The Access To COVID-19 Tools Accelerator (ACT-A) was the largest and most ambitious global effort to ensure equitable availability for anti-SARS-CoV-2 technologies—vaccines, treatments, and diagnostics. The intent deserves high praise. But the result fell far short of expectations. As Suerie Moon and colleagues pointed out in 2021, the roles of organisations constituting ACT-A were unclear. Accountability was almost non-existent. The exclusion of low-income and middle-income countries from the creation of ACT-A was an egregious mistake. The 8 co-convenors—WHO, GAVI, The Global Fund, CEPI, World Bank, UNITAID, Wellcome, and FIND—included the usual global health power brokers. The Bill & Melinda Gates Foundation was a donor to all co-convenors (except Wellcome) and was a member of the ACT-A Principals Group and Facilitation Council. Why? An independent external evaluation, published in October, 2022, provided a further rebuke. Large funding gaps meant that urgently needed ACT-A financing was not mobilised at sufficient speed. Continued lack of meaningful engagement with countries has destroyed collective ownership. The scope of COVAX was too ambitious. But ACT-A isn't only about ACT-A. What was WHO thinking when it co-created ACT-A? WHO is now promising a new medical countermeasures platform to be in prototype by April and operational by September. There is a general, if not publicly acknowledged, agreement that ACT-A needs to be terminated. A hastily convened “senior level technical meeting” this week in Johannesburg, South Africa, aimed to build consensus for a replacement. But have the lessons of ACT-A truly been learned?
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The only group holding this competition for power in pandemic planning accountable is the Independent Panel for Pandemic Preparedness and Response, co-chaired by Helen Clark (former Prime Minister of New Zealand) and Ellen Johnson Sirleaf (former President of Liberia). The Panel's original report, published in 2021, was a landmark assessment of the world's inadequate readiness to confront future epidemics. Clark and Sirleaf set out critical actions to raise the danger of a new pandemic to a higher level of political attention. The centrepiece of their vision was a Global Health Threats Council, whose rotating membership would include Heads of State or Government, together with representatives from civil society, academia, and the private sector. The functions of the Council, a body independent of WHO, would be to elevate political commitment to pandemic preparedness, monitor progress, ensure high-level advocacy, mobilise funding, and strengthen accountability. The Panel's proposal was immediately resisted by WHO, which instead offered its own version of a global health emergency body, but as part of the constitution and governance of WHO. Pandemic preparedness had become a fight for control. WHO might dearly wish that the Independent Panel disappears into history. But the agency underestimates the tenacity of Clark and Sirleaf, two ex-Heads of Government who won't go away.
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Last week, a small and diverse group of individuals, including some of those who worked on the original Independent Panel, was brought together by Clark and Sirleaf in Bellagio, Italy, to chart a way forward beyond ACT-A. What was especially interesting about this gathering was the testimony of those trying to establish regional end-to-end research, manufacturing, and delivery hubs for pandemic tools. Their efforts to establish the principle of freedom to research in the public interest are being blocked by the pharmaceutical industry and private foundations—parts of the same global health elite that presided over ACT-A's failure. The only way to break these forces is the Panel's proposed independent Global Health Threats Council. But WHO seems to be acutely fearful of losing its commanding influence. Instead of welcoming input from two former Heads of Government, WHO's director of communications publicly questioned the legitimacy of a group gathered to explore how pandemic preparedness could be improved. Although these messages were later deleted and an apology given, if WHO's communications strategy continues to be so thin-skinned, countries should feel anxious about the agency's sincerity in consulting about future pandemic prevention measures. WHO gives the no doubt incorrect impression that it is more concerned about itself than those at risk of future epidemics.
© 2023 Richard Horton