COVID-19 VACCINE
GOVERNANCE:SIDELINING
MULTILATERALISM

T

he year 2020 has singularly affected the world likeno other in recent memory—uniting people in the miseryit brought and disuniting countries in the politics that camewith it. The pandemic of COVID-19
has been momentous for people
across the world. It has been decisive for the governance of global health like never before. Goingby the evolution of global publichealth policy in this short spanof a few months, it is clear thatmultilateralism in global healthhas been transformed forever.
It is debatable whether, as a result,multilateralism has strengthened.
To be sure countries have cometogether in an effort towards solidarity in this time of crisis. However, whether ‘donor-driven’ international cooperation couched in thelanguage of charity, as witnessedin 2020, can address the tricky
questions on equitable access to
medical products is hard to say. In
general, fairness in global healthdecision-making processes at themultilateral level has been lacking
during this crucial period when
the foundations of the responseto this pandemic were being laid.
2

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IntroductionT

he World Health Organization (WHO), which is ostensibly leading the responseto the pandemic, has risen to thechallenge by delivering on thetechnical and normative fronts,
even as countries showed uneven willingness and capacity todeal with the crisis. While there
are varying levels of agreement
between member states and other actors on the extent of WHO’s
successes and missteps, WHO haslargely been perceived as leadingfrom the front, although straining
from internal and external limitations. WHO has delivered despite
the distractions of vicious geopolitics, grave uncertainties onfunding and a relatively smallerrole than one would expect it tohave assumed in the worst public health crisis in a century. The
institution has delivered on numerous levels, from spearheading the scientific and technicalresponses to establishing massive
clinical trials for medical products;
COVID-19 AND GLOBAL HEALTH GOVERNANCE

from determining the logistics ofthe response to being a catalyst
in coordinating actions with other organizations and international
actors; from driving responses onother areas of public health outside of the pandemic to working
alongside countries in the faceof simultaneous emergencies.
However, as the year drew to aclose, it became clear that WHO
was not able to exercise its political leadership effectively enough.
There have been reports1 about
the influence certain member
states have had on WHO’s assessment of the pandemic responseat national levels. As per reports,
WHO suppressed an independent report that examined thestrengths and weaknesses of Italy’s COVID-19 pandemic response.
In addition, China’s2 alleged influence on WHO since the earlydays of the pandemic quickly set
1
Nicoletta Dentico and Elaine Ruth Fletcher,“World Health Organization’s Censorship of Reporton Italy’s Pandemic Response Sets Dangerous
International
Precedent—Critics
Say,”Health
Policy Watch, December 15, 2020, https://
healthpolicy-watch.news/the-world-health-organizations-censorship-of-report-on-italys-pandemic-response-sets-dangerous-conflicts-of-interest-precedent/.
2
Elaine Ruth Fletcher and Nicoletta Dentico,“‘China Box’: Buried WHO Report of Italy’s COVID-19
Response Cited ‘Inconvenient Facts’ on Pandemic’s
Initial Spread in Asia,”Health Policy Watch, December
23, 2020, https://healthpolicy-watch.news/chinabox-buried-who-report-on-italys-covid-19-responsecited-inconvenient-facts-on-pandemics-initialspread-in-asia/.
3the tone for the rest of the year.3
In early 2021, China faced a public
push back from WHO. WHO Director-General Tedros Adhanom
Ghebreyesus expressed his disappointment with China when thelatter turned back international scientists who were meant tostudy the origins of SARS-CoV-2.4
Further, countries and other actors have expected more from
WHO. While WHO has brought
actors in global health together,some have pointed to the institution’s controversial role in lending
its credibility to new forums rather
than asserting the role of the WHO
as the leading multilateral forum.
It appears that WHO has beenable to effectively deploy its leadership only in certain areas andnot as much in others. This is, ofcourse, a general consequenceof years of financing trends andshifts in power plays in global
health. Unfortunately, this hascome home to roost at this criticaljuncture when WHO’s leadershipis needed the most, including inmatters such as ensuring equitable access to COVID-19 medical
products for people the world over.
3
Selam Gebrekidan, Matt Apuzzo, Amy Qin andJavier C. Hernández, “In Hunt for Virus Source, WHO
Let China Take Charge,” New York Times, November 3,
2020, https://www.nytimes.com/2020/11/02/world/
who-china-coronavirus.html.
4“ WHO Director-General’s Opening Remarks
at the Media Briefing on COVID-19—5 January 2021,”
January 5, 2021, https://www.who.int/director-general/speeches/detail/opening-remarks-for-the-mediabriefing-on-covid-19-5-january-2021.
4

WHO launched a voluntary technology pooling mechanism5 toaddress the challenges in accessing medical products during the
pandemic, known as the COVID-19
Technology Access Pool (C-TAP)
that has neither been able to galvanize enough countries nor elicit private-sector participation. In
fact, the pharmaceutical industry
promptly dismissed this initiative
for the voluntary pooling of patents and sharing of technology.6
Civil society actors are of the viewthat even if WHO had managed
to sign on more nations to C-TAP,
the reliance on the voluntary nature of commitments is insufficient to deal with the challengesof this pandemic. Binding commitments7 on sharing technology and knowledge would havebeen more effective in meetingthe unprecedented demands
brought on by the COVID-19 crisis.

5“COVID-19 Technology Access Pool,”https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/covid-19-technology-access-pool,<accessed 14 January 2021>.
6
Grace Ren, “Progress On COVID-19
Technology Pool Inches along As Sister Initiative to
Pool Vaccine Procurement Accelerates,” Health Policy
Watch, September 2020, https://healthpolicy-watch.
news/progress-on-covid-19-technology-pool-inches-along-as-sister-initiative-to-pool-vaccine-procurement-accelerates/.
7
Priti Patnaik, “COVID19 Tech Platform—
Countries Pass Up Opportunity for a Binding
Mechanism to Ensure Equitable Access to Meds,”
Geneva Health Files, May 28, 2020, https://genevahealthfiles.com/2020/05/28/covid19-tech-platformcountries-pass-up-opportunity-for-a-binding-mechanism-to-ensure-equitable-access-to-meds/.
PEOPLE’S HEALTH MOVEMENTInstead, it appears that with
WHO’s goodwill, its better funded partners in global health wereable to swiftly strike deals on vaccines, diagnostics and therapeutics under the Access to COVID-19
Tools (ACT) Accelerator. However,as we shall explain later, mechanisms such as the ACT Accelerator are not designed to yield
the maximum benefit for the
maximum number of people, irrespective of where they live.

tiple stakeholders, including international organizations, the private
sector, philanthropic foundations,
global public–private partnerships (GPPPs) and, sometimes,
civil society. While this is not a
new international development,
and certainly not in global health,this kind of engagement raises
questions on intent, transparency and governance, especiallyin the context of the pandemic.

The institution’s embrace of multistakeholderism may become thefinal blow to the legitimacy of thismember-state-driven organization. Multistakeholderism involves
the process of engaging with mul-

A year into this brave new worldof pandemic response, the results
are here to see on what this shift
has meant for its member states.
Countries have raised questions on
why they haven’t been consulted

COVID-19 AND GLOBAL HEALTH GOVERNANCE

5

adequately on crucial matters, even as private actors have been provided with vast sums of public money with inadequate oversight. Whatis worse, for many in the industry, the pandemic appears to be a perfect profit-maximizing opportunity, and they are unfailingly cashingin on the poorly coordinated responses by member states. Politicians
and government leaders worldwide have often ended up striking illthought-out8, desperate deals with private companies. Ruling parties
globally have been under pressure to be seen to be doing enough to address the pandemic. Even as vast amounts of public funding have beenpoured into the pandemic response, including for research and development, public authorities have not succeeded in negotiating theseinvestments to ensure that public health needs remain safeguarded.9
The pandemic presented the perfect opportunity to assume control
on decision-making around critical areas of Covid-19 response. Looking back, questions will be raised as to whether WHO stepped aside
to allow larger donor countries and powerful private actors to set therules of the response, or whether, indeed, there were efforts to preserve the multilateral nature of the organization. The response to thehealth crisis has undoubtedly caused a fragmentation of authority.

It appears that WHO has been able to effectively
deploy its leadership only in certain areas andnot as much in others. This is, of course, a generalconsequence of years of financing trends and shifts
in power plays in global health. Unfortunately, thishas come home to roost at this critical juncture whenWHO’s leadership is needed the most, including
in matters such as ensuring equitable access to
COVID-19 medical products for people the world over.

8
Lucien Hordijk and Priti Patnaik, “Covid-19: EU Countries Spent over €220m Stockpiling Remdesivir
Despite Lack of Effectiveness, Finds Investigation,” British Medical Journal, December 8, 2020, doi: https://doi.
org/10.1136/bmj.m4749.
9
Zain Rizvi, “Covax’s Choices,” Public Citizen, November 16, 2020, https://www.citizen.org/article/
covaxs-choices/.
6

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WHO and the
ACT
ACCELERATOR
The creation of the
ACT-AcceleratorOn 24 April 2020, WHOalong with its partners
called for a global collaboration to hasten the development and production of diagnostics,
therapeutics
andvaccines, while ensuring their equitable access, to fight COVID-19.
The ACT Accelerator, a multi-stakeholder initiative, was powered in May 2020 in a pledging
event. It is driven by the European
Commission10, more than a dozen
countries11, the Bill & Melinda Gates
Foundation12, key Gates-funded
10“The Access to COVID-19 Tools (ACT)
Accelerator,” Frequently Asked Questions, https://www.who.int/initiatives/act-accelerator.
11
Governments of Austria, Belgium, Canada,
France, Germany, Italy, Mexico, Morocco, New
Zealand, Norway, Saudi Arabia, South Africa, Spain andthe United Kingdom, and the European Commission
have so far committed to the ACT-Accelerator.
12
Rohit Malpani, Brook Baker and Mohga
COVID-19 AND GLOBAL HEALTH GOVERNANCE

global health actors13, as well as
the World Bank Group and WHO.
Some have suggested that theidea of a private-sector-led response in the form of what became the ACT Accelerator was
initially conceived by the Bill
& Melinda Gates Foundation.14
In a matter of months, nearly USD
16 billion15 were pledged, though
only a part has actually been disbursed. In addition, the bulk ofthese resources are already committed funds under various development assistance programmes
rather than additional funds.
However, at the end of 2020,
the ACT Accelerator continued to
be seriously underfunded, withan estimated financing gap ofnearly USD 24 billion in 2021.16
Kamal-Yanni, “Corporate Charity—Is the Gates
Foundation Addressing or Reinforcing Systemic
Problems Raised by COVID-19?” Health Policy Watch,
October 31, 2020, https://healthpolicy-watch.news/
gates-foundation-address-systemic-covid-19/.
13
These include the Coalition for Epidemic
Preparedness Innovations (CEPI), the Global Alliance
for Vaccines and Immunizations (GAVI) and the
Global Fund to fight AIDS, Tuberculosis and Malaria(GFATM or the Global Fund), apart from Unitaid, theFoundation for Innovative New Diagnostics (FIND)
and the Wellcome Trust.
14
Megan Twohey and Nicholas Kulish, “Bill
Gates, the Virus and the Quest to Vaccinate theWorld,” The New York Times, November 23, 2020,
https://www.nytimes.com/2020/11/23/world/bill-gates-vaccine-coronavirus.html.
15“EU Global Coronavirus Response,” https://global-response.europa.eu/index_en,<accessed
on 14 January 2021>.
16“ACT
Accelerator:
UrgentPriorities
andFinancing
Requirements
at10
November
2020,”
November
12,2020,
h t t p s : // w w w.w h o. i n t /p u b l i c a t i o n s /m / i te m /7

Figure 1: ACT-Accelerator Global Response to COVID-19’

Image Source: Initial documents from April 2020 describing governance mechanisms of
the ACT Accelerator/ EUROPEAN COMMISSION

Governanceconcerns
Concerns have been raised as towhether issues such as funding
and strategy for the pandemic response should have been placedoutside WHO’s multilateral framework. After all, oversight of the useof resources and accountability
in decision-making will be awayfrom the influence and consideration of WHO member states.
The mandate of the ACT Accelerator was quickly divided
up between the leading partners. Four pillars constitute the
ACT Accelerator: vaccines, diagnostics, therapeutics and the
HealthSystems
Connector.17

While the Global Alliance for
Vaccines and Immunizations(GAVI) and the Coalition for Epidemic Preparedness Innovations(CEPI) co-lead the vaccines pillar
which houses the COVAX Facility,
Unitaid and Wellcome Trust are
responsible for the therapeutics
pillar. The Foundation for Innovative New Diagnostics (FIND) is thelead actor for the diagnostics pillar. The Health Systems Connector is overseen by the World Bank
(Figure 1). While the vaccines pillar has been in the spotlight, theother pillars have received lessattention, although diagnostics
and therapeutics for the pandemic have been
mobilized
through the ACT Accelerator.

urgent-priorities-financing-requirements-at-10-november-2020.
17
The Health Systems Connector pillar works across the other three pillars and is convened by the WorldBank and the Global Fund. It aims to strengthen the health systems and local community networks in the context
of COVID-19.
8

PEOPLE’S HEALTH MOVEMENTTable 1: Donor contributions to ACT-Accelerator

Image Source: ACT Accelerator financing from internal WHO documents.

The different pillars are responsible for their own fund-raising,
grant management and internalreporting.18 Through a support
structure known as the ACT-Accelerator Hub WHO has a coordinating role across all the pillars,
though without an oversight role.

Diminution of therole of WHO
The run-up to the creation of
the ACT Accelerator was dominated by old narratives, such as
this: ‘WHO is unable to address
challenges effectively, so there
is a need to carve out new forums.’ As a result, it has been
justified that ‘the few’ can takedecisions more effectively andefficiently—outside of the multilateral system comprising the
194 countries that make up WHO.
18

The formation of the ACT Accelerator was the clearest and boldest move, not to mention an extremely well-planned one and aquick diplomatic win, by the big
countries in the European Union
to direct decision-making in response to the pandemic. It is also
important to keep in mind thatthese events unravelled against
the backdrop of the retreat of
the USA from WHO and the perceived threat of a ‘Chinese takeover’ of WHO. And undoubtedly,
the ACT Accelerator mechanism
also demonstrated the powerof influential donors such as theBill & Melinda Gates Foundation,
which have had an instrumental role in shaping this initiative.
The ACT Accelerator is effectively run by donors (Table 1). Countries such as Canada, Franceand Germany, the European

Author’s personal interview with a WHO spokesperson for this paper.

COVID-19 AND GLOBAL HEALTH GOVERNANCE

9Commission and prominent
actors in global health, notably
the Bill & Melinda Gates Foundation, are in effect free-ridingon WHO’s convening power atthe expense of the majority ofits member states who have no
say either in the way the resources to fight COVID-19 are being
spent nor in any decision-making or meaningful participation.
It is not clear whether WHO
had any choice in the way the
ACT Accelerator was drawn up.
As the leading authority on vaccines, diagnostics and therapeutics, WHO could have been alead actor or at least could have
led in partnership with otherdomain actors. After all, among
other steps, WHO activated the
R&D Blueprint in response to the
COVID-19 pandemic , supported research and other efforts on
international clinical trials, anddeveloped COVID-19 Emergency Use Listing Procedures to accelerate the availability of safeand effective COVID-19 vaccines.
The extent of WHO’s involvement across the various pillarsof the ACT Accelerator appears
to be uneven. Some sourcesfamiliar with the functioningof the Act Accelerator say thatwhile WHO officials are part ofthe briefings, they are often notleading the discussions. The
ACT Accelerator Support Hub
does not make decisions on implementing plans or handlingfunds, but serves to facilitate coordination, according to WHO.19
Thus, there is a perception that
the WHO Secretariat has been
limited to performing the roleof a facilitator for other better
funded actors in global health,instead of securing the interests of WHO member states.
The ACT Accelerator is also
guided by a Facilitation Council,20 which is represented byvarious actors, including donor countries, private philanthropists and civil society. The
Council seeks to provide strategic guidance on policy andfinancial matters to ensure delivery, financing and equitable access to medical products
during the pandemic. Norway
and South Africa are co-chairsof the Facilitation Council. But
the effective role of this Council in terms of improving governanceremains
unclear.
The ACT Accelerator has struggled to raise funds required tomeet the needs of an effective

19
Donors and recipient organizations provide the Hub with high-level overviews of their financial
flows, according to a WHO spokesperson (author’s personal interview for this paper). On financial flows, see“COVID-19 Funding Tracker,” The Economist, Intelligence Unit, https://covidfunding.eiu.com/.
20“ACT Accelerator Facilitation Council,” https://www.who.int/docs/default-source/coronaviruse/act-accelerator/act-a-facilitation-council-terms-of-reference-21-september-2020, <accessed on 14 January 2021>.
10

PEOPLE’S HEALTH MOVEMENT

Figure 2: ACT-Accelerator Budgetry Requirements

Image Credit: ACT Accelerator Investment Case November 2020
[Urgent Priorities & Financing Requirements at 10 November 2020].

response to the pandemic (Figure2). There is the realization that thefocus of ACT Accelerator has beenskewed in favour of vaccines, withmuch less attention given to theother pillars or to strengthening
health systems in low- and middle-income countries (LMICs). If
these issues are not addressed,
the health systems in LMICs, already weak, will be crippled.21
Presently, 190 countries (ofwhich 92 are LMICs) are part of
the COVAX Facility22 and will potentially benefit from the pooled
procurement of vaccines from a
broad portfolio administered by

Gavi. COVAX secured manufacturing capacity for 1 billion vaccine
doses as on November 2020. But
so far, it has not been able to secure adequate supply from manufacturers and has failed to ensure equitable access to vaccines
for the pandemic as promised.
The optimism around COVAX isbeginning to fray. Even as the first
vaccines began to reach vulnerable groups in wealthy countries,
there was the weight of great expectations and tremendous pressure on Gavi and its partners, including WHO, to fulfil the statedpromise of equitable access to21
Ann Danaiya Usher, “COVID19 Support Scheme Faces Massive Funding Crisis, Calls for USD 10b Moreto Prevent Collapse of Health Systems,”Development Today, November 10, 2020, https://www.development-today.com/archive/dt-2020/dt-8--2020/covid19-support-scheme-faces-massive-funding-crisis-calls-for-usd-10bmore-to-prevent-collapse-of-health-systems.
22“COVAX Announces Additional Deals to Access Promising COVID-19 Vaccine Candidates; Plans Global
Rollout Starting Q1 2021,” Joint News Release, December 18, 2020, https://www.who.int/news/item/18-12-2020covax-announces-additional-deals-to-access-promising-covid-19-vaccine-candidates-plans-global-rollout-starting-q1-2021.
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11

vaccines. At the end of 2020,23 they
had failed to ensure the delivery of
COVID-19 vaccines in all parts of theworld, a particularly disturbing situation considering that people andmanufacturers from the Global South
have contributed to making thesevaccines a reality. What is even moretroubling is the risk that the COVAX
programme will leave out some ofthe poorest countries in the world
without access to vaccines, especially those that have depended on COVAX and have not been able to strikebilateral deals with manufacturers.24

23
Priti Patnaik, “COVAX In 2021: Will the Pieces
Come Together?” Geneva Health Files, December 24,
2020,https://genevahealthfiles.com /2020/12/24/
covax-2021-the-gavi-board-dossiers/.
24“WHO Vaccine Scheme Risks Failure, Leaving Poor
Countries with No COVID Shots until 2024, The Economic
Times, December 16, 2020, https://economictimes.indiatimes.com/news/international/world-news/who-vaccinescheme-risks-failure-leaving-poor-countries-no-covidshots-until-2024/articleshow/79764851.cms?from=mdr.
12

Image: Hakan Nural on Unsplash

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What theCOVAX
Facility
Tells Us
about Global
HealthGovernanceAt the time of the pledging
event, organizations behind the ACT Accelerator
said that ‘the estimated overall
costs for development, manufacture and procurement of Vaccines
will be far higher than Diagnostics and Therapeutics and it isrecommended that donors consider this when making pledges
and apportioning their resources.25’ It is not clear why this was
so decided. And sure enough, inthe following months, vaccines
have indeed accounted for a significant percentage of resources
raised by the pledge (USD 2 billion
25
Initial ACT Accelerator documents at the timeof the pledging event in May 2020, seen by the author.
COVID-19 AND GLOBAL HEALTH GOVERNANCE

out of the USD 3 billion pledged),
and it is projected to remain so.
Although COVAX has been theposter child for the ACT Accelerator mechanism, it is already beginning to show the limitationsof the public–private partnershipapproach. Experts have questioned the short-term approachof the COVAX Facility that seeks
to procure 2 billion vaccine doses by the end of 2021—less than
15 per cent of the total demand
for the world’s population26.

Promoting equitable
access?
International cooperation has
been affected because of vaccine nationalism, with a number of high and middle income
countries striking bilateral deals
In thiswith manufacturers.27
context, COVAX has come to be
seen as a panacea for a world
divided by trade wars and thehoarding of medical supplies.
One hundred and ninety countries have joined COVAX, withvarying degrees of commitment, thereby placing their
26
Global demand for vaccinating the world’s
population is at a modest estimate of 15 billion doses, a two-dose regimen for 7 billion of the world’s
population.
27
Nsikan Akpan, “WHO Set to Approve a
COVID-19 Vaccine by end of 2020—Increasing
Hopes for Equitable Access,” National Geographic,
December 4, 2020, https://www.nationalgeographic.
com/science/2020/12/world-health-organizationset-to-approve-coronavirus-vaccine-by-end-of2020-hopes-for-equitable-access.
13

Image: Thirdman from Pexels

trust in GAVI’s ability and willingness to negotiate optimal prices with big pharma for their country’s access to vaccines.
In practice, the process has been opaque and non-transparent. There is not enough understanding of the terms and pricing
mechanisms that GAVI is negotiating with vaccine manufacturers
through the financial mechanism of Advance Market Commitment(AMC)28 and the extent to which provisions on intellectual property rights and transfer of technology that would contribute to equitable access have been insisted upon. It is not clear who will shoulder liabilities if any of the vaccine candidates create adverse events.
COVAX proposes that only a small percentage of each country’s
population will be served by vaccines during 2021.29 It is not clear
what countries will do in order to get the vaccines they will need.

28“The Gavi COVAX AMC Explained,” October 13, 2020, https://www.gavi.org/vaccineswork/gavi-covax-amc-explained.
29“Fair Allocation Mechanism for COVID-19 Vaccines through the COVAX Facility,” September 9, 2020, https://www.who.int/publications/m/item/fair-allocation-mechanism-for-covid-19-vaccines-through-the-covax-facility.
14

PEOPLE’S HEALTH MOVEMENTAt a press briefing in late2020,30 Director-General Tedros
acknowledged that the COVAX
Facility will not be able to solve
the problem of vaccine nationalism. This admission should
not be surprising given what isseen by many to be a short-termist approach to addressing apandemic that is likely to lastfor more than a few years. Many
believe that the COVAX Facility has thus far been limited inits scope and ambition and has
been unable to provide a robust
framework for equitable access.
Further, despite several callsfrom a host of countries at theWorld Health Assembly in May
2020 to make vaccines a global public good, this has notbeen agreed upon.31
There isno clear understanding of what
this would mean for intellectual
property rights, the transfer oftechnology and issues of pricing. WHO has not been able
to convene member states effectively enough to make vaccines a global public good.

Sidelining 				multilateralism: WHO
member states lackdecision-making role
At the WHO Special Executive Board meeting32 in October 2020, a number of countries
called on WHO33 to assume agreater role in the governancedecisions of the COVAX Facility and raised the wider concern of access to medical products during the pandemic.
In raising issues ranging fromthe allocation framework for
Covid-19 medical products thatwill determine countries’ access,to the governance structure of
the COVAX Facility,34 countries
seemed to suggest that they
have been left out of these decision-making processes. Many,among them Austria, the UK,
Romania and Kenya, have asked
for greater consultation andengagement on these issues.
Kenya specifically pushed for
greater transparency in the decision-making process and urged

30
WHO Press Briefings.
31
In fact, the WHA resolution on COVID-19 response had watered down the language on vaccines as a
global public good.
32“Executive Board: Special Session on the COVID-19 Response,” October 5–6,
2020, https://www.who.int/news-room/events/detail/2020/10/05/default-calendar/
executive-board-special-session-on-the-covid19-response.
33
Priti Patnaik, “‘Consult Us More’: Countries to WHO,” Geneva Health Files, October 8, 2020, https://
genevahealthfiles.substack.com/p/consult-us-more-countries-to-who.
34
Israel, for example, raised detailed questions on behalf of Australia, Chile, Japan, New Zealand, theRepublic of Korea, Switzerland, Singapore among others, on the allocation framework and governance mechanisms around the COVAX facility.
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15

the Director-General35 to use provisions in the WHO Constitution inthis direction. Civil society actors
have raised concerns that major
policy decisions within the ACT
Accelerator, including the ones on
diagnostics,36 appear to be madewith only ‘donor’ countries at thetable. Many LMICs were not awareof these discussions and agreements. The process is very much
top–down. There is a perception
among some high income countries (HICs) and western observersthat LMICs have failed to engage
enough and to effectively negotiate on issues of concern to them.
Without an official, streamlined
multilateral process of engagement within the framework of the
ACT Accelerator, this might be difficult to accomplish to begin with.

Limitations to civilsociety engagement

to be heard, instead of using theirenergies to contribute directly to policy-making discussions.
In response to efforts by civil society organizations (CSOs) to engage with the processes of the
ACT Accelerator, various agencies
in the ACT Accelerator sent a letter
to Gavi37 in early July 2020 statingthat civil society and community
organizations have ‘critical roles
to play, especially in ensuring the
successful realization of the ACT
Accelerator goals promising engagement with the civil society’.
However, considering the controversial nature of decision-making
in this mechanism, it remains tobe seen if public interest and equity approaches will be integrated, or if civil society participation
will rather be a mere attempt tolegitimize the multi-stakeholder
approach.

The pandemic has been a turning
point for civil society engagementin global health policy-making.
While there has never been a moreacute time for greater discussions
with communities and experts, it
is precisely at such a juncture thatcivil society actors are struggling
35
In his response to member states’ concern, Director-General Tedros promised to continue with weekly
meetings with member states and acknowledged the importance of closer working relations with the governing
bodies of WHO. See Patnaik, “‘Consult Us More’: Countries to WHO”.
36
Priti Patnaik, “COVID-19 Diagnostics: The Full Picture,” Geneva Health Files, October 1, 2020, https://genevahealthfiles.substack.com/p/covid-19-diagnostics-the-full-picture.
37
This letter was signed by the heads of WHO, CEPI, the Wellcome Trust, Unitaid, FIND, the Global Fund, theWorld Bank Group and the Bill & Melinda Gates Foundation. And, after some resistance, also by Gavi according tosources.
16

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4

What theFuture Could
Look likeA

gainst the backdrop of the
impact of the pandemic of COVID-19, a numberof governance reform proposals38 have emerged, among others from the USA and Brazil,39
and from Germany and France.40

Global healthsecurity
There is a push to view the governance of WHO and the wider
global health sphere through thelens of global health security. The
38
Priti Patnaik, “Competing Visions for
WHO Reforms,” Geneva Health Files, January 8,2021,
https://genevahealthfiles.com/2021/01/08/
competing-visions-for-w-h-o-reforms/.
39
Priti Patnaik, “US & Brazil Team Up for
WHO Reform,” Geneva Health Files, November 5,2020,
https://genevahealthfiles.substack.com/p/
us-and-brazil-team-up-for-who-reform.
40
Priti Patnaik, “WHO Reform Proposal,”
Geneva Health Files, September 10, 2020,
h t t p s : //g e n eva h e a l t hf i l e s . s u b sta c k .c o m /p /who-reform-proposal-vaccine-prices.
COVID-19 AND GLOBAL HEALTH GOVERNANCE

reform proposals led by Germany
and France, for example, seek tolink the strengthening of WHO’s
emergency response with bolstering global health security.
While this is partly seen as a
genuine effort to strengthen
multilateralism in global health,some countries believe that theemphasis on global health security can draw away attention
from WHO’s other core normative work and from a more comprehensive approach towards thestrengthening of health systems.

Funding
While there is recognition that
WHO should be in a position toplay a central role in global healthgovernance, some HICs stress that
‘WHO’s partner organizations
have outgrown WHO’s budget by
far with the consequence that it isquestionable whether WHO really is on an equal level playing field,
able to defend its leading andcoordinating role vis-à-vis thesefinancially far more powerful actors.41’ While the WHO budget
might remain smaller than thatof other global health actors, its
legitimacy stems from its technical capacities as well as its
multilateral character. That said,
the current financing of WHO
41
For more on ‘The proposal, “Non-Paper onstrengthening WHO’s leading and coordinating role inglobal health—with a specific view on WHO’s work inhealth emergencies and improving IHR implementation”, being discussed at various levels,’ see ibid.
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is undermining both aspects.
Inextricably linked to the question of governance is the question of financing of WHO. As thelarge majority of WHO’s funds
are tied contributions, those who
hold the purse strings for WHO
are in the driver’s seat of the organization. To be sure it is not
only about member states, butalso powerful actors such as theBill & Melinda Gates Foundation.
Tied contributions distort governance and spending priorities, andtherefore WHO’s financing needs
greater voluntary contributions.
Undoubtedly all countries mustalso pay more in the form of assessed contributions to strengthen multilateralism in global health,though the ability to increase
contributions may be constrainedby the economic challenges
in the wake of the pandemic.

Formalizing
multistakeholderism
Essentially the problem aroundthe governance of the ACT Accelerator seems to be the following:thedecision-making
has been moved away from aninter-governmental
platform(which is what is understood bymultilateralism) to a small groupof self- nominated donors (richdonor countries, public–private
partnerships,
philanthropies
and private companies), often
referred to as multi-stakeholders. LMICs, other UN institutions
and CSOs may be present, butthey have had little or no opportunity or space to be part ofthe decision-making processes.
The preference for multistakeholderism has recently gained
considerable endorsement at thehighest levels and is heartily embraced by donor countries. And
increasingly there are indications
that the new mechanisms built
around an alliance of the powerful—and excluding the majority
of countries and peoples’ voices—which came into being during
the pandemic, will be formalized.
In a short intervention, during the WHO Executive Board
meeting in early October, Director-General Tedros seemed tosuggest that it was perhaps time
to formalize the structures of the
ACT Accelerator for future pandemics.42 This was striking, given that these structures are effectively located outside of WHO.
Sure enough, this was reiterated43

42
For the text of the comments made by Dr Tedros at the Executive Board on formalizing the ACT Accelerator,
see Patnaik, “‘Consult Us More’: Countries to WHO”.
43
James Hacker, “Health Leaders Plea Against ‘Flash In The Pan’ Attitude to Global Cooperation, As World
Health Summit 2020 Closes, Health Policy Watch, October 27, 2020, https://healthpolicy-watch.news/healthleaders-plea-against-flash-in-the-pan-attitude-to-global-cooperation-as-world-health-summit-2020-closes/.
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Figure 3: ‘Paris Peace Forum tweet praising two key donors’.

Image Credit: Paris Peace Forum/ Twitterin the World Health Summit44 in October 2020, which took place justahead45 of the (resumed) World Health Assembly. A concern raised bymany LMICs was that if the ACT Accelerator succeeds in profiling itself
as a response to the challenges of the pandemic, it is unlikely that thecountries that funded these structures will revert to funding the WHO.
Consequently, WHO will be permanently sidelined. Another indicationof the formalizing of the governance structures around the ACT Accelerator, came during the World Health Assembly in November 2020, at
the influential Paris Peace Forum.46 The Forum not only raised funds forthe global pandemic response, more importantly it was significant insolidifying the roles of key donors of the ACT Accelerator and appeared
to be a de facto declaration of formalizing this mechanism (Figure 3).47
As a result, multilateralism becomes a casualty at the altar of multistakeholderism. The pandemic illustrates how private partners in global health have come to assume more space even as smaller countries
have been edged out of the table and their populations pay the pricefor the lack of transparency and equity in global health governance.

44“World Health Summit,” October 2020, https://www.worldhealthsummit.org/summit.html.
45
Top leaders in global health reportedly believe that ‘new modes of interagency collaboration triggeredby the COVID-19 pandemic should be used as a model to advance more progress post-pandemic, on important
Sustainable Development Goals (SDGs) related to health’. See Hacker, “Health Leaders Plea Against ‘Flash In The
Pan’ Attitude”.
46“3 Days to Bounce Back to a Better Planet: Reviewing the Success of the Third Edition,” Paris Peace
Forum, November 5, 2020, https://parispeaceforum.org/.
47
Priti Patnaik, “The Splintering of the Centre of Global Health, Geneva Health Files, November 13, 2020,
https://genevahealthfiles.substack.com/p/the-splintering-of-the-centre-of.
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What WHO must do
To be sure, WHO and its Secretariat are also hamstrung bypolitical and financial pressures,
which ultimately impact theoverall leadership of the organization in global health and beyond.
WHO has supported South Africa
and India’s proposal48 at the WTO
for a Trade-Related Aspects of Intellectual Property Rights (TRIPS)
waiver during the pandemic. The
waiver proposal seeks to allow all
countries to not grant or enforce
intellectual property protection
for the duration of the pandemic.
The proposal recognizes intellectual property, trade secrets andindustrial designs as barriers to
sharing technology, expanding
manufacturing and supplying
medical products. The co-sponsors of the proposal include Kenya, Eswatini, Mozambique, Pakistan and Bolivia. Some of thecountries who have opposed the
TRIPS waiver proposal at WTO
are also key funders of WHO.
By the end of 2020, the TRIPS
waiver proposal49 had progressed
within the WTO through several rounds of formal and informal

consultations at the TRIPS Council. By the close of the year, it hadreached the General Council—theorganization’s highest level decision-making body. There will befurther discussions in early 2021.
Experts say that no matter what
the final destiny of this proposal
is, the needle has moved.50 Given the scrutiny of the role of intellectual property as a barrier in the access to medicines in
the course of these discussions,this debate has already been
elevated to a significant level.
Given the urgency in pushing the boundaries on what is
possible to meet the demands
on equitable access to medical products that this pandemic
has unleashed, WHO must show
greater leadership within theconstraints it faces. WHO’s C-TAP
is a case in point. Even in its current weak form, some perceivethat the initiative has not been
sufficiently promoted and ownedeven within the WHO Secretariat.51 There is potential to pursue
and strengthen this initiative, including by convening countries,
and make serious efforts to force
the private sector to commit to48“Members Discuss Intellectual Property Response to the COVID-19 Pandemic, October 20, 2020,
https://www.wto.org/english/news_e/news20_e/trip_20oct20_e.htm#:~:text=TRIPS.
49
Priti Patnaik, “Road Ahead for Greater Deliberation in 2021: Trips Waiver Proposal at WTO,” Geneva Health
Files, December 18, 2020, https://genevahealthfiles.com/2020/12/18/moment-in-the-sun-for-trips-waiver-plan/.
50
Priti Patnaik, “Trips Waiver: The Needle Has Moved, but the Fight Is On, Geneva Health Files, November
26, 2020, https://genevahealthfiles.com/2020/11/26/trips-waiver-discussions-moving-the-needle/.
51
This information is based on interviews of sources familiar with the processes around C-TAP, which theauthor conducted in the course of reporting during 2020.
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price control and transparency. The industry has dismissed the initiative, and WHO did not publicly question its stand. Many have pointed out that, for example, the WHO did not push for the COVAX Facility
to get vaccine manufacturers to share technology through the C-TAP.
The governance of global health can be greatly influenced bywhat WHO chooses to do and what it does not. This it can do,even within the existing constraints that the organization faces.

About the author
Priti Patnaik is the founding editor of Geneva Health Files(https://genevahealthfiles.substack.com/) a journalistic initiativethat tracks the governance of global health, reporting on power andpolitics in international health policy. She has reported on finance,banking and commodities, for different publications in Geneva, NewYork and New Delhi during the last 15 years. She can be contacted at
patnaik.reporting@gmail.com, and can be followed @pretpat or@filesgeneva on Twitter.
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