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<div>As a f/u to yesterday's Reflection:<br> </div>
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<p style="MARGIN: 0in 0in 0pt"><font face="arial,sans-serif"><font size="2"><b><span style="FONT-SIZE: 11pt">The underlying values and ideology of the leadership of the Global Health Institutions:</span></b><span style="FONT-SIZE: 11pt"></span></font></font></p>
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<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif" size="2">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,<span> </span>all actors on the global stage work in their own interest or, in the case of organizations, <span> </span>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).</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif" size="2">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. </font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif"><font size="2">3.So, where does this dispersed leadership lie then?<span> </span>Leadership is only to a lesser and a more <u>technical</u> 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<span> </span>the SDH). A good part of the leadership in health has shifted to the World Bank (WB) and global public-private partnerships (PPPs). <span> </span>WHO has, therefore, <span> </span>really only become a partial global 'actor' in the global health scene.<span> </span></font></font></span></p>
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<p style="MARGIN: 0in 0in 0pt; TEXT-ALIGN: justify"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif" size="2">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.<span> </span>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.<span> </span>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.</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif" size="2">5.Additionally, WHO has become ineffective as a global leader in health due to the following reasons: </font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: normal; TEXT-AUTOSPACE: ideograph-numeric"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 11pt">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. </span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: normal; TEXT-AUTOSPACE: ideograph-numeric"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 11pt">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...).<span> </span>An <span>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…<span> </span>Who are we fooling here?</span> </span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: normal; TEXT-AUTOSPACE: ideograph-numeric"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 11pt">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. </span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: normal; TEXT-AUTOSPACE: ideograph-numeric"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 11pt">WHO is ineffective at country level, where under-resourced WHO offices are attached to low-prestige ministries of health, and</span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 11pt">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. </span></font></font></p>
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<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif" size="2">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.</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif" size="2">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.</font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif" size="2">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. </font></span></p>
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<p style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif" size="2">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. </font></span></p>
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<p style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: normal"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif" size="2">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. </font></span></p>
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<p style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: normal"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt">11.<strong>To achieve this, WHO will have to take measures to position itself as an organization of <strong>governments</strong>, <u>as well as</u> of <strong>the people</strong>.</strong> 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<i> </i>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.<span> </span></span><span style="FONT-SIZE: 11pt">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.</span></font></font></p>
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<p style="MARGIN: 0in 0in 0pt; TEXT-ALIGN: justify"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif" size="2">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<span> </span>'Health For All Now'.</font></span></p>
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<p style="MARGIN: 0in 0in 0pt; TEXT-ALIGN: justify"><span style="FONT-SIZE: 11pt"><font face="arial,sans-serif" size="2">13.The advocacy strategy should, among other, include:</font></span></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; TEXT-ALIGN: justify"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 11pt">A naming and shaming campaign<i> </i></span><span style="FONT-SIZE: 11pt">targeted at countries that are not fulfilling their commitments to the funding of WHO. </span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; TEXT-ALIGN: justify"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 11pt">More coordinated lobbying during the World Health Assembly<i>. </i>Civil society presence at the World Health Assembly is inadequately coordinated; ergo, a process to coordinate civil society participation is needed.</span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; TEXT-ALIGN: justify"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 11pt">Ensuring a strong and SDH-committed leadership.<i> </i>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. </span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; TEXT-ALIGN: justify"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 11pt">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<i> </i>explicit campaign to promote the mandate of WHO to engage more vigorously in tackling the structural and social determinants of health.</span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; TEXT-ALIGN: justify"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol"><span>·<span> </span></span></span><span style="FONT-SIZE: 11pt">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:</span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.75in; TEXT-INDENT: -0.25in; TEXT-ALIGN: justify"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt"><span>o<span> </span></span></span><span style="FONT-SIZE: 11pt">The Executive Board, its directives and agenda setting.</span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.75in; TEXT-INDENT: -0.25in; TEXT-ALIGN: justify"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt"><span>o<span> </span></span></span><span style="FONT-SIZE: 11pt">The annual WHA resolutions being implemented.</span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.75in; TEXT-INDENT: -0.25in; TEXT-ALIGN: justify"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt"><span>o<span> </span></span></span><span style="FONT-SIZE: 11pt">WHO-corporate partnerships.</span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.75in; TEXT-INDENT: -0.25in; TEXT-ALIGN: justify"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 11pt"><span>o<span> </span></span></span><span style="FONT-SIZE: 11pt">WHO strengthening key regional and WHO country offices, and </span></font></font></p>
<p style="MARGIN: 0in 0in 0pt 0.75in; TEXT-INDENT: -0.25in; TEXT-ALIGN: justify"><font face="arial,sans-serif"><font size="2"><span style="FONT-SIZE: 12pt"><span>o<span> </span></span></span><span style="FONT-SIZE: 11pt">WHO gradually changing the professional backgrounds and skills mix of its staff.<span> </span></span></font></font></p>
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<div><font size="1">Claudio Schuftan, Ho Chi Minh City</font></div>
<div><font size="1"><a onclick="return top.js.OpenExtLink(window,event,this)" href="mailto:cschuftan@phmovement.org" target="_blank">cschuftan@phmovement.org</a> </font></div>__________________<br>
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<p style="MARGIN: 0in 0in 0pt; TEXT-ALIGN: justify"><span style="FONT-SIZE: 12pt"><font face="arial,sans-serif" size="2"> </font></span><span lang="EN-GB" style="FONT-SIZE: 9pt"><font face="arial,sans-serif" size="1">Reference:</font></span></p>
<p style="MARGIN: 0in 0in 0pt; TEXT-ALIGN: justify"><span lang="EN-GB" style="FONT-SIZE: 9pt"><font face="arial,sans-serif" size="1">'Making WHO Work Better: An Advocacy Agenda for Civil Society and NGOs' (<i>A discussion document produced by the Global Health Watch 2 Working Group,</i> July 2006<i>)</i>.</font></span></p>
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