Making the World Health Assembly fit for the 21st centuryBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g4079 (Published 18 June 2014) Cite this as: BMJ 2014;348:g4079
- 1Graduate Institute of International and Development Studies, 1211 Genève 21, Switzerland
- 2Institute of Public Health, University of Heidelberg, D-69120 Heidelberg, Germany
The 67th World Health Assembly, the annual meeting of the 194 member states of the World Health Organization and its supreme decision making body, ended on 24 May this year. This latest assembly was record breaking: it had 3500 registered participants—2200 delegates of member states led by more than 130 ministers of health and about 1300 observers from international and non-governmental organisations officially related to WHO. This does not include all the others who come to Geneva to lobby and to network. The assembly discussed 66 agenda items; it passed 20 resolutions and 10 decisions based on 80 background papers amounting to about 1000 pages. Some debates continued until 3.30 am, and many agenda items reached their final conclusion only late on Saturday evening, when most participants had left.
It was clear that the assembly is changing its nature. For some, this assembly was the most exhausting meeting they had ever attended, and the director general conceded that the pace of work had been “unhealthy.” Yet for others it reflected the extraordinary vigour of the global health community. Although the deliberations of member states remain at its core—in plenary, in committees A and B—many other events take place. As well as the five technical briefings prepared by WHO and about 40 side events in the overcrowded Palais des Nations,1 meetings organised by countries, civil society, and the business sector take place throughout Geneva. Both WHO and non-governmental organisations participated in Twitter,2 with more than 11 800 Twitter users joining the conversations, and the United Nations Foundation supported a one hour outreach programme every day that summarised the key issues. During these days Geneva can truly call itself the “global health capital.”
Is this just a talkfest or does it make a difference? The week illustrated that the most important body of global health governance is not working as well as it should. Although some breakthrough agreements were reached,3 there was much frustration that many important problems were not resolved, such as the rules regarding cooperation with non-state actors. Neither the WHO secretariat nor the member states are fully geared to prepare, organise, and conduct a meeting of this magnitude, density, and complexity. The standard response is to call for the number of agenda items to be restricted. But the number of pressing health problems and the diversity of political interests in a multipolar world make it impossible to go back to the circumscribed assemblies of the past.
To start with the easy things—technology, space, and time. If the present trends continue, the Palais de Nations will be too small and the assembly will be too short. The technology at the palais does not meet the requirements of the 21st century; webcasting of all public sessions (an approach already being used at other UN conferences4) must be considered. This can improve transparency and accountability. It can also open an avenue to limiting the number of people attending physically. Some observer delegations had more than 75 delegates; this is the number of delegates from the United Kingdom, Japan, and Germany combined. The Serpent Lounge—the key informal meeting and negotiation space—is so full of other actors it crowds out the delegations. No national parliament could function in this way.
But the key problem is the management of the debate and the quality of the presentations, both in the main plenary and the committees. Not all committee chairs are up to the task and not all delegations make constructive contributions. The secretariat could do a better job in distributing documents on time,5 linking debates and documents electronically, providing background information, and explaining the strategic relevance of agenda items. Yet the problem goes much deeper. Many member states do not prepare well for the assembly. Consequently, they do not add value to the debate and take up precious time reading out nondescript statements that could easily be posted on an internal web portal. And, it must be said, many civil society statements are not much better. This cannot be resolved by traffic lights for speakers. Effort must be put into ensuring that member states use the assembly to make strategically relevant contributions based on the key question: how do we contribute collectively to improving global health and global health equity. Voters and civil society back home must hold them to account. The media must report on the deliberations.
As WHO seeks new ways to interpret article 2a of its constitution—“to act as the directing and coordinating authority on international health work”—the changing nature of the assembly takes on an important role. Network governance in the 21st century requires norm-setting hubs, which enable improved communications, knowledge exchange, dialogue, and outreach. We suggest that the assembly is increasingly fulfilling two functions. It is becoming the hub of a global network of networks that make use of the constitutional meeting to engage a wide array of actors in agenda setting for global health. But the assembly can fulfil this role only if at the same time it upholds its unique governance responsibilities by setting norms, rules, and standards that must be developed collectively. The WHO constitution says that governments have a responsibility for the health of their peoples. It follows that health is a political choice, and the World Health Assembly is at heart a political, not a technical, meeting. In this spirit the WHO secretariat and its member states need to re-emphasise the uniqueness and the importance of the assembly and act decisively to ensure its impact.
Cite this as: BMJ 2014;348:g4079
Thanks to David Legge for some very helpful input.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: IK has had contracts with WHO on various technical issues and on developing the WHO European health policy framework 2020 and is a former WHO member of staff; the Global Health Programme has also held contracts; there are no contracts at present; the programme has developed training materials for WHO. BMB: None.
Provenance and peer review: Commissioned; not externally peer reviewed.