Why does the world still need WHO?BMJ 2002; 325 doi: http://dx.doi.org/10.1136/bmj.325.7375.1294 (Published 30 November 2002) Cite this as: BMJ 2002;325:1294
The landscape of global health is changing. New donor money, disease control initiatives, and trade laws have all had an impact on international health cooperation. WHO is being forced to rethink what its functions should be
WHO used to dominate international health. But in the 1990s, the World Bank took its place as the premier global health agency,1 and a wide array of health initiatives were launched, bringing new money and fresh ideas to tackle disease. Globalisation is presenting new challenges to an increasingly fragmented global health landscape.2 What are the implications for WHO of these changes?
The World Bank, Gates Foundation, and Global Fund have become major financiers of global health activities
WHO has little influence over the spending of these new health funds
The poorest countries need WHO's support in applying for funds and rolling out new global health initiatives
As international health cooperation fragments, WHO's role in setting global standards has become crucial
WHO's integrity in setting standards remains open to undue influence
New money for global health
The World Bank has become the largest external financier of health activities in low income and middle income countries.1 In the 1990s its health loans far exceeded WHO's total budget (fig 1), and its health sector activities have continued to grow. Its new Multi-Country AIDS Programme alone provides $500m over three years to Africa—where the prevalence of HIV in adults is now 8.6%—to scale up existing HIV/AIDS interventions.3
The Gates Foundation, the largest charitable donor of the 20th century,4 is often called the new “800 pound gorilla” in global health. By September 2002, it had granted $2.8bn in health funding.5 Its biggest donation was $750m over five years as a start up grant to the Global Alliance for Vaccines and Immunisation (GAVI), which aims to increase children's access to vaccines in poor countries. It also pledged $100m to the International AIDS Vaccine Initiative (IAVI), whose mission is the development of and universal access to an HIV vaccine.
Gates avoided putting his billions into the United Nations system. He channelled them instead into smaller, independently governed initiatives that focus on “quick fix,” high profile health problems. Gill Walt, professor of international health policy at the London School of Hygiene and Tropical Medicine, said these new initiatives “peeled off bits of the WHO,” forcing the organisation to reflect on what its remaining functions should be.
Another source of funding is the Global Fund, an independent financing mechanism that has pledged $2.1bn over five years to country based projects tackling AIDS, tuberculosis, and malaria.6 It was launched with great fanfare and impressive promises from donor governments, who have recently come under pressure to fulfil their pledges.7
“The fund was developed,” said Daniel Tarantola, one of Brundtland's senior policy advisers, “in a spirit of wanting to create something very independent from the UN.”
But by establishing the fund outside of the UN, weren't donors expressing a vote of no confidence in the UN's ability to deal with the AIDS epidemic? “That is one interpretation,” said Peter Piot, executive director of the joint UN programme on HIV and AIDS. “But I would say that, with the UN Secretary General, whom I was involved with in negotiations for the fund, we felt right from the start that an investment fund, a financing mechanism, would best be independent.”
Piot believes that if the UN had controlled the fund, it would have changed the nature of its work. “I firmly believe,” he said, “that you can do much better normative work, advocacy work, and policy work if you're not the one writing the cheque. That's one of the problems with the World Bank—often the one who writes the cheque determines policy. Will that happen with the Global Fund? It remains to be seen.”
New donor power
Who determines how this new money is spent? The spending decisions are clearly outside of the governance of WHO's member states.
One health expert in Africa, who has worked at WHO, said that the Global Fund, GAVI, and IAVI together “put three billion dollars of global funds for health outside of the world's global health agency.” Eduardo Missoni, a critic of the Global Fund, said: “One may ask, why have an ‘independent’ board to decide about the use of resources for public global health, and not WHO, which has the mandate and the legitimacy for it?”8 Many WHO staff I interviewed expressed deep disquiet at the way that the organisation has been sidelined by these “spin offs” of WHO. “Why weren't we more proactive,” said one senior insider, “in saying that WHO should play a central role?”
As the architecture of global health changes, its governance is shifting away from WHO and towards donors. The World Health Assembly may be slow and bureaucratic, but it has the advantages of representative legitimacy—192 countries, poor and rich, all have equal voting power—and accountability to countries themselves. The new global health initiatives are outside of the assembly's governance and largely accountable to their donors—private foundations and rich governments. These initiatives are arguably weakening the UN's influence on how global health funds are spent, by choosing which health interventions to fund (mainly communicable disease control), which strategies to use (predominantly vertical programmes), and which countries should receive support.
Hazards of fragmentation
The fragmentation of global health carries a number of risks, including overlap and duplication of efforts. “With all these funds coming up,” said Piot, “there's a danger of Balkanisation of efforts and less efficiency.”
There could be a diversion of financial and human resources away from WHO, making it harder for the organisation to carry out its core functions. Although health funding from the Gates Foundation is new, the money allocated through the Global Fund may represent donor money that would have flowed through WHO.
There is currently no coherence between all these initiatives. The Global Fund, for example, has a mandate for controlling three diseases. Yet other alliances involving WHO are already tackling these—Roll Back Malaria, Stop TB, and UNAIDS—and it is unclear how they will all fit together.
Piot believes, however, that the new actors are welcome to the global health stage. Both he and Gro Brundtland fought hard, he said, to get a wider spectrum of society involved in health. The result is that health cooperation is “more complicated, but that's an exciting challenge—it should push us all to rethink what we can do, what is our added value.”
WHO's “added value”
Billions of dollars are now potentially available through GAVI, the Global Fund, and the World Bank. But many of the neediest countries could miss out on benefiting from these funds because they lack the resources needed to apply for and implement them. A strengthened and better funded WHO could support countries with this application and implementation.
David Alnwick, Roll Back Malaria's project manager, believes that the partnership is already carrying out this role. “All of the countries,” he said, “bar Madagascar, that were successful in the first round of Global Fund proposals were countries in which RBM had worked fairly intensively, working with countries to prepare these proposals.”
Box 1:WHO's six core functions10
Articulating consistent, ethical and evidence-based policy and advocacy positions
Managing information by assessing trends and comparing performance; settingthe agenda for, and stimulating, research and development
Catalysing change through technical and policy support, in ways that stimulate cooperation and action and help to build sustainable national and intercountry capacity
Negotiating and sustaining national and global partnerships
Setting, validating, monitoring and pursuing the proper implementation of norms and standards
Stimulating the development and testing of new technologies, tools, and guidelines for disease control, risk reduction, health care management, and service delivery
Recipient countries have to negotiate their way through a maze of partnerships and funding mechanisms. In addition, they receive development assistance from multilateral, bilateral, and non-governmental organisations—an “unruly melange of donors.”9 WHO, through its core function of “technical and policy support” to countries (box 1), is the best placed organisation to make sure that the poorest countries get the most help.
In the new global health set up, WHO's performance at country level becomes crucial, yet it has shown little improvement during Brundtland's term. Although belated in the reform process, WHO's “country focus initiative” might finally see the organisation devolving its resources from headquarters to countries (box 2).
Box 2:WHO's country focus initiative11
WHO provides tailormade technical support to countries to help them achieve sustainable national health policy goals. It also draws on the experience of individual countries to build a body of public health knowledge that can benefit all countries.
The goal of WHO's planned “country focus initiative,” which will be presented to the executive board in January 2003, is to massively scale up WHO's health and development work through improving its performance at country level. A consultation draft on the initiative outlines six key components:
Strengthening country teams—WHO country representatives would be given additional financial and human resources, which they would manage
“Country cooperation strategies”—these are specific plans on working with each country; about 25 will be formulated each year over the next 5 years
Better technical support to countries from headquarters and regions—the draft recognises that “currently the credibility of country offices is sometimes undermined by weak coordination of planned activities of regions and HQ”
Increased administrative capacity of country offices
Greater access by countries to reliable health information—this would include online access at country level, and the posting of country-related information on WHO's intranet
Better working with UN system and development partners (including GAVI and the Global Fund)
Xavier Leus, WHO's director of cooperation and communication, said, “We think we should be similar to agencies like Unicef in terms of financial resources to country teams and their ability to source technical cooperation.” But for the initiative to succeed, he said, it will have to change entrenched powers and ways of working. “For example, WHO country representatives will be recruiting advisers and mobilising resources. This could anger regional advisers—disempower them. People from headquarters might also see a loss of power.”RETURN TO TEXT
It is not just countries that need strong technical guidance from WHO, but also its partners, bilateral agencies that are assisting countries, and the new health initiatives. Brundtland believes that WHO's technical expertise is vital to GAVI and the Global Fund. “Without WHO,” she told me, “these institutions would not have credibility.” But a senior WHO staff member said that the organisation still has to prove that it can give these institutions the support they need: a crucial question is: “To what extent can WHO position itself to be a credible partner to meet the needs of the Global Fund?”
Piot believes that the fund “should focus on getting money in and money out. In order to do that properly, and to keep transaction costs low, the fund has to rely on existing international structures, in the first case WHO—through Roll Back Malaria and Stop TB—and UNAIDS.”
The fund is designed to be purely a mechanism for the rapid disbursal of money. While it has a technical review panel that assesses applications from countries seeking funding, the panel excludes staff working for UN agencies12 and its panel members may not be familiar with the specific needs of particular countries. In contrast, the recent external evaluation of Roll Back Malaria argued that “a strengthened RBM should be in an excellent position to make technical judgments that are informed by the full range of country-specific context and history.”13 These judgments will be invaluable for the fund.
Brundtland has argued that “the world is increasingly looking for greater coordination among development organisations.”14 WHO's technical judgments are central to this coordination, because they can help other agencies with their budgetary planning. For example, if WHO notes a rise in resistant malaria in a country, requiring a switch from chloroquine to more expensive drugs, it should alert the World Bank so that the bank can plan its country support accordingly.
In the new global set up, WHO's work in global monitoring of diseases takes on added importance for two reasons. Firstly, the Global Fund will rely heavily on data collected by Roll Back Malaria, Stop TB, and UNAIDS to measure the performance of the projects it funds. Secondly, these partnerships will play a key role in monitoring progress towards the millennium development goals.15 The UN General Assembly adopted these goals at its millennium summit in September 2000, and they include combating HIV/AIDS, malaria, and other diseases (box 3).
Box 3: UN targets for controlling major diseases15
Target: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
Indicators to measure success:
HIV prevalence among 15-24 year old pregnant women
Contraceptive prevalence rate
Number of children orphaned by HIV/AIDS
Target: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases
Indicators to measure success:
Prevalence and death rates associated with malaria
Proportion of population in malaria risk areas using effective malaria prevention and treatment measures
Prevalence and death rates associated with tuberculosis
Proportion of cases of tuberculosis detected and cured under DOTS (directly observed treatment for tuberculosis)
Defining global standards
One of WHO's comparative advantages is its unrivalled reputation in setting global standards. It produces invaluable guidelines, reports, and training manuals used by health systems worldwide.
Box 4:WHO's successes in setting global norms and standards
Framework Convention on Tobacco Control (www5.who.int/tobacco)
The world's first international tobacco control treaty, set to be completedin May 2003
Legally binds signatory states to measures aimed at reducing tobacco consumption
International Code of Marketing of Breast Milk Substitutes (www.who.int/nut/documents/code_english.PDF)
Adopted by the World Health Assembly on 21 May 1981, with 118 votes in favour and one (the United States) against
Aims to contribute to the provision of safe and adequate nutrition of infants by protection and promotion of breastfeeding
Governs the marketing of breast milk substitutes
Joint FAO/WHO Codex Alimentarius Commission on food standards(www.who.int/peh/food.htm)
Created in 1963 as a joint intergovernmental body of the Food and Agriculture Organisation and WHO
Provides a basis for international food standards and guidelines and codes of practice for international food trade
In 2001 it established the first global principles for the safety assessment of genetically modified foods, maximum levels of certain food toxins, and guidelines for organic livestock production
International health regulations(www.who.int/emc/IHR/int_regs.html)
An international framework to detect and prevent the spread of infectious diseases
In force since 1971, when they replaced the International Sanitary Regulations adopted by the World Health Assembly in 1951
Goals are to detect, reduce, or eliminate sources from which infection spreads; improve sanitation in and around ports and airports; prevent dissemination of vectors
WHO's credibility in this area rests partly on its governance mechanism, with its near universal representation, and partly from its “convening power”16—its ability to bring together experts into committees to help determine best practice. “Whenever you need a global consensus on a tough issue,” said Jonathan Quick, director of WHO's essential drugs and medicines policy programme, “we have the mechanisms where—because we have representative oversight with a scientific core—we can get expert groups together.”
Derek Yach, WHO's executive director of non-communicable diseases and mental health, believes that globalisation—including the rise of international trade laws and of industry self regulation—is challenging WHO to take a more proactive role in setting global standards. For example, the World Trade Organisation's international trade agreements have important implications for public health. “Instead of trying to put so much energy into reforming the WTO to include greater health conditionalities [provisions for public health],” said Yach, “we are better served by having stronger UN agencies—in this case, stronger investment by WHO in international norms and standards which can then become the basis of dispute resolution and discussion.”
Some of the best things that WHO can do, he said, are “global advocacy, international norms and standards, surveillance of infectious diseases and risk factors for disease, being able to provide authoritative voices on interventions, and enhancing research to provide evidence of what works and what doesn't.” These activities have come together to produce an international treaty on tobacco, a code on infant feeding, a commission on food safety, and a set of international health regulations (box 4).17–20
But for WHO to maintain its credibility in setting global standards, it needs to do better in ensuring that its staff and expert committees declare any conflicts of interest. Two recent controversies show how undeclared interests can corrupt WHO's policies and processes.
WHO has had to revise its 1999 hypertension guidelines, which recommended expensive medication for mild hypertension.21 Because of the possibility of industry influence in the formulation of the guidelines by an expert committee, a new committee had to be convened. The revised guidelines will have a stronger focus on non-drug measures and cheaper medication for mild hypertension.
The second controversy came at the start of Brundtland's term. As part of the settlement of a US lawsuit, tobacco companies were forced to make industry documents publicly available.22 Brundtland was alerted to the possibility that the documents showed tobacco industry influence on WHO and set up an independent inquiry. The inquiry found overwhelming evidence that the industry had a planned strategy to “contain, neutralise, reorient” WHO's tobacco control initiatives.23 One way in which it could do this was to finance members of WHO expert committees.
“As an institution,” said Yach, “we were weak in requiring any kind of oversight of declaration of interests. Before you can blame industry for adverse influence, you have to look at how well you are protecting yourself.”
In the light of these controversies, all members of WHO expert committees are in theory being asked to sign a form for declaration of competing interests. But a recent internal review found only patchy performance by staff in ensuring that these forms are filled out and in analysing them to look for important competing interests. WHO's integrity in setting norms and standards thus remains open to undue influence.
Are the new players in health putting WHO out of business? On the contrary, there is now an even greater need for an overarching health agency. Its functions are to act at a global level to coordinate the disparate activities in health, and at the country level to ensure that the poorest people benefit the most from the latest injection of health funds. Such an agency would provide evidence based and trustworthy guidance to a globalised world.
For WHO to become that agency, two things must happen. The organisation needs to overcome the major hurdles in its reform process—it needs a structure that devolves resources to country level and a culture of greater openness and debate. And if we, the international health community, want WHO to carry out the tasks for which it has the comparative advantage, we need to provide it with adequate resources for these vital activities.
Competing interests This is the fourth of five articles
Competing interests: The BMJ receives submissions and commissions papers from many WHO authors, but GY is no longer involved in this process. GY now works for BMJ Unified, a joint venture between the BMJ Publishing Group and United HealthCare Services Inc (http://www.besttreatments.org/).