Info Service on Health Issues (May16/03)
- The WHO is at a critical crossroad but actions can and need to be taken to ensure that it fulfills its public health mission -
By German Velasquez and Mirza Alas(1)
The governing bodies of the World Health Organization (WHO) are the Executive Board (EB) that meets twice a year (comprised of 34 member countries) and the big World Health Assembly (WHA) that convenes once a year, during the month of May, with the participation of the delegations of 193 member states. The participation of many observers is in a way not as effective as it can potentially be. Observers attend and listen in order to develop better knowledge of the different debates but the channels in which to express their views are not clear. The “silent participation” of the observers may give an impression of acceptance or sometimes even complicity on what is being discussed and agreed upon.
This limited participation sometimes turns into an uncomfortable position for many of the observers, when faced with the lack of progress in the debates or with the endless diplomatic language that is used without reaching any concrete agreements and with resolutions and decisions where in the end it is almost impossible to identify the substance and therefore difficult to see their real value. Long debates take place, often with some Member States blocking progress through rhetoric, while millions of diseases and preventable deaths are happening far away from what is being discussed at “the highest levels” of international public health policy arena.
Thus, the Secretariat of the WHO, Member States and the observers, should honestly admit that we have so far fallen very short of the WHO Mission. We have made the organization a huge bureaucratic structure while at the same time under-resourcing it where needed so that it is currently incapable of providing a timely response to the urgent health needs happening in the world. The organization is also being privatized or sold to a small group of donors.
Never in the 65 years of the existence of the organization has a Director-General submitted to Member States key documents that have been rejected until recent years. This has happened three or four times in the last four years. The reform of the WHO, the Framework of Engagement with Non-State Actors (FENSA), financing dialogue, topics related to quality or intellectual property of the CEWG (Consultative Expert Working Group on Research and Development: Financing and Coordination) and SSFFC (substandard/spurious/falsely-labelled/falsified/counterfeit medical products) are clear examples of this.
The current Director-General launched at the end of her first term (2012) a “big reform of the institution” with many different and confusing topics that more often than not get mixed and that are taking place in a poorly articulated manner or sometimes even contradictory one – how the organization is financed, how it is governed, what would be the role of the so called non-state actors, what role would be played by natural disasters, health emergencies and new or old epidemics that appear and disappear in different parts of the world (Ebola, Zika). Gro Harlem Brundtland, former Director-General (1998-2003), reformed the WHO to give it a more normative character than an operational one. The avian flu, H1N1, Ebola and now Zika have caused confusion to the Director-General and to the member countries that no longer know if the organization should be a normative body, a humanitarian one, or both.
The current chair of the Executive Board, Ms. Precious Matsoso of South Africa, who comes from a country that has shown remarkable leadership in many health and medicines issues in the post-apartheid era had a really hard time managing the time for all the different agenda items at the January 2016 EB. She tried all sorts of methods to get countries to stay within the three minutes allocated time for the interventions, to the extent that sometimes this affected the development of in-depth discussions. If there are concerns with the time allocated for the interventions the solution should be to reduce the number of agenda items or that the time for the meeting gets extended, or that country interventions get cleaned from repetitive, rhetoric language that many times does not provide new inputs or do not make meaningful contributions to the topics being discussed.
For example one of the topics discussed at the January EB was a draft global strategy for viral hepatitis. The strategyดs main goal is to eliminate viral hepatitis as a major public health threat by 2030 and even though it provides comprehensive information on the use of vaccines, diagnostics, available treatments and other health interventions the document remains mostly silent on how to overcome the challenges that make access to these health interventions possible, particularly for developing countries. The document hardly mentions the challenges related to the extremely high cost of patented drugs particularly for the treatment of hepatitis C. Moreover, the strategy lacks guidance on any measures that countries can take to ensure that treatment is available and affordable for people who need it. During the discussion on this agenda item a long time was used by countries on listing major achievements and very few Member States made a point to signal out the issue of high prices a nd the importance to include the use of TRIPS flexibilities as a right that countries can exercise in order to be able to afford treatment for their citizens and be able to actually accomplish the goal of this strategy.
Another agenda item that was of concern was the report by the Secretariat on addressing the global shortages of medicines, and the safety and accessibility of childrenดs medication. Although it was recognized by all countries that shortages and issues related to childrenดs medications are of a serious concern, the way in which this report was presented ignored some very important elements and presented little clarity in others. First, the report addressed two equally important but distinct issues, namely, shortages and quality. Many developing countries pointed out that the causes for shortages were not thoroughly addressed by the report and that the proposed solutions such as advanced purchasing commitment could harm competition and limit the procurement of cheaper generics. Second, the role of local manufacturing capacity as a possible strategy for countries to ensure the production of important medicines was also absent.
The main and most serious issue of the organization has been the progressive and vertiginous loss of control of the regular, public and compulsory budget. A progressive privatization of the organization is currently taking place. In just 8 years the budget went from 50% financed through public funds, constituted by assessed contributions, to currently only 18%. WHO is currently in the hands (approximately 82% of its Budget) of philanthropic foundations such as the Bill and Melinda Gates Foundation, a small number of industrialized countries that provide voluntary earmarked funds and big pharma. These voluntary contributions are channeled to health priorities decided by the funders and not the government members of the organization.
The way in which the organization has been taken hostage by the earmarked funding has been echoed by many civil society organizations for many years now. This year at the January EB meeting a coalition of over 50 organizations issued a letter regarding the process of negotiations on the Framework for Engagement with non-State Actors and the lack of progress in key issues such as the a conflict of interest policy, secondment issues and engagement with the private and philanthropic sector. The letter addressed to all Member States called once again for increased assessed contributions. This is the only way to ensure that WHO continues doing its core work without having to incessantly follow donor driven agenda priorities.
The second most urgent and necessary reform is the recovery of the central power of “this monster with 7 heads” (the Geneva headquarters and its six regional offices each with a good dose of autonomy and disconnected from the main governing bodies, the Executive Board and World Health Assembly). Today in the WHO, as the case of Ebola demonstrated, there is a clear breakdown in the chain of command, between Geneva and the six fully independent regional offices, which do not report to the Director-General. The power relations and operational response between headquarters, regional offices and 150 country offices are not clear, which leads to an organization without a central authority. This disassociation provokes inefficiency and delays in responding to problems such as the avian flu, H1N1 and Ebola crises.
The third problem that would need to be addressed is the dilemma between a normative agency in charge of formulation and creation of international standards, the administration of the international health code regulations and the creation of binding agreements in global health versus a humanitarian agency that implements projects that have been financed by international จcharityจ competing and duplicating efforts of other agencies such as the Global Fund, or other UN agencies such as UNICEF or UNDP or big NGOs such as MSF. The blame of the big mistakes made with the epidemic of H1N1 and Ebola have created a movement that has given the organization a double mission – a normative one as well as an operational one. However, WHO should be a normative agency and not an operational one and it needs to be properly resourced and reorganized to perform its task.
These ideas and others could help the re-orientation of the organizations and issues such as the role of public health in the current context of international trade and investment and the challenges brought forth by climate change and the commitments made by governments at the Paris climate conference last December, specifically in the area of health, and should become an object of debate for the selection and appointment of the new Director-General of the organization, a process that is now on its way.
(1) The views expressed are entirely the writers’ own.