Remco van de Pas, Wemos  

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Next week, the Executive Board (EB) of the World Health Organization (WHO) gathers for its 134th session in Geneva, Switzerland. An impressive range of issues will be discussed and negotiated during the 6- day meeting. Amongst these issues are policies that are of great importance to global health governance, such as the draft terms of reference for the global coordination mechanism on the prevention and control of non-communicable diseases, a framework for WHO’s engagement with non-state actors and maternal, infant and young child nutrition.  Once again, the People’s Health Movement will have an experienced team of WHO watchers in Geneva, analyzing in detail the Board documents, providing comments and observing the debate at the EB.

WHO is since 2011 involved in yet another process of reform. One can read in the evaluation report of the Second stage evaluation on WHO reform by PwC the following:

There are concerns from academia and partners that WHO has been weakened with the expansion of global health initiatives, in what has been called ‘the golden era of global health’. Interviews have shown that although WHO is seen as a critical player, and that its intergovernmental nature is valued, it has not addressed with enough vigour the question of its role in global health governance. There is a feeling that WHO is ‘tip-toeing around the essence of the organisation’, as presented by a global health advisor interviewed”.

This mimics a concern I raised after a consultation on WHO’s engagement with non-state actors in October 2013, concluding that the organization still lacked a strategic vision on its   potential role in global health governance. This month several academic articles have been published, which more or less share a common message: they all call for alternative global governance mechanisms for health, an urgent requirement in our 21st century globalized world, they say. John Lidén argues for UN agency heads (from WHO, UNICEF, UNFPA) to come up with bold ideas, vision and leadership. Ilona Kickbush suggests systematically following the flow of money through the global health domain, and the set-up of a high-level independent panel on global health impact. It would analyse and oversee the implementation of the health and other international agreements adopted (such as in trade, the environment, and food) and report regularly to the UN General Assembly and World Health Assembly.  Julio Frenk and colleagues  make in the Lancet the case for a renewed concept of Global health that would be governed by “the construction of a global society, that emerges as a feasible alternative to harness interdependence in a world polity where sovereign nation states coexist with expansive social networks transcending national boundaries”.

In the journal Public Health, Steven Hoffman and John Arne Rottingen provide examples why WHO should be split in two, separating its technical and political stewardship functions into separate entities, with collaboration in areas of overlap. And lastly, Kelley Lee and Tikki Pang  challenge us to go beyond navel gazing, and move the WHO to a truly Global Health Organization, “with a more carefully described mandate and power, yet having a more binding authority, to make its role more meaningful in terms of effectively delivering the essential functions needed to protect and promote health in a globalised world, governed in a ‘cosmopolitan democracy’’”.

What strikes me in all these articles related to global health governance and/or global governance for health is that relatively little attention is being paid to global health equity.

But (global health) equity is an essential, too often neglected, aspect of globalization that requires urgent and committed attention, as many actors and institutions now agree, and global health governance debates should center around this concern. The gap between the “globalizers” and the “non-globalizers” is growing, and its impact can be seen in population health outcomes becoming more unequal, both between and within countries. It is hence good to reread the work of Ronald Labonté and colleagues who wrote in 2007 about health-equitable globalisation and the corresponding need for more Rights, Regulation and Redistribution. They provided in this report the framework of three ‘Rs’:

“• systematic resource redistribution between countries and within regions and

countries to enable poorer countries to meet human needs,

• effective supranational regulation to ensure that there is a social purpose in the

global economy, and

• enforceable social rights that enable citizens and residents to seek legal redress”

I will not go into detail what this implies for global governance structures, the report provided some good recommendations in this respect. Bottom line is that before we create new institutions and mechanisms, we should analyze why these three Rs cannot be provided by our current global institutions, including WHO. This is in essence analyzing political and economic injustice, and identifying barriers to a more just world.

I would like to provide one reflection though. The Lancet Commission on  Global Health 2035 as well as the president of the World Bank recently made the plea for more investments and ‘for a Grand Convergence’ in health as collectively we have the financial and technical means to do so.

They argue that Universal Health Coverage will fulfill the human right to health, and that pro-poor investment (progressive universalism) is an appropriate redistribution mechanism on  the pathway towards UHC. What I miss in these, and many other papers, is that there is also an absolute need for binding regulations for health, whether at the national, regional or global level. Regulations are not only needed to guarantee sufficient international financing for health (such as an international transaction tax, or other global taxation mechanism), but  they are also necessary to prioritize health above other global forces, eg trade liberalization, ecological erosion, unhealthy food or the intellectual property regime.  But maybe the Lancet Commission on Global Governance for Health will talk about this in more detail in its report, to be published on 11 February.

Anyhow, regulation will always be hard, as it clashes with our ongoing appetite for liberty and individual freedom…..

Next week, during the EB, member states will be too busy discussing other urgent and relevant matters in global health. The debate on WHO’s role in global health is still open and needs to be discussed in the nearby future. I agree with Kelley Lee’s assessment: “the creation of a truly global health community faces a watershed movement”.  However, I also realize that while potentially in a globalized world we are all equal, some of us are more equal than others. And, to paraphrase a notorious former British prime minister, TINA,  “There is no alternative”: either we find a way to tackle the huge inequality in this world, or this world won’t have a meaningful future.

Let’s keep that in mind when moving WHO forward or coming up with alternative governance mechanisms.

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