PHM-Exch> ENGAGING IN GLOBAL HEALTH: WHO SETS THE AGENDA?

[Claudio Schuftan]

EQUINET NEWS IS THE ELECTRONIC MAILING LIST OF THE NETWORK FOR EQUITY IN
HEALTH IN EAST AND SOUTHERN AFRICA (EQUINET)

 http://www.equinetafrica.org/


*Editorial*

*ENGAGING IN GLOBAL HEALTH: WHO SETS THE AGENDA?*
Bente Molenaar Neufeld, The Centre For Trade Policy And Law, Canada

 The World Health Organization (WHO) states in its constitution that it aims
to achieve "the attainment by all people of the highest possible level of
health." The World Health Assemblies (WHAs) provide a key opportunity to
engage on the achievement of this aim. Yet in an interesting study by
Kitamura et al. in May 2013 in Health Policy reviewing the agendas of the
WHAs between 1970 and 2012, the authors concluded that "agenda items of the
WHA do not always reflect international health issues in terms of burdens of
mortality and illness."

So how are countries and stakeholders shaping the WHA agenda?

 One way is through the WHO Executive Board (EB), particularly as it plays a
role in setting the provisional agenda for the WHA. EB members are
individuals nominated by countries with technical expertise in health. Of
the 34 members of the Executive Board, seven are from the African region.
Currently these are from Cameroon (2011-2014), Chad (2012-2015), Namibia
(2013-2016), Nigeria (2011-2014), Senegal (2011-2014), Sierra Leone
(2011-2014) and South Africa (2013-2016). As EB members, they are
well-positioned to be heard and to bring concerns from their regions to the
table. They can also block issues being discussed. The WHO secretariat also
plays a role in agenda setting. Procedurally, the provisional EB agenda is
proposed by the WHO Director-General. Getting issues on the agenda for the
WHA is, however, not difficult. According to the rules of procedure, every
proposal brought by a member state and any proposals submitted by the DG
should be included in the provisional WHA agenda. So how are these policy
levers being used?

 Take the 2014 EB agenda for example. Many agenda items were not
controversial as they are carried over from previous years, after broad
agreement around their importance. This included non-communicable diseases
(NCDs), neglected tropical diseases and reform of the WHO. Other agenda
items may be more controversial. For example, when in 2012 the United States
of America and Thailand successfully petitioned to include lesbian, gay,
bisexual and transgender (LGBT) access to health in the WHO EB agenda for
consideration it provoked debate, with Egypt and Nigeria, on behalf of their
regions, asking for the item to be deleted.

 This issue exemplified how health concerns can reflect and raise political
division. Bringing health into diplomacy platforms, including that of the
WHO, poses a challenge for how to avoid foreign policy concerns
overshadowing health issues. The US delegate, Nils Daulaire, speaking about
the demands for deletion of the LGBT item in 2012 said that it was
"unprecedented for WHO member states to come together to attempt to remove
an item legitimately placed on the Executive Board agenda by another member
state. We believe it is important to afford each other the courtesy to
discuss these important health items, even those with which not everyone
agrees. Changing this deeply-established precedent risks politicizing all EB
agenda items moving forward." At the same time, countries are sensitive
about health platforms being used to advance wider foreign policy agendas.

 On the specific agenda item, a compromise position was reached to delete it
and to ask the DG to consult with members on how to address the public
health issues for future discussion. African diplomats in Geneva noted that
the issue could continue to cause a stalemate unless the DG brings
compromise solutions from her consultations within the regions. In the 2014
EB the item thus appeared as '[deleted]' on the final agenda, and there was
no discussion of it, as Member States had not agreed on a title or content
of accompanying documentation for it. Until they do, the item will not be
discussed.

 Agenda setting can and does thus fall victim to politics and requires
diplomacy to reach solutions that are acceptable to the membership. However
African countries have successfully brought items to the WHA agenda, such as
that of ethical recruitment of health workers. What may restrict both the
inclusion and action on agenda item may be the limits set by the General
Program of Work (GPW). The GPW is set for the organization every 5 years.
Unless a suggested item falls within the GPW and has funding allocated to
it, it is unlikely to make it onto the formal agenda. The Organization is
currently working on its 2014-2019 GPW and bases its' plans on a set of
distinct categories in the GPW that have been agreed to by Member States -
that is communicable diseases, non-communicable diseases, promoting health
through the life course, health systems, and preparedness, surveillance and
response. One reform of the WHO underway, according to the WHO website, is
to "allow greater flexibility in allocating resources to priorities within
these categories", which may then give flexibility for new agenda items not
yet covered in the GPW.

 Even when issues make it to the WHA agenda, will they receive adequate
attention?

 The agenda of both the EB and the WHA have become longer and longer over
the years. In May 2013, for example, the WHA agenda included numerous
weighty issues, including health post 2015, NCDs, communicable diseases
(including malaria and neglected tropical diseases), WHO reform,
substandard/spurious/falsely-labelled/falsified/counterfeit medical products
and a range of other issues. With such packed agendas, smaller delegations
to the WHA face challenges in participating when equally important issues
are being discussed at the same time. Dr. Emmanuel Makasa, health attache at
the Zambia high commission in Geneva noted in one 2013 meeting in the region
that African delegations have responded to this by working as a group: "We
work together as the African Group of Health Experts in Geneva to tackle
issues and engage as a group, which helps with our individual member state
staff shortages and different professionals present at the meetings."

A lengthening agenda may also reflect the widening reach of global factors
and policies in health, or the widening range of concerns claiming for
attention. Either way, countries need proactive strategies to get their
health concerns onto the global agenda, to ensure that they obtain attention
and are addressed. It implies long term thinking, preparing and
collaborating with partners in advance to develop positions and organizing
the evidence, expertise and alliances to raise and advance agenda items. As
Chigas et al. highlighted in 2007 those who can early on "frame the
definition of the problem and the terms of the collective debate, can have
enormous influence on the subsequent negotiations and their outcomes."

Please send feedback or queries on the issues raised in this briefing to the
EQUINET secretariat: admin at equinetafrica.org. The Centre for Trade Policy
and Law is working with EQUINET on a research programme on GHD in
association with the ECSA HC Strategic Initiative on Global Health
Diplomacy. For more information on the issues raised please visit
www.equinetafrica.org
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