(Photo: Christoph Engeli)

The World Health Organization’s overall goal as defined in Article 1 of its Constitution is “the attainment by all peoples of the highest possible level of health”. In order to achieve its objective, the organization was endowed with extensive normative powers “to act as the directing and co-ordinating authority on international health work”. However, in the changing global scenario, the World Health Organization (WHO) has been facing increasing challenges in playing that leading role deriving from its constitutional mandate.

In December 2010 Jack Chow a former assistant director general of WHO, considering the organization as “outmoded, underfunded and overly politicized”, put forward a provoking question: “Is the WHO becoming irrelevant?” (Chow 2010) The first answer came from WHO's Director General, Dr. Margaret Chan. She explained that given “today’s crowded landscape of public health” leadership cannot be mandated but must be earned through strategic and selective engagement. “WHO can no longer aim to direct and coordinate all of the activities and policies in multiple sectors that influence public health today” she added. (WHO. The future of financing for WHO 2011)

Increased inefficiency of the global health system

On one side, with the acceleration of the globalization process the social determinants of health have been considerably affected by dynamics outside the health sector. On the other, while an unprecedented level of global funding has been directed to health issues over the last two decades, the increase was mostly driven by vertical initiatives for the control of HIV/AIDS and a few other diseases. This was associated with the mushrooming of new organizations and global public-private ventures, bilateral programs and the rise of non-state actors – over all the Bill and Melinda Gates Foundation – that often overshadowed WHO and brought to increased inefficiency of the global health system, an unsustainable fragmentation also at country level, and confusion in global health governance. Finally WHO had to face priority-setting and planning constraints imposed, among others, by the way it is financed.

Regular budgetary funds (RBFs) are provided through a series of assessed contributions from member states calculated biennially according to the UN scale of ability to pay (based on GNP and population). On the basis of the system a small number of high-income countries provide most of WHO’s core funding. Within its regulations, the WHO attempts to maintain autonomy by enforcing the rule that no single country can contribute more than 1/3 of the total RBFs. However, the US remains the largest single source, providing 22% of the RBFs. (Lee 2009)

From the 1950s additional voluntary contributions, i.e. Extrabudgetary Funds (EBFs) came to provide a vital, though highly earmarked, non flexible, source of financing for disease control and eradication programs. In the 1970s EBFs accounted for 20% of total WHO expenditure, with over half of these funds coming from other UN organizations. At least in part in response to the alleged “politicization” of UN agencies such as UNESCO and the International Labour Office (ILO), in 1982 major donors (known as the Geneva group) imposed a policy of zero real growth (adjusting for inflation) to the regular budget of all UN organizations, that remained in place until 1993 when an even more austere zero nominal growth (not inflation adjusted) was introduced. (Lee 2009) In a similar fashion, some of WHO's initiatives had been strongly opposed. “Health for all” and the Primary Health Care strategy was counteracted by the “Selective PHC”. The International Code of Marketing of Breast-milk Substitutes was adopted with the opposing vote of the United States. Finally, the Essential Drugs Program, harshly opposed by US-based pharmaceuticals companies, led the United States to withhold their contribution to WHO's regular budget in 1985. (Missoni 2009)

Gates Foundation as the second largest donor

Since the freezing of RBFs in the 1980s WHO has seen an increase in the proportion of EBFs largely earmarked by funders for special purposes. By the mid-1990s EBFs already exceeded RBFs and today they represent around 80% of the total budget of the organization. In 2010 almost 53% of EBFs come from member-states and 21% from the United Nations and other intergovernmental organizations, and 26% from private donors including Foundations (18%), NGOs and other institutions (7%) and corporate sector (1%). The Bill and Melinda Gates Foundation ($220 m) is the second largest donor after the USA ($280 m). (WHO. Voluntary Contributions 2011)

Over 86% of the voluntary contributions have no degree of flexibility and lack predictability, challenging WHO's priority setting, planning ad implementing capacity. In fact, while the WHO exerts discretionary control over the RBF, through EBFs donors increase their control over planning and management. In addition the already scarce RBFs suffer from the arrears to the WHO of a number of countries, including the United States whose arrear was equivalent in 2010 to about 5% of WHO's Regular Budget. (WHO. Status of collection of assessed contributions 2011) Correcting this situation and avoiding the possibility for members states and non-state donors to use the financial leverage to influence WHO's strategies is of paramount importance and represents an obvious priority.

Thus is it not surprising that focusing on the above mentioned imbalance between assessed and voluntary contributions the idea of Reform has been on the WHO agenda since May 2009. However, it gained extra speed and scope over the last year. The item discussed under the title "The Future of Financing for WHO" (A64/4) presented at the sixty-fourth World Health Assembly (WHA) (Geneva, 16-24 May 2011) actually introduced a broader reform plan containing far-reaching agenda likely to reshape the way in which the organization operates, is governed, makes decisions and is financed, and probably its overall role in the global public health arena.

The report touched upon seven issues: focusing core business (summarized in: Convening for better health; Generating evidence on health trends and determinants; Providing advice for health and development; Coordinating health security, and Strengthening health systems and institutions); Increasing Organizational effectiveness; Improving results-based management and accountability; human resource policy, planning and management; Strengthening financing, resource mobilization and strategic communication; WHO’s effectiveness at country level, and WHO’s role in global health governance. (WHO. The future of financing for WHO 2011)

WHO’s role in global health governance

In relation to the questioned relevance of WHO in today's world, the latter is possibly the most compelling issue, encompassing all the others. No surprise that attention of many observers, especially those expressing the views of civil society committed to a stronger WHO “playing a leading role in global health governance” (People's Health Movement 2011) was especially focused on it.

As an essential element of the new global health governance system, the report proposed the creation of a World Health Forum (WHF), a multi-stakeholder forum, to be held in November 2012, involving Member States, civil society, private sector, academia and other international organizations, and with “a role in identifying, from the different perspectives of its participants, future priorities in global health”. Nevertheless it was reassuringly anticipated that the proposed mechanism “may help shape decisions and agendas, but it will not usurp the decision making prerogatives of WHO’s own governance”. In a previous paragraph, however, the document stated that WHO would meet “the expectations of its Member States and partners”, and this reference to “partners” beyond the Members States was a reason, among others, for serious concerns expressed by several Member States and civil society organizations, fearing an increasing influence of the private sector and donors in setting the health agenda in the WHO. “How can the WHF meet the expectations of commercial actors without usurping the prerogatives of WHO’s own governance?” could be read in a joint statement circulated by major civil society networks. (IBFAN Press Release 16th May 2011)

An additional reason for mistrust was due to the late appearance of the “detailed development plan for the program of the reform” just days before the World Health Assembly. “Calling for endorsement of a general plan without detail is asking Member States to sign a blank cheque” commented the People's Health Movement, a position echoed by many others representatives of non-governmental organizations, that Nigel Hakes, on the British Medical Journal, tagged as “the purists who believe WHO should not sup with the devil” and to whom the proposal of such a World Health Forum “looked like an attempt to subvert WHO's principles of governance and cosy up to private industry”. (Hawkes 2011) Worrying was also the unveiling of the plan of WHO's Secretariat to let partly fund the reform program by the Bill and Melinda Gates Foundation, an information that one cannot avoid to directly link to the repeated deferential reference to that global philanthropy made by Margaret Chan to Bill Gates in her closing remarks at the WHA. (Chan 2011)

The WHA endorsed the agenda for Reform as set out by the Director General (DG) and requested the Executive Board to establish an appropriate process to examine the issues related to WHO’s governance identified in the report. (WHO. WHO Reform 2011) Discussion at the WHO Executive Board (EB) meeting immediately following the WHA, pushed for a more transparent and Member State-driven process, resulting in the adoption of a new decision on WHO's reform.(EB 129/8) This new decision set out a more transparent and inclusive consultative process for the finalization of a reform plan in the following six months for consideration of a Special Session of the EB (SSEB) to be convened in November.

Regaining the leadership of the reform process

Concept papers on relevant parts of the reform process (Governance, Independent Evaluation, and World Health Forum) were released in July 2011 by the WHO Secretariat WHO. These papers were subject to further consultation and revision between August and the end of October, including a web-based consultation and face to face discussion at the six regional committees which met in that period. By mid October the DG circulated a new version of WHO Reforms for a Healthy Future building on and incorporating comments on the three earlier discussion papers and a new Road Map for organizational review and reform for discussion at the SSEB. (WHO. WHO reforms for a healthy future 2011) The report covering reform proposals with 18 recommendations organized in three broad areas – Programs and Priority-setting, Governance and Managerial Reforms – was presented by the DG at the Special Session of the EB that took place in Geneva from the 1st to the 3rd of November 2011. At that stage, Dr. Chan communicated to the participants that the controversial proposal for a World Health Forum had been abandoned as “feedback from Member States was not supportive.”

In a lengthy debate, involving the representatives of some 100 member states, including those represented on the EB, and interventions from civil society representatives, the EB substantially reviewed and amended the proposal prepared by the Secretariat, in a fashion that some observers would perceive as an attempt to regain control of the leadership of the reform process. (WHO. Executive Board 2011)

On “Programs and priority-setting” the EB's decision clearly established that “a Member State-driven process” would be put in place following the Executive Board at its 130th session in January 2012, with a view to providing recommendations for the consideration of the Sixty-fifth World Health Assembly in May 2012. To that purpose the EB asked the Secretariat to prepare by January 2012 a back-ground document with in depth information on a number of issues such as: current criteria and mechanisms for priority setting, their application to planning and impact on resource allocation and results; current activities carried out at all levels of the organization, and resources allocated correspondingly; proposals for how criteria and priorities could be set and applied in the future and a detailed proposal for a Member State-driven process.

In relation to “Governance” the EB's decision stated that in search of inclusiveness the principle of multilateralism should be respected and made clear that “WHO’s governing bodies have a key role in priority setting, with the Health Assembly playing a policy and strategic role and the Executive Board playing a strengthened advisory, executive and oversight role”. Even the engagement with other stakeholders should be guided by “the intergovernmental nature of WHO’s decision-making” which “remains paramount”, whereby “building on existing mechanisms should take precedence over creating new forums, meetings or structures”. Besides recommendations to increase the efficiency of the work of governing bodies (including some relatively micro-managerial ones such as the reduction of draft-resolutions or the institution of a “traffic light” system and enforcement by chairmen of time-limits in the debates) and to improve coordination, once again a strengthened collaboration – “as appropriate” – with non-state stakeholders was recommended with the important caveat of taking into account the “managing conflicts of interest”. Nevertheless, “options for a framework to guide interaction between all stakeholders active in health” were left to be explored “in the longer term”.

A smuggled in reform

About the Managerial reform the EB requested the DG to take forward the proposals contained in the proposal of the Secretariat related to: organizational effectiveness, alignment and efficiency; financing of the Organization; human resources policies and management; results-based planning, management and accountability, and strategic communications. Made aware by the WHO's staff association of ongoing restructuring, resulting in a loss of jobs for nearly150 staff, the EB urged caution and further analysis and consultation in areas of reform such as strategic relocation of staff, resources, programs and operations, as well as in relation to the proposed introduction of an annual “budget re-costing mechanism” to protect against currency fluctuations that have been severely affecting the organization's budget in concomitance with current global financial turbulence.

Finally the EB decided to proceed with an independent evaluation, to be implemented in a two-stage approach in parallel with other aspects of the reform, to provide input into the reform process. The first stage consisting of a review of existing information with a focus on financing challenges for the Organization, staffing issues, and internal governance of WHO to be completed in time for the Sixty-fifth World Health Assembly. Stage two of the evaluation would build on the results of stage one and further consultations with Member States, focusing in particular on the coherence between, and functioning of, the Organization’s three levels: global, regional and national.

Adequate and transparent information on which to base decisions is a prerequisite to decision. Thus the statement by the DG that the evaluation “will proceed in parallel to other aspects of the reform” (WHO. WHO reforms for a healthy future 2011) elicited concern among civil society organizations for the illogical sequencing of management reforms running in parallel with a formal evaluation, with strategical staff relocation happening before organizational priorities and structure can be reviewed. (People’s Health Movement 2011)

Work done during the SSEB enables the regular January 2012 Board meeting to do the groundwork for taking specific reforms further and prepare the ground for the World Health Assembly’s meeting in May 2012. Where the reform is heading is still difficult to say, however it is clear that both process and content will be further debated.

Regarding the former the fact that the Reform process was introduced, rather smuggled in, through considerations on financial difficulties without analytical considerations and rationale for the reform, is disturbing. (People’s Health Movement 2011)

In terms of contents, three aspects appear to be critical: Empowering WHO in its constitutional mandate; ensure predictable, flexible financing; strengthening the country level.

What is the vision?

The vision of the World Health Organization appears to be the first and overarching aspect to define. As “Governments are no longer the sole stewards of public health” for an intergovernmental organization such as WHO “it is unclear what role the WHO should even play anymore” points out Jack Chow, highlighting how new actors (such as the Global Fund to fight Aids, Tuberculosis and Malaria, and the Bill and Melinda Gates Foundation) “are taking health in their own hands” and the WHO is no longer setting the agenda of global health”. (Chow 2010)

Noting the broad range of actors now involved in the field of global health, with private firms, foundations and NGOs playing an important role across national borders, Kirton and Cooper insist on the emerging of a multi-stakeholder, multi-level governance and the “incomplete” power of international organizations, exemplified in WHO. In assessing the responsiveness, appropriateness and effectiveness of the current “Westphalian” system they conclude that the question of “who beyond the state has the responsibility to respond to the rights that all individuals in the world presumably possess”, goes still unanswered. (Kirton/Cooper 2009)

The second aspect to consider in this context is how to give voice to multiple stakeholders of global health, but also to be able to differentiate among them and their respective interests in participating in the governance of global health, and their coincidence or distance from the objectives and public interest mandate of WHO.

WHO decisions and commercial interests

Those who saw in the proposal for a Global Health Forum “a major step” of the Director General (DG), also claimed that the new setting should afford stakeholders “real voice and representation, effectively shaping the WHO's decisions”. The same authors seems to see some risks inherent to that request where they add that “while actively engaging the private sector the WHO should also set standards for and ensure compliance of key private partners such as the food, pharmaceutical, and biotechnology industries”, as well as assure clarity and enforcement of conflict-of-interest rules. (Sridhar/Gostin 2011) It seems rather naive to imagine that stakeholder allowed to shape WHO's decisions would do it against their commercial interest!

Experience tells that even when left out of the room, private interests conflicting with those of public health, make their way into the decision-making process through heavy lobbying and complicity of likeminded governments. This can only been counteracted by an equally organized lobbying of civil society movements and other public health advocates, and obviously by the integrity of both national and international civil servants. In that sense, the establishment of the Framework Convention on Tobacco Control (FCTC), a legally binding treaty for countries that ratified the agreement, represents one of the highest example of what WHO can achieve, even against the powerful interests of the Tobacco cartel and with the opposition of its most influential Member States. (Missoni 2009) The negotiation of the FTCT, a process explicitly framed from the outset as a necessary response to an issue strictly linked to global political and economic change, can be regarded as the paradigmatic example of the WHO's interest in developing new dynamics of health governance in response to globalization, a global complement to national actions. Holding of public hearings, open to all stakeholders including civil society, and tobacco industry, represented a good example of how to ensure adequate voice to stakeholders and take advantage of their contribution. (Colin/Lee 2009)

The International Health Regulations (IHR) were the only other international legally binding agreement led by WHO. In 2003, as part of the Global Outbreak Alert and Response Network, WHO adopted the possibility of gathering outbreaks data from non-states actors communicating directly with internet-connected and empowered citizens. That possibility subsequently included in the IHR, is just another example of how WHO's action can take into account challenges and opportunities of a globalized world without the need to recur to the establishment of new “global” structures, rather reaffirming its unique competence, and mandate, as the global health regulatory authority. (Kirton/Cooper 2009)

Regulating key health issues

Recognizing that challenges to health more than ever are linked to social and economic determinants external to the health sector, cannot be an excuse to limit WHO's role in “activities and policies in multiple sectors that influence public health today”. (WHO. The future of financing for WHO 2010) It rather calls for WHO taking more active role in regulating on key issues with an impact on health, including alcoholic beverages, food safety and nutrition, and energetically engaging in international regimes with powerful health impacts such as trade, intellectual property, finance and climate change. (Sridhar/Gostin 2011) WHO, indeed remains the appropriate institutional instance for regulatory and legislative efforts related to issues that overlap with other realms of international concern (such as human rights, trade, environment, and others) but are central to the public health mandate of WHO and beyond the core mission of another public international organization. (Taylor 2002)

Some consider that politics should be maintained out of WHO and would prefer to see its role reduced to that of a purely technical body. But politics has been invariably embedded in the WHO throughout its history. The challenge is not to somehow remove politics from the organization, but rather to ensure its healthier political functioning. (Lee 2009)

The Executive Board (EB) requested the Secretariat to take forward the proposal to “improve Organization-wide resource mobilization” but care should be taken to engage with donors without putting at risk WHO's authority and independency. In her report to the WHA in May, Dr. Chan said that WHO will “seek to attract new donors” including foundations and the private and commercial sector and she added “without compromising independence or adding to organizational fragmentation”. (WHO. The future of financing for WHO 2010) Legitimate concerns were expressed about risks of “privatization” of WHO through unsafe or inappropriate relationships and institutional conflicts of interest, if those are not clearly spelled out before establishing any fund-raising activity. To “attract” resources WHO may need to offer something in exchange to potential private donors, and it has not much more to offer than some space on the “driver seat” and may be a hand on the steering wheel!

In its Special Session the EB also agreed that WHO's five core areas of work should concentrate on health development, health security, strengthening health systems and institutions, generating evidence on health trends and determinants, and convening for better health.

Finally, the overall responsibility over WHO belongs to Member States. It is up to them to act collectively as “genuine shareholders” and refrain from exerting narrow political interests. (Sridhar/Gostin 2011) Choices made by the EB and decisions taken by the WHA will forge the future of the organization. The vision that will prevail will determine if WHO will be empowered “to act as the directing and coordinating authority on international health work”, or downgraded to some kind of technical adviser subordinated to global private interests, whether corporate or philanthropic, and definitively displaced by the so called Global Public Private Partnerships (GPPS), mainly fed by States. Among them those that deny untied contributions to WHO.

There is no doubt that WHO quickly needs to reposition itself in a leading role in the wider global health governance scenario, supported by the necessary resources and trust to fully exert it. Trust that can only be built on its capacity to act independently from external undue influences, in the sole interest of public health and peoples' right to “the attainment of the highest possible level of health.”

*Eduardo Missoni is a Medical doctor, specialist in Tropical Medicine at the Rome University "La Sapienza" and Master of Science at the London School of Hygiene and Tropical Medicine. Since September 1st, 2002 he has been adjoint professor at the Università Commerciale "Luigi Bocconi" of Milan. He also teaches at the Faculty of Sociology of the Bicocca University of Milano. His main teaching and research fields are Global Health and Development Cooperation. He is a co-founder and former president of the Italian Global Health Watch (OISG – Osservatorio Italiano sulla Salute Globale). Contact: mail@eduardomissoni.net

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