PHA-Exchange> WHO in Transition

[aviva]

From: "DBanerjee" <nhpp at bol.net.in>

The Rockefeller Foundation and The Lancet had brought together scholars
from
different parts of the world to participate in a consultation on: The
World
Health Organization: A Time of Transition during May 5-9 2003 at
Bellagio in
Italy. Apart from the heads of the host organisations, there have been
key
participants in their individual capacities from WHO, World Bank,
Harvard
University and the International AIDS Initiative, on the one hand and
those
who have been associated with work among people living on the `other
side of
the moon', on the other. It did not simply reveal the enormous gulf
existing
in between the two schools of public health scholars, but it also
provided a platform for narrowing the gap through presentation of
scientific
evidence based on the WHO Constitution and the Alma Ata Declaration.

The hosts had been successful in creating a congenial setting for
interaction
among the participants on a wide range of issues: Global Health in the
Next
Decade; Surveillance and Public Health Policy; Standards and Norms
Setting;
International Health Law: WHO's role as an advocate; Global
Partnerships;
National Health Systems; Health Research Strategy; Transparency and
Accountability in WHO's Functioning; WHO Staff Morale and Capacity.
They
will prepare a full report on the consultation. Professor David
Sanders may also share his experiences with other members of PHM, when
he
visits Geneva. As I had sought inputs from some of the members of PHM,
I am
sharing my personal views on some of the important issues:

 1. I had felt that WHO has strayed far away from its Constitution
which
enjoins it to work for promoting health of all the people of the world.
I
pleaded forWHO's renewal of commitment to equity by attending to the
needs
of the poorest who are unserved and underserved and promoting the
principles
of Primary Health Care worldwide, including use of essential drugs,
appropriate technology and traditional systems of medicine.

 2. I had singled out use of highly questionable data in policy
formulation by WHO as the most important flaw in its functioning.
Absence of
good baseline data
has made it impossible to carry out any surveillance and evaluation of
its
selective global initiatives, such as those in immunization,
tuberculosis,
AIDS and malaria.

 3. I had also raised the question of ethics in WHO's use of
`estimates' of different diseases on the bases of such data and using
them
for calculation of DALYs and DALE and global burden of diseases. I had
contended that lack of transparency and accountability in WHO is the
outcome
of
use of such flawed data. I had also pointed out how use of such flawed
data
has called into question the cost calculations made by the Sachs
Commission.
Giving of highly paid WHO jobs to key government negotiators in return
for
their `cooperation' in securing government acceptance of a WHO
programme was
given as a blatant example of conflict of interests which amounted to
offering of bribes.

 4. An insightful observation mentioned that there are `Two WHOs'. One
ought
to be WHO of high technical excellence; the other ought to be a WHO
high
moral stature. By and large, WHO's record has been dismal in both the
fields. The success of getting approval of the Framework Convention on
Tobacco-free Initiative in the teeth of bitter opposition by powerful
vested interests was held up as a rare achievement of the Moral WHO. It
was
emphasised that WHO similarly stands up to pressures of one or more of
its
member states in fulfilling its moral obligations, even if that meant
foregoing substantial financial
contributions to its budget.

 5. WHO's record in promoting partnership with transnational
corporations,
particularly those in the pharmaceutical sector, offers instances of
compromise of its mandate in return for financial support. It was
rightly
contended that the discourses and practices of `civil society',
`public-private partnerships (and `multistakeholder dialogues') tend to
make
TNCs and their business associations into legitimate public-policy
makers.
Over and above, there is the rise of legally independent global
alliances,
such as GAVI, GAIN and the Global Fund, which seek to severely
undermine the
notion and possibilities of democratic international policy making ( I
have
made use of inputs from PHM) .
Expectedly, an attempt was made in the consultation to designate E Merk
as a
`civil
society', as it
has to respond to its stakeholders. This idea was, however, hastily
withdrawn
because of widespread objections from other members.

 6. Unfortunately, the participants could not go into the root causes
which
have hindered the development of a research strategy to support the
health
services during the past several decades. This is probably due to lack
of
capacity for conducting research among those who set out to promote
capacity
building in other countries. What has been the outcome of WHO's long
activities in the form of having research units to back up the
Global/Regional Advisory Committees on Medical/Health Research? In what
way
the International Commission for Research for Development, 1990 and its
subsequent high pressure promotion of `Essential National Health
Research'
contribute to research inputs to strengthen the health services? How
did the
 International Commission on Health Research for Development of 2000
improve the dismal record of research? How is it that the  highly rated
members of the Sachs Commission gave different meanings to term,
operational
research, at three different places in the report, while the use of OR
has
paid rich dividends in optimising health systems in India as far back
as in
1961? Such questions, once again went unanswered.

 7. Perhaps the inability to grasp the issues in implementing health
systems
research is also linked with inadequate understanding of a national
health
system. It is an outcome of a complex interaction of a large number of
sub-
and sub-sub-... systems which require the use of such interdisciplinary
methods as OR and systems analysis and linear programming. As far back
in
the
1950s, Hugh  Leavell had concepualised it on the bases of the natural
history of various health problems in an individual; similarly, Edward
Macgavran had visualized it as a practice of `community-side medicine'.
Invoking the works of Dubos and of Grigg, they have also shown how the
trends in the natural histories of health problems in a community over
a
time horizon can be used in health systems development.

 8. Significantly, the question of WHO staff morale and capacity came
up
only incidentally. Reference was made to the damaging report on the
administration and management within WHO by Lerer and Matzopaulos of
Health
Care Initiative of Paris. It was also possible for me to use inputs
from PHM
to raise the voice of those within WHO who were disappointed at the
refusal
of WHO to take a stand on the impact of the war on the health of the
Iraqi
people and how the murmurs were suppressed by the higher echelon in
bluntly
asking these people to submit their resignation if they did not like to
go
along with WHO's stand. This marks a new low in WHO's moral stature.

 9. There was also a discussion on the manifesto given by Dr JW Lee,
based
on his response to the ten questions posed by the Lancet, prior to his
election for nomination as the DG by the EB/WHO. It is yet to be seen
how he
can reconcile his activities of the past two decades with some very
encouraging ideas he wishes to implement (e.g.. decentralisation and
transparency and accountability). It is, however, clear that he intends
to
pursue the recommendations of the Sachs Commission and that he intends
to
pursue the partnerships concepts which were developed by his
predecessor..
How do these then measure up with his commitment to follow his vision
of the
WHO Constitution?

I am glad that I could  raise (along with inputs from some PHM
members)
the voice of the voiceless. 

Debabar Banerji
Emeritus Professor,
Jawaharlal Nehru University,
New Delhi