PHM-Exch> WHO under construction: 75 years after its foundation

[Claudio Schuftan]

75 years after its foundation, the World Health Organization (WHO) seems to
be in need of reform in many places. What steps need to be taken?

By Dr Andreas Wulf, Medico International and PHM

The iconic World Health Organization (WHO) headquarters above Lake Geneva,
overlooking the Mont Blanc massif, has been a major construction site for
some time now; new parts of the building are currently being constructed
here. The hall where the Executive Board comprising 34 rotating Member
States normally meets twice a year is also in need of renovation. A
situation that is not just very inconvenient for delegates, but that also
limits the presence of independent organisations, the “non-state actors in
official relations with WHO” (NSA). These are actors like the People’s
Health Movement, Health Action International and the Geneva Global Health
Hub, which medico international has had ties with for many years. Their
delegations have been radically downsized due to the modernisation of the
WHO Secretariat. Direct contact with the delegates has also been heavily
curbed due to the remodelling. Since the COVID-19 pandemic, the plenary
sessions have at least been livestreamed; the more important negotiations,
of course, continue to take place behind closed doors.
Cooperation and “multistakeholderism”

The cooperation between the 75-year-old multilateral institution, where the
Member States call the shots, and a civil society that is committed to
critically commenting on and influencing the health policies of the states
and their world organisation, is one of the standing issues at these
negotiations. The few opportunities for the NSAs to take the floor on
agenda items were already cut back to one minute at previous meetings. The
WHO’s current proposal after five years of consultations to put in place a
Civil Society Commission at the Secretariat is at least a further step
towards accommodating those who not only criticise the WHO but also defend
it against attempts to gain influence through commercial and
profit-oriented interests.

For as much as the WHO, in the 75th year of its existence, formally refers
to its role as the “directing and coordinating authority” in global health
policy, as was established in 1948, and bases its authority on the
membership of almost all states in the world (194 currently), this role has
long been jeopardised by the process of “multistakeholderism” as people
like to call the modern form of a political “governance” that involves all
interest groups, so “stakeholders”, in the decision-making processes,
mostly without the inclusion of fundamental conflicts of interest that
exist, for instance, between actors whose (private) interests require
regulation and actors who are supposed to put in place such (public) rules.
Challenges during the pandemic

The most recent and certainly most drastic example of a conflict of this
kind was the inability of states at the World Trade Organisation (WTO) to
agree on the temporary suspension of intellectual property rights for
health products needed in response to COVID-19 (vaccines, medicines,
diagnostics, personal protective equipment, medical technology). The huge
pressure from industry contributed to this in a major way, leveraging the
world’s reliance on its products. The latest revelations about price hikes
for mRNA vaccines for the European Union in the course of 2021 by Moderna
and Pfizer/Biontech, as well as the announcements from the US that prices
would be increased again 4 to 5-fold once the pandemic was “officially”
over, make these power relations all too clear. They secured profit margins
for the companies involved that one suspects are otherwise only achieved by
state-funded arms manufacturing and illegal drug trafficking.

So it is no accident that in the first draft of a new “Pandemic
Preparedness Treaty” currently being negotiated under the umbrella of the
WHO and which numerous civil society actors have contributed to, access to
health products and the regulation of intellectual property rights in the
event of a pandemic loom large. The coming months will reveal how much of
this will be forfeited again in the course of the negotiations by
governments standing firmly on the side of “their” pharmaceutical and
medical technology companies (with the German Federal Government being
particularly prominent here). A critical public - as was mobilised globally
during the pandemic, but which ultimately was unable to exert any real sway
on patent decisions at the WTO – will remain important.

The position and influence of the WHO Secretariat and the current
Director-General (DG) Dr Tedros as the directly elected boss of the
organisation is as ambivalent in this regard as it is with other
controversial global health issues. As former chair of a number of
prominent public-private partnerships (PPPs) in global health, the Global
Fund to Fight AIDS, Tuberculosis and Malaria, the Roll Back Malaria
Partnership and the Partnership for Maternal, Newborn and Child Health,
Tedros is firmly on the side of this partnership concept of
multistakeholderism. And as the top fundraiser of his organisation, he has
to be on good terms with the major donors: not just with the rich Member
States, which pay for a large part of the WHO budget, but also with the
philanthropic foundations (Gates, Buffett, Rotary International), which
make key parts of the WHO’s work possible in the first place thanks to the
additional funding they provide, but which also have their sights firmly on
their own priorities and (like the Gates Foundation) are also actively
involved in steering the big PPPs.

At the same time, Tedros also has a special obligation towards those
governments of the global South which, in a highly symbolic move, elected
him as the first African Director-General in the crucial first-time vote at
the World Health Assembly in 2017. Previously, such decisions had first
been adopted in the smaller circle of the Executive Board and de facto just
confirmed by the Assembly.

And so, during the pandemic, he never tired of criticising the rich
countries for practically going it alone in procuring and supplying first
masks and tests and then vaccines, going so far as to speak of
“vaccine[1]apartheid”. However, this also brought into sharp relief how
weak the seemingly “leading” WHO actually is. Its initiative to do away
with this unequal access with a Covid-19 Technology Access Pool right at
the start of the pandemic was woefully neglected, supported only by a few
small states and openly boycotted by the pharmaceutical companies. And the
mRNA Vaccine Technology Transfer Hub, which the WHO has been building with
local institutions in South Africa since 2021 and which is designed to
share knowledge and technology via a network of collaborating companies
faces equally clear resistance.

WHO also played a supporting role in setting up the Access to COVID-19
Tools Accelerator (ACT-A) in the spring of 2020, which came into the media
spotlight mainly through its vaccine procurement pillar COVAX. Large PPPs
such as the Global Fund, Gavi (vaccines) or the Wellcome Trust
(therapeutics), among others, were responsible for procuring and
distributing products to countries. COVAX in particular was soon juggling
billions of US dollars. WHO was left to assume the thankless task of
“health system strengthening”, which hardly any funds were made available
for, but which was pivotal to the speed of vaccination programmes in many
countries. It had an important role in testing the efficacy and safety of
the vaccines, medicines and diagnostics purchased and distributed by the
ACT-A. Its recommendations on the globally equitable distribution of the
initially scarce vaccines, on the other hand, were deliberately ignored,
whilst the rich countries hoarded vaccine and only generously let their
surplus doses be distributed through COVXAX from the second half of 2021
onwards as a charitable gesture that looked good in the media.
Conflicts between Member States

The supposedly strong WHO is also caught right in the middle on other
issues: for instance, when its members use the WHO stage to argue amongst
themselves. The COVID-19 pandemic was again just the most visible tip of
this: the open conflict between the US Trump administration and the
People’s Republic of China over the questions of timely information on and
the origin of the virus (wild animals or research laboratory) – at its core
a bilateral conflict over economic clout and regional/global influence -
was answered by China with a stubborn insistence on its national
sovereignty. The WHO attempted to counter this with the traditional
diplomatic charm offensives, but increased the ire of Trump in the process,
who threatened to quit the WHO and cut off US funding, which luckily was
prevented by his failure to secure re-election at the end of 2021.

Another example of conflict between individual Member States is how the
issue of sexual and reproductive health/rights is handled. Here, positions
vary particularly drastically and are expressed in the struggle over the
inclusion of concepts such as “sexual education” and the mention of “sexual
minorities” as target groups of prevention measures. The Russian
delegation, for instance, bemoans “provocations” in official texts, also in
an attempt to forge alliances that additionally help it defend itself
against criticism on the war it is waging in Ukraine, for instance when the
“Western alliance” condemns the attacks on civilian and health
infrastructure in the plenary speeches and resolutions.
Huge dependencies

In all these dilemmas, the WHO remains diplomatically trapped. It is de
facto a “servant” of its Member States, which decide the WHO’s work
programme and funding. Especially since the WHO has no means whatsoever to
compel its members to implement the very rules they have signed off on
themselves. This became dramatically apparent during the pandemic, as
exemplified by the International Health Regulations, when WHO
recommendations on preparing for or combating the pandemic and against
border closures were openly ignored by many.

So the WHO is courting important states in other ways, for instance in new
“signature projects”. The Pandemic and Epidemic Intelligence Hub
established in 2021 to improve the dovetailing of data collections for
pandemic monitoring, is largely funded by Germany and so is located in
Berlin. The new WHO Academy, a “state of the art lifelong learning centre”
for health professionals, is not conceivable without the contribution from
the French government and so is located in Lyon. The WHO could not run such
initiatives from its regular budget.
Uncertain funding

The key question of “who will pay?” preoccupies the WHO, its supporters and
critics alike. In January 2022, the Executive Board was still celebrating
the gradual increase of compulsory membership fees to enable 50% of the
total budget to be funded by the Member States in the future (at present it
is not even 20%), but one year on, given the recession, the global economic
impacts of the Russian war against Ukraine and rising inflation, it is
unclear whether this can actually be implemented swiftly. And at the same
time, as usual, key parts of the budget plan are not covered. The WHO’s
proposal to hold a regular fundraising event (replenishment) instead of
seeking new donors for each individual programme puts it in direct
competition with the PPPs, which have professionalised this kind of
“performance show” over the past 20 years. Whether WHO can assert itself
here as a latecomer remains to be seen.

The new “WHO Foundation” launched two years ago also faces justified
criticism. If you want to collect money from rich private individuals and
companies, you will quickly find yourself keeping bad company. The
foundation's statutes stipulate that the arms and tobacco industries are
not permitted, but even the problematic food corporations like Unilever,
Nestlé and Coca-Cola, whose fast food and sugar drinks are in the firing
line as contributing to major chronic diseases, are not ruled out
categorically.

The WHO has experienced many dilemmas and dependencies like this over its
history. The legendary “Alma Ata Conference” in 1978, at which the Primary
Health Care (PHC) concept was adopted, only took place there because the
USSR wanted to inflict a blow on China in the struggle for control of the
narrative in the socialist world and so provided the funding for the
conference. At least the WHO was able to ensure that the conference was not
held in Moscow and instead in the regional capital of poor Kazakhstan,
where there had been positive experiences with PHC programmes.
The effort can be worthwhile

So is there anything at all to celebrate on the 75th anniversary of this
World Health Organization? The WHO remains as good and bad as the world it
exists in. That is the simple answer. What we make of it is key is the
complicated answer. Without the WHO, there would be nothing to check and
balance the pragmatic PPP movers and shakers and no forum to continue to
argue and debate about health system strengthening, equitable resource
distribution between countries and the necessary support for countries
especially hard hit by the global realities of exploitation. Rights of
minorities and discriminated groups do not always secure the majority in
WHO resolutions, but the stage that Member States use for their
geopolitical battles must also be made available to those who otherwise
have even less of a voice in their own countries.

This means developing alliances of a critical civil society and like-minded
governments at the WHO level. The new Brazilian government has already
presented an initiative for a resolution on the health of indigenous groups
and peoples. Fighting for the spaces where global policy is made is
worthwhile - despite the efforts and difficulties to be overcome.
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