Truth to power: reforming the World Health Organization

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The World Health Organisation has a vital role to play in global health but 65 years after it came into being, it’s plagued by ossified structures that prevent it from exercising the flexibility it needs to become an efficient and effective organisation.

The United Nations created the World Health Organization (WHO) on April 7th, 1948 as the first UN agency — a date we now celebrate annually as World Health Day. The WHO Constitution expresses the universal aspiration that health is “basic to the happiness, harmonious relations and security of all peoples”.

The WHO today remains the undoubted leader in global health: there is no substitute for the organisation, with its incomparable expertise, global influence, and normative powers.

Despite this rich endowment, the organisation faces a crisis of leadership. Even its former Assistant Director-General recently asked, “Is WHO becoming irrelevant?” Given the importance of global health cooperation, few would dispute that a stronger, more effective World Health Organisation would benefit all.

My colleague Devi Sridhar and I have made five proposals for re-establishing WHO’s leadership.

1) Give voice to multiple stakeholders

As an agency of the United Nations, the World Health Organisation is comprised solely of member countries, which govern through the World Health Assembly (WHA) and Executive Board (EB).

Yet, WHO would be more effective if it gave a voice and representation to key stakeholders, including philanthropies, businesses, public/private partnerships, and civil society.

The world of global health is rapidly changing with powerful new players such as the Gates Foundation and the Global Fund for AIDS, Tuberculosis, and Malaria.

The WHO is currently taking a major step in proposing a Global Health Forum—regular multi-stakeholder meetings under the guidance of the WHA.

The Global Health Forum must afford stakeholders’ real voice and representation for effectively shaping WHO decisions. Most importantly, the World Health Organisation must capture the energy and power of civil society, which is yearning for fundamental improvements in global health.

2) Improve transparency, performance, and accountability

Good governance also requires clear objectives, transparent decision-making, information dissemination, monitoring progress, and accountability.

Stakeholders will demand clarity on how their resources will achieve improved health outcomes, as they shift towards results-based financing and performance-based measures.

But a recent evaluation of multilateral organizations graded the WHO as “weak” on key parameters, such as cost-consciousness, financial management, public disclosure, and fulfilling development objectives.

To improve its standing, the organisation must rigorously evaluate programs and demonstrate that they effectively translate into better health for all.

3) Exercise closer oversight of regions

The WHO’s decentralized, regional structure poses a significant challenge in demonstrating results and delivering on priorities. The six WHO regional offices are uniquely independent within the UN system, with full power over regional personnel, including appointment of country representatives.

The World Health Organisation’s headquarters should exercise more oversight and control over regional personnel, funding, and decision-making. It is vital that the world’s leading global health organization speaks with one powerful voice.

4) Exert legal authority as a rule-making body

The WHO Constitution grants the agency extraordinary rule-making powers, but in more than 60 years the agency has promulgated only two major treaties: the International Health Regulations and the Framework Convention on Tobacco Control.

The organisation could take a more active role in regulating key global health issues, including counterfeit medicines, alcoholic beverages, food safety, and nutrition.

It could be more engaged and influential in international regimes with powerful health impacts, such as trade, intellectual property, arms control, and climate change.

The agency could exert normative power through innovative international treaties or through “soft” power such as codes of practice.

There must be strong enforcement and incentives for compliance. A Framework Convention on Global Health, for instance, could act as a powerful international treaty to set priorities, coordinate fragmented actors, and deliver results. The Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI) is a mass civil society movement advocating for this framework convention.

The WHO must offer leadership for urgent challenges facing the global health, such as emerging infectious diseases and noncommunicable diseases (cardiovascular diseases, diabetes and cancer).

5) Ensure predictable, sustainable financing

The World Health Organisation is financed through two main streams. First, member-states pledge a set amount based on each country’s wealth and population. The second stream is through voluntary contributions often earmarked for specific diseases.

The WHO is currently in a dire budget crisis, with a deficit of more than $300 million. More importantly, its extra-budgetary expenditure rose from 48.8% to 77.3% from 1998/99 to 2008/09.

It is unsustainable and unreasonable to have voluntary funding represent nearly 80% of the agency’s budget. Extra-budgetary funding has transformed the WHO into a donor-driven organization, restricting its ability to direct and coordinate the global health agenda.

Extra-budgetary funding also skews global health priorities. Mandatory contributions are more aligned with the actual global burden of disease than voluntary funding.

The WHO’s voluntary funding, for instance, is primarily for infectious diseases (60%), with negligible allocations for non-communicable diseases (3.9%) and injuries (3.4%). Yet, non-communicable diseases account for 62% of all deaths worldwide, and injuries constitute 17% of the global burden of disease.

The ideal solution for this is to set higher member state mandatory contributions. Member states must become genuine shareholders in the World Health Organisation’s future, act collectively, and refrain from exerting narrow political interests.

The WHO must undergo fundamental reform if it’s to retain its rightful place as the leader in global health. While remaining true to its normative and bold vision of health-for-all, the organisation must adapt to a new political climate, demonstrate global leadership, and deliver results.
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