PHA-Exch> The Commission on SDH's Report and WHO - A follow-up

[Claudio Schuftan]

As a f/u to yesterday's Reflection:


>  *The underlying values and ideology of the leadership of the Global
> Health Institutions:*
>
>
>
> 1.Unfortunately there is no global agent to act in humanity's interests in
> an unbiased, neutral way. To a higher or a lesser degree,  all actors on
> the global stage work in their own interest or, in the case of
> organizations,  the interest of its more powerful members. As is true for
> other UN bodies, WHO is a meeting place in which the nations of the world
> pursue their own values and often narrow interests. Because of the huge
> disparities in the power of individual members, WHO is no exception to this.
> Global politics do influence WHO's ideological position vis-a-vis global
> health and particularly the social determinants of health (SDH).
>
>
>
> 2.This being said, one can ask: Is there a distinct leadership in global
> governance (GG) in health? And the answer would be: Not really.
>
>
>
> 3.So, where does this dispersed leadership lie then?  Leadership is only
> to a lesser and a more *technical* degree exerted by WHO. (We are all
> aware that mostly doctors with upper-middle class values occupy strategic
> positions in WHO; they are primarily technocratic and not really (yet)
> attuned to the importance of  the SDH). A good part of the leadership in
> health has shifted to the World Bank (WB) and global public-private
> partnerships (PPPs).  WHO has, therefore,  really only become a partial
> global 'actor' in the global health scene.
>
>
>
> 4.The de-facto shift of the GG leadership and health-influencing power to
> the WB has made the role of WHO's regional offices, the WHA and WHO's
> Executive Board significantly more limited.  WHO has also lost its role as
> a GG leader in good part by the proliferation of PPPs which are undermining
> a coherent global and more comprehensive (as opposed to disease-oriented)
> response to poor health, as well as the development of the capacity of
> national health systems in many poor countries.  The benefits, risks and
> costs of global public-private partnerships have never been openly debated
> and compared to alternatives. WHO needs more transparency in establishing
> and dealing with these PPPs to safeguard against conflicts of interest.
>
>
>
> 5.Additionally, WHO has become ineffective as a global leader in health due
> to the following reasons:
>
> ·         With the deepening and entrenchment of poverty through the
> unfair and exploitative structure of the global political economy, on top of
> international financial institutions and PPPs, other actors such as the
> governments of the G8 and transnational corporations (mostly pharmaceutical
> houses) have gained undue influence on health issues that also often
> outweighs WHO's. On top of this, groups with an interest in preserving the
> status quo overtly or covertly want to weaken WHO's public health ability to
> tackle the structural determinants of preventable global ill-health,
> malnutrition and poverty. Under pressure, WHO has often been forced to take
> a weakened position on important economic (and health) issues.
>
> ·         WHO's core funding has remained static; its budget amounting to
> a tiny fraction of the health spending of rich member states. In addition, a
> large (more than two thirds) proportion of WHO's expenditure comes in the
> form of conditional, extra-budgetary funds that are earmarked for specific
> projects by contributing countries. This definitely distorts priorities when
> conforming to the desires of donors (as in the case of many an NGO...).  An
> example from the health sector would be: We have seen Herculean efforts and
> donor resources being poured into the Expanded Program of Immunization; who
> could fault that when it saves children's lives? But saves lives for how
> long?: Until the child saved from dying from one of the six immunizable
> diseases, because s/he is malnourished and lives in a poor and contaminated
> environment, falls prey to a pneumonia or a diarrheal episode for which we
> do not have a vaccine yet…  Who are we fooling here?
>
> ·         Since WHO has been forced to increasingly rely on private
> sources of financing and on public-private partnerships, this, has resulted
> in a subtle erosion of public accountability and public health principles to
> accommodate the commercial and business interests of its new partners while
> adding to the problems of fragmentation of governance by adding even more
> institutional partners to the international health aid mix.
>
> ·         WHO is ineffective at country level, where under-resourced WHO
> offices are attached to low-prestige ministries of health, and
>
> ·         There are internal management and administrative weaknesses, as
> well as an over-abundance of doctors in WHO. This is said to sustain the
> skewed bias towards biomedical approaches to health reform, away from
> tackling the SDH.
>
>
>
> 6. Because of what the WB, PPPs and the other actors depicted above stand
> for, what all this has meant ideologically is that there has been an
> increasing application of the neoliberal economic model to health.
>
>
>
> 7. Espousing these principles, the World Bank operates in direct
> competition with WHO as the leading influence in developing country health
> sector policy. This influence has been inadequately challenged in public by
> WHO, causing it to lose credibility and authority. WHO simply remains
> inadequately equipped and ideologically ambivalent to question and challenge
> the public policy prescriptions and advice of the Bank. Therefore, while WHO
> is often the target of advocacy messages, it is not the right addressee to
> send our advocacy messages to.
>
>
>
> 8.As a consequence, the values that underlie the predominant present GG in
> health stand mostly for technical and managerial fixes, for privatization,
> for vertical programs, for disease-centered approaches: all technocratic and
> top-down. But, as the CSDH is trying to prove, the difficulty with these
> approaches is that they tend to work in favor of the powerful rather than
> the weak.
>
>
>
> 9.Given these characteristics of the current global health governance
> leadership, the changes that are badly needed are unlikely to come from
> above. Needed are more bottom-up empowering interventions.
>
>
>
> 10.We contend that WHO needs to strengthen its role, authority, leadership,
> capacity and accountability to improve global health and health equity.
> There is no other way. Therefore, among other, extra-budgetary donations to
> WHO must be made to follow agreed overall priorities. And, as is contended
> by the CSDH, WHO must work towards a more focused action agenda that shifts
> emphasis towards the SDH.
>
>
>
> 11.*To achieve this, WHO will have to take measures to position itself as
> an organization of governments, as well as of the people.* This involves
> opening up to representation of broader groups of interest, including civil
> society, and setting up explicit processes that ensure a wide range of
> voices is heard and heeded. Greater openness will bring many benefits,
> including closer scrutiny of policy developments and creating a* *counterweight
> to the ability of rich member states and corporate interests to bully WHO.
> Southern civil society organizations need particular support to have such a
> more direct voice.  The benefits and importance of civil society, NGOs and
> networks like the People's Health Movement participating in the advancement
> of health through global health governance structures is well-recognized,
> and provides a counter-weight to the indifference of many governments
> towards the social justice and health rights of the poor and the vested
> interests of corporations.
>
>
>
> 12.For this participation to work, there needs to be a shared, coordinated
> and planned advocacy and action agenda amongst the various civil society
> organizations (CSOs) committed to improving global health, first of all, for
> the achievement of  'Health For All Now'.
>
>
>
> 13.The advocacy strategy should, among other, include:
>
> ·         A naming and shaming campaign* *targeted at countries that are
> not fulfilling their commitments to the funding of WHO.
>
> ·         More coordinated lobbying during the World Health Assembly*. *Civil
> society presence at the World Health Assembly is inadequately coordinated;
> ergo, a process to coordinate civil society participation is needed.
>
> ·         Ensuring a strong and SDH-committed leadership.* *The
> politicized, non merit-based nature of the elections of the director-general
> (and regional directors) needs to be challenged. Candidates must publish a
> campaign platform and WHO facilitate widespread debate of the same before
> the most qualified candidate is offered the position.
>
> ·         A strategic assessment document of where WHO should be more
> influential in the interests of health and its social determinants needs to
> be commissioned followed by an* *explicit campaign to promote the mandate
> of WHO to engage more vigorously in tackling the structural and social
> determinants of health.
>
> ·         Civil society needs to set up a 'monitoring and watchdog'
> program around discrete subject areas of such a new approach. It would at
> least include monitoring actions of:
>
> o        The Executive Board, its directives and agenda setting.
>
> o        The annual WHA resolutions being implemented.
>
> o        WHO-corporate partnerships.
>
> o        WHO strengthening key regional and WHO country offices, and
>
> o       WHO gradually changing the professional backgrounds and skills mix
> of its staff.
>

Claudio Schuftan, Ho Chi Minh City
cschuftan at phmovement.org
__________________

>  Reference:
>
> 'Making WHO Work Better: An Advocacy Agenda for Civil Society and NGOs' (*A
> discussion document produced by the Global Health Watch 2 Working Group,*July 2006
> *)*.
>
>
>
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