The World Health Organization and global health

Bengt Skotheim, Bjørn-Inge Larsen, Harald Siem About the authors
Artikkel

The World Health Organization (WHO) is the largest single UN organisation, and since its establishment in 1948 it has played a significant role in global health. WHO has enjoyed a great amount of trust through the strength of its political independence and professional expertise. Viewed as a whole, WHO has been the most important actor in this field. Today, however, the organisation is under pressure and its reputation is suffering.

The centre for the World Health Organization in Geneva. Photo SCANPIX

The World Health Organization (WHO) was established just after the Second World War. Franklin D. Roosevelt (1882 – 1945) had made his renowned speech about the four freedoms: freedom of speech, freedom of religion, freedom from want and freedom from fear. Director of Health Karl Evang (1902 – 81) took part in establishing the organisation, and an ambitious goal was set for its work: «The objective of WHO shall be the attainment of all peoples of the highest possible level of health.»

Gro Harlem Brundtland (born 1939) was the Director General of WHO from 1998 to 2003, and during her tenure the world experienced health as a global concern during the SARS (severe acute respiratory syndrome) outbreak.

Since 2006, WHO has been headed by Director General Margaret Chan (born 1947) from China. The organisation has 193 member states and has its headquarters in Geneva. It employs 8 000 people from 150 countries, either at its headquarters in Geneva, its six regional offices or in its 147 country offices. Norwegian Chief Medical Officer Bjørn-Inge Larsen (born 1961) has been voted in as a member of WHO’s Executive Board for the period 2010 to 2013 and is the member for Europe on the board’s working committee. In this context a Norwegian WHO strategy has been developed (1).

In the post-war years WHO united the nations and regions of the world in the fight for better health for all. The organisation made a contribution to this by eradicating the smallpox virus, directing successful vaccination campaigns and showing far-sightedness in holding the Alma Ata Conference on Public Health in 1978. In addition WHO has drawn up two legally binding agreements. The International Health Regulations (IHR) are linked to health security and are intended to stop the spread of disease (2), and during Gro Harlem Brundtland’s tenure, measures were taken to establish the Framework Convention on Tobacco Control (FCTC) as an important tool in the anti-tobacco effort (3).

The victories have been many, but WHO has lately on occasion attracted strong criticism. The organisation has been accused of being outdated, underfunded and over-politicised. It has also been criticised for being sluggish and bureaucratic in times of crisis, and for lacking scientific expertise, being too close to the pharmaceutical industry and of giving unclear health advice due to the consensus-based governance of the organisation (4). The critics often emphasise the organisation and the secretariat; however, this is mistaken. For the most part it is the member states that should be criticised. The member states are the World Health Organization. The organisation is a means to achieve a common goal of health. When the organisation does not work, this can of course be blamed on poor leadership in the secretariat, but it can justifiably be claimed that poor governance and disagreement between member states are also to blame. Many rich countries spend more money on other, non-democratic organisations than they do on the World Health Organization. This may contribute to challenging the democratic foundation of WHO in global health.

Despite its faults, there is a need for WHO as a coordinating organisation in the global health effort – it is hard to see how global public health can be safeguarded by anyone else. Global health is an area in which we are mutually interdependent. (5). No single country can think about or work with national health and welfare in isolation within its own borders. This also applies to our region. The recent financial crisis and the influenza pandemic (H1N1) both illustrate this. WHO is the only organisation with a clear mandate and legitimacy granted by 193 member states, and the authority to develop international health legislation and give advice on health issues. This is the strength of WHO and it must be developed.

WHO is described as underfunded, but if we look at how its funding has grown, the budgets which have been somewhat reduced in the past few years appear large when viewed in a historical context. Many member states emphasise that the budget of approximately 4 billion US dollars is a considerable one. However, this budget must be viewed in the light of the growth in funding of global health as a whole.

Globalisation of health

The interest in global health issues has greatly increased in recent years. This has resulted in an upsurge in health initiatives driven and supported by NGOs, private enterprises and national confederations. It is almost possible to see a paradigm shift in global health since 1990. The funding for the whole of this area has risen from 5.7 billion US dollars in 1990 to 26.9 billion in 2010 (6). However, WHO has not followed this upward trend and has gone from being by far the largest global health organisation in 1990 to becoming part of the general picture in 2010. In some areas WHO is challenged by innumerable large and small health initiatives. Interest and commitment are of course positive, but the many actors have also helped create a complex global health landscape.

Norway has contributed to the establishment and funding of global health initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (7) and the Global Alliance for Vaccines and Immunizations (8). Through the US President’s Emergency Plan for AIDS Relief, the USA has supported the fight against the HI/AIDS epidemic. Private sector involvement is well illustrated by Bill Gates (born 1955). He started his own organisation, the Bill & Melinda Gates Foundation. Today this is one of the most significant organisations involved in global health. Gates spoke warmly about vaccines during the World Health Assembly in May 2011 (9). It is no surprise that he addressed this assembly – he is, after all, second only to the USA as WHO’s largest donor.

While this effort is important, it can be claimed that the many global health initiatives lack real legitimacy; the effort they make is real, but at the end of the day they are only responsible to their own elected boards. WHO on the other hand, as the UN Joint Inspection Unit (JIU) pointed out very clearly in an evaluation of WHO in1993, is responsible for the health of every inhabitant of its 193 member states: «In WHO, more than in any other organization of the common system, ineffective management is best equated to the number of persons and families who could have been saved from disease and death…» (10). For this reason alone it is important to contribute to a strong and robust WHO.

Many of the global health initiatives are disease-specific, or vertical as they are termed. Vertical programmes have been effective in the fight against HIV/AIDS, polio, Chagas’ disease, and tuberculosis, but they can also have negative consequences. The criticism of vertical programmes revolves around lack of coordination, duplication of work, poor use of resources and short-term funding. Vertical health programmes can also disrupt national health priorities especially since some illnesses, such as HIV and AIDS, receive a great deal of attention while other areas remain neglected (11). No programmes can function alone; mutual interdependency applies here too, or to put it simply – everything is linked to everything else. It is therefore necessary to examine how the vertical programmes can work in cooperation with a robust health-care system with an emphasis on public health.

Yet many countries are also overwhelmed by the programmes they have to adhere to. In Uganda alone there are 20 different health initiatives (12). During the cholera epidemic in Haiti, 196 different organisations wanted to play their part, all with their own ideas of how the situation should be dealt with (13). It goes without saying that this is an untenable situation. Not only is it impossible for Haiti to deal with 196 donors in an emergency, but it is also a sign of the failure of the global health governance system.

Evening mood in Geneva. Photo SCANPIX

Reform of WHO

WHO must be the foremost agent of scientific, research-based health advice and a resource for every country. The organisation should be a meeting place for the best expertise and coordination in global health. Emphasis must be placed on knowledge brokering regarding public health and building health-care systems. The challenge is that today WHO is not equipped for such a task. Member states have therefore requested a reorganisation.

WHO is overworked and faces great challenges regarding governance and funding. Member states are continually imposing new tasks without looking at how the organisation will actually solve them or, importantly, how they will be funded. WHO’s income comes from contributions from all the member states and from voluntary contributions. Today as much as eighty per cent of its budget is from voluntary contributions. In their quest for results in return for their contributions to WHO, many donors and member states earmark their resources for those tasks they themselves consider important. This undermines the ability of the World Health Assembly and the Executive Board to determine a real, workable programme and budget. A review is therefore needed of how WHO is funded so that the Executive Board can govern the organisation more effectively (1).

During its handling of the influenza epidemic (H1N1), WHO was criticised for its close ties to the big pharmaceutical companies. The organisation was later absolved by an independent review committee regarding the alleged conflict of interest (14). Nevertheless this suspicion illustrates that WHO has problems with reputation and trust, especially with regard to civil society. WHO reform that is now underway must therefore be centred on how, through openness and the inclusion of civil society, WHO can regain the trust of the world community and thereby its legitimacy.

The reform provides opportunities. The member states are the World Health Organization and they should seize the chance to give the world a robust coordinating body for global health. The member states and the organisation as a whole must be bold enough to carry out a reform that makes it possible to support countries in building health-care systems and with public health work. WHO already laid the groundwork for this at the Alma Ata Conference in 1978: »…a main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life.» This is the bedrock. There is already agreement on the goal, and the potential is undoubtedly there. Roosevelt spoke of the four freedoms. WHO must speak up for the right to health for all.

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