WHO reform at crossroads

DISCLAIMER: All opinions in this column reflect the views of the author(s), not of EURACTIV.COM Ltd.

The EU and the WHO have to complement each other instead of rivalry in shaping European health policy, writes Mihály Kökény, Hungary's former Minister of Health and former chairman of the WHO executive board.

Mihály Kökény is former Minister for Health of Hungary and former chairman of the World Health Organisation's executive board. He contributed this commentary exclusivity to EURACTIV.

"The last decade has challenged the basics of health action as never before. Increasing health inequities in poor and well-off states alike, significant and only-just-starting long-term health impacts of the economic downturn, systemic shocks such as like devastating earthquakes and long-term effects of urbanisation, ageing, climate change etc. – the combination of all these is unique to our times.

This requires synergy of solutions, because countries demand innovative, tailored guidance in shaping their health policies in an uncertain environment. They need stable, responsive, flexible, knowledge-based global health actors. This also means a renewed World Health Organisation. Will WHO survive the test?

Some symptoms

The WHO has reached its limits in terms of finances and ability to fulfil its role “to act as the directing and coordinating authority of international health work” (Constitution, Article 2a). It suffers from imbalances in funding and too many commitments. The single-disease-oriented global health initiatives from all international actors including key donor countries and the private sector absorb $22 billion annually. WHO will have less than $2 billion for the next year in its budget.

Most of this money comes from earmarked resources and only a relatively small percentage from the regular membership contributions of the member states. This makes the organisation dependent on voluntary contributions of the “donor” countries. This has certainly brought many successes:

Of course, the WHO has achievements like the smallpox eradication, improving mother and child health, strengthening health systems and, more recently, the Framework Convention on Tobacco Control (2003), the International Health Regulations (2005) or the Pandemic Influenza Preparedness Framework of this year.

Nevertheless, WHO lacks an inspirational strategic vision for the 21st century. This makes it hard to set priorities and refuse proposals and requests from member states that mainly serve political interests or raising of a country’s prestige, by associating itself with a single disease global action. The WHO European Region addresses this difficulty by developing an “umbrella” strategy called Health 2020, which might be a useful idea to be followed globally.

The reform agenda

WHO Director-General Margaret Chan recognised the critical situation of the organisation and set a reform agenda including five key areas: internal managerial reforms, changes in the way WHO is financed, in the policies WHO interacts with other global stakeholders,  internal governance of the organisation and in creating a visible mechanism how WHO sets priorities.

The World Health Assembly in May 2011 gave a green light to go ahead with the reform. Easy to say, difficult to implement. Although there seems to be a consensus for the need of a smart WHO prepared to survive during the 21st century, the way to achieve this remains difficult to find.

Various stakeholders – for instance, international health journals, health policymakers and NGOs – express concerns about whether WHO will be capable of reinventing itself, under powerful fiscal and political pressures. Yet, the reform is moving forward with strong support from many countries.

In early November WHO’s Executive Board discussed a new report proposing a tangible and detailed agenda for change, with feasible options to choose. A roadmap was approved, of course, the devil is hidden in the details.

Balances needed

WHO will have to strike several balances on reforming the way it works. Let me share the content of three such factors:

  1. The speed of transition should be carefully considered: consensus building needs time (emphasised by poorer countries which are afraid of strong influence from the rich ones), while in parallel key donor countries are anxious for quick-fix solutions.
  2. Immediate and long-term actions should synergise one another through a proper sequencing. WHO may start with an ambitious set of internal reform steps (new staffing arrangements, strengthening normative work, improving efficiency of the governing bodies, etc.) and leave time for continuous long term measures in global health governance (e.g. negotiations for a global health charter or a non-binding agreement on the ground rules of coordination in global health architecture).
  3. Diverging views have emerged on how the voice of non-state stakeholders would be better heard and taken into account. How will WHO foster and enhance democratic inclusiveness in a global health organisation in times when it has to demonstrate more efficiency and outcome orientation?

The EU and the WHO reform

The European Union has played and still playing a proactive role in setting and crystallising profound changes of WHO. Not by chance:

  1. More than half of the 53 European member states of WHO belongs to the EU, but with candidate and potential candidate countries, the non-EU members of the European Economic Area as well as those involved to the European Neighbourhood Policy project almost 90% of the WHO’s European member states are affected by EU policies.
  2. Health, under the umbrella of human and social development theme of EU development policy, is said to be both at the heart of development process and an objective of this policy in many countries.
  3. The healthcare industry has a significant part in preserving EU’s competitiveness in the world markets. Just in 2010 only the research-based pharmaceutical industry invested an estimated €27 billion in R&D in Europe. It directly employs 640,000 people and generates three to four times more employment indirectly – upstream and downstream – than it does directly.

These reasons led to an increasing EU interest in international health and WHO reform. In May 2010 the Foreign Affairs Council Meeting adopted conclusions on the EU role in global health. This document recognises WHO’s key mandate in the global health arena by supporting “the leadership of  WHO at global, regional and country level, in its normative and guidance functions addressing global health challenges as well as in technical support to health systems governance.”

The statements of the EU Presidency during the subsequent sessions of the WHO governing bodies encourage changes in the same way: “the efforts to make WHO fit for the future had the European Union’s full backing…The time is right for consolidation rather than expansion; hence the importance of WHO’s efforts to increase efficiency, effectiveness, accountability and transparency…”

However, while EU fully respects WHO’s head role in global health governance, emphasis is given to managerial improvements.

In this manner the EU and the WHO Regional Office for Europe have reorganised their cooperation. In September 2010 during the 60th session of the WHO Regional Committee for Europe, a joint declaration was signed by the regional director of WHO and the EU Commissioner for Health and Consumer Affairs calling for a more cohesive effort to improve health throughout the WHO European Region.

EU and WHO have to complement each other instead in shaping European health policy. With a limited health mandate EU can benefit from exploiting WHO experiences in assisting health system reforms in preparing the implementation of the breakthrough new regulation on cross-border health care. 

In general, through coherence between an increased number of policy arenas for health, EU and WHO together can have a strong European voice in global health governance and be an advocate for sustainable European commitment to global health."

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