By Germán Velásquez*
GENEVA (IDN-INPS) – The World Health Organization (WHO) is in the most critical crossroad of its history but actions can and should be taken, to ensure its public health mission. This is the challenge for the new Director-General to be elected in May 2017.
This year is the last year of the mandate of the current Director-General, Margaret Chan, who fought for 9 years, to maintain a public agenda for the organization, that a small group of industrialized countries and philanthropic foundations had difficulty in accepting and supporting.
For the next DG, good intentions and tireless work, as shown by the current Director-General, would not suffice. The commitment of all member countries, to uphold a public and independent agency, that will be able to set up the rules to guide the global public health challenges for the next 20 years, will be fundamental.
Some of the problems/challenges that the new Director-General will have to face are as follows.
The public / private role of WHO
The main and most serious issue facing the WHO has been the progressive loss of control of the regular, public and compulsory budget. An increasing privatization of the organization has been taking place. In less than 20 years the WHO’s budget went from more than 50% financed through public funds, constituted by assessed contributions, to currently only 18 to 20%.
WHO is currently in the hands (approximately 80% of its Budget) of philanthropic foundations such as the Bill and Melinda Gates Foundation, a small number of industrialized countries that provide voluntary earmarked funds and big pharma. These voluntary contributions are channelled to health priorities decided by the funders and not the governments, who are the members of the organization.
It is very strange that an organization such as WHO does not have a philosophy and clear rules between public and private. WHO should be defined as an international public agency and therefore at least 51% of its budget should be public. Similarly, to preserve its independence, any contributor to the budget of the organization should not give more than 15 or 20% of the overall budget.
The dilemma for the member countries of WHO and the new Director-General is clear – they will have to choose between: an office to manage projects financed by the private and philanthropic sector, or rebuild a public and independent international agency to watch over public health. The increase of the regular budget is the only way to ensure that WHO continues doing its core work without having to incessantly follow donor-driven agenda priorities.
Closely linked to the loss of control of the regular budget were the difficult negotiations on the Framework of Engagement with Non-State Actors (FENSA) finally adopted by the 69th World Health Assembly (2016).
The adoption of FENSA is the conclusion of a process initiated 5 years ago, as part of the WHO reform in 2011. The FENSA process was at the heart of the debate on the nature of the organization. What will be the future role of the different categories of non-governmental organizations (NGOs) that are non-commercial and non-profit, NGOs working for profit, the private industry, and the philanthropic foundations?
Instead of developing a comprehensive conflict of interest policy, as the majority of developing countries wanted, the resolution requests the Director-General “to include in the Guide to staff, measures that pertain to application of the relevant provisions contained in the existing WHO policies on conflict of interest, with a view to facilitating the implementation of FENSA”.
However, it is not clear that WHO currently has such policies, except for the existing and often criticized form for the declaration of conflict of interest to members of the various committees of experts currently used by the organization.
The resolution also requests the Director-General to conduct an evaluation of FENSA implementation in 2019 and submit the results of the evaluation along with any revisions to FENSA to the January meeting of the Executive Board in 2020.
The dilemma for the next Director-General will be to wait until January 2020 for the result of the evaluation to see if the FENSA agreement represented a progress to the present “status quo” or to start from the beginning of his/her mandate to clarify what is the nature of the organization.
Voluntary resolutions or binding instruments
In May 2012, a resolution adopted by the World Health Assembly in Geneva1 represented a first step towards a change in the dominant model of WHO operations, that is to say: promoting health through voluntary resolutions.
This resolution follows up on the report of the “Consultative Expert Working Group on Research and Development: Financing and Coordination” – known under the acronym of CEWG -, which recommended starting negotiations on a binding international convention to promote research and development on drugs.
Relying on a binding global treaty or convention, negotiated in WHO, could allow sustainable financing of the research and development of useful and safe drugs at affordable prices for the population and the public social security systems. The adoption of a convention of this sort, within the framework of the WHO, based on article 19 of its constitution2, would also allow global health governance to be rethought. The negotiation of “global and binding instruments in health issues of global concern” is perhaps the most promising clue of the role WHO could take on in the future.
The CEWG recommended in 2012 for WHO Member States to start negotiations on a binding international instrument on health R&D under Article 19 of the WHO Constitution, as the best way to create an appropriate framework to ensure priority setting, coordination, and sustainable financing of affordable medicines for developing countries.
The CEWG stated that “… a binding instrument on R&D is necessary to secure appropriate funding and coordination to promote R&D that is needed to address the diseases that disproportionately affect developing countries.”3
However, the main recommendation of the CEWG to kick-start negotiations on an international biomedical R&D agreement has not been considered by the WHO Member States (including in the deliberations and resolution discussed during the 69th WHA), owing to political opposition from developed countries.
This is unfortunately a historical missed opportunity for WHO to take the lead on the important subject of access to medicines in the present economic and social global environment.
Priorities for standard setting versus humanitarian aid
Another important problem, to be faced by the new Director-General, that would need to be addressed is the dilemma of the WHO being a normative agency in charge of formulation and creation of international standards and being responsible for the administration of the international health regulations and the creation of binding agreements in global health; versus being a humanitarian agency that implements projects that have been financed by the international community often competing with and sometimes duplicating the efforts of other agencies.
Ideally the WHO should play its important normative role and much better too; as well as an operational role to prevent and respond to emergencies, new and emerging diseases and health crises in poor countries. But with its financial resources being so limited and with much of this coming from voluntary funds rather than the regular budget, it will be difficult for the WHO to get the balance right. The danger is that the norm-setting and standard-setting role of the WHO will be more and more marginalised; while it would still be lacking adequate resources to take on its operational role.
The dilemma more than ever is between what a few donors of the organization want, what the organization does, and what the world needs today from a United Nations agency devoted to health.
1 65th WORLD HEALTH ASSEMBLY WHA65.22 “Follow-up of the report of the Consultative Expert Working Group on Research and Development: Financing and Coordination”, 26 May 2012.
2 Article of the WHO Constitution, which grants the organization the possibility of adopting binding international conventions or treaties. This article was used only once since the existence of WHO with the adoption of the convention on tobacco control adopted in 2003.
3 South Centre, Innovation and Access to Knowledge Programme Background Note on the Sixty-Ninth Session of the World Health Assembly, 23-28 May 2016.
*Germán Velásquez is the Special Adviser on Health and Development of the South Centre. This article first appeared in South Bulletin 98, 17 March 2017. [IDN-InDepthNews – 17 March 2017]
Photo: The competition for the leadership of the World Health Organization is now down to three (left to right): Britain’s David Nabarro; Pakistan’s Sania Nishtar; and Ethiopia’s Tedros Adhanom Ghebreyesus. Source: devex | UN and the World Economic Forum.
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