Whither WHO reform? The future of the World Health Organization

On 11 March 2011, Dr. Margaret Chan, Director-General of the World Health Organization (WHO), convened an "informal advisory meeting" to review different approaches to "securing greater coherence in global health" and to further WHO's core function of "the directing and coordinating authority on international health work". A summary report of this informal advisory meeting and the WHO's background paper on "Global Health Governance and the WHO" can be found here: http://keionline.org/sites/default/files/WHOglobalhealthgovernancedraft.pdf

This informal advisory meeting drew its direction from discussions at a January 2011 meeting of the WHO Executive Board which identified three themes to ensure WHO "become more fit for purpose". These recommendations include the following:

  • WHO should capitalize more effectively on its leadership position in global health
  • WHO must retain the flexibility to adapt to a changing environment and have the capacity to address new challenges
  • WHO cannot sustain the diversity of its current activities, and must be more selective in setting priorities

Contained in the "Setting the Scene: A Changing Paradigm" section of the report are the following observations:

  • The model of development characterized by donors and recipients of aid is dead. In its place we need to think about collective responsibility, shared vulnerabilities, shared values, sustained solidarity and health as a global public good.
  • A world where an increasing number of stakeholders have a role in shaping and making policy is a given. Governance does not equal governments alone. The task is not to create new structures or architecture, but to be more adept at managing complexity: seeking creative solutions that promote convergence and coherence around common goals.
  • Governance is concerned with both health as an outcome of global policies in areas such as trade, human rights and the environment (global governance for health) and with addressing common health problems (global health governance).

In terms of benchmarking new, successful approaches to global health governance, the WHO report states:

  • Any mechanism proposed needs to be based on and tested against principles of good governance. These might include transparency; participation and engagement with accountability for success and failure; focused on coordination and coherence; with clear priority setting; justice and the rule of law.
  • Any new venture needs to respond to the new environment described above particularly with regard to being inclusive of all key stakeholders. There is a new look at what has happened in key areas such as climate, food security, the environment and in other settings which previously involved only governments. A particular challenge is to ensure that voices of those affected by health problems, and not just those that make policy are heard. Not just an all-of-government, but an all-of-society approach.
  • The preamble to the WHO Constitution, in addition to acknowledging health as a right, as a public good, and as fundamental to the attainment of peace and security, specifically acknowledges that States should cooperate with others to promote and protect the health of all peoples. This broader principle is separate from setting the policies of the Organization which is the prerogative of Member States. It is therefore useful to distinguish decision-shaping from decision-making.

It should be noted that the Dr. Chan's "informal advisory meeting" included stakeholders from UNFPA, DFID, Brazil, US, UNAIDS, World Vision International, Georgetown Law, Canada, GAVI, Global Fund, Graduate Institute, OECD, Hungary, France, South Africa, Kenya, Japan, , China, IFPMA, World Economic Forum, Syria, Wemos, Switzerland, Global Health Council, Norway and WHO. From the summary report, it appears that the emergent consensus from the WHO's informal meeting with selected stakeholders on Global Health Governance was that the WHO should convene an annual Global Health Forum. The contours and mandate of this Global Health Forum proposal, which will be submitted to the 64th session of the World Health Assembly in May 2011 have yet to be determined. The report categorically states that the Global Health Forum "should be decision shaping, influencing but not setting agendas. It should not be part of the decision making process of WHO". One wonders what this distinction would mean in practice. The WHO report noted that many participants from the aforementioned countries and institutions favored a structured approach with some voices favoring a looser "more carnival than council" approach. It would appear a key objective of the Forum is to open the WHO decision shaping process to more stakeholders including marginalized voices and "increase trust". A key operational aspect of the Forum is to link it to the WHO Executive Board in lieu of the World Health Assembly thus ensuring it remains an advisory rather than a decision making Forum.

In addition to the summary report, WHO drafted a background paper on Global Health Governance. The background paper recognized that the global public health landscape has evolved into a complex ecosystem requiring a considered response from WHO. Consequently, the Global Health Forum is posited by WHO as solution for "addressing aspects of global health governance, possibly including a framework for engagement in global health" to bring together WHO member states, "global health funds, development banks, partnerships, nongovernmental organizations, civil society organizations, and the private sector" calling for the first Forum to be held in May 2012.

With respect to public health and trade, the report notes:

"Health in effect is part of a nexus of global public policies that connects food security, climate change, financial stability, trade among many others. Two consequences of this trend are particularly important. First, it results in a growing demand for inter-governmental, rather than the purely technical processes with which WHO is traditionally more familiar. Second, the nature of the issues concerned are those where there are existing international rules and regimes managed by different institutions (e.g. Intellectual Property, Human Rights and Trade). The challenge is therefore to avoid further fragmentation and foster synergy along with seeking to ensure a focus on better health as a key outcome."

On the Global Health Forum, the background paper notes:

The basic choice is between a more tightly-structured model, based on the World Health Assembly, but with a wider range of constituencies, and a more open process modeled on, say, the World Social Forum of the World Economic Forum. The former would require careful thought about representation, constituencies and would be more likely to focus on a finite number of specific agenda items, possibly leading to specific recommendations. The latter would be more open to all-comers and depend more on the diffusion of new ideas, emergence of key trends - influencing participants through engagement in discussions rather than meeting decisions.

As the World Health Assembly considers the WHO Secretariat's proposal to convene a Global Health Forum in 2012, the Assembly should carefully consider if the "decision shaping" character of the Forum, linked to the WHO Executive Board, would truly secure greater coherence in global public health, or instead manifest itself as another incarnation of Trojan multilateralism, gradually ceding the sovereign decision making authority of WHO Member States to donor governments, global health funds, development banks, foundations and the private sector.

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