Last week the Executive Board (EB) of the World Health Organization conducted its 130th session. This board, consisting of 34 member states, governs the organisation on behalf of the World Health Assembly, the overall governing body of the WHO that consists of 194 member states. Seating in the EB by a member state is for 3 years, and done on a rotational basis, aiming a balanced geopolitical representation.
Last week the EB had to provide guidance for and decide on several elements of reform that the organisation requires. Over the last 20 years WHO has become “outpaced” by other actors in the growing global health arena, including global health initiatives like the Global Fund on AIDS, Tuberculosis and Malaria, the World Bank, philanthropists like the Bill and Melinda Gates foundation, but also other UN Agencies as UNAIDS, UNFPA and UNICEF.
The reform, that has become somewhat a process in its own, was during the EB discussed in the sub-themes “priority setting for the Organisation”, “internal governance and the relation with external stakeholders like companies and NGOs”, and “financing, management and evaluation”. I will not go into detail on the reason and background of the reform, the precise content of the last EB discussions and its outcomes, as these have already been extensively covered by others such as WHO Watch, Medicus Mundi International, the Centre for Global Health Policy and Innovation and the Global Health Diplomacy Network.
I take a step backward and look to the process. The WHO functioning, necessary reforms and more precisely its lack of available and predictable financing for core tasks have been already discussed since two years. What can be observed is that after a formal reform process, a special session of the EB in November 2011, discussions at the regional committees of the WHO and numerous consultations and background papers further …so little progress is made: The 130th EB only decided that an intergovernmental working group will develop further criteria for priority setting in February 2012; that a new consolidated document for the World Health Assembly 2012 will be prepared with a more detailed proposal for stakeholder engagement; and thirdly that a new financing mechanism (a financing dialogue and pledging conference) will be further elaborated. One could assess this process from two sides; either you see it that the member states taken it very serious and cautious; hence moving on a step-by-step approach to strengthen the constitutional mandated leader in global health; or that WHO currently lacks real relevance in global geo-politics.
An article by David Fidler that analyses the “rise and fall of global health as a foreign policy issue” supports the last thesis. WHO has become more irrelevant in a multi-polar world where health, more specific infectious diseases and pandemic influenza threats, have become less of a security risk for affluent states. This perception of a decreased security risk follows the containment of SARS, H5N1 (Avian flu) outbreaks, the H1N1 (Mexican flu) pandemic and global decrease in new HIV infections. One could argue whether all this has resulted because of or despite WHO interventions like the Pandemic Influenza Preparedness (PIP) framework. More actors are getting technically and institutional equipped to deal with global viral epidemics, like the Centres for Disease Control and Prevention, The European Centre for Disease Prevention and Control, The Infectious Disease Control Training Centre in Hong Kong.
The current non-communicable disease epidemic (diabetes, cancers, cardio-vascular diseases and COPD) that has a huge impact on disease burden worldwide is however much less of a security risk for nation states. Strong regulation via a global convention and treaty (to be negotiated via the WHO) is hence not necessary and member states rather opt for softer self-regulation and cooperation with non-state actors (eg. the food and beverage industry). This can be read in the political declaration on the prevention and control of NCD’s adopted by the UN general assembly. The focus is less on health security but rather on the economic impact of the epidemic (US$. 47 trillion by 2030) as one can read in this study of the World Economic Forum.
Will WHO remain relevant? That’s hard to say. Last week Margaret Chan was re-elected for her second five-year term as Director General of the WHO. She was the only candidate for the post. This indicates that member states choose for a technocratic option for the WHO in this time of reform, rather than to play a political power game over leadership.
While the WHO reform and direction is democratically debated in the EB and World Health Assembly, a first stage evaluation will be conducted to re-organize the organisation. Already 450 staff has to leave the organisation as no predictable budget is foreseen to maintain all employees. It’s like putting the cart before the horse in downsizing the organisation before it has been decided what the future priorities of the WHO will be. In the corridors of WHO office in Geneva last week, some have called it the ‘shock doctrine’ being applied to the organisation, opening the door further for cooperation with commercial actors as propagated in the UN Global Compact (of which WHO is not an official participant).
The question is whether the UN system in itself is still considered as relevant. In a multi-polar world order much pressing global issues are discussed under the G20 umbrella and directly between regional blocks (like EU, UNASUR and ASEAN). Ban-Ki-Moon, the UN Secretary General also recently elected for a second five year term, highlights the challenges coming ahead for the UN system, with its 15-member security council remaining deadlocked. The current financial austerity will affect considerably the voluntary contributions from member states and donors to several UN agencies.
While the health focus of WHO has broadened to areas like health systems strengthening, the social determinants of health and NCDs, its traditional focus on infectious disease control, elimination and eradication (e.g. smallpox, malaria, polio) in “developing” countries has proportionally reduced. WHOs current focus is less on health security and more on health development, where equity and human rights are important values. States tend to act in terms of (their own) security and it takes true courage for statesmen to bridge this paradigm and propagate a global good (a good example is the Polish foreign minister Sikorksi that addressed Polish arch-rival Germany last November to lead the necessary reform within the European Union related to the financial and political crises). WHO will benefit from likewise “connectors” within the member states to make the case for the public good that global health is.
An issue that possibly could WHO catapult in the centre of global policies is that, on advice by an American commission related to the CDC, it was last week decided to put a moratorium on man-made pandemic H5N1 flu research. Details on scientifically mutated H5N1 virus research by the universities of Rotterdam and Wisconsin was not published (yet) as it could provide crucial information for potential bioterrorist attacks. This “censorship” of not sharing a pandemic influenza strain for potential security reasons is in contradiction with the PIP- Framework. This is even more ironically if one realises that the original H5N1 strain was provided by Indonesia under hard pressure by WHO and several member states. (See for more background this information by the Third World Network). The issue was only addressed indirectly during the EB discussions on the PIP framework last week. The Indonesian representative made it tactfully clear that there should be coherence, fairness and equity while sharing pathogenic strains and vaccines and requested WHO to promptly follow it up…
In the EB discussion on priorities setting for the WHO, USA Delegate Nils Daulaire mentioned that the USA is “concerned that health security and communicable diseases are not reflected enough in the 7 proposed categories of the Global Program of Work”. Whether WHO will be relevant or not for member states will hence not so much be determined by a process of reform, but rather if there will be (a threat of) a pandemic viral outbreak in the coming decade. Looking back in recent history we can be sure that health security threats will remain, and so the relevant role of the WHO!
Remco van de Pas, Wemos