Offline: Solving WHO's “persisting weaknesses” (part 1)

Abstract

When the 34 members of WHO's Executive Board gather in Geneva on Jan 25—first, for a special session on the response to the Ebola outbreak and, second, for its 136th meeting—countries will have an unprecedented opportunity to reflect on the future of the world's only global health agency. Why unprecedented? Because, in WHO's own words (from documents submitted to the Board and available on WHO's website), Ebola has put “enormous strain” on the agency's managerial structures and systems. The outbreak has had a “significant impact” on WHO's non-Ebola work, with the result that “time-bound projects will be affected”. Ebola has “exposed… persisting weaknesses” in the organisation. This crisis offers a paradoxically welcome opportunity to re-examine WHO's purpose, structure, operation, and impact.If one was to draw up a balance sheet of WHO's successes and failures, it might look something like this. In the poorest countries of the world, WHO remains trusted and influential. The agency attracts talented individuals to lead its programmes. WHO retains extraordinary convening power. Important achievements since 2006 (the beginning of Director-General Margaret Chan's first term of office) deserve praise and recognition—championing Universal Health Coverage; leading a global strategy, Every Woman, Every Child, for reproductive, maternal, newborn, child, and adolescent health; securing a Political Declaration on the Prevention and Control of Non-Communicable Diseases; making accountability one of the most important forces shaping global health today; and promoting climate change as a crucially important health priority. The Executive Board's agenda in Geneva this month includes several urgent matters. (Strangely, no time has been set aside for a substantive discussion about either universal health coverage or the post-2015 era for health.) From the provisional agenda one might highlight, in addition to Ebola and related concerns (such as the robustness of International Health Regulations), progress towards the MDGs, future work on non-communicable diseases, and antimicrobial resistance. WHO's Dec 30, 2014, report on the health-related MDGs is especially bitter-sweet. Seven goals are emphasised: hunger (MDG 1C), child survival (MDG 4A), maternal mortality (MDG 5A), reproductive health (MDG 5B), HIV/AIDS (MDG 6A, 6B), malaria, tuberculosis, and neglected tropical diseases (MDG 6C), and access to essential medicines (MDG 8E). Only the targets for halting and beginning to reverse the spread of HIV/AIDS, malaria, and tuberculosis have been met so far. In its reports to the Executive Board, WHO highlights its most alarmingly under-funded programmes—vaccine-preventable diseases, integrated health services, non-communicable diseases, alert and response capacities, and health and the environment. All of these programmes are core activities for WHO. Their chronic underfunding illustrates the operational emergency facing WHO—the agency simply is not able to meet the expectations of its multiple constituencies. WHO also draws attention to the continuing anomaly at the heart of its financing. Of a total budget for 2014–15 of US$4·13 billion, only $0·93 billion comes from assessed contributions. 78% of WHO's budget comes from much more unpredictable voluntary contributions. Worse still, 80% of these voluntary contributions come from just 20 contributors, 11 of whom are non-state actors (eg, the Gates Foundation).View Large Image Copyright © 2015 ALJIBE/AFP/Getty ImagesView Large Image Copyright © 2015 Andrew Burton/Getty ImagesIn 2011, Dr Chan initiated a programme of “WHO reform” to create “an organisation that was ‘fit for purpose’, able to respond rapidly and effectively to the public health challenges of today, and those we will face in the future”. It is too harsh to conclude, as some critics do, that WHO's response to Ebola proves the agency's reforms have failed. But WHO itself acknowledges that Ebola has revealed areas where “further reforms may be required” and where there is an “urgent need to accelerate implementation of key elements of reform”. Why does WHO's Ebola response and the success of its reform strategy matter so much? WHO answers this question in its own financial strategy—”The willingness of Member States and other contributors to provide voluntary contributions will reflect their confidence in the Organisation.” Put more bluntly, a properly funded WHO depends on whether donors believe the agency is competent to deliver results. Ebola has severely dented that belief. But what should a further phase of WHO reform look like?View Large Image Copyright © 2015 Daniel Acker/Bloomberg via Getty Images When the 34 members of WHO's Executive Board gather in Geneva on Jan 25—first, for a special session on the response to the Ebola outbreak and, second, for its 136th meeting—countries will have an unprecedented opportunity to reflect on the future of the world's only global health agency. Why unprecedented? Because, in WHO's own words (from documents submitted to the Board and available on WHO's website), Ebola has put “enormous strain” on the agency's managerial structures and systems. The outbreak has had a “significant impact” on WHO's non-Ebola work, with the result that “time-bound projects will be affected”. Ebola has “exposed… persisting weaknesses” in the organisation. This crisis offers a paradoxically welcome opportunity to re-examine WHO's purpose, structure, operation, and impact. If one was to draw up a balance sheet of WHO's successes and failures, it might look something like this. In the poorest countries of the world, WHO remains trusted and influential. The agency attracts talented individuals to lead its programmes. WHO retains extraordinary convening power. Important achievements since 2006 (the beginning of Director-General Margaret Chan's first term of office) deserve praise and recognition—championing Universal Health Coverage; leading a global strategy, Every Woman, Every Child, for reproductive, maternal, newborn, child, and adolescent health; securing a Political Declaration on the Prevention and Control of Non-Communicable Diseases; making accountability one of the most important forces shaping global health today; and promoting climate change as a crucially important health priority. The Executive Board's agenda in Geneva this month includes several urgent matters. (Strangely, no time has been set aside for a substantive discussion about either universal health coverage or the post-2015 era for health.) From the provisional agenda one might highlight, in addition to Ebola and related concerns (such as the robustness of International Health Regulations), progress towards the MDGs, future work on non-communicable diseases, and antimicrobial resistance. WHO's Dec 30, 2014, report on the health-related MDGs is especially bitter-sweet. Seven goals are emphasised: hunger (MDG 1C), child survival (MDG 4A), maternal mortality (MDG 5A), reproductive health (MDG 5B), HIV/AIDS (MDG 6A, 6B), malaria, tuberculosis, and neglected tropical diseases (MDG 6C), and access to essential medicines (MDG 8E). Only the targets for halting and beginning to reverse the spread of HIV/AIDS, malaria, and tuberculosis have been met so far. In its reports to the Executive Board, WHO highlights its most alarmingly under-funded programmes—vaccine-preventable diseases, integrated health services, non-communicable diseases, alert and response capacities, and health and the environment. All of these programmes are core activities for WHO. Their chronic underfunding illustrates the operational emergency facing WHO—the agency simply is not able to meet the expectations of its multiple constituencies. WHO also draws attention to the continuing anomaly at the heart of its financing. Of a total budget for 2014–15 of US$4·13 billion, only $0·93 billion comes from assessed contributions. 78% of WHO's budget comes from much more unpredictable voluntary contributions. Worse still, 80% of these voluntary contributions come from just 20 contributors, 11 of whom are non-state actors (eg, the Gates Foundation). In 2011, Dr Chan initiated a programme of “WHO reform” to create “an organisation that was ‘fit for purpose’, able to respond rapidly and effectively to the public health challenges of today, and those we will face in the future”. It is too harsh to conclude, as some critics do, that WHO's response to Ebola proves the agency's reforms have failed. But WHO itself acknowledges that Ebola has revealed areas where “further reforms may be required” and where there is an “urgent need to accelerate implementation of key elements of reform”. Why does WHO's Ebola response and the success of its reform strategy matter so much? WHO answers this question in its own financial strategy—”The willingness of Member States and other contributors to provide voluntary contributions will reflect their confidence in the Organisation.” Put more bluntly, a properly funded WHO depends on whether donors believe the agency is competent to deliver results. Ebola has severely dented that belief. But what should a further phase of WHO reform look like? WHO and the health of LGBT individualsIn his Offline, Richard Horton (Jan 10, p 100)1 recently emphasised WHO's “persisting weaknesses”1,2 ahead of their Executive Board session. With WHO reform in the air, Director-General Margaret Chan stated in her opening remarks that the “agenda covers some of the most pressing public health problems” and that there is “growing evidence that well-functioning and inclusive health systems contribute to social cohesion, equity, and stability.”3 The saga of agenda item 6.3 of the Executive Board—improving the health and wellbeing of lesbian, gay, bisexual, and transgender persons (LGBT)4 —in the past few years has shown that WHO's members are indifferent to these notions of inclusive health systems and equity. Full-Text PDF