Remco van de Pas (Wemos Foundation, the Netherlands)
The World Health Assembly (WHA), the annual meeting of WHO’s governing body, in which its 194 Member states review and provide strategic direction for pressing global health issues, ended this week. Its agenda was dense, with decisions to be taken on important issues, such as WHO’s own reform, a new Global Program of Work and related program budget, including a new financing mechanism. Important themes such as Universal Health Coverage (UHC), a global action plan for the prevention and control of non-communicable diseases, health in the post- 2015 development agenda, and the International Health Regulations have been discussed, the latter against the background of a new global health threat, a novel coronavirus outbreak that has caused infections and several deaths in the Middle East region since it emerged in April 2013.
We have been closely following the reform process of the WHO over the years. The reform should lead to a stronger and more efficient organization able to take a leadership role in a fragmented and complex global health scene. WHO itself doesn’t speak about global health architecture anymore, but rather of global health governance, “the use of formal and informal institutions, rules, and processes by states, intergovernmental organizations, and non-state actors to deal with challenges to health that require cross-border collective action to address effectively”.
In short, so far WHO has failed to meet the expectations to re-emerge as the leading organization in global health. During the reform process, major steps have been taken to strengthen internal management and effectiveness of the organization, leading to a program of work built around 6 categories and results based outcome indicators. What has been lacking so far, though, is a more fundamental debate about the role of WHO in the international system. This is also the conclusion of a policy paper produced by Chatham House in February 2013. “The current process does not ask fundamental questions about WHO’s place in the international system as it has now evolved, nor whether WHO’s governance, management and financing structures need more fundamental change than is currently envisaged. It is therefore unclear whether the latest reform efforts will be sufficient to enable the organization to fulfill its potential”.
Interestingly, there are formal documents on WHO’s role in global health governance as a reference for debate for WHO’s Executive Board (EB) members, see for instance EB132/5 Add.5 (January 2013) and EB 133/16 (May 2013). While writing this blog, the 133th EB has been busy for several hours discussing whether the item “Improving the health and well-being of lesbian, gay, bisexual and transgender persons” should remain on the agenda for discussion or not. A fundamental discussion on WHO’s role in global health will hence also not take place at the 133th EB. Because of diplomatic reasons, the (majority) of the member states do not want to have an open debate on this issue, as this could lead to strong ideological and political friction. It fits with the analysis that the WHO is choked and bereft of any institutional autonomy as the majority of its funds are provided via extra-budgetary voluntary contributions which – through the WHO – actually serve the interests of particular state and non-state donors. The OECD has called this development muIti-bi financing. Through this increasing trend, participating governments and others are controlling international agencies more tightly, thereby impacting on their policy priorities.
If not the WHO, which institution is then allowed to set the scene in global health? This WHA also saw the re-emergence of an old friend and foe in global health: the World Bank! Its new president, Dr. Jim Yong Kim gave an impressive speech in which he heralded the drive for Universal Health Coverage and committed himself to the “values of the Alma-Ata Conference on Primary Health Care, health equity and development in the spirit of social justice “ (!) Hold a minute, the World Bank and comprehensive primary health care, wasn’t that a rather awkward combination in the 80s and 90s? Has the WB indeed learned from its past?
It confessed its mistakes in these words by Kim: “And let me acknowledge that Thailand launched its universal coverage program against concerns over fiscal sustainability initially raised by my own institution, the World Bank Group. Thailand’s health leaders were determined to act boldly to provide access for their whole population. Today the world learns from Thailand’s example”.
With also the support of Paul Farmer, fellow founder of Partners in Health, and Tim Evans as the new director of the Health, Nutrition and population Department, the WB’s new (health staff) leadership is strongly rooted in the health policy and paradigms promoted by the Harvard School of Public Health. So what can we expect? One question came to my mind when reading the speech by Dr. Kim: why do we need to “close the gap in access to health services and public health protection for the poorest 40 percent of the population in every country”? Why not closing the health inequalities gap for entire populations? Isn’t a focus on the poor leading automatically to a two-tiered system? A minimum basic package provided by public or contracted services for the poor, and high quality private services for the richer part of the population. Both the WHO and the World Bank keep on repeating that UHC is “not about a minimum service package or a one-size-fits –all approach to service delivery, but rather emphasizes progressive realization of coverage according to a country’s situation”.
An essential question remains. Will progressive coverage of health services contribute to improved health equity in and between countries? Is it wise to invest both public and private finances so much in health care delivery and not in essential public health measures? Colleagues like Charles Clift and Laurie Garret who have followed this debate also question the direction and role of the WB in UHC.
By the way, the recent article by Kim and Farmer on redefining global health-care delivery (Lancet, May 2013), is in stark contrast with Kim’s clear speech at the WHA. I found it rather indigestible and it doesn’t provide new insights into health care delivery. Basically the authors advocate a more integrated and diagonal approach in health care delivery (which they call a value chain). They remind us several times that these concepts are well known, and argue that health care delivery systems can be a strong contributor to economic development.
The focus on health care delivery, UHC and economic development, although all important, might distract us from the devastating health impact of a globalized economy, that has led to a deeper divide between the wealthy and the poor, and has resulted in austerity measures and higher mortality in several European countries and the US over the last 5 years. For a good overview of these (dire) effects, it is valuable to read the just published “The Body Economic, why austerity kills” by David Stuckler and Sanjay Basu. David Stuckler puts it like this: “If there actually was a fundamental trade-off between the health of the economy and public health, maybe there would be a real debate to be had. But there isn’t. Investing in programmes that protect the nation’s health is not only the right thing to do, it can help spur economic recovery. We show that. The data shows that.”
Will the World Bank and WHO be leaders in advancing strong, equitable health systems under the umbrella of UHC, or will the powerful political powers in this world again interpret UHC in their very own way and use the Bank and WHO as convenient vehicles? The story will unfold, and we will be closely watching it!