“Irrelevant” WHO outpaced by younger rivalsBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5012 (Published 09 August 2011) Cite this as: BMJ 2011;343:d5012
- Nigel Hawkes, freelance journalist
For as long as many can remember, the World Health Organization has been facing a crisis. From decade to decade, the nature of that crisis might change, but it never quite goes away.
Despite its past accomplishments, WHO fits increasingly uneasily into a world with a growing number of international players who seem fleeter of foot and deeper of pocket. Set up as an agency to provide advice to governments at a time when government health departments were the prime movers in health policy and delivery, it seems passé beside such upstarts as the Global Fund to Fight Aids, Tuberculosis and Malaria, the GAVI Alliance (formerly known as the Global Alliance for Vaccines and Immunization), and private philanthropies such as the Bill and Melinda Gates Foundation.
Setting the agenda of global health?
The existence of such organisations is a reproach to WHO, whose bureaucracy and politicisation have been increasingly bypassed by governments in the interests of getting something done. Jack C Chow, a former assistant director general of WHO, claimed last year that the organisation was becoming irrelevant.1 It was outmoded, underfunded, and overly politicised, he said. “WHO is no longer setting the agenda of global health; it’s struggling to keep up.” His theme was echoed this year by Barry R Bloom, professor of public health at Harvard, who pointed out that of WHO’s budget of $3.9bn (£2.4bn; €2.7bn) in 2008-9, less than $1bn came from member states’ mandatory contributions.2 The rest were earmarked funds provided by countries or foundations for specific projects, indicating a lack of confidence in WHO’s ability to set the right priorities if left to itself.
But as if to prove that whatever WHO does will alienate some of its stakeholders, a reform package announced in May to deal with these concerns caused outrage to several international non-governmental organisations. A report by the director general, Margaret Chan, called The future of financing for WHO (64th World Health Assembly, Agenda item 11, paper A64/4) admitted many of the criticisms were true. WHO was overcommitted, overextended, and in need of specific reforms, she said. “Priority setting is neither sufficiently selective nor strategically focussed. Given the large number of agencies now active in health, duplication of effort and fragmented responses abound, creating an unprecedented need for greater coherence and more effective coordination.”
New ways were needed of working with other global actors, her report added. They needed to participate and have their voices heard in the shaping and making of health policy. While less than a quarter of WHO’s budget came from predictable and flexible funds (national contributions) it would not be free to determine its own priorities, so member states were urged to increase their contributions. But at a time when government budgets were under pressure, WHO would also need to attract new donors and explore new avenues of funding, including “foundations and the private and commercial sector.”
The first World Health Forum
To help involve such people, she said, WHO would organise the first World Health Forum, to be held in Geneva in November 2012. Along with member states, this would include representatives of non-governmental organisations, the private sector, academia, and other international organisations. To purists who believe WHO should not sup with the devil, this caused huge anxiety. To them it looked like an attempt to subvert WHO’s principles of governance and cosy up to private industry. Their suspicions were heightened by the late appearance of the plan, just days before the World Health Assembly—WHO’s governing body—met for its 64th meeting.
A wide range of non-governmental organisations were unhappy, and launched a protest at the assembly. Patrick Durisch, speaking on behalf of Health Action International, Knowledge Ecology International, the Third World Network, the Berne Declaration, the People’s Health Movement and International Baby Food Action Network (IBFAN) said that the new policy raised conflicts of interest for WHO. Dr Chan’s plan presented “an unrealistic and empirically unsupported assumption that all stakeholders will collaborate to advance the public interest.” Any changes in governance structures should deal with those conflicts of interest in a realistic manner, he said, and members of WHO should guard against initiatives that would give private interests and donors a greater role in its governance.
“Nobody was being very clear” says Patti Rundall of Baby Milk Action, a long term opponent of food giant Nestlé. “Margaret Chan said, in effect, ‘we want your money’ and that if it was forthcoming, WHO would meet its partners’ expectations, You can’t do that and also meet the expectations of the member states.
“We depend on WHO being a health advocate that puts health first. Without that, we wouldn’t now have 60 countries banning advertising of formula milk for babies. Involving private companies in setting priorities creates an unsurmountable conflict of interest. Margaret Chan says that she’ll only deal with the ‘good’ companies, but how will she know?”
The proposed World Health Forum provided a target around which the non-governmental organisations circled. “We find this proposal absolutely unacceptable, especially since WHO has given member states no time to discuss and consider the implications,” said Arun Gupta, regional coordinator for IBFAN Asia. Médecins Sans Frontières joined him and others in condemning the claim that the forum would not usurp the decision making prerogatives of WHO’s own governance as “not credible.” A joint statement asked: how can the World Health Forum meet the expectations of commercial actors without usurping the prerogatives of WHO’s own governance?
Dr Chan’s plan survived the World Health Assembly, but came in for further criticism at the WHO executive board that followed. She was instructed to produce three papers, on the governance of WHO, the independent evaluation of WHO, and the World Health Forum, by the end of June and to convene a special session of the executive board in November to discuss them. Although open to all, only the 34 members of the board will have a vote. Anxieties were expressed at the meeting at the WHO Secretariat’s plan that the development of the reform programme be partly funded by the Gates Foundation. Germany raised the issue of WHO’s financing, a key to the reforms but not one of the issues Dr Chan is required to report on. It proposed that financing be added to the governance paper, but Dr Chan responded by arguing that there was too little time to include it and Germany withdrew its amendment.
Andrew Cassels, director of the office of the director general of WHO, says that the critics of the plan are wrong to argue that it will subvert WHO’s traditional governance, or dilute the voice of developing countries. The reform plan started, he says, as a means of achieving a better alignment of WHO’s income and its work. “Some parts of the work are underfunded, and with greater flexibility of funding we could do a better job. Member states responded to the suggestion they should increase assessed contribution by saying yes, but only when we’re clear what WHO’s priorities are.
“It would be nice to increase the proportion of voluntary contributions that are less closely specified. But the key thing is not to be too concerned about total resources, but to make them predictable.”
From this, he says, followed the need to discover what other global players believed WHO’s priorities should be. “The director general is keen to bring greater coherence to WHO’s activities. If we are going to achieve that, we need some forum to discuss the issue that isn’t just governments.” That would be the World Health Forum. So far, the forum has yet to gain the formal approval of the executive board, which will discuss it at its November meeting and again next January.
“The concern that some people have is that it will change WHO’s decision making process, but it’s not about that,” says Dr Cassels. “Its conclusions would speak to all global health organisations, not just WHO. The purpose is not to influence WHO’s own governance procedures, which would remain unchanged.”
The three papers Dr Chan was mandated to produce are complete, but not publicly available, and are being discussed by WHO’s regional committees. Different views have been expressed about the need for an independent evaluation of WHO, one of the key changes called for by Professor Bloom, who argues that the World Bank, the Global Fund, and GAVI all have extensive external review procedures, but WHO does not. However, Dr Cassels says that in the discussions so far, some have questioned whether the timing is right, some whether an independent evaluation is even necessary.
In the background, financial pressures are rising. WHO ran a deficit last year, and Dr Chan found it necessary to assert in her speech to the World Health Assembly that “we are most definitely not bankrupt.” The executive board meeting was picketed by staff members protesting at cuts. To balance its books, it needs to persuade governments and others to contribute more by persuading them that it is on the right track—or to cut costs. Neither is easy.
A former staff member says: “WHO as usual tries to do too much, its priorities aren’t very clear, and its power to make real executive decisions that would cut some programmes is limited, and always has been. Individual departments compete with each other for funding so there’s little sense of a united front and unwillingness to make sacrifices for the common good. Staff morale is low and some people are actually losing their jobs.”
Funding for global health initiatives
Yet funding for global health initiatives is not lacking. The money devoted to global health related activities by donors, including governments and foundations, has risen from $5.6bn in 1990 to $26.8bn in 2010,3 and the third replenishment meeting of the Global Fund in 2010 raised $11.7bn for 2011-13. This is less than the fund had asked for but is still very substantial.
That WHO should be facing budget cuts is an eloquent commentary on how its performance is perceived. The urgent need is to win back trust, Professor Bloom argues. But with so many stakeholders to satisfy that remains a very tall order.
Cite this as: BMJ 2011;343:d5012
Competing interests The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from him) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.