WHO reform for a healthy future. WHO EURO meeting, third day

The third day of the Regional Committee meeting had on its agenda the item most relevant for the Democratizing Global Health (DGH) coalition to which Wemos and the Medicus Mundi International Network belong: the WHO reform for a healthy future. The DGH coalition is following the reform intensively, as we believe that WHO needs to remain the unique mandated global authority to coordinate international health with the aim to reach and safeguard the right to health for all. We have concerns that some elements of the WHO reform might actually weaken the organisation, rather than re-enforce its leadership.

We expressed our concerns to the member states in a letter that is available on the WHO Euro website. So I was excited to follow the panel that is well covered on the WHO Euro website in the highlights of Regional Committee day 3.

The discussion was prepared the day before during a technical briefing; and part of the discussion was held in three working groups that covered the items of governance, core business, and managerial reforms. NGOs were invited as observers to the working groups, a much appreciated practice that is not common during working groups at the World Health Assembly.

WHO DG Margaret Chan briefed the Committee about the discussion at other regional committees, in the AFRO and SEARO regions. The African countries like WHO to reform, but are cautious that it proceeds too fast, or that it would lead to a reduced presence by WHO at country level. There was little discussion in the SEARO region on the reform.

In the EURO region key elements emerging during the panels and working groups are:

• The reform is at this stage focused on the internal reform of the WHO and less so on its relation with external actors.
• The Governance part focused on the functioning and alignment between the Executive Board (EB) and the World Health Assembly (WHA), setting priority for resolutions, preparation and engagement by member states (MS), alignment between the global, regional and country level. There were crucial questions how legitimate the EB functions within the mandate of the constitution, and if there should actually be adaptations to the 60 year old constitution within a changing global health context. Everybody agrees that the constitution remain the basis on which the organisation functions.
• Legaly, The WHO constitution is actually set up as treaty, that must be seen as a living document and can be improved over time.
• NGOs and private actors are currently not involved in the WHO reform. For the moment it is an exclusive MS driven process.
• There is little willingness to elaborate further on a new World Health Forum. It was suggested that in the future public hearings or a model based on the Pandemic-Influenza-Preparedness (PIP) consultation could be used instead.
• The core functions discussion made clear that WHO should stay away from business, guarantee democracy and legitimacy in its proceedings and that currently WHO uses its leadership position more limited then the constitution would allow. There is no need to expand the five core functions. What is important is that MS speak with one face when working with WHO. Now ministries of health represent a MS during the WHA, but funding to WHO departments or WHO supported partnerships are often provided via ministry of foreign affairs or development cooperation. Priorities and funding by these two departments are not always aligned. This demonstrates the need for policy coherence at national level.
• Regarding managerial reforms, the most important is a need for more full and flexible income for the organisation that is not tied to program activities. A suggestion arose to split the WHO budget in a core and project part, and hence to guarantee that the organisation has about 40% of its total funds available for flexible use. MS are hesitant to install a “replenishment financing model”, like the Global Fund. This can destabilise long-term available funding levels.

The direction of the reform envisaged by the member states of WHO Europe provided me with more trust in the outcome of the reform process. However; the other regions still have to come with their deliberations and the debate will continue further with the Geneva based missions and during an extraordinary EB meeting in November. The process can still lead to several directions. For us it is now important to monitor and work with MS regarding their position within the WHO, WHA and EB. Some states simply are not prepared or do not respect or know the procedures of the organisation. Often states agree on WHA resolutions, without providing financial resources or take responsibility for its implementation. In this regard, let me refer to chapter XIV, art, 61-65 of the WHO constitution: MS should annually report to the organisation how it improved the health of their citizens. It is therefore important to monitor and promote MS discipline regarding constitution, WHA and RC resolutions as well as showing one face to the organisation.

After the discussion, we were able to present our statement on the reform to the secretariat and member states.

Lastly, a remark about the European Non-Communicable Diseases (NCD) action plan that was discussed in the afternoon. This concerns the following excerpt: “The Netherlands was particularly opposed to the emphasis on population measures rather than personal choice in the promotion of healthy lifestyles. A resolution endorsing the action plan as amended to reflect some of these concerns would be considered on Thursday." The Netherlands amended the resolution on 10 points and the resolution was eventually adopted on the fourth day. These amendments reflects a changing national view on health promotion and prevention and it also precedes a position ahead of the UNGA highlevel meeting and political declaration on NCDs coming week. Frankly, and especially as a citizen of the Netherlands, my hart sinks to see that a national political position can influence in such a way the resolution of an important multilateral established health strategy that all countries have been waiting for.

For an visual impression of the Regional Committee meeting have a look here.

Remco van de Pas, Wemos

Social Determinants of Health. WHO EURO meeting, second day

This is a small update after the second day of the 61st WHO European regional commitee in Baku. Higlights are also available at the WHO EURO website. Let me outline two items from its agenda.

Firstly, the address by WHO DG Margaret Chan. Here some excerpts:

"The greatest challenge of our health plans: maximizing measurable and equitable health gains at a time when budgets for health, nationally and internationally, are stagnant or shrinking."

"Stronger leadership from WHO can promote greater coherence in the actions of multiple health partners and better alignment of these actions with priorities and capacities in recipient countries."

"We need to do a better job in communicating the nature of our work and the impact it has. Even our biggest supporters tell us this. If we want parliamentarians to fund the work of WHO, their constituents need a much better understanding of what we do and why it is important."

"The world needs a global health guardian, a protector and defender of health, including the right to health. Reform in WHO, in my view, starts from a position of strengths: the unique functions and assets of the Organization."

These messages indicate that there is not only a need for an internal WHO reform, but there is sorely needed public and political debate at national level requiered. What is the relevance and value for money that WHO can bring as multilateral agency facing complex health problems? Is WHO merely a development organisation for Low and Middle income countries or is it a global health organisation relevant for national health issues? Within countries facing expanding health budgets; we have as civil society to advocate and debate that (investments in) a global health guardian and leader is best for all our health.

Secondly; member states elaborated further on the Health 2020 strategy, via a ministerial panel on health equity. Member states could exhange here concrete examples to adress the social determinants of health and intersectoral cooperation. Sir Michael Marmot initiated the discussion by focusing on three elements that the health sector, health workers and minsters of health can do to reduce health inequities. 

1. To put it's house in order to guarantee qualitative services and universal health coverage.
2. To be a health advocate and embrace cross-sectoral action; whether at WHO/ ministerial or at frontline health care level.
3. To provide the evidence on health equity and addressing the social determinants by proper monitoring and evaluation.

At the end of the ministerial panel (see for the member state examples highlights of day 2), a general consensus emerged that health ministers should not only address disease control and prevention, but must really engage and guarantee for health with other sectors (like agriculture, transport, financing, housing and education).

Let me end with the final remarks by Michael Marmot:

"With the work on health equity, the European health 2020 strategy and upcoming world conference on social determinants of health, we reach a moment of great clarity in how we have to improve health, similar to the establishment of WHO over 60 years ago, and the Alma-Ata declaration on primary health care 30 years later".

Remco van de Pas

Health 2020. WHO EURO meeting, first day

I am in Baku, Azerbaijan, to attend the 61st regional commitee of the WHO European region as a representative of the Medicus Mundi International Network. This year two essential topics (amongst others) are debated by the member states. Firstly, the strategic development of Health 2020, an overall European health strategy to reduce health inequities within the region by 2020. Secondly, the European perspective on an upcoming WHO reform.

On the first day, a ministerial interactive panel was held to debate the Health 2020 strategy. The strategy is informed by several studies. One is the study Governance for health in the 21st century. A second study is the so called Marmot review, the Interim second report on social determinants of health and the health divide in the WHO European Region.

The panel was facilitated by Mihaly Kokeny, former minister of Health of Hungary and former chair of the WHO Executive board. Ilona Kickbush from the Geneva Graduate institute initiated the debate by explaining there are two aspects of governnance to be considered:

1. Governance within the (global) health system; and
2. Urgent needed governance for health that extends to other sectors and external actors (so called "whole-of- government" and "whole-of-society" approach).

Interestingly, but maybe not not surprisingly, countries like Sweden, Russia, Letvia and Poland explained the scope of their national health strategies, how to reach universal coverage, the impact of the economic crises, NCD's and demographic shifts (like the aging population).

They explained hence mainly the governance within the health system and not so much the relation with other sectors needed for policy coherence (Seeing health not only as addressing diseases but contributing to improved human wellbeing).

The Netherlands delegation reacted on the panel by announcing that Ministries of Health cannot be solely responsible for a whole-of-government approach. MoH should be responsible for accessible and affordable health services and programs, and work within their competencies.

They are cautious moving forward in intersectoral programs that are not evidence-based or cost efftective. With that statement they requested to amend the draft resolution on European health 2020 by canceling the resolution paragraphs on a whole-of-society and whole-of-governance approach (par 4), the report as an overall frame work (par 5-6) and all acts of paragraph 8 on health inequities. Instead it was proposed to further pursue consultations with member states, develop evidence based tools, and best practices. This amendment was supported by most Western-European and Scandinavian countries, except the UK. It demonstrates that these countries have cold feet engaging the health ministries with wider national socio-economic policies. There are worries that this wider public health approach, in contrast to a narrower health services approach, will require (financial) committents that most ministries are not yet willing to make.

The discussion on health inequities and social determinants of health as basis for healt 2020 will continue the second day. What remains in the air is the governance for health question. How should member states and WHO address health in wider context, recognising that most determinants of health (85%) have their origin outside the health sector? This is a crucial question in global health now inequalities in health within and between countries are on the increase. Food for further thoughts and debate.

Remco van de Pas, Wemos

Get involved in global health!

Why should nongovernmental organizations dealing with international health cooperation get involved in global health, in high politics, debates on issues such as the reform of the World Health Organization or the development of a Framework Convention on Global Health?

As many representatives of the Medicus Mundi International Network you might answer: "Good question. I do not know why I should. And now please let me continue my work. Got many reports to write. Many funding applications to screen. And problems to resolve with our local partners."

I do not mind. I even do not mind if you ask me: "And anyhow, what do you think that we can change at a global level?" I also agree with you that it makes sense to share tasks among people and institutions working in different ways towards the shared vision of health for all.

Nevertheless, I do not like to ask those academics specialized in global health issues or that couple of highly professional lobbyists working for those few highly professional international NGOs to represent my voice and my interests in the global arena.

Also in smaller NGOs and NGO networks there are people interested and able to get involved in global health issues. Not following all the "hot" issues, but some of them. Not knowing everything, but trying to learn and share. Not getting always involved, but sometimes at least. I will do this - join me, if you dare.

Thomas Schwarz, Executive Secretary, MMI Network
contact: schwarz@medicusmundi.org


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Social advocacy aims at changing the “what is” into a “what should be” - a more decent and more just society. In a globalized world, social change requires advocacy beyond countries’ borders: transnational advocacy and international advocacy, based on international networks and coalitions. Joint advocacy adds a layer of value to the MMI Network’s activities. Supporting our members’ efforts to achieve the shared vision of “Health for All”, our joint advocacy aims at influencing the international policy landscape in which our members’ and their partners’ activities takes place. The Network will play a role in passing its members key advocacy messages to the international level. On the other hand, the MMI Network aims at encouraging and facilitating its members’ and their partners’ advocacy activities on a national level in the countries they are based or engaged in. (Medicus Mundi International Network, Strategy 2011-2015, pdf)