Co-authored by KM Gopa Kumar (Third World Network), Sandeep Kishore (Young Professionals Chronic Disease Network), Tim Reed (Health Action International), and Rachel Kiddell-Monroe (Universities Allied for Essential Medicines)
We are writing from the 68th World Health Assembly, where a drafting group of Member States are discussing the Framework of Engagement With Non-State Actors (FENSA). This process aims to determine the rules of engagement between WHO and non-State actors (NSAs), a moniker encompassing academia, nongovernmental organizations, philanthropic foundations, and the private sector. Many from civil society view this process as a way of safeguarding WHO's independence from private interests.
One might say that FENSA is meant to be a "fence" protecting the public's health from undue influences. In the context of policy making, holes in the fence provide new opportunities for the interests of industry to overtake those of the public. It is well known that in recent years tobacco firms, pharmaceuticals, and the beverage lobby have designed campaigns to undermine public health measures (e.g., those concerning plain packaging of tobacco, intellectual property policy, and restrictions on sugary drinks).
At the WHO Executive Board in January 2015, it was decided that the draft FENSA would move to an open-ended intergovernmental meeting, with the goal of being adopted at the WHA. Along with FENSA, draft WHO policy on engagement with all four types of NSAs are being considered. Much insight can be gleaned from the textual proposals submitted by Member States during this process.
Critically, the proposals reveal the fault lines of the most contentious issues concerning FENSA, including whether or not industries impacting human health should be named. At the start, paragraph 44 of FENSA (titled "Engagement with particular industries") read, "WHO does not engage with the tobacco or arms industries. In addition, WHO will exercise particular caution when engaging with other industries affecting human health or affected by WHO's norms and standards."
During the open-ended process, India supported including language in paragraph 44 that named specific industries WHO should exercise caution in engaging with such as the food, beverage, alcohol, and infant formula industries. India further proposed, "WHO's engagement will be strictly limited to assisting such industries to comply with WHO's norms and standards or guideline or policy."
On behalf of the African group, Zimbabwe asserted that the "framework should explicitly list the types of industries that WHO will deal cautiously with and the reasons for the cautious engagement," also naming alcohol, food, and beverage. Greece argued, "strict rules should govern its [WHO] engagement with the pharmaceutical industries." Finland recommended a "high level of restriction" for engagement with industries that have "clear interests in health policies," referencing non-communicable disease control.
Yet these calls were rejected by Canada, Denmark, Norway, and the United States. U.S. sought to eliminate the line concerning "other industries affecting human health" altogether. Many fear that if it is this difficult to discuss specific industries and reasons for cautious engagement in theory, it will prove even more so in practice.
Amongst other issues, there also has been debate on evidence-gathering by NSAs. India proposed that evidence gathered by NSAs should be made available for independent verification. Specifically regarding private entities, India proposed that, "WHO shall not collaborate with private sector entities in the generation of evidence, in knowledge management, in information gathering and in research." This move was challenged by US and UK comments on the matter.
Other issues up for debate have been secondments from the private sector, as well as restrictions and/or ceilings on financial contributions from NSAs. India, for example, proposed a ceiling of 50,000 USD (from NGOs), above which monies would go to the core voluntary fund. We support this idea, as WHO should not be hamstrung by donor priorities in its ability to mobilize resources.
FENSA also calls for a publicly available registry of NSAs -- we fully agree with this and eagerly await its arrival. This week we had a chance to speak with Malebona Precious Matsoso, South Africa's Director General of Health, who asked, "The question is, how are we going to go about due diligence? What exactly are we going to do to minimize risk in a practical manner?"
In the changing landscape of global health, we acknowledge that all NSAs -- including the private sector - have a valuable role to play in the field. The question now is not if the WHO will engage with NSAs, but rather -- how. Not all NSAs are created equal; conflicts of interest exist to varying degrees within entities across the public and private sectors. We must remain particularly vigilant against allowing private interests to drive technical recommendations and policy-making.
We urge Member States to ensure that FENSA creates a strong enough "fence" to safeguard our public's health. In the name of engagement, FENSA must not become an instrument to legitimize industry influence and undermine the independence of WHO. WHO must be given the mandate to adequately assess perceived and actual conflicts of interest, monitor risks of engagement in an ongoing fashion, and subsequently manage all engagements with full transparency. Make no mistake -- the stakes are high.