The World Health Organistion's Access to COVID-19 Tools (ACT) Accelerator was formulated in March 2020, in the context of the COVID-19 pandemic. However since then it has faced multiple challenges, including questions regarding its governance structure. In this virtual seminar, a panel of experts consider ACT-A's approach to governance and its overall sustainability. To watch it please visit our seminar page here.
- Prof Ross Upshur, Head, Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Canada
- Prof Suerie Moon, Co-Director, Global Health Centre, Professor of Practice, Interdisciplinary Programmes and International Relations/Political Science, The Graduate Institute Geneva, Switzerland
- Dr Owen Schaefer, Assistant Professor, Centre for Biomedical Ethics, National University of Singapore, Singapore
- Ms Katy Kydd Wright, Director, Global Fund Advocates Network, Ottawa, Canada
1. The ACT-Accelerator is a 'framework for collaboration', not a new organization or decision-making body. What ethics and governance challenges has this raised? How might these challenges be addressed?
2. Three principles are embedded in the ACT-Accelerator's founding mission statement: participation, transparency, and accountability. Are these principles sufficient to guide the work of the ACT-Accelerator? To what extent has the ACT-Accelerator been able to realize these principles in its work?
3. As a global collaborative effort, to what degree has the ACT-Accelerator been able to incorporate and track the interests of key stakeholders, like the interests of the governments and people in low- and middle-income countries and civil society organizations?
Dr Owen Schaefer began this seminar by giving an overview of the World Health Organisation’s Access to COVID-19 Tools (ACT) Accelerator, which to quote directly is:
A time-limited global collaboration designed to rapidly leverage existing global public health infrastructure and expertise to accelerate the development, production and equitable access to COVID-19 tests, treatments and vaccines in order to expedite the end of the acute phase of the pandemic.
This collaboration, which consists of governments, civil society, and industry is bound together by a single framework consisting of three pillars: vaccines (in this case COVAX), diagnostics, and therapeutics. It also has two cross-cutting work streams, the ‘health systems connector’ workstream and the ‘access and allocation’ workstream. Both allow for the equitable distribution of the three pillars in a climate of scarcity. Each pillar is coordinated and managed by two or three co-convening partner organisations. ACT-A doesn’t have a formal governance structure. It is also not a legal decision-making body, nor was it intended to be. However, the principles of governance, transparency, accountability, and engagement, recur in all ACT-A documents; from the initial April 2020 commitment and call to action, to the July 2021 WHO ACT Accelerator Ethics and Governance Working Group ‘Ethical Framework for WHO’s work in the ACT-Accelerator’ statement. The latter, was an attempt to synthesise the various values and principles that underline this collaborative; however, Dr Schaefer notes this, in fact, leaves unanswered questions.
Professor Suerie Moon followed up on this, using her presentation to highlight the key findings of her recently published paper. General consensus among colleagues was that the ACT-A governance structure was confusing. It was difficult to discern how decisions were being made, who was making them, and how and why the target kept changing. This confusion dates back to 2020, when ACT-A was set up rapidly in response to the COVID-19 pandemic. By tracing ACT-A’s evolution from the 26th March 2020 G20 Leaders Summit all the way through to the 1st year anniversary impact statement in September 2021, three governance challenges became apparent. Firstly, the roles of individual organisations in regard to decision-making are unclear. Some organisations have multiple overlapping roles raising questions about the appropriateness of separation of oversight versus implementation. Secondly, there is an absence of a clear decision-making body; and because each co-convening organisation has their own individual data policies, information transparency is uneven. Finally, due to lack of national representation, the role of government, and governance is receding. This raises the question of what is the political legitimacy of ACT-A. The three governance challenges listed above impede meaningful participation, and obscure accountability; particularly public accountability by and through governments. In the short-term Professor Moon argues that there needs to be a more clearly described and defined set of roles and responsibilities in regard to decision-making. Secondly, there should be a common transparency policy across organisations. Thirdly, there should be a regular forum for meaningful broad-based public debate of ACT-A activities. In the longer term however, governments need to be involved in the negotiation of international rules, commit to financing, and design governance arrangements which ensure principles are taken seriously. Professor Moon summarised by stating ethical governance is part of pandemic preparedness, and therefore should be more clearly defined in the ACT-Accelerator.
From the perspective of Civil Society Organisations (CSOs), Ms Katy Kidd Wright confirmed all of Professor Moon’s findings. She argued that since June 2020, CSOs and Community Representatives have struggled to participate. This is due to the ACT-Accelerator’s opaque decision-making processes and the fact that meaningful dialogue often takes months, and is at times adversarial. Likewise, in terms of ACT-A soliciting meaningful participation from CSOs, everything is rushed. Documents which require extensive consultation often have a twenty-four hour turn-around time. This makes engagement almost impossible. It also relies on the unwarranted assumption that CSOs can operate in the same way as dedicated, multi-lateral staff members who may have vested interests in the outcomes. Ms Wright has said since June 2020, the primary CSOs goal has been to find meaningful ways to contribute to the discussion; however, this has proven difficult. In response to a recently published ACT-A strategic review the Global Fund’s Advocate Network has said ‘there is a lack of transparency and clear decision-making structure within ACT-A and a complete absence of mechanisms or tools for accountability, with an acute lack of meaningful inclusion for LMIC governments, CSOs and communities for whom equity is at risk at all levels of decision-making.’ While CSOs including the GFAN continue to make inroads; it is not an easy space to navigate.
Who came up with the ethical framework, and to what extent were key stakeholders such as CSOs and representatives from LMICs involved in deliberating them?
Dr Schaefer notes that the framework was drawn up and written by the WHO ACT Accelerator Ethics and Governance Working Group as a synthesis of the co-convening organisations’ principles. However, despite the fact that the three principles of transparency, accountability, and participation are congruent with most organisational principles, if these particular organisations weren’t themselves inclusive, then the process by which these principles were devised would be exclusionary. Professor Moon argued that, not discounting Ms Wright’s experience, she and colleagues own mapping indicates over time, CSOs have been tentatively formalised into the ACT-Accelerator governance structure. However, LMIC government was not present, except in the facilitation council which is an advisory body. This is troubling and raises the question of who is actually accountable. In Professor Moon’s experience, the level of public criticism of ACT-A is unprecedented and reflects real frustration with the lack of participation. She concludes by reminding everyone of the scale of the project. Last year, ACT-A utilised $19 billion in public funds, and is requesting a further $23 billion for 2022. Because this is public money, there needs to be a more clearly defined governance structure. Ms Wright concluded by saying that since community representatives live in settings where equitable access is a real and fundamental concern, they too must be involved in governance.
How do we navigate the tension between the stated use of not having formalised processes and procedures and actually needing a more substantial governance structure? What are the immediate next steps to improve governance?
Professor Moon argued that a deliberative democracy model is needed. At the international level you can’t always have full representation on every mechanism. To counter-balance weaknesses, the space should be opened up for deliberation and increased transparency. Addressing government structure weaknesses will increase confidence in collaboration. In a sense, if we can’t make short-term reforms, harder long-term reforms become increasingly difficult. Ms Wright said, CSOs are at a loss of how to move ACT-A forward in a meaningful way. She argued that while 2020 was a challenging year, there was space to shape it into something much more participatory; however, this didn’t happen. Dr Schaefer added that in regard to pandemic preparedness, preparations should be done in advance, and that a move towards a more centralised governance structure could be better.
In terms of pandemic preparedness and response, what future questions do we need to think about?
Ms Wright stated that ethics is not just written rules, but unwritten rules as well. In the case of ACT-A there’s something clearly wrong, and the governance structure needs improving. Professor Moon argued a key question would be how you can create arrangements and institutions which embody ethical values so that we’re not only talking about it, but constructing decision-making processes. In regard to ACT-A, encouraging a more open-dialogue, even at professional risk, exposes to the world to the ‘unwritten rules’ Ms Wright spoke about. This directly relates to governance. Dr Schaefer concluded by saying political pragmatism is needed. There’s a need to balance ethical ideals in relation to the actual processes which need to take place. If they aren’t, this will impact the ability of any organisation to achieve anything in relation to pandemic preparedness and response. Governance however, is of course the starting point.
- What is the Access to COVID-19 Tools (ACT) Accelerator, how is it structured and how does it work? (who.int) April 2020, version. 6
- Suerie Moon, et al, (2021) Governing the Access to COVID-19 Tools Accelerator: towards greater participation, transparency, and accountability, the Lancet, https://doi.org/10.1016/S0140-6736(21)02344-8.
- ACT-Accelerator Strategic Review: An Independent report prepared by Dalberg (Oct 2021)