Info Service on Health Issues (May18/04)
Geneva, 21 May (K M Gopakumar) – The recommendations of a draft report on non-communicable diseases (NCDs) that is work in progress disturbingly favour corporate interest.
The draft dated 1 May 2018 is the result of meetings of the World Health Organization’s Independent High Level Commission on NCDs and a technical consultation in March. A web-based consultation took place from 10 to 16 May.
The WHO Director-General constituted the Commission in October 2017 for a period of two years. The Commission consists of 20 members from governments, UN agencies, non-governmental organisations (NGOs), the private sector, philanthropic foundations, and academic institutions. The Co-chairs are President Tabaré Vázquez of Uruguay, and Ms Sania Nishtar, former minister of Pakistan and founder and President of an NGO, Heartfile. They serve as the link to the WHO Director-General.
Two immediate outputs of the Commission are:
Preparations for the General Assembly September meeting will be discussed at the 71st World Health Assembly, the decision making body of the WHO, when it meets at the WHO headquarters in Geneva from 21 to 26 May 2018.
The draft report makes recommendations in four areas: identification and prioritisation of a small set of priorities within the NCD agenda for implementation; increase engagement with the private sector; increase funding for action against NCDs; and strengthen accountability for action on NCDs.
At least three specific recommendations in the area of prioritisation and engagement with the private sector favour corporate interests.
Vaccination for elimination of cervical cancer
The draft report recommends elimination of cervical cancer through vaccination, screening and treatment as a prioritised intervention. However, the report is silent on the price of these vaccines. There are currently only two manufacturers producing vaccines against human papillomavirus (HPV) infection viz. GlaxoSmithKline (brand name Cervarix) and Merck Sharp & Dohme (brand name Gardasil). The market price of these vaccines range between USD 35 to 55 per dose in developing countries.
(Merck is the name of the company in the United States and Canada; everywhere else it is known as Merck Sharp & Dohme or MSD.)
In order to scale up the vaccination, the Global Alliance for Vaccines and Immunisation (Gavi, the Vaccine Alliance) negotiated and brought down the price to USD 4.50 per dose. WHO recommends 2 to 3 doses depending on the age of the children to be vaccinated.
However, a 2016 academic study titled “Manufacturing cost of HPV vaccines for developing countries” reveals that the manufacturing cost could be a fraction of even the Gavi price. The study states: “This detailed sensitivity analysis, based on the best available evidence, finds that after a first set of batches for affluent markets, manufacturing costs of Gardasil for developing countries range between $0.48 and $0.59 a dose, a fraction of its alleged costs of $4.50.” (https://www.sciencedirect.com/science/article/pii/S0264410X16308568)
Further, not all countries are getting the Gavi price. Gavi has currently approved 28 countries for its HPV Demonstration Support. One of the manufacturers has pledged the same price after Gavi’s support ends (https://www.Gavi.org/results/countries-approved-for-support/).
However, it is not clear whether other developing countries which do not satisfy the Gavi eligibility criteria would get obtain the Gavi price. Further, as shown in the study the GAVI price itself is still high. The draft NCD report thus makes a recommendation without any reference to the cost implications nor any recommendation on ways to reduce the price.
The rationale behind the recommendations is as follows: “The Commission agreed upon certain criteria for inclusion in the recommendations: specifically, recommendations should have the potential to be actionable, innovative, transformative, and scaled up (and thus be transformative in Terms of their health impact) and feasible to implement across all contexts”.
However, there is no explanation about the cost implications of “elimination of cervical cancer through vaccination, screening and treatment” and its feasibility in the non-Gavi countries.
Private sector engagement
The recommendations in the area of enhancement of engagement with the private sector effectively ignore the risks of such engagements. The draft report contains the following recommendations:
These recommendations do not address the findings of the WHO Secretariat’s report to the 71st session of the World Health Assembly that highlights industry actions to regularly prevent governments from implementing best buys and other interventions for the prevention and management of NCDS. It states:
The draft report effectively ignores the above serious concerns in the Secretariat’s report. While the draft report notes “the wide availability and heavy marketing of many of these products, and especially those with a high content of fat, sugar or salt, challenge efforts to eat healthily and maintain a healthy weight, particularly in children” the overall messaging is that engagement with the private sector is the primary course of action and when public-private partnerships encouraged in the draft report fails, then “governments should employ their regulatory and legislative powers to protect their populations”.
Even then, the draft report makes a very soft recommendation, calling for the WHO Member States to “explore” regulation. Further, it also asks WHO to support Government engagement with the private sector taking into account the rationale, principles, benefits, and risks of such engagement. By including the word “benefits” the assumption is that all private sector engagements have benefits.
Resurrecting “World Health Forum”
The draft report recommends the holding of a health forum for investors to support action against NCDs. The idea of a World Health Forum was dropped after the first edition of WHO Global Forum: Addressing the challenges of non-communicable diseases, held in April 2011 before the Global Ministerial Conference on Healthy Lifestyles and on Communicable Disease Control in Moscow. The October 2011 document titled “WHO reforms for a healthy future” states: “A previous concept paper discussed the idea of a World Health Forum, but feedback from Member States was not supportive” (http://apps.who.int/gb/ebwha/pdf_files/EBSS/EBSS2_2-en.pdf).
While there is a general recommendation that “governments and private sector entities should ensure access to affordable, quality-assured essential NCD medicines and vaccines” the issue of unaffordable prices set by manufacturers, as in the case of HPV, is not addressed in the draft report.
Conflicts of interest
Interestingly the recommendations on the private sector are silent on the issue of conflicts of interest. The draft report recommends in its rationale for recommendations section that, “all activities be framed within existing principles (i.e., human rights and equity-based approaches, multi-sectorial and multi-stakeholder action, health-in-all policies … and management of conflicts of interest”.
However in the specific recommendations that strongly encourage and support private sector involvement the draft report sidesteps the risks of conflict of interests as well as the evidence of industry intimidation and discrediting of current scientific knowledge, available evidence and reviews of international experience as highlighted in the WHO Secretariat report.
Of particular concern is that at least two members of the Commission have close links to the HPV vaccine manufacturers discussed above. One is Arnaud Bernaert, Head of Global Health and Healthcare, World Economic Forum (WEF). GlaxoSmithKline, one of the manufacturers of the HPV vaccine, is a partner of WEF’s dialogue series on NCD (https://www.weforum.org/projects/dialogue-series-on-ncds).
Katie Dain, CEO of the NCD Alliance is another member of the Commission. The NCD Alliance’s website states: “NCD Alliance Supporters include all current funders of NCDA, including NGOs, foundations, and private sector companies”. The annual report of 2016 reveals that 46% of that year’s income was from the private sector. Merck is a supporter (https://ncdalliance.org/sites/default/files/NCDA_2016AnnualReport_Web.pdf).
Any engagement with non-state actors (NSA) is to be included in the WHO NSA register. However, the register is partially functional and therefore there is no information available about WEF and the NCD Alliance.
Paragraph 5(e) of WHO Framework Convention on Engagement with non-State Actors (FENSA) adopted in 2016 states that any engagement must “protect WHO from any undue influence, in particular on the processes in setting and applying policies, norms and standards”. The footnote further explains that policies, norms and standards setting include information gathering, preparation for, elaboration of and the decision on the normative text. The inclusion of senior officers of WEF and the NCD Alliance as part of the Commission that is tasked to make “actionable recommendations made as input towards the Third High-level Meeting of the United Nations General Assembly on NCDs” would be in breach of paragraph 5 of FENSA.
Further, paragraph 45 of FENSA makes it mandatory for WHO “to exercise particular caution, especially while conducting due diligence, risk assessment and risk management, when engaging with private sector entities and other non-State actors whose policies or activities are negatively affecting human health and are not in line with WHO’s policies, norms and standards, in particular those related to non-communicable diseases and their determinants”.
WEF’s NCD dialogue partners include alcohol companies like Carlsberg and Heineken, as well as soft drink companies like PepsiCo and Coca-Cola Company. It is not clear what particular caution was exercised while including a WEF official as part of the Commission.+
(Edited by Chee Yoke Ling.)