Will the world’s premier health organization be able to reform itself to revive its global health leadership in the years ahead? Such was undoubtedly the question on the mind of health officials and civil society from around the world as they attended the 64th World Health Assembly (WHA) last month, the World Health Organization’s annual meeting of its governance body, comprised of all 193 of its Member States.
With WHO reform the marquee item on a crowded agenda that touched on many of the most pressing global health issues, this seemed destined to be a historic WHA.
And in some ways, it was – though at least in part, due to another issue. As the 2003 WHA secured its place in history by adopting the first global health treaty, the Framework Convention on Tobacco Control, and the 2005 WHA adopted the revised International Health Regulations, the 2011 WHA set the stage for greater international cooperation in responding to novel influenza viruses by adopting the Pandemic Influenza Preparedness Framework.
Pandemic Influenza Preparedness Framework
Despite being non-binding, and frankly underwhelming, it does for the first time set up a three-pronged global process of increase access of people in developing countries to vaccines and antiviral medication: 1) voluntary vaccine donations by vaccine manufacturers to a WHO stockpile to be used primarily in developing countries; 2) tiered pricing for vaccines and antivirals, and; 3) technology transfer for vaccines and antivirals. Manufacturers are also expected to contribute financially to support WHO’s global influenza surveillance and response system.
With WHO seeking 150 million doses of the H1N1 vaccine for its stockpile, a clear metric exists as an initial gauge whether the voluntary donations are likely to be sufficient – though success for a virus that proved less virulent than feared and is some sense already old news (though a continued threat) hardly guarantees success if and when a new, more lethal influenza virus appears. One can hope that technology transfer will soon lessen the need to rely on voluntary donations, much of the emergence of generic AIDS drugs manufactured in developing countries, especially in India, was central to far greater access especially to AIDS medications. During the WHA, a number of states emphasized the importance of the technology transfer provisions of the framework, according to WHO Watch. (WHO Watch is an initiative of the People’s Health Movement and other organizations, part of the Global Health Governance Reform Initiative.)
As for WHO reform itself, perhaps the central official outcome was: stay tuned and get involved. The WHA’s resolution on the WHO Secretariat’s reform proposal simply endorsed the reform agenda and affirmed the Secretariat’s proposed pathway forward, including having the first meeting of the multi-stakeholder World Health Forum in November 2012 and the first report of an independent evaluation of WHO to be presented at the next WHA in May 2012.
Apparently, the reform proposal sparked some animated discussion not captured in the rather humdrum resolution. As reported here and here by WHO Watch and by the Third World Network, Member States raised a number of concerns, especially the need for the reform agenda to be driven by WHO Member States (and not only by the Secretariat), the need for more detailed on the reform plans, and concern about the need for WHO to have more flexible funding (as opposed to earmarked funds). The last point is rather ironic, given that of course if Member States chose to allocate WHO funding for its core budget, or other flexible funding, they could easily resolve this concern.
In response to Member States’ desire to drive the reform process, WHO Director-General Dr. Margaret Chan concluded the discussions on the reform agenda “by stating that she will ‘consult, consult and consult’ until Member States are ‘satisfied’ with the reform process.”
Comments of several states stand out. Brazil’s comments were particularly heartening, focusing on the importance of WHO listening more to civil society and the need for WHO’s main goal to be “social justice, equality and fairness in access to health for all.” Brazil also described “WHO‘s core business [as] the promotion of the right to health.” Thailand expressed perhaps the most skepticism of the reform process, suggesting that the present reform effort of WHO was insufficient, and what WHO really needed was a “rebirth.”
The WHO Executive Board meeting that immediately followed the WHA agreed to a more detailed process of WHO’s reform over the coming months, including requesting the WHO Secretariat to draft three concept papers by the end of June, hold consultations with Member States on these papers, including through a web-based platform, and have the WHO Regional Committees discuss the reform process. The Executive Board will hold a special session in November 2011, open to all Member States, to discuss the outcomes of the consultative process and other matters related to WHO reform.
World Health Forum
At least from civil society discussions I have heard, along with the need to address WHO’s financing, perhaps the greatest focus on WHO’s reform agenda has been around the World Health Forum, a multi-stakeholder meeting that would help influence – but not set – WHO’s agenda. I have heard concerns about the Forum, that it would allow corporate interests in particular a greater say in global health decision-making. I am glad, though, to see that the Forum idea has advanced. Influence by non-state actors, from corporations to NGOs, does and will continue to happen, for better and for worse, whether or not there is a World Health Forum. Far better that this influence should occur in an open and transparent process, so that arguments can be countered and who is saying what made known to all. And hopefully the Forum will give increased space for more marginalized voices from civil society and from community organizations to be heard.
I do wonder what sort of potential the World Health Forum really has to be the centerpiece of WHO’s efforts to become a more inclusive organization. There are already many meetings at which WHO and a wide range of other stakeholders are all around the table talking about virtually every major health issue of our day. And at the national level, non-state actors can influence governments, and thus indirectly help shape WHO’s agenda and actions.
In this environment, making a real difference will take more than simply facilitating a global health meeting of people from various constituencies. It will take strong leadership from WHO, and innovative approaches to ensure that the Forum amounts to more than one additional setting at which different perspectives can come together to talk.
One way in which the Forum presumably will be different than what exists now will be a focus on WHO itself, and influencing its agenda, approaches, and priorities. It could also be a place to address such big picture global health issues as a global health framework, as Dr. Chan has proposed and fits in very nicely with the efforts of the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI).
Along with addressing the WHO and broad global health issues that go beyond the focus on any one global health partnership or institution, the Forum could help ensure that people who are less likely to have a seat at the same table as their governments can make their voices heard. I think that key to the Forum’s value will be its ability to ensure that people who are generally able to participate in such settings – including members of marginalized populations, and people who are very poor and whose realities those in the seats of power may little understand – are heard clearly, and are heard in such a public forum that they are their views cannot simply be ignored or wished away. Indeed, developing some process for enabling these communities to be part of the Forum, even if some governments would rather they not be, would be one way that WHO could exercise its global health leadership and be true to its constitutional commitment to the right to health.
WHO might also consider ways to ensure that points raised at the Forum are not simply ignored, such as by establishing a format or process that requires some form of public response – whether from governments, WHO itself, or both – to proposals or other action items that emerge from the Forum. This would help make the Forum a process that enhances the accountability of WHO and governments to the people whom both ultimately serve, directly (governments) or through its Member States (WHO). And building on an idea I heard from members of the People’s Health Movement, the WHO should encourage and facilitate national efforts to link the Forum national processes, such as hearings on health that could help set their governments’ agendas.
Even as the World Health Forum process moving forward, I hope that less prominent but critical reforms to give more voice to civil society also move forward, such as loosening the rules for NGOs to formally participate in the World Health Assembly, as mentioned in this letter from several NGOs.
Looking beyond the World Health Forum and civil society involvement in the WHA, I commend readers to an article published recently in JAMA by O’Neill Institute Faculty Director, Lawrence Gostin, and Devi Sridhar from Oxford University, who offered five key proposals for reform: 1) giving real voice to multiple stakeholders; 2) improving its transparency, performance, and accountability; 3) providing closer oversight of regions; 4) exerting its legal authority as a rule-making body; and 5) ensuring predictable, sustained financing.
UN General Assembly 2011 Comprehensive AIDS Review
An issue that has begun to transform the role that civil society and marginalized populations have in health decision-making is HIV/AIDS. From a just completed major global health event in Geneva, I turn briefly to one about to get underway in New York. This is a very important week for the global fight against AIDS (and, as ever, against the stigma, discrimination, and other human rights violations that help perpetuate it). The UN will hold its ten-year review of the 2001 Declaration of Commitment on HIV/AIDS later this week, June 8-10, 2011.
Prevention will no doubt be high on the agenda, as it must be. With a growing number of biomedical strategies to improve prevention, and forever recognizing the centrality of human rights to the fight against AIDS, the rights of women, men who have sex with men, injecting drug users, and other populations who are subject to discrimination and other forms of abuse, the potential for enhanced prevention has never been greater.
Perhaps the biggest question at the UN General Assembly 2011 Comprehensive AIDS Review, though, will be around treatment, and commensurate funding for prevention, care, and treatment. Will the world commit to a new treatment target, one that meets some meaningful definition of universal access by 2015? At a minimum, this requires a target of 15 million people in developing countries on by 2015 – among key civil society demands – up from about 6.6 million at the end of 2010. This would be about 80% of the more than 18.3 million people who are expected to need to be on treatment by 2015 under the current WHO guidelines, which recommend treatment for people with CD4 counts below 350. Michele Sidibé, the Executive Director of UNAIDS, has called for this target, as a minimum. Indeed, with recent evidence that starting on AIDS treatment even earlier could dramatically reduce HIV transmission rates, as described here and here, 15 million is indeed only a minimally acceptable target. UN Secretary-General Ban Ki Moon has proposed, among other targets for 2015, ensuring that 13 million people are on treatment.
As ever, achieving a target of at least 15 million people on AIDS treatment is very much a question of money and priorities. The global powers let the goal of universal access by 2010 slowly and lethally fade into oblivion. We will know by the end of this week whether the nations of the world are going to make another go at universal access, or whether they will let savings millions of lives take a backseat to deficit reduction and other spending priorities. It forever boggles my mind that in a world of such incredible wealth, so many lives are still viewed so cheaply, indeed, essentially as dispensable. Let us hope – let us insist – that the UN review this week, and in the months ahead, the WHO and its Member States as they seek to revitalize the world’s premier health organization, position health and human rights as the driving forces, the top priorities, rather than secondary, next-in-line considerations.