Social services

Background

The role of the World Bank in ensuring universal and equitable COVID-19 vaccines for all

26 March 2021 | Minutes

Moderator:  Anna Marriott, Public Services Policy Manager, Oxfam
Panelist 1:  Opening remarks: Winnie Byanyima, Executive Director, UNAIDS
Panelist 2:  Rangarirai Machemedze, Coordinator for Cluster on Engaging Global Policies Regional Network on Health Equity in Eastern and Southern Africa (EQUINET)
Panelist 3:  Allana Kembabazi, Programs Manager, Right to Health Initiative for Economic and Social Rights (ISER, Uganda)
Panelist 4:  Dr. Muhammad Ali Pate, Global Director, Health, Nutrition and Population, World Bank

1.       Winnie Byanyima, Executive Director, UNAIDS

Current global vaccines apartheid. the global plan – 1 person person per second in global north is being vaccinated while less than 1% of African population has been vaccinated.

There is a moral obligation for a people’s vaccine, as it is a human right. Painful lessons from AIDS pandemic, in which 10 million lives were lost in global south.

International Chambers of Commerce projects that delays in international vaccination rollout may cost $9 trillion with half in developed countries.

The pandemic has resulted in the greatest economic crisis impact since the founding of World Bank and IMF. The world must place health and healthcare at centre of its response.

There is an urgent need for sustained public investment in public health systems, as 4/5 of Low-income countries are spending more on debt payments than on health.

We must act as a global community. However, we face an artificial supply problem which is resulting in increased global tensions. COVAX aims to vaccinate 27% of population in global South by the end of the year. Need a global herd immunity goal of 70% by the end of the year. The large pharmaceutical companies must share knowhow through WHO knowledge access fund. Rich countries must support this initiative. Indeed, rich countries are blocking India and South African efforts at the World Trade Organisation (WTO) to increase production by expanding it in the global South.   Efforts should support the repurposing of factories – must prioritise health workers. 17,000 health workers have lost their lives during the pandemic.

Vulnerable groups must be prioritised and access must be based on need, not ability to pay. The trends are worrying. In Nigeria elite are off to Dubai to be vaccinated, while the poor continue to lack protection.

World Bank must act as a voice at a global level – and highlight the artificial scarcity. It must support research on manufacturing in the global south. Pharma seems to argue that things are more complex than it is the case. World Bank must ensure that its support is premised on state commitment of free vaccine for all. The World Bank was created, after all, to eradicate poverty, not place profits in the pockets of the rich.

The World Bank must support greater pricing transparency. It is unacceptable that Djibouti must borrow to meet its public health needs and yet has had pay higher prices than countries in the global North.

The World Bank must provide grants, not loans. It must be on the side of the right to health. The international community needs a plan. The response to the pandemic cannot be left to markets.

Anna Marriott, Public Services Policy Manager, Oxfam:

A recent Oxfam report has found many flaws with Bank’s programmes, including the fact that many World Bank-supported projects contain user fees and lack of support for health workers.

2.       Rangarirai Machemedze, Coordinator for Cluster on Engaging Global Policies Regional Network on Health Equity in Eastern and Southern Africa (EQUINET)

Congratulates Bank on $12 billion support for vaccination, however the World Bank must acknowledge that the pandemic goes beyond a health issue. It is a developmental catastrophe vulnerable to political, economic and social crises.

The World Bank’s resources go beyond finance and, as such, it must use its political leverage to ensure it focuses its founding mandate development mandate of reconstruction and development.

The pandemic has heightened the need to reconstruct health sectors ‘decapitated’ by the World Bank and IMF. Indeed, the same policies are pursued still today through a variety of neoliberal approaches, including privatisation and wage cuts of public workers. This fact must be accepted – policies also led to deindustrialisation. There is continuum from the Structural Adjust Programmes to the policies supported today, such as community insurance, privatisation drive and commercialisation of essential service. These trends pre-date the pandemic.

The current debt crises erode state capacity to respond to a series of overlapping crises. The World Bank has a moral responsibility to return to ‘innocence’ and focus on reconstruction and development.

The World Bank must urgently focus on re-investment in public health systems to address accumulated health inequalities.

The World Bank must also support more distributed local production and invest in local manufacturing capacity. It must go beyond production and also support local logistics and other systems.

It must invest in knowledge transfer and, crucially, support the TRIPS waiver.

The World Bank must support countries to implement the One Health approach outlined in the 2005 Global Health Regulations of 2005.

Pose two questions:

a)       What can the World Bank do about technical capacity transfer?  Must it call for changes in intellectual property rules?

b)      What can Bank do to ensure fairness and equitable access to services?

Seeks a response from Bank representative.

3.       Allana Kembabazi, Programs Manager, Right to Health Initiative for Economic and Social Rights (ISER, Uganda)

Underscores that intellectual property issues are not theoretical. To date, 67 countries in Africa have not vaccinated a single person. African Union has paid more for Astra Zeneca vaccine than EU. It cannot afford other vaccines.

The lack of fiscal space in many countries must be urgently addressed. In Uganda, a ‘tiny’ surge in December resulted in full ICU beds.

The World Bank’s silence on vaccine pricing, TRIPS waiver and lack of support of local capacity is very disappointing.

The World Bank has leverage with its financing to try to get better prices for vaccines while it works to address structural factors. How can the Bank justify the use of loans within its $12 billion vaccination support programme? Uganda’s debt has increased by 21% during the last year alone as it responds to the pandemic. In the long-term new loans will force states to cut services, affecting the most vulnerable.

In its programme, the World Bank has not stated unequivocally that vaccines should be free. In Uganda parliament has discussed the idea of ‘payment by those who are able.’

While the World Bank has acknowledged the current crisis should be used as an opportunity to address structural issues, it seems very focused on support for private systems and market-based solutions.

The reality is that support must be focused on public services, as that is where the most vulnerable rely.

The World Bank must focus on transparency of pricing. How will CSOs assist with monitoring and accountability of the Bank’s programme? It is extremely worrying that companies have hidden behind confidentiality agreements which do not allow for oversight. While the World Bank president has expressed some support for greater transparency, this must be emphasised throughout.

Anna Marriott, Public Services Policy Manager, Oxfam:

Uganda was reportedly charged three times the price for the Astra Zeneca vaccine initially publicly discussed. Were Uganda to vaccine all citizens with vaccines purchased at the reported recent purchase price, it would have to spend twice its health budget to do so.

4.       Dr. Muhammad Ali Pate, Global Director, Health, Nutrition and Population, World Bank

Would like to clarify that Uganda has not yet entered the Bank’s $12 billion programme.

The pandemic has magnified pre-existing inequities, as stated by Winnie. High-income countries can work toward herd immunity, however no one is safe in the absence of a coordinated approach, as the virus will exploit the lack of a coordinated response.

150 million additional people may be pushed into extreme poverty. Disruptions in regular health services are also having a dramatic impact.

The World Bank has focused on broad and fast response with the use of a Multiphase Programmatic Approach which is  additional to pre-existing health programmes. The vaccination programem is part of a wider $160 billion programme to mid-2021. IDA includes significant pandemic support, including debt forgiveness.

Fair, broad, and equitable access is essential, hence the $12 billion programme. In addition to $6 billion initially allocated, which focused on stakeholder outreach.

Vaccine programmes in a further 43 countries are under consideration.

Effective partnerships are a focus of action. The Bank has been working with the Global Financing Facility (GFF) to strengthen frontline response as vaccines become available, but work must be done in advance of arrival of vaccines.

While it is true that COVAX is facing serious challenges, one must acknowledge that it has been quicker to react than it was the case with the AIDS pandemic. One should also focus on the speed of vaccine development – even if challenges in distribution remain.

The Bank’s funding is deliberately flexible. The World Bank has to be careful not to prescribe solutions. GFF has approved support for health response.

The Bank undertook readiness assessments with other partners such as WHO across numerous countries.  A document on the World Bank’s health support MPA has just been released.  An addition 121 countries require readiness assessment. IFC has set up a global response fund platform to expend manufacturing capacity. This in recognition that the private sector must be part of the solution.

We must transform and build resilient health systems – must learn and deliver high-quality services. Accelerating universal heath access. The Bank is focused on Fragile, Conflict-affected and Violent settings.

The World Bank has early on accepted that health is a multi-sectoral issue, with 1993 World Development Report outlining this fact.  The Bank has been heavily involved in Covax and was also pivotal in the Ebola response.

The call for global action must not result in the imposition of colonial actions. Global actions must support country actions. World Bank supports the calls for price transparency and for free vaccines.

Anna Marriott, Public Services Policy Manager, Oxfam:

Apropos of sovereignty, that is the origin of the call for local production and increased local distribution. There remains an urgent need to turn around years of under-investment in health services. World Bank must ensure that its financing models support an equitable response to the crisis. Welcomes Bank call for free vaccine access.

Response: Dr. Muhammad Ali Pate, Global Director, Health, Nutrition and Population, World Bank

Some voluntary manufacture by local manufacturers is already in place – new WTO leader seems to have a new perspective.

World Bank recognises that the pandemic is a wake-up call, highlighting the need for research and development investment in the global South.

The World Bank agrees on vaccine development plans with clients, and this includes oversight. Civil society has as key role to play at the country level. In Lebanon, for example, the Bank contracted civil society partners to support oversight of the programme.

Unable to comment on the World Bank’s position on the TRIPS waiver, but is committed to liaising with colleagues in the Bank to seek to clarify the institutional position.

In answer to the question about whether Dr Pate acknowledges the relevance of the criticisms of SAPs and the continued relevance and negative consequences of the framework, Dr Pate noted that he does not want to revisit the past.

Doctor Pate did not respond whether his statement on the imperative of sovereign policy ownership and the need to avoid a colonial approach implies that the World Bank would no longer use prior conditions in its Development Policy Finance loans. He repeated instead that only leaders have the legitimacy to chart a country’s development paths.

Winnie Byanyima:

Voluntary licensing is indeed a positive development and Astra Zeneca its best model, as it has licensed eight sites around the world. Covax rollout is being supported by this arrangement. That said, this arrangement is not good enough. We cannot depend on the goodness of companies to license vaccines. This is a health and political crisis, and the international community must ensure sufficient production is available. Moderna’s research was fully funded by US taxpayer support and yet it has said that it will focus on sales to high-income countries at highest prices. Market-based solutions do not recognise, nor respond to state responsibilities.

The waiver issue is extremely important and the World Bank should support it, as the WHO and UNAIDS already do.

Question of sovereignty should not be used to hide responsibility – Bank must support oversight of implementation of its vaccine and health programmes and ensure sufficient deliberation, etc. Ugandan historical experience with undemocratic loans to dictatorships undertaken behind closed doors is illustrative. The World Bank must work with CSOs to ensure democratic oversight. Red flags are already visible as the Uganda demonstrates – where vaccination of a wealthy person under 65 has been vaccinated in contravention of rules while others languish. The World Bank must ensure that its clients will have robust systems in place to assure equitable responses.

Allana Kembabazi:

Have heard wonderful language from Dr Patel, however words must be accompanied by actions. Need Bank to support waiver.

The Bank must ensure that it will only support pandemic response through grants. Uganda is in discussions for additional loans with Bank while in a sever debt crisis. Regarding the question of sovereignty, the reality is that the World Bank has more leverage than its citizens – that is why it must ensure that all clients agree to make all vaccines free. The Bank cannot hide behind sovereignty.

Regarding voluntary licensing: The arrangement is problematic for many reasons, including the fact that a determination that the pandemic has ended – likely focused on developments in the global North, may result in an end to the agreement and high prices while the effects of the pandemic in the global South continue.

Rangarirai Machemedze:

Agrees that the TRIPS waiver is essential. Also notes that the SAP question remains pertinent as it cannot be ignored. Programme for Results are an extension of SAPs. You speak of sovereignty and yet conditions remain.

Winnie Byanyima:

Trade rules must be changed.

Dr Pate:

Maintains that there is a need to get away from the past (beyond SAPs) and look forward. Need to focus on sovereignty. International bodies are constituted by member states. Agrees that the World Bank must ensure all have access to vaccines – however how to do this must be decided by sovereign decision-makers. Strongly supports the people’s vaccine.

Will look into Bank’s position on TRIPS.

Regarding DPF and Programme four Results financing: No country is required to engage with the World Bank and doing so is a sovereign policy decision.

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