Can the World Health Organisation be reformed?

5 August 2011

The keynote speaker was Professor Lawrence Gostin, Linda and Timothy O'Neill Professor of Global Health Law at Georgetown University

The prospects for reform of the World Health Organisation (WHO) were explored in a lively seminar co-hosted on 2 August by Sydney Law School's Centre for Health Governance, Law & Ethics, and the George Institute for Global Health.

Chaired by Associate Professor Rebecca Ivers, Director of Injury Research at the George Institute, the seminar featured Professor Lawrence Gostin, Linda and Timothy O'Neill Professor of Global Health Law at Georgetown University, with responses from Professor Stephen Leeder AO, Professor of Public Health and Community Medicine at the University of Sydney, and Director of the Menzies Centre for Health Policy, and from Associate Professor Stephen Jan, Senior Health Economist at the George Institute, and Associate Professor in the Sydney Medical School.

The seminar was chaired by A/Professor Rebecca Ivers, Director of Injury Research at the George Institute

When the WHO Constitution came into force on 7 April 1948, WHO was intended to be the "directing and coordinating authority on international health work". WHO's unique Constitution gave it extensive regulatory powers, including the power to adopt both conventions, and regulations (the latter bind countries automatically unless they make a conscious decision to opt out).

As the first specialised agency of the United Nations, WHO was also born as a human rights organisation, with the goal of achieving the highest possible standard of health for all people. Health was conceived of broadly as a "state of complete physical, mental and social well-being and not merely the absence of disease".

In his keynote address, Professor Lawrence Gostin, who also directs the WHO Collaborating Centre on Public Health Law and Human Rights at Georgetown University, pointed out that despite these high hopes, WHO has failed to live up to the high expectations that its Constitution reflects.

WHO enjoys prestige as a scientific organisation, it has strong convening powers and the legitimacy of being an inter-governmental organisation run by its member States. At the same time, WHO exists in a changed landscape, overshadowed by influential and economically more powerful players in global health. These include large public/private health initiatives (eg the Global Alliance for Vaccines and Immunisation; the Global Fund to Fight AIDS, Tuberculosis and Malaria), large bilateral programs (eg the US President's Emergency Plan for AIDS Relief: PEPFAR), as well as private philanthropies with global reach (the Bill and Melinda Gates Foundation).

According to Professor Gostin (who has served as a member of the WHO Director-General's Ad Hoc Advisory Committee on the WHO and Global Health Governance), WHO has no significant footprint on a number of important issues that are now critically important to health, including international trade and intellectual property.

Furthermore, WHO is kept in a near-constant state of penury by its member states. In 2011, WHO faces a deficit of over $300 million. Only 30% of the WHO's budget is under its direct control; the remaining 70% comes from extra-budgetary- voluntary- grants from the European Union, the United States, Australia, the Gates Foundation, and other large funders. In 2008/09, 60% of extra-budgetary funding was directed towards communicable diseases, with negligible amounts for non-communicable diseases (3.9%), and injuries (3.4%). These disparities in funding necessarily influence WHO's strategic direction, and undermine WHO's capacity to direct resources in a manner commensurate with evidence of the burden of disease.

Professor Gostin's suggestions for reform of WHO, recently published in the Journal of the American Medical Association (in an article written with Dr Devi Sridhar), include giving key stakeholders- philanthropies, public/private partnerships, and NGOs- a clear decision-shaping role within WHO, through formal governance structures. The Director-General has recently proposed a Global Forum, which would report back to the World Health Assembly.

WHO needs predictable, sustainable financing that is scalable to the kinds of global challenges it needs to address. Responding to the gross imbalance between budgetary and extra-budgetary finance is one of the most difficult challenges WHO faces. Options include imposing higher assessed contributions from countries, or failing that, WHO could raise its overheads, retaining perhaps 20 cents of every dollar of extra-budgetary donations to support its core activities. Neither option is palatable and may be actively resisted by member countries; the latter could also potentially backfire, encouraging funders to re-direct their voluntary contributions to other agencies, and weakening WHO even further.

The responses were given by Professor Stephen Leeder, Professor of Public Health and Community Medicine at the University of Sydney, and Director of the Menzies Centre for Health Policy

In his response to Professor Gostin's paper, Professor Stephen Leeder pointed out why WHO continues to matter. The causes and solutions to global health challenges like global warming and non-communicable diseases lie across many sectors outside the health system, and no other agency is as capable as WHO in marshalling stakeholders and fulfilling the leadership role that is required in a multilateral environment.

WHO retains tremendous prestige around the world. It remains unsurpassed as a knowledge-based organisation: a repository for evidence about health matters worldwide. Professor Leeder raised the question: when you have an old organisation that is labouring and under stress, "with all the barnacles and decaying bits", will attempts to improve it achieve their intended goal, or could they result in unintended consequences that weaken WHO's contribution overall?

In his presentation, Professor Leeder focused on what Australia can do to support and strengthen WHO. In response to the need for greater accountability, and greater coordination of the activities of WHO's six regional offices, Professor Leeder suggested that "Australia can assist by ensuring that its participation in regional WHO activities is diplomatically tinged with recognition of the importance of keeping the head office on side and in the loop." Australia should also apply diplomatic pressure to assist WHO in its need for a predictable, sustainable budget- a budget which is miniscule when compared to the health budgets of many cities in developed countries, including Australia. Professor Leeder also argued that Australia should support WHO's efforts to strengthen legal capacity, including in relation to the control of non-communicable diseases.

-and by A/Professor Stephen Jan, Senior Health Economist at the George Institute, and Associate Professor in the Sydney Medical School

Professor Stephen Jan also replied to Professor Gostin's paper, floating a wholly novel example of the kind of legal leadership that WHO might provide. Currently, national health plans in certain low-income countries don't align well to the burden of disease. At the same time, countries are reluctant (like WHO itself) to turn away funds from willing donors. Nevertheless, large bilateral grants, given to fund specific concerns (such as vaccination, or HIV/AIDS) can cause tremendous damage at the country level, by diverting local resources away from publicly-funded programs, siphoning off scarce human resources, and weakening country health systems overall. Professor Jan pointed out that public sector health care services, and chronic disease programs, in particular, tend to lose out.

One possible solution, in Professor Jan's view, would be to develop an international framework through which countries could make a collective commitment to accept development aid only when it is aligned with and would not undermine the achievement of the health priorities set out in national health plans. If the conditions to the receipt of vertical funding were made collectively, this could encourage a culture where all prospective funders invested framed their investments for the longer-term benefit of the health system and health workforce of the recipient country. It is difficult to think of any organisation other than the WHO that would be better placed to act as an honest broker in facilitating this kind of framework.

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