World Health Assembly 2021: our rolling diary of events and developments

12 min read
WaterAid/Guilhem Alandry

Throughout the virtual 74th World Health Assembly, a WaterAid delegation will attend virtual meetings, track proceedings and work to hold health ministers accountable for the implementation of the resolution on water, sanitation and hygiene in healthcare facilities, adopted in 2019. Here, our WaterAid teams will document the day-to-day events from the meeting. Be sure to check back throughout the week to catch-up on developments.

Monday 24 May

In the months leading up to the World Health Assembly (WHA), WaterAid has focused on influencing at a national level. We’ve called on health decision makers where WaterAid works to prioritise access to water, sanitation and hygiene (WASH) in healthcare facilities, and uphold the responsibility they have to their citizens to improve access to safe, clean and dignified healthcare.

Dr Tedros Adhanom Ghebreyesus, the Director-General of the World Health Organization (WHO), opened the WHA today with a powerful reminder of the importance of health workers and their need for a safe and dignified working environment. He said:

Health and care workers do heroic things, but they are not superheroes. They are humans like the rest of us. They sweat and swear; they laugh and cry; they fear and hope. Many feel frustrated, helpless and unprotected, with a lack of access to personal protective equipment and vaccines, and the tools to save lives … We owe them so much, and yet globally health and care workers often lack the protection, the equipment, the training, the decent pay, the safe working conditions and the respect they deserve.

This protection and safe working environment includes having water, sanitation and hygiene in healthcare facilities, which is why we welcome Dr Ghebreyesus’s recognition that “we cannot build a safer world from the top down; we must build from the ground up”. He continued:

Preparing for, preventing, detecting and responding rapidly to epidemics doesn’t start in the world’s corridors of power. It starts in the streets of deprivation and overcrowding; in homes where there is not enough food; in communities without access to health workers; and in the villages and towns whose clinics and hospitals lack electricity or clean water. It starts with strong primary healthcare and public health systems, skilled health workers, and communities empowered and enabled to take charge of their own health. That must be the focus of our attention, and our investment.

We couldn’t agree more. Without investing in the fundamental building blocks of clean water, decent toilets and good hygiene, achieving progress on issues such as pandemic preparedness and response, and universal health coverage, won’t be possible.

Before the World Health Assembly, WaterAid was a key partner in a side event hosted by the Global Taskforce on Cholera Control. Tim Wainwright, WaterAid UK CEO, and Pamela Chisanga, Country Director for WaterAid Zambia, were speakers at this high level event, joined by the Minister of Health from the Democratic Republic of Congo, and speakers from the US Centers for Disease Control and Prevention, the World Health Organization, the Bill and Melinda Gates Foundation, Medecins Sans Frontieres and others.

Water, sanitation and hygiene was well represented by speakers as the long-term solution to cholera. Speakers agreed on the urgent need for the health and WASH sectors to work more closely together to end cholera, which still causes between 21,000 and 143,000 deaths worldwide every year.

Zambia was spotlighted as a country leading the way on the fight against cholera, serving as an example to many. Working closely with the Zambia National Public Health Institute, WaterAid showcased the power of collaboration with key stakeholders to get where we are today, and how political leadership has been key to driving this change.

Helen Hamilton and Megan Wilson-Jones, senior policy analysts for health and hygiene. Follow @HelenCHamilton and @MegsWJ on Twitter.

Nurse obstetrician Mariam Diarra uses the newly installed tap at Kemeni communal health centre, circle of Bla, Segou region, Mali, November 2016
Nurse obstetrician Mariam Diarra uses the newly installed tap at Kemeni communal health centre, circle of Bla, Segou region, Mali, November 2016
WaterAid/Basile Ouedraogo

Tuesday 25 May

During the second day of the WHA, discussions focused on the current COVID-19 response, and the preparedness and response to future public health emergencies, including around the functioning of the International Health Regulations (2005). The IHR were adopted by the WHA in 2005 “to prevent, protect against, control and provide a public health response to the international spread of disease”. Although the IHR provide a framework for global health emergencies, their implementation at national level has been weak and insufficient and, as a result, the world was devastatingly unprepared for COVID-19.

A coordinated and effective response to public health emergencies – including the ongoing COVID-19 pandemic and future health threats – requires significant scaling up of the most fundamental pillars of public health: water, sanitation and hygiene. In fact, the IHR were proceeded by the International Sanitary Regulations adopted by the WHA is 1951, where water and sanitation were central components.

However, findings from three independent review panels – the Independent Panel on Pandemic Preparedness and Response, the Independent Oversight and Advisory Committee on WHO’s Health Emergencies Programme (IOAC), and the Review Committee on the Functioning of the IHR – all highlight gaps in our public health response, and especially in engaging stakeholders beyond the health sector to strengthen preparedness and response. As the chair of the IOAC, Dr Felicity Harvey, put it so clearly: “Global health is truly a shared responsibility.”

For WHO member states, the issue of vaccine equity was front and centre of COVID-19 discussions, with strong collective support for the COVAX initiative as the mechanism to ensure equitable access to COVID-19 vaccines. While access to vaccines remains unequally distributed globally, the WHO reiterated the importance of public health measures, including hand washing at scale, to address the current pandemic.

As we look ahead to the rest of the week, in particular agenda items on antimicrobial resistance, patient safety and women’s, children’s and adolescents’ health, we hope that the importance of WASH to these key health issues, in addition to pandemic preparedness and response, will be recognised and prioritised by member states, the WHO and partners to ensure we are collectively and effectively addressing the most pressing health issues of our time.

Megan Wilson-Jones

Sam Saony, 35, holds her baby girl Seymach while she is given an immunisation by nurse Chou Boeun at Boeung Kontout Health Centre, Krokor District, Pursat Province, Cambodia. August 2016.
Sam Saony, 35, holds her baby girl Seymach while she is given an immunisation by nurse Chou Boeun at Boeung Kontout Health Centre, Krokor District, Pursat Province, Cambodia. August 2016.
WaterAid/Tom Greenwood

Wednesday 26 May

During the third day, participants and other interested WASH stakeholders were invited to engage with two separate avenues: committee discussions/presentations hosted by the WHO, and a live tweet chat organised by WaterAid West Africa.

In the WHO platform, the morning discussions centred around how COVID-19 has derailed governments’ interventions to provide universal health coverage for their citizens, and what needs to be done to make it happen by 2030.

Meanwhile, stakeholders across the globe took part in WaterAid West Africa's first-ever live tweet chat, with participants exchanging views and making demands focused on three key questions:

  1. Why is hygiene so important?
  2. Is your country making progress on WASH in health care facilities resolution?
  3. How can we ensure that everyone, everywhere has a safe place to wash their hands?

Amongst other asks, participants underscored the importance of WASH stakeholders’ collaboration; and governments’ increased investments to improve hand hygiene, especially in developing countries.

Extensive presentations and deliberations were made whilst covering the topic ‘Global Action on Patient Safety’, with special emphasis on mental health, especially in the wake of the COVID-19 pandemic. Mental health, most speakers affirmed, has not been given the needed attention by both WHO and member countries. During the deliberations on the health conditions in the occupied Palestinian territory, including East Jerusalem, and in the occupied Syrian Golan, a grim picture was painted of the residents’ state. Speakers overwhelmingly expressed how the physical violence undermines the enjoyment of citizens’ health rights, including that of protection against COVID-19, and asked for global solidarity to address the malaise.

The live tweet chat could not have come at a better time, running concurrently with the WHO Committee sessions. We hope that the concerns raised and recommendations offered in the chat platform will be mirrored in the consciences of health ministers as they deliberate ways to guarantee good hand hygiene in healthcare facilities in the respective countries.

As the end the week approaches, WaterAid representatives to the WHA are keenly looking forward to getting the opportunity to make their statements, essentially calling for increased investments and prioritisation of WASH.

Christian Lawrence is Senior Policy and Advocacy Manager at WaterAid Sierra Leone

Mukisa,12, is a member of his school's health club in Kampala, Uganda. March 2017.
Mukisa,12, is a member of his school's health club in Kampala, Uganda. March 2017.
WaterAid/James Kiyimba

Thursday 27 May

Today's proceedings began with a discussion on the WHO's proposed programme budget, with a special focus on sustainable financing for the WHO and its results framework. As key for progress, several member states emphasised the need for:

  • predictable and guaranteed financing for public health awareness
  • a solid foundation for resilient healthcare systems, including increasing public health funding in order to manage infections
  • a bottom-up approach to programme delivery and country ownership

Madagascar in particular bemoaned the risk of using limited approaches in the short term rather than focusing on public health goods. “Countries must not be made to choose between emergencies and universal health coverage. These are interlinked and it is important to fund public health goods," said a representative from WaterAid Madagascar. Such public health goods include water, sanitation and hygiene, which are fundamental for achieving universal health coverage.

Such investments lay the foundations for the success of initiatives such as the prevention and control of non-communicable diseases, and expanding access to treatments of rare diseases and cancer, and to diagnostics and vaccines. Member states and non-state actors highlighted the inequity in access, especially for those in low- and middle-income countries. These are the very same contexts where the lack of access to WASH in healthcare facilities is blunting efforts to prevent and control infections, making it difficult for health care workers to protect their patients. We therefore support calls by member states for increased attention to patient safety and the threat of antimicrobial resistance, which was the focus of the remainder of the afternoon.

According to the WHO, patient safety is fundamental to the provision of health care in all settings, yet globally, unsafe care contributes to 2.6 million deaths annually in low and middle income countries. The WHO has drafted a global action plan on patient safety. This provides stakeholders with a strategic direction for eliminating avoidable harm and improving patient safety in healthcare settings through policy actions. Within this framework, member states were called upon to develop national action plans on patient safety that are aligned with existing strategic instruments for improving patient safety in all clinical and health-related programmes. We are in full agreement with the patient safety action plan’s vision of a world in which no one is harmed in health care, and every patient receives safe and respectful care.

Keeping patients safe while providing healthcare is fundamental, yet according to the 2020 Global Progress Report on WASH in Healthcare Facilities,one in four facilities have no basic water services, one in 10 have no sanitation services and one in three do not have adequate facilities to clean hands at the point of care. As members continue to deliberate on patience safety and antimicrobial resistance tomorrow we welcome calls for more action on improving WASH in healthcare facilities as a proven public health measure for improving patient safety, combating antimicrobial resistance and protecting us all from current and future pandemics.

Annie Msosa is the Advocacy Lead for WaterAid's Hygiene for Health campaign. Follow @anniesheria on Twitter.

Midwife Anita Fakoli with a patient at Providence Clinic, Small Gobachop, Paynesville City, Monrovia, Liberia. September 2016.
Midwife Anita Fakoli with a patient at Providence Clinic, Small Gobachop, Paynesville City, Monrovia, Liberia. September 2016.
WaterAid/Carielle Doe

Friday 28 May

Over the past few days at the World Health Assembly, WHO proceedings have included discussions on the health workforce, particularly nursing and midwifery, and the Global Strategy for Women’s, Children’s and Adolescent’s Health.

We know that women make up 70% of the health workforce and are more likely to be frontline health workers, such as nurses, midwives, community health workers and cleaners. Poor water, sanitation and hygiene (WASH) and cleaning infrastructure in healthcare facilities endangers female health workers and their patients.

In May 2019, I presented an unusual ‘prize’ to Tedros Adhanom Ghebreyesus, Director General of the WHO, in a side meeting of the 72nd World Health Assembly in Geneva. The meeting was focused on the alarming situation of poor WASH facilities in more than a quarter of healthcare facilities, and the impact on patient safety and dignity, and the risks to health workers. I wanted to draw attention to a crucial member of the healthcare workforce – cleaners. These champions of hygiene are often untrained, poorly-paid, marginalised, and work without proper personal protective equipment and cleaning materials. And yet they carry on – day in, day out. Dr Ghebreyesus’s unexpected attendance at the meeting provided an opportunity to take the matter to the highest level. I had begun my talk holding a mop – the most basic of equipment for cleaners – and in a flash of spontaneity and perhaps recklessness, I presented the ‘Golden Mop’ to Dr Ghebreyesus calling on him to be an ambassador for hygiene champions across the world.

Two years on, has this duty been fulfilled? As the virtual 74th World Health Assembly takes place, pressing questions on progress feature prominently in every part of the agenda – from non-communicable diseases to polio, to whole health systems. But the elephant in the room for all of these conversations is COVID-19.

Back in May 2019, none of those witnessing the mop moment could have envisaged a global pandemic that would have direct implications for the wider context around environmental cleaning – WASH, infection prevention and control (IPC), patient safety, antimicrobial resistance, and quality of care. And in accepting the mop, Dr Ghebreyesus could not have foreseen the enormous dependence on hygiene champions that would emerge owing to COVID-19.

Environmental cleaning has been forced to change given the mode of transmission of COVID-19. In healthcare facilities, cleaning duties, particularly by nurses, have intensified but the extra workload and risks have not always been matched by the requisite PPE, or the recognition cleaners deserve. But certain opportunities have signalled a change, such as; the addition of environmental cleaning indicators to the WHO-UNICEF Joint Monitoring Programme (JMP); the launch of best practice guidelines by the US CDC and the Infection Control Africa Network; the inclusion of cleaning in WHO documents on tackling AMR; the increasing demand for the TEACH CLEAN training package; and the first Thank Your Cleaner Day in October 2020.

Now, we need investment and action on hygiene in healthcare facilities to ensure health workers and cleaners have the resources, equipment and training they need. We need to:

  • recognise that cleaners need a reliable supply of water, supplies and equipment, as well as training
  • promote cleaners as full members of the health workforce, addressing employment rights, pay, contracts, continuing professional development and accreditation
  • promote and acknowledge the crucial role of nurses and midwives in key aspects of environmental cleaning
  • strengthen national commitments to, and the availability of, data on environmental cleaning in healthcare facilities through the JMP
  • identify and test innovative options for scaling-up participatory training and supportive supervision of cleaners
  • acknowledge and deliver on the research and development agenda on environmental cleaning, including; devising a budgeting tool, expanding the use of objective assessments of cleaning performance, capturing patient demand for cleaner health facilities, and identifying and mitigating the specific occupational risks of cleaners

Beyond the 'Golden Mop' moment, there is a serious underlying message: health for all depends on all health workers. In accepting the mop, Dr Ghebreyesus acknowledged this, and has reminded us at this World Health Assembly that global health progress, including the fight against COVID-19, depends on leaving no one behind, including cleaners.

Wendy Graham is Professor of Obstetric Epidemiology at the London School of Hygiene and Tropical Medicine.

Further reading:

Top image: Dr Martin Koné, 33, ealth Director at Talo Health Centre, washes his hands with soap. Municipality of Falo, Circle of Bla, Segou Region, Mali. July 2018.