The World Health Assembly (WHA), the annual meeting of WHO’s governing body, in which its 194 Member states review and provide strategic direction for pressing global health issues, ended this week. Its agenda was dense, with decisions to be taken on important issues, such as WHO’s own reform, a new Global Program of Work and related program budget, including a new financing mechanism. Important themes such as Universal Health Coverage (UHC), a global action plan for the prevention and control of non-communicable diseases, health in the post- 2015 development agenda, and the International Health Regulations have been discussed, the latter against the background of a new global health threat, a novel coronavirus outbreak that has caused infections and several deaths in the Middle East region since it emerged in April 2013.
We have been closely following the reform process of the WHO over
the years. The reform should lead to a stronger and more efficient
organization able to take a leadership role in a fragmented and complex
global health scene. WHO itself doesn’t speak about global health
architecture anymore, but rather of global health governance, “the
use of formal and informal institutions, rules, and processes by
states, intergovernmental organizations, and non-state actors to deal
with challenges to health that require cross-border collective action to
In short, so far WHO has failed to meet the expectations to re-emerge
as the leading organization in global health. During the reform
process, major steps have been taken to strengthen internal management
and effectiveness of the organization, leading to a program of work
built around 6 categories and results based outcome indicators. What
has been lacking so far, though, is a more fundamental debate about the
role of WHO in the international system. This is also the conclusion of a
policy paper produced by Chatham House in February 2013. “The
current process does not ask fundamental questions about WHO’s place in
the international system as it has now evolved, nor whether WHO’s
governance, management and financing structures need more fundamental
change than is currently envisaged. It is therefore unclear whether the
latest reform efforts will be sufficient to enable the organization to
fulfill its potential”.
Interestingly, there are formal documents on WHO’s role in
global health governance as a reference for debate for WHO’s Executive
Board (EB) members, see for instance EB132/5 Add.5 (January 2013) and EB 133/16 (May 2013). While writing this blog, the 133th EB has been busy for several hours discussing whether the item “Improving the health and well-being of lesbian, gay, bisexual and transgender persons” should
remain on the agenda for discussion or not. A fundamental discussion on
WHO’s role in global health will hence also not take place at the 133th
EB. Because of diplomatic reasons, the (majority) of the member states
do not want to have an open debate on this issue, as this could lead to
strong ideological and political friction. It fits with the analysis
that the WHO is choked and bereft of any institutional autonomy as the
majority of its funds are provided via extra-budgetary voluntary
contributions which – through the WHO – actually serve the interests of
particular state and non-state donors. The OECD has called this
development muIti-bi financing.
Through this increasing trend, participating governments and others are
controlling international agencies more tightly, thereby impacting on
their policy priorities.
If not the WHO, which institution is then allowed to set the scene in
global health? This WHA also saw the re-emergence of an old friend and
foe in global health: the World Bank! Its new president, Dr. Jim Yong
Kim gave an impressive speech in which he heralded the drive for Universal Health Coverage and committed himself to the “values of the Alma-Ata Conference on Primary Health Care, health equity and development in the spirit of social justice “ (!) Hold a minute, the World Bank and comprehensive primary health care, wasn’t that a rather awkward combination in the 80s and 90s? Has the WB indeed learned from its past?
It confessed its mistakes in these words by Kim: “And let me
acknowledge that Thailand launched its universal coverage program
against concerns over fiscal sustainability initially raised by my own
institution, the World Bank Group. Thailand’s health leaders were
determined to act boldly to provide access for their whole
population. Today the world learns from Thailand’s example”.
With also the support of Paul Farmer, fellow founder of Partners in Health, and Tim Evans as the new director
of the Health, Nutrition and population Department, the WB’s new
(health staff) leadership is strongly rooted in the health policy and
paradigms promoted by the Harvard School of Public Health. So what can
we expect? One question came to my mind when reading the speech by Dr.
Kim: why do we need to “close the gap in access to health services and
public health protection for the poorest 40 percent of the population in
every country”? Why not closing the health inequalities gap for entire
populations? Isn’t a focus on the poor leading automatically to a
two-tiered system? A minimum basic package provided by public or
contracted services for the poor, and high quality private services for
the richer part of the population. Both the WHO and the World Bank keep
on repeating that UHC is “not about a minimum service package or a
one-size-fits –all approach to service delivery, but rather emphasizes
progressive realization of coverage according to a country’s situation”.
An essential question remains. Will progressive coverage of health
services contribute to improved health equity in and between countries?
Is it wise to invest both public and private finances so much in health
care delivery and not in essential public health measures? Colleagues
like Charles Clift and Laurie Garret who have followed this debate also question the direction and role of the WB in UHC.
By the way, the recent article by Kim and Farmer on redefining global health-care delivery
(Lancet, May 2013), is in stark contrast with Kim’s clear speech at the
WHA. I found it rather indigestible and it doesn’t provide new insights
into health care delivery. Basically the authors advocate a more
integrated and diagonal approach in health care delivery (which they
call a value chain). They remind us several times that these concepts
are well known, and argue that health care delivery systems can be a
strong contributor to economic development.
The focus on health care delivery, UHC and economic development,
although all important, might distract us from the devastating health
impact of a globalized economy, that has led to a deeper divide between
the wealthy and the poor, and has resulted in austerity measures and
higher mortality in several European countries and the US over the last 5
years. For a good overview of these (dire) effects, it is valuable to
read the just published “The Body Economic, why austerity kills” by David Stuckler and Sanjay Basu. David Stuckler puts it like this: “If
there actually was a fundamental trade-off between the health of the
economy and public health, maybe there would be a real debate to be had.
But there isn’t. Investing in programmes that protect the nation’s
health is not only the right thing to do, it can help spur economic
recovery. We show that. The data shows that.”
Will the World Bank and WHO be leaders in advancing strong, equitable
health systems under the umbrella of UHC, or will the powerful
political powers in this world again interpret UHC in their very own way
and use the Bank and WHO as convenient vehicles? The story will unfold,
and we will be closely watching it!
Remco van de Pas (Wemos Foundation, the Netherlands)
Published first in IHP Newsletter, 30 May 2013