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The WHO, what, where and how

The World Health Organisation’s (WHO) ‘brochure’ The Global Guardian of Public Health (2016) is an at-a-glance document meant to convey vital statistics and information.

The 12-page magazine describes an organisation with an expansive reach: 194 member states; a headquarters in Geneva; six regional offices; over 150 country offices; more than 7,000 staff; and a history laced with major contributions to global public health, such as its role in smallpox eradication.

But it is an incomplete snapshot of a heavily-layered body. The section ‘Who pays for WHO?’ imparts no budgetary figures (which can be found elsewhere on the WHO website) and a timeline of ‘historic landmarks’ falls silent on the WHO’s tragically slow response to the Ebola crisis, describing only how the WHO Secretariat activated “an unprecedented response to the outbreak” in West Africa.

In many respects, the Organisation’s response to Ebola in 2014 was an historic landmark, exposing deficiencies that could not be glossed over. It has prompted considerable soul-searching in global public health.

The stark conclusions in the report of the Ebola Interim Assessment Panel, published by the WHO in July 2015, reached their apex in the delicately-delivered judgement that “the declaration of a PHEIC [public health emergency of international concern] can lead to disagreements with national governments, and the Panel notes that independent and courageous decision-making by the Director-General and the WHO Secretariat is necessary with respect to such a declaration. This was absent in the early months of the Ebola crisis”.

Funding and mobility issues, shortcomings in the International Health Regulations (2005), and inadequacies in WHO’s relationships with wider health and humanitarian systems were also raised in the Panel’s report. The fact that people working for the WHO were among those who risked their lives in responding to Ebola was acknowledged.

Since that crisis, public health stakeholders have been debating the WHO’s future. Many believe its vast potential is strangled by overwrought bureaucracy, deference to political sensibilities, lack of flexible funding as well as poor transparency.

The debate will sharpen as the deadline looms in September for WHO Member States to submit names of candidates for the post of the Organisation’s chief technical and administrative officer, the Director-General (DG). The incumbent Dr Margaret Chan concludes her second five-year term in June 2017.

If the Organisation does not substantially reform, some funders may turn to alternative organisations. The formal launch of the Africa Centres for Disease Control and Prevention (Africa CDC) in 2015 was a reminder that the global public health architecture is not set in stone.

The Africa CDC is not a part of the US Centres for Disease Control and Prevention (CDC), although the US organisation worked with the African Union Commission in its establishment and contributes expertise. The Africa CDC will help African countries monitor public health, respond to public health emergencies and build capacity. The concept pre-dates the Ebola epidemic.

A spokesperson for the US CDC in the US told the Medical Independent (MI): “The Africa CDC will work with governmental partners such as the CDC, the China CDC, the European CDC, the Japan Mission to the African Union and African Member States, as well as many international and non-governmental partners, such as UN agencies, including WHO.”

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Dr Margaret Chan, WHO Director-General

‘Failing’

Prof Devi Sridhar is Professor of Global Public Health at the Centre for Population Health Sciences, University of Edinburgh, UK. She was one of the co-Chairs of a distinguished panel convened by the Harvard Global Health Institute and London School of Hygiene and Tropical Medicine that analysed the global response to Ebola. A number of its recommendations centred on the WHO, including the need for more focused financing arrangements and better governance.

Prof Sridhar also co-authored a recent analysis in the BMJ, ‘Facing forward after Ebola: questions for the next Director General of the World Health Organisation’ (19 May 2016).

“There is consensus that the Organisation is failing. Why it is failing — that is where you get disagreement,” she informed MI.

Some say it is mainly about money, said Prof Sridhar. Around 80 per cent of the WHO’s budget is earmarked “and if 80 per cent is earmarked, you are very limited in what you can do”.

According to the WHO, dues paid by Member States (calculated relative to wealth and population) comprise less than a quarter of its budget. The rest comes from voluntary contributions from Member States and other organisations.

Continuing, Prof Sridhar said some consider the WHO’s structure as its critical failing: it has six regional offices that hold considerable autonomy and regional directors are elected by countries rather than selected by the DG.

And there are those who feel the Organisation lacks leadership and cite the DG’s handling of the Ebola crisis and not being sufficiently aggressive in setting the agenda.

“But what exactly is wrong and what is the priority — that is where you see people emphasising all kinds of different things, which of course have different solutions,” said Prof Sridhar.

Should Member States be paying more? “This is a difficult one,” said Prof Sridhar, who suggested it may well be a case of “paying different”.

The WHO’s budget for the biennium 2016-2017 is almost (US) $4.4 billion, representing an increase from $3.9 billion for 2014-2015. However, the WHO is beholden to the priorities of donors, outlined Prof Sridhar.

In the allocation for 2016-2017 approved by the WHO’s World Health Assembly, the largest single amount of $986 million is designated to “polio, tropical disease research and research in human reproduction”. This is followed by communicable diseases ($765 million), corporate services/enabling functions ($734 million) and health systems ($594).

Delegates at the 2016 Assembly also agreed to establish a new Health Emergencies Programme. The programme “adds operational capabilities for outbreaks and humanitarian emergencies to complement its traditional technical and normative roles”.

A budget of $494 million for the programme for 2016/2017 was agreed. According to the WHO, this represents an increase of $160 million to the existing programme budget for the WHO’s work in emergencies.

Its impact will take time to gauge, with the DG due to report in 2017 on progress in establishing and operationalising the programme.

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Prof Devi Sridhar, global health expert, University of Edinburgh

Philanthropy

The issue of contributions from corporates and philanthropy organisations has sparked some debate. One of the most significant contributors to the WHO is the Bill and Melinda Gates Foundation (the Gates Foundation).

A Foundation spokesperson told MI that, in 2013, its estimate for its contribution to the WHO for the two-year period 2014-2015 was $570 million.

“Our latest estimates for 2016-2017 indicate that we will maintain this level of investment. While we provide funding for several WHO priority areas, more than half of our funding for the WHO has consistently been dedicated to polio eradication,” said a Foundation spokesperson.

“Polio eradication is a goal that WHO Member States adopted as a priority a decade before the Gates Foundation was established, and the Foundation has sought to partner with WHO and Member States to address critical resource gaps in the global eradication effort.”

The spokesperson insisted that the Foundation strongly supports the WHO’s “commitment to set its own funding priorities and to determine how voluntary contributions to the organisation should be used”. The WHO “must be accountable to its Member States, and it should be guided by the priorities that these Member States set through the World Health Assembly”.

The Trust handling the investments of the Foundation has held shares in companies such as McDonald’s and Coca-Cola (media reports last year stated that these shares were sold but that it retained shares in a large McDonald’s franchisee). On the other hand, the WHO has a mandate to tackle the growing challenge of obesity. These types of interplays raise important questions.

“The endowment that funds the Gates Foundation is independently managed by a separate entity, the Bill and Melinda Gates Foundation Trust. The Trust does not comment on its investment holdings and decisions, but I will make them aware of your inquiry,” said the Foundation’s spokesperson.

Meanwhile, the need for greater transparency at the WHO was a salient point in the BMJ paper co-authored by Prof Sridhar. The paper stated that candidates for the DG position need to consider how accountability could be strengthened in relation to health and emergency outbreak response. It posited the creation of a freedom of information policy and inspector-general as examples of suitable measures. 

Moroever, the process to select a DG does not engage the wider public, noted Prof Sridhar. “We have already seen the change in the process for the UN Secretary General, where there is now much more scrutiny and public debate and engagement,” she informed MI.

Promises

The WHO has committed to reforms of varying degrees. A spokesperson for the WHO also told MI that its “oversight function” is fulfilled by the Office of Internal Oversight Services (IOS). “Every year, they provide a report at the Executive Board about their area of work. Their reports are public,” said the spokesperson.

Delegates at its World Health Assembly in May agreed three proposals from the DG to “increase transparency around the upcoming election of her successor”, although these particular reforms were conservative in nature. 

One was that the DG could publicly acknowledge the names of prospective candidates submitted before the deadline, provided the nominating country was in agreement; secondly, it was agreed that the Candidates’ Forum, due to be held in November, would be webcast (participation in the forum is limited to member states); and thirdly, that candidates nominated by the Executive Board to the World Health Assembly will have the opportunity to address the Assembly before voting takes place.

These addresses should be webcast on the WHO website, decided delegates.

Another recent measure was adoption of the WHO Framework of Engagement with Non-State Actors (FENSA), after more than two years of inter-governmental negotiations. Yet it will be seen by many as not going far enough. It re-enforced the WHO’s stated position of not engaging with the tobacco and arms industries, but there remains a grey area in respect of other sectors that potentially harm human health or conflict with WHO policies.

The Framework states: “WHO will exercise particular caution, especially while conducting due diligence, risk assessment and risk management, when engaging with private sector entities and other non-State actors whose policies or activities are negatively affecting human health and are not in line with WHO’s policies, norms and standards, in particular those related to non-communicable diseases and their determinants.”

WHO received 3.8m DoH funding from 2014 to date

Some €1,947,434 was provided to the WHO by the Department of Health in 2015, up from €1,668,638 in 2014. 

Last year’s total included an annual contribution of €1,747,433 (up from €1,468,628 the year before) and €200,000 for membership of the European Observatory on Health Systems and Policies (compared to €200,010 in 2014).

The European Observatory on Health Systems and Policies “supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of the dynamics of healthcare systems in Europe”, according to its website. It is hosted by the WHO Regional Office for Europe.

WHO-related expenditure in 2016 (to June) by the Department is €243,714, which includes €200,000 for membership of the European Observatory and €43,714 to the WHO Framework Convention on Tobacco Control (developed by countries in response to the globalisation of the tobacco epidemic).In total, funding from the Department of Health to the WHO from 2014 to June 2016 was €3,859,787.

The Department of Foreign Affairs and Trade also funds the WHO. This included €500,000 in 2014, 2015 and 2016 to the WHO’s Global Health Workforce Alliance; and €1 million in 2014 and €400,000 in 2015 to the Global Polio Eradication Initiative.

It has also provided voluntary core funding to the WHO as follows: €1.15 million in 2014; €1 million in 2015; and €300,000 in 2016.

According to the Department of Health, the WHO has a number of entities that work to ensure “funding is spent appropriately”.

Neither of the Departments seconded staff to the WHO during this period. Hawkins House reported that Ireland had not received funding from the WHO within the same timeframe. 

The Department of Health makes Ireland’s annual assessed contribution to the WHO and leads on the management of Ireland’s overall relationship with the Organisation.

Expenditure incurred by the Department of Health in 2015, in respect of sending delegates to WHO meetings, conferences and seminars etc, amounted to €11,199. This figure included conference fees for attendance and individual travel and subsistence claims by staff, stated the Department.

Attendance was recorded at the following: WHO Executive Board meeting in Geneva; WHO Euro Regional Committee meeting in Vilnius; various conferences/meetings hosted by the WHO on systems financing in Barcelona; on health and wellbeing in Zurich and Paris; on tobacco in Moscow; on food safety in Bonn; on infant formulae in Geneva; World Health Assembly in Geneva; meetings/conferences on integrated non-communicable disease surveillance in Vilnius; and on nutrition in Rome.

The main work programmes with which the Department of Health interacts and liaises with the WHO include the Global Strategy on Human Resources for Health: Workforce 2030; the Global Health Workforce Alliance (GHWA); and the new Human Resources for Health Network.

Ireland has had particularly high-level representation in the GHWA. The alliance was established in 2006 as a common platform for action to address the predicted global health worker shortage (WHO estimates a global shortage of 8.5 million health workers).

Dr David Weakliam, Programme Lead of the HSE’s Global Health Programme, was the most recent chair of GHWA’s board.

GHWA completed its 10-year mandate in May, closing with a one-day board meeting. The GHWA board endorsed plans for a transition towards a new, multi-sectoral network on Human Resources for Health (HRH) to support attainment of the sustainable development goals (SDGs), universal health coverage and the implementation of the WHO Global Strategy on Human Resources for Health: Workforce 2030.

MI asked the Department of Health if it had any position on the WHO’s acknowledged need for reform.

According to a spokesperson: “In recent years, through its governing bodies, Member States have been driving a process of reform of WHO to ensure that it is fit-for-purpose to meet 21st Century global health challenges. Ireland fully supports efforts to make the WHO more transparent and accountable.”

The spokesperson said it was important to ensure that the lessons learned from the WHO response to the Ebola outbreak were “taken on board” and “integrated into plans to meet future international health emergencies in a more effective way”. This process has included a focus on the WHO’s role in global health governance, they added.

“Health governance implies ‘the use of formal and informal institutions, rules and processes by states, intergovernmental organisations and non-State actors to deal with challenges to health that require cross-border collective action to address effectively’. Instruments such as the International Health Regulations and Pandemic Influenza Preparedness (PIP) Framework are important instruments in this regard.”

Meanwhile, a spokesperson for the Department of Foreign Affairs and Trade noted that Ireland is a member of the Multilateral Organisation Performance Assessment Network (MOPAN), which is hosted in the OECD. MOPAN undertook an assessment of the WHO in 2013 and found that “financial accountability is seen as one of WHO’s strengths”.

MOPAN is considering including the WHO on its 2017/18 assessment cycle. 

Ireland

The World Health Assembly is attended by delegates from WHO Member States as well as representatives from many agencies, organisations, foundations and other groups working in public health.

Member States approve resolutions in committee before formally adopting them in the plenary session at the end of the Assembly.

Prof Malcolm MacLachlan, Director of the Centre for Global Health, Trinity College Dublin, attended the Assembly in May. This was in the context of Global Co-operation on Assistive Technology (GATE), a project led by the WHO in collaboration with UN agencies, international organisations, donor agencies, academia and disability rights organisations.

It aims to improve access to high-quality, affordable, assistive products and Prof MacLachlan is the lead on research and innovation.

One of GATE’s initiatives is the development of a Priority Assistive Products List, which was launched at a side-event of the Assembly. The list of 50 products includes items such as fall detectors, pressure-relief cushions and electrically-powered wheelchairs, and aims to replicate the impact of WHO’s Model List of Essential Medicines.

The launch event was hosted by eight governments, including that of Ireland. The next stage is that the list will go to the Assembly, potentially next year, and be adopted as formal policy of WHO.

“It is obviously a very political affair, in terms of different countries putting forward different proposals and looking for co-sponsors,” said Prof MacLachlan of the Assembly.

Reflecting on the role of WHO, he said synthesising the world’s health priorities and getting all nations to agree in the context of widely different geopolitical realities is a “huge ask”.

“I would start by saying that, from a global health point of view, what they are trying to do certainly needs to be done, but it is almost impossible to do. Everybody accepts that and therefore it is a matter of trying to establish the best principles you can operate by,” he told MI.

The WHO has placed an increasing emphasis on the social determinants of health, which represents a shift from purely biomedical and technical solutions to examining living conditions and health inequalities.

“Really, a phrase you hear nowadays in WHO a lot, which you wouldn’t have heard certainly ten years ago, is ‘social justice’…So whether it is HIV, TB, mental health problems, disabilities; it is moving upstream more and saying what are the conditions that produce the different sorts of prevalence rates around the world?”

He said the growing emphasis on strengthening health systems is also welcome.

“When I started working with them about 10 years ago, that would have been funny language. Whereas now, everything is — how does it relate to strengthening health systems? If you look at most definitions of global health now, for instance, very few of them relate to things like diseases, most relate to the idea of social inequality, to systems’ strengthening, and so on.”

Prof MacLachlan also said the WHO faces a number of operational challenges.  

He noted that the roles of major philanthropy organisations in an agency like the WHO could be just as problematic as that of corporates.

Due to their funding being so significant, philanthropic entities can set agendas in different countries. Such organisations can “obviously do a lot of good but they can be very domineering, and interestingly, groups like Gates [Foundation] with their global challenges, they tend to be much more scientific, technically focused and have been, I would say,  behind the curve in coming to more of a systems-focus… ”

As to Ireland’s role (see panel), Prof MacLachlan said the best strategy is to select and champion specific areas that cross over many diseases, which this country already does to a certain extent. 

Ireland has the advantage of a “very good” diplomatic mission in Geneva, where the WHO is headquartered, he added.

“I think our aim in Ireland should be trying to champion a few ideas and then leverage large amounts of funding from other countries to support those ideas. I think Ireland can host donor conferences and things like this, and provide leadership in that way,” he concluded.

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