Remco van de Pas, Wemos foundation
This month member states of the World Health Organization (WHO) gathered in Geneva for two meetings that will probably shape the direction of the organization for the coming years. End of March, a second informal consultation on WHO’s engagement with non-state actors took place, and this week (23-25 April), member states came together to discuss a global coordinating mechanism for Non-Communicable Diseases (NCDs).
The meetings are closely related to each other, because they both discussed cooperation and coordination of WHO with other actors than state governments, defined as “Non-State Actors” (NSAs). While the first meeting on WHO’s engagement with NSAs discussed a general policy framework for how WHO should interact with different actors in (global) health, the second meeting focused on the governance mechanism for cooperation between different actors to address the burden of NCDs. Interestingly, both meetings were for member states only. Outside observers were not allowed. Formal decisions and resolutions are taken during the WHO’s Executive Board (EB) meetings and the annual World Health Assembly (WHA). Observers, such as NGOs, are allowed during these meetings and can even provide formal statements for consideration of the member states. Due to an often cramped agenda during the EB and the WHA, more and more of the multilateral diplomatic debate on global health issues takes place outside these governance bodies and hence away from public scrutiny. This is a worrying trend, as the ongoing reform of WHO should make the organization more accountable and transparent instead.
What is at stake?
The debate on WHO’s involvement with NSAs is not new. Early 2000s there was already a proposition for WHO to cooperate with NGOs in a so-called civil society initiative. This proposition didn’t pass the WHA in 2004, due to opposition by some member states. As part of the WHO reform, new models for cooperation have been suggested since 2010, such as a proposal for a committee C of the World Health Assembly and a proposal for a World Health Forum (see par. 84-89). They both didn’t make it either. These days, a new policy proposal for WHO’s engagement with NSAs is being considered (note the different terms used over time; “Non-State Actors”, “Civil Society Organisations”, and “Non-Governmental Organisations”). The main debate between the member states is to what extent there should be a distinction between NGOs and private entities, and what the mechanisms should be to address potential conflicts of interest. In this report about the March member state consultation, it seems that there is no consensus about the policy. A diplomat who attended the consultation said that ‘the United States and the United Kingdom complained that the draft policy sets a high degree of scrutiny for the private sector compared to other NSAs.’ Indeed, pharmaceutical companies, but also food and beverage industries, have much (legitimacy and financial profit) to gain if they can work in a more strategic partnership with WHO. And yes, this would likely have an impact on the public health programs and health standards that WHO provides. I find it quite amazing that in the papers there is little discussion about the actual public health benefits of these partnerships: “In the main, WHO’s engagement with non-State actors brings important benefits to global public health and to WHO itself (p15)”. The US, EU and other donors of WHO push for these multi-stakeholder approaches, including a role for private commercial entities. There is resistance from a number of low and middle-income countries to this as many of them already face an overload of selected patented Western pharmaceuticals and cheap food on their domestic markets.
Global coordination mechanism on the prevention and control of NCDs
Annex 2 of the EB document 134/14 (p11-20) provides insight in the actual negotiations on the creation of a new global coordination mechanism to manage the global NCD burden. In par. 7 – 15 the different positions of the member states can be found. The EU and some other countries see a large role for an “international advisory group, comprised of public health and technical health experts in the field of NCDs “(par.8), as well as a “consultation segment with selected representatives of the private sector” (USA, par.10). Brazil, Iran and Pakistan object to the latter, and have reservations about the expert advisory group (par 7). The USA promotes a strong role for WHO and more in particular wants its Non-communicable Diseases and Mental Health cluster to be the secretariat and main coordinator of the global coordination mechanism, (par.14-15). Brazil, China and India and some African countries promote stronger involvement of member states and WHO regions in the coordination mechanism on NCDs (par 8. 11, 16).
Why is there such a push for WHO to be the main convenor in a multi-stakeholder global coordination mechanism on NCDs? Two answers come to my mind. First, Alison Katz elaborated in a recent article in detail the question whether NCDs are a true global health priority or rather a market opportunity determining priorities for WHO? Her central thesis is that while NCDs might be the main burden of disease in Europe, the Americas and a few emerging economies, this is not the case (yet) in most of Africa, South-East Asia and the Eastern Mediterranean. ”Very high levels of avoidable disease and premature death due to infectious diseases, maternal, perinatal and nutritional conditions persist in low income countries”. She recommends WHO to pay more attention to clean drinking water, sanitation and nutritious food as key determinants to overcome both infectious and non-infectious diseases instead of the exclusive, vertical, rather biomedical focus on NCDs and its risk factors. In her view, the NCD agenda is imposed on low income countries, as it’s lucrative for the pharmaceutical, food & and beverage industries, as well as for some NGOs, to develop commodities and expand markets for addressing chronic diseases (see for example the advertisement of ‘healthy products’ on the shelves of supermarkets for the new middle classes).
Second, the lessons from the Global Fund (to fight Aids, Tuberculosis and Malaria) and the GAVI alliance have taught WHO that it has to follow the conditions of the main funders, or otherwise these donors will create global health partnerships outside its control. WHO would thus rather convene and obtain funding for a partnership (the global coordinating mechanism) on NCDs within its own house instead of having to cooperate with a partnership outside its premises (which is now the case with the Global Fund and GAVI). The US, EU and some of its member states as well as the Bill and Melinda Gates Foundation are the biggest funders of WHO. WHO in 2012 received US$264 mln.as voluntary specified funds from the Gates Foundation which is more than the US Government’s voluntary specified contribution of US$208 mln. This ‘steering’ of the priorities of multilateral organisations by its donors is known as multi-bi financing.
What will happen next?
A new framework of engagement with non-state actors will be presented for discussion to the programme, budget and administrative committee (PBAC) of the Executive Board on 14-16 May 2014 (also not accessible to observers), and then presented to the 67th World Health assembly for consideration. A new proposal for the Global Coordinating Mechanism will also be presented to the WHA, based on the outcomes of the April consultation with member states. Despite the opposition by several lower and middle-income countries to the multi-stakeholder model proposed it is most likely that these policy proposals will be adopted as this is what the main donors want.
The simple reason is that so far there is little interest by emerging economies to fund WHO on a voluntary basis or even to plea for higher assessed (membership) contributions. It has been analysed by Devi Sridhar and colleagues that despite the growing influence by BRICS countries in global governance for health, this hasn’t translated into more funding commitments to WHO (or other multilateral health organisations) so far. Perhaps these countries have little faith in the autonomy of WHO as the global health authority and thus prefer to solve their issues on a regional basis? The same trend is also visible in other UN global governance regimes (such as on climate change).
At issue is thus WHO’s legitimacy. Having followed the WHO reform over the last years, it’s evident that the organisation’s reform has focused on managerial and organisational aspects so far. The main challenge, how to enhance the (democratic) legitimacy of WHO, has been dealt with in a very pragmatic way. The backdrop of the WHO reform was, of course, a severe economic crisis in the main donor countries (among the donors, only Bill Gates wasn’t affected by the crisis, but he’s in a league of his own).
You can’t help but wonder what the future position and legitimacy of the WHO will be in a more multipolar world.