joint approach is necessary to recover tional €50 million to WHO as well as a €90 from the pandemic and the socio-economic million commitment towards founding a crises that will follow. In her State of the new WHO Academy. Union address, Commission President Ursula von der Leyen called for a European Health Union. She announced plans to bolster the Formal EU and WHO Cooperation ECDC and the European Medicines Agency. An expansion of EU competence in the field The relationship between WHO and the EU of health is to be discussed in the Confer- is based on an exchange of letters dating ence on the Future of Europe, which the back to 1972. The EU–WHO cooperation European Commission will organise in 2021. is modelled on the work done by WHO and She also announced the establishment of a the EU on the global, regional, and national European Biomedical Advanced Research levels. Firstly, the EU and WHO Headquar- and Development Authority (EU BARDA) to ters in Geneva interact through designated

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2 Figure 1

staff in the EU delegation and via Senior Of- regional economic integration organisa- ficial Meetings. Both are mostly concerned tions. with global issues. Secondly, the European Despite various levels and areas of co- Commission as well as the ECDC have a prac- operation and the EU’s observer status in tical partnership with the WHO Regional WHO’s governing bodies, the EU and WHO Office for Europe (WHO EURO) in Copen- partnership still feels shaky and less clari- hagen, which is primarily focused on topics fied than it is for other partnerships between concerning the European region. Thirdly, EU and UN institutions. The EU has, for the EU cooperates through its delegations instance, pushed for an enhanced observer with WHO country offices at the national status within the UN General Assembly level worldwide. (UNGA) that gives the Union, among others, The coordination among EU member the right to speak early in the debate of states on WHO matters has been prepared the UNGA and to be invited to the general by the EU delegation in Geneva since 2010. debate. Furthermore, WHO is primarily Despite some initial questions on legitima- considered a development organisation for cy and trust, it is now clearly in the driving public health standard-setting outside the seat to bring across a common EU position EU. The COVID-19 pandemic may change between European countries on key issues. this misconception for the better, since all It is backed by the European Commissions’ countries are dependent on WHO recom- Directorate-General for Health and Food mendations, followed by many – but not Safety (DG SANTE) and the EEAS. However, all – EU member states. the EU only has an observer status, as only The political support and increased joint nation-states can join WHO. This prevents action could strategically strengthen EU– the Union from fully participating in WHO WHO cooperation at all levels by building governing body meetings. Hitherto, the EU on existing collaboration and partnership has not made any attempts to change this. models (Figure 1). Three aspects are critical However, with the current global climate in the EU’s web of relations with WHO. of retreat from multilateralism, there might Firstly, the European Commission does not be a window of opportunity for the EU to have formal partnerships with regional upgrade its status as well as that of other WHO offices aside from WHO EURO, which

SWP Comment 47 October 2020

3 could enable the EU to engage in global platform for global coordination on inter- health diplomacy within and outside the national health priorities. European region. Secondly, the cooperation The EU pledging conferences are an with WHO EURO seems to be primarily example of “fast multilateralism”, but focused on European issues, which is un- their focus is only on the development of derstandable. However, the next program- vaccines, therapeutics, and diagnostics for matic partnership between WHO EURO and one infectious pandemic disease, leaving the European Commission might therefore other pressing health challenges neglected. focus on global priorities that are equally Questions remain as to how more structural important to both parties, such as projects investment in and with WHO can be created about the environment and health, gender to sustain global health multilateralism equity, and the commercial determinants and create a sustainable impact on people’s of health. Thirdly, collaborative efforts health. between EU delegations with WHO country Secondly, in the first ever virtual World offices could be made more visible, coordi- Health Assembly (WHA) – the highest nated, and harmonised through shared learn- decision-making forum of WHO’s member ing and training sessions. states – the EU led the development of the main resolution, which focused exclusively on the response to the COVID-19 outbreak. The EU As a Geopolitical Actor in Multilateral support for this resolution came Global Health from China and the EU leadership, but not from Russia, the United States, or India – Commission President von der Leyen has with the latter having a large pharmaceu- expressed a willingness of the Commission tical sector. The resolution includes four to become more geopolitical, which could main features: the request for a broad UN imply a more proactive and instrumental response; a call to WHO member states to approach to multilateral organisations, respect the International Health Regula- but it also bears the risk of implying an tions, the internationally binding set of EU-first bias. So far in the COVID-19 crisis, rules to prevent, detect, and respond to in- the EU has responded to the challenge of fectious diseases; a call to international providing equitable access to vaccines, organisations to create a voluntary patent therapeutics, and diagnostics in three inter- pool for the development of a COVID-19 national fora. vaccine to ensure affordable access for all; Firstly, in early May 2020, the EU organ- and the request for WHO to establish an ised an international pledging conference impartial, independent, and comprehensive to raise funds for the development of vac- evaluation of the coordinated international cines, therapeutics, and diagnostics. Later, health response to COVID-19. a second conference was organised. These The remuneration of pharmaceuticals conferences can be regarded as a double- is regulated by international patent law. edged sword: On one side, they provide sup- However, since the global and simultaneous port for WHO’s goal to develop vaccines, demand for COVID-19 diagnostics, vaccines, therapeutics, and diagnostics as global pub- and therapeutics is so high, conventional lic goods – goods that should benefit every- patent licensing could make rapid devel- one equally. According to von der Leyen, opment and large-scale production difficult, the intention is not to distribute these which therefore could delay access and exclusively among EU member states, but distribution of a vaccine. According to the to make them available and affordable resolution, a COVID-19 technology access worldwide. On the other side, the confer- pool should be the mechanism to remedy ences position the European Commission this challenge, ideally based on best prac- and the EU as leaders for COVID-19 soli- tices; one example is the UNITAID-estab- darity, thereby sidelining WHO as the main lished and supported Medicines Patent Pool.

SWP Comment 47 October 2020

4 However, the devil will be in the details, accelerator” Facilitation Council (COVAX because the implementation of a patent facility), a new multi-stakeholder platform pool requires internationally recognised that is intended to guide key strategic, Trade-Related Aspects of Intellectual Prop- policy, and financial issues during the erty Rights (TRIPS) flexibilities by the EU development of new COVID-19 diagnostics, and its member states. These flexibilities therapeutics, and vaccines – with commit- are not discussed at WHO, but at the World ments by over 180 WHO member states. Trade Organization TRIPS Council, where Still, parallel bilateral initiatives, such as South Africa recently pushed for initiating advanced market commitments between a resolution with the aim of simplifying the EU and pharmaceutical and biotech the requirements for TRIPS flexibilities, companies to secure doses of vaccines for including compulsory licensing of COVID- European populations, might run against 19 diagnostics, therapeutics, and vaccines. efforts within the COVAX facility to provide This was proposed in order to legally guar- affordable vaccines for all, especially in low- antee access to diagnostics, therapeutics, and middle-income countries. However, the and vaccines for COVID-19 as a global pub- EU is now willing to engage in the COVAX lic good, including in low-income countries. facility after having advised its member The compulsory licensing of medical prod- states to not buy vaccines through COVAX ucts from pharmaceutical and biotech com- earlier. panies can better protect public health and What is still missing is an outspoken secure access to essential technologies. How- stance on how WHO should function with- ever, major pharma-producing countries, in the plethora of global health arrange- including from the EU, prioritise voluntary ments (World Bank, GAVI, Global Fund, licensing and stress that the current market- etc.) – vis-à-vis other powerful stakeholders based system suffices to guarantee access such as philanthropic institutes and the in low- and middle-income countries. pharmaceutical industry – as an independ- There seems to be a contradiction be- ent watchdog during infectious disease out- tween the EU’s desire for global vaccine ac- breaks (e.g. exposing cover-ups by states cessibility and EU member states’ commer- where an outbreak has started), as well as cial interests and political will to protect what its topics of focus should be and what patents, since a lifting of patent restrictions organisational structure would be most could create a potential precedent for other adequate. In the lead-up to the announce- vaccines and medicines. EU member states ment about the US withdrawal from WHO prefer to keep control over the licensing of in July 2021, Germany and France allegedly new medical products, and therefore they were discussing WHO reform with the US opt for voluntary licensing via a patent administration, which points to a recogni- pool. In theory, this could still allow global tion of the need for changes to the current access, but the international experience set-up. However, it is not clear which av- with gaining access to medicines for other enues of reform the European Commission diseases, such as HIV/AIDS and hepatitis C, and EU member states prefer. By intensify- would indicate otherwise. The COVID-19 ing cooperation with WHO, the European pandemic could potentially provide the position on reform and the WHO reform momentum for reforming the governance process itself could be accelerated; despite of TRIPS flexibilities, which could have WHO’s limitations, the pandemic has illus- implications on whether universal access to trated perhaps more than ever how much medical products is allowed. The EU would the organisation is needed. A non-paper benefit from this in the long term when presented by Germany and France gives considering both the economic and public some clues about the felt need for increased health perspectives. funding and a strengthening of the early Thirdly, WHO and the European Commis- warning and monitoring systems during sion co-host an “Access to COVID-19 Tools epidemics and pandemics. But other issues,

SWP Comment 47 October 2020

5 such as the regional structure of WHO and institutions and across different sectors – its norm-setting function as well as global including trade, energy, and the European health aid and advice to developing coun- Semester of economic and fiscal policy tries, were not addressed. coordination – followed by a clear mandate and solid financial global health resources. A strategic unit with financial, Future Choices for the EU on personnel, and thematic resources needs to Global Health be created within the EEAS that would have the mandate to coordinate several directo- As the COVID-19 pandemic enters a pro- rates on global health matters. One Com- longed phase, the EU and its member states missioner should clearly be responsible on are in the position to jointly contain the global health vis-à-vis the European Parlia- virus and begin to structurally recover by ment, the European Council, and individu- investing in the development of strong and al member states. This could either be the resilient public health systems. To become High Representative or the Health Commis- a reliable and capable partner for WHO and sioner. The unit in the EEAS would have beyond, the EU could strengthen its capac- to collaborate closely with experts from the ities in the following areas. Commissions’ DG SANTE and could liaise Firstly, the EU could update its Council with WHO and other multilateral partners Conclusions on global health. A new, co- more strategically. Moreover, it could also herent EU global health strategy should have a specific global health diplomacy focus on facilitating resilient health systems function as well as active collaboration that are rooted in sustainable development with EU delegations contributing to its for- as well as the right to health, in addition to eign policy. being prepared for external shocks such as Thirdly, the EU could strengthen its health security risks and consequences of health competences domestically to be climate change. A new global health strat- stronger abroad. Giving attention to, and egy should offer a broad, more geopolitical, linking, both the internal and external European perspective. Elements that could health dimensions of European policy, the be included are references to the Union’s EU could promote the internal strengthen- values (access to health, equality, democracy, ing of EU global and public health policy. accountability); links to the Sustainable The programme EU4Health 2021–2027, Development Goals (SDGs); a health focus whose eventual budgetary allocation is still in all policies; a bolstering of the imple- uncertain, should enhance European com- mentation of the International Health petences and coordination by boosting the Regulations; as well as reference to the EU’s EU’s preparedness for major cross-border strategic autonomy with regard to medical health threats, strengthening health sys- supplies and medicines (see also Kickbusch tems across the EU in an equitable way, as and Franz). well as providing agreement on a common New Council Conclusions should be vaccine policy. To complement this, the accompanied by a concrete roadmap and ECDC could be strengthened and given a monitoring mechanisms in order to be more prominent role and mandate in the effective and transparent. Most important EU’s global health policy-making. It is im- is that they be developed and owned by perative for the EU to become more strate- health, development, and foreign policy gically autonomous with regard to medical actors of the EU member states and insti- supplies, but this should not be to the detri- tutions. Without their commitment, a ment of global solidarity. recurrence of the 2010 Council Conclusions Fourthly, the COVID-19 pandemic has may happen when COVID-19 is behind us. also shown that EU member states have to Secondly, the EU needs to establish stra- act more coherently and in concert with EU tegic global health capacities within EU institutions as well as during exchanges

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6 with civil society actors to avoid duplicating could strengthen the partnership by so- and contradicting (global) health policies. lidifying the cooperation within a Mem- Therefore, a space for communication, co- orandum of Understanding that replaces ordination, and collaboration between EU the exchanging of letters. More and well- institutions, EU member states, the Euro- coordinated meetings need to take place pean Parliament, and civil society actors between senior representatives of WHO, has to be created in order to enhance the the European Commission, and the EU and member states’ abilities to perform EEAS. Consideration could be given to more coherently on the international stage including representatives of EU member and within international partnerships, such states to keep them engaged. as with WHO. The Global Health Policy Extend the EU’s cooperation with Forum could be revived and upgraded for WHO regional offices: A new roadmap ∎ this purpose by broadening its functions as for the partnership between WHO EURO well as expanding membership to include and the European Commission is cur- the Council, the Parliament (aside from the rently in the making. Now is the time Commission), the EEAS, and civil society for EU member states to have a strategic actors. debate on WHO EURO and its future Lastly, the EU needs to establish a stra- relations with the EU. New priorities tegic global health budget to pursue an and programmes should be aligned with ambitious agenda that is financially backed. achieving the SDGs – in Europe and The various budgetary channels that are globally. In line with the EU’s Green Deal supporting global health policies should be objectives, projects with WHO promoting harmonised, or at least mapped. This would environment and health could equally offer an overview of European financial pave the way for new areas of coopera- resources for global health, making them tion. A solid monitoring mechanism for transparent for the European public and the new five-year plan is key to creating helping with the strategic decision-making a sustainable impact as well as account- as to which partnerships should be finan- ing for joint actions. The establishment cially supported, depending on the global of formal relations with WHO regional health issue. Support for WHO could then offices outside of Europe, such as WHO be much more targeted and in coherence AFRO, would put EU efforts at the coun- with other partnerships. try level within a broader synergistic and strategic approach. Increase and sustain WHO’s budget: Recommendations WHO’s financing is mainly based on in- ∎ dividual donor interests, leaving WHO To strengthen and deepen its cooperation highly dependent and vulnerable to the with WHO, the EU needs to increase its top 15 donors, which contribute more work in the following areas: than 80 per cent of all voluntary contri- Upgrade the EU’s status at WHO: The butions. An increase of assessed and core European Commission and EU member voluntary contributions, as demanded by ∎ states should jointly ask for an upgrading many experts as well as governments, is of the EU’s status with WHO to increase necessary to ensure WHO’s ability to act the EU’s visibility as a powerful unified on its core functions. Financially, the an- actor and to enable it to speak with one nounced US withdrawal could be partly voice. This could be done either through compensated for by the EU, but the EU a resolution, a special agreement, or by should also work for sustainable financ- strengthening WHO’s representation at ing and reform of WHO, including en- the EU in Brussels, which is already work- suring autonomy and the global public ing not only on a European but on a legitimacy of the organisation. Sustain- global mandate. In a first step, the EU able and long-term predictable financing

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7 leads to sustainable human resources Develop a new EU global health strat- planning with staff that can implement egy that addresses WHO reform and ∎ reforms and deliver what is demanded is backed by health, development, and of WHO. foreign affairs stakeholders from EU Consider WHO recommendations and institutions and member states. Such the results of the Independent Panel for a global health strategy should include ∎ Pandemic Preparedness and Response issues regarding WHO’s raison d’être, its (IPPR): A high level of political support current organisational structure, areas for WHO can be shown by applying of focus, and independence during out- WHO norms and standards at home as breaks of infectious diseases. It should © Stiftung Wissenschaft well as in international global arrange- also make choices about, or create a bal- und Politik, 2020 ments. This should include unequivocal ance between, the EU’s desire to uphold All rights reserved financial support by the EU and its mem- multilateral arrangements and simul- ber states for – as well as the commit- taneously become more strategically This Comment reflects ment to – WHO’s COVAX facility. WHO’s autonomous. the authors’ views. role in global health can also be strength- A renewed partnership between the EU The online version of ened by referring to and promoting and WHO during the COVID-19 pandemic – this publication contains WHO’s role as the supreme global health despite nationalistic trends and geopolitical functioning links to other authority. Based on the WHA resolution, tensions – offers a glimmer of hope. The SWP texts and other relevant WHO has established the IPPR, which EU should seize on this opportunity but sources. evaluates the global COVID-19 response. not outshine WHO, as collective efforts are SWP Comments are subject This initiative is strongly supported by needed more than ever to secure global to internal peer review, fact- the EU and its member states and can, as public goods and uphold the international checking and copy-editing. an indirect effect, potentially defuse some health order. For further information on of the geopolitical tensions around the our quality control pro- global governance of the COVID-19 pan- cedures, please visit the SWP website: https://www.swp- demic. The IPPR was launched in July berlin.org/en/about-swp/ 2020 and is co-chaired by former Prime quality-management-for- Minister of New Zealand Helen Clark and swp-publications/ former President of Liberia Ellen Johnson Sirleaf. An interim report to the WHA is SWP expected in November 2020. European Stiftung Wissenschaft und Politik countries need to properly consider the German Institute for results of the independent evaluation and International and further strengthen the autonomy of Security Affairs WHO. Lead the WHO reform debates: The Ludwigkirchplatz 3–4 EU should have the ambition to reshape 10719 Berlin ∎ Telephone +49 30 880 07-0 multilateral global health structures Fax +49 30 880 07-100 while establishing WHO at the centre. www.swp-berlin.org The EU should provide voice and leader- [email protected] ship in an institutional and legitimate reform process of WHO, which was slow ISSN 1861-1761 doi: 10.18449/2020C47 and ineffective before the COVID-19 pandemic. The German–French non-paper already provides relevant proposals.

Susan Bergner and Maike Voss are Associates in the Global Issues Division at SWP. Both work in the “Global Health” project, which is funded by the German Federal Ministry for Economic Cooperation and Development. Remco van de Pas is a public health doctor and global health researcher. He is a Research Fellow at the Institute of Tropical Medicine, Antwerp, and Research Associate at the Clingendael Institute. Louise van Schaik is Head of Unit EU & Global Affairs at the Clingendael Institute.

SWP Comment 47 October 2020