Global health

WHO under construction

75 years after its foundation, the World Health Organization (WHO) seems to be in need of reform in many places. What steps need to be taken?

By Dr Andreas Wulf

The iconic World Health Organization (WHO) headquarters above Lake Geneva, overlooking the Mont Blanc massif, has been a major construction site for some time now; new parts of the building are currently being constructed here. The hall where the Executive Board comprising 34 rotating Member States normally meets twice a year is also in need of renovation. A situation that is not just very inconvenient for delegates, but that also limits the presence of independent organisations, the “non-state actors in official relations with WHO” (NSA). These are actors like the People’s Health Movement, Health Action International and the Geneva Global Health Hub, which medico international has had ties with for many years. Their delegations have been radically downsized due to the modernisation of the WHO Secretariat. Direct contact with the delegates has also been heavily curbed due to the remodelling. Since the COVID-19 pandemic, the plenary sessions have at least been livestreamed; the more important negotiations, of course, continue to take place behind closed doors.

Cooperation and “multistakeholderism”

The cooperation between the 75-year-old multilateral institution, where the Member States call the shots, and a civil society that is committed to critically commenting on and influencing the health policies of the states and their world organisation, is one of the standing issues at these negotiations. The few opportunities for the NSAs to take the floor on agenda items were already cut back to one minute at previous meetings. The WHO’s current proposal after five years of consultations to put in place a Civil Society Commission at the Secretariat is at least a further step towards accommodating those who not only criticise the WHO but also defend it against attempts to gain influence through commercial and profit-oriented interests.

For as much as the WHO, in the 75th year of its existence, formally refers to its role as the “directing and coordinating authority” in global health policy, as was established in 1948, and bases its authority on the membership of almost all states in the world (194 currently), this role has long been jeopardised by the process of “multistakeholderism” as people like to call the modern form of a political “governance” that involves all interest groups, so “stakeholders”, in the decision-making processes, mostly without the inclusion of fundamental conflicts of interest that exist, for instance, between actors whose (private) interests require regulation and actors who are supposed to put in place such (public) rules.

Challenges during the pandemic

The most recent and certainly most drastic example of a conflict of this kind was the inability of states at the World Trade Organisation (WTO) to agree on the temporary suspension of intellectual property rights for health products needed in response to COVID-19 (vaccines, medicines, diagnostics, personal protective equipment, medical technology). The huge pressure from industry contributed to this in a major way, leveraging the world’s reliance on its products. The latest revelations about price hikes for mRNA vaccines for the European Union in the course of 2021 by Moderna and Pfizer/Biontech, as well as the announcements from the US that prices would be increased again 4 to 5-fold once the pandemic was “officially” over, make these power relations all too clear. They secured profit margins for the companies involved that one suspects are otherwise only achieved by state-funded arms manufacturing and illegal drug trafficking.

So it is no accident that in the first draft of a new “Pandemic Preparedness Treaty” currently being negotiated under the umbrella of the WHO and which numerous civil society actors have contributed to, access to health products and the regulation of intellectual property rights in the event of a pandemic loom large. The coming months will reveal how much of this will be forfeited again in the course of the negotiations by governments standing firmly on the side of “their” pharmaceutical and medical technology companies (with the German Federal Government being particularly prominent here). A critical public - as was mobilised globally during the pandemic, but which ultimately was unable to exert any real sway on patent decisions at the WTO – will remain important.

The position and influence of the WHO Secretariat and the current Director-General (DG) Dr Tedros as the directly elected boss of the organisation is as ambivalent in this regard as it is with other controversial global health issues. As former chair of a number of prominent public-private partnerships (PPPs) in global health, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Roll Back Malaria Partnership and the Partnership for Maternal, Newborn and Child Health, Tedros is firmly on the side of this partnership concept of multistakeholderism. And as the top fundraiser of his organisation, he has to be on good terms with the major donors: not just with the rich Member States, which pay for a large part of the WHO budget, but also with the philanthropic foundations (Gates, Buffett, Rotary International), which make key parts of the WHO’s work possible in the first place thanks to the additional funding they provide, but which also have their sights firmly on their own priorities and (like the Gates Foundation) are also actively involved in steering the big PPPs.

At the same time, Tedros also has a special obligation towards those governments of the global South which, in a highly symbolic move, elected him as the first African Director-General in the crucial first-time vote at the World Health Assembly in 2017. Previously, such decisions had first been adopted in the smaller circle of the Executive Board and de facto just confirmed by the Assembly.

And so, during the pandemic, he never tired of criticising the rich countries for practically going it alone in procuring and supplying first masks and tests and then vaccines, going so far as to speak of “vaccine[1]apartheid”. However, this also brought into sharp relief how weak the seemingly “leading” WHO actually is. Its initiative to do away with this unequal access with a Covid-19 Technology Access Pool right at the start of the pandemic was woefully neglected, supported only by a few small states and openly boycotted by the pharmaceutical companies. And the mRNA Vaccine Technology Transfer Hub, which the WHO has been building with local institutions in South Africa since 2021 and which is designed to share knowledge and technology via a network of collaborating companies faces equally clear resistance.

WHO also played a supporting role in setting up the Access to COVID-19 Tools Accelerator (ACT-A) in the spring of 2020, which came into the media spotlight mainly through its vaccine procurement pillar COVAX. Large PPPs such as the Global Fund, Gavi (vaccines) or the Wellcome Trust (therapeutics), among others, were responsible for procuring and distributing products to countries. COVAX in particular was soon juggling billions of US dollars. WHO was left to assume the thankless task of “health system strengthening”, which hardly any funds were made available for, but which was pivotal to the speed of vaccination programmes in many countries. It had an important role in testing the efficacy and safety of the vaccines, medicines and diagnostics purchased and distributed by the ACT-A. Its recommendations on the globally equitable distribution of the initially scarce vaccines, on the other hand, were deliberately ignored, whilst the rich countries hoarded vaccine and only generously let their surplus doses be distributed through COVXAX from the second half of 2021 onwards as a charitable gesture that looked good in the media.

Conflicts between Member States

The supposedly strong WHO is also caught right in the middle on other issues: for instance, when its members use the WHO stage to argue amongst themselves. The COVID-19 pandemic was again just the most visible tip of this: the open conflict between the US Trump administration and the People’s Republic of China over the questions of timely information on and the origin of the virus (wild animals or research laboratory) – at its core a bilateral conflict over economic clout and regional/global influence - was answered by China with a stubborn insistence on its national sovereignty. The WHO attempted to counter this with the traditional diplomatic charm offensives, but increased the ire of Trump in the process, who threatened to quit the WHO and cut off US funding, which luckily was prevented by his failure to secure re-election at the end of 2021.

Another example of conflict between individual Member States is how the issue of sexual and reproductive health/rights is handled. Here, positions vary particularly drastically and are expressed in the struggle over the inclusion of concepts such as “sexual education” and the mention of “sexual minorities” as target groups of prevention measures. The Russian delegation, for instance, bemoans “provocations” in official texts, also in an attempt to forge alliances that additionally help it defend itself against criticism on the war it is waging in Ukraine, for instance when the “Western alliance” condemns the attacks on civilian and health infrastructure in the plenary speeches and resolutions.

Huge dependencies

In all these dilemmas, the WHO remains diplomatically trapped. It is de facto a “servant” of its Member States, which decide the WHO’s work programme and funding. Especially since the WHO has no means whatsoever to compel its members to implement the very rules they have signed off on themselves. This became dramatically apparent during the pandemic, as exemplified by the International Health Regulations, when WHO recommendations on preparing for or combating the pandemic and against border closures were openly ignored by many.

So the WHO is courting important states in other ways, for instance in new “signature projects”. The Pandemic and Epidemic Intelligence Hub established in 2021 to improve the dovetailing of data collections for pandemic monitoring, is largely funded by Germany and so is located in Berlin. The new WHO Academy, a “state of the art lifelong learning centre” for health professionals, is not conceivable without the contribution from the French government and so is located in Lyon. The WHO could not run such initiatives from its regular budget.

Uncertain funding

The key question of “who will pay?” preoccupies the WHO, its supporters and critics alike. In January 2022, the Executive Board was still celebrating the gradual increase of compulsory membership fees to enable 50% of the total budget to be funded by the Member States in the future (at present it is not even 20%), but one year on, given the recession, the global economic impacts of the Russian war against Ukraine and rising inflation, it is unclear whether this can actually be implemented swiftly. And at the same time, as usual, key parts of the budget plan are not covered. The WHO’s proposal to hold a regular fundraising event (replenishment) instead of seeking new donors for each individual programme puts it in direct competition with the PPPs, which have professionalised this kind of “performance show” over the past 20 years. Whether WHO can assert itself here as a latecomer remains to be seen.

The new “WHO Foundation” launched two years ago also faces justified criticism. If you want to collect money from rich private individuals and companies, you will quickly find yourself keeping bad company. The foundation's statutes stipulate that the arms and tobacco industries are not permitted, but even the problematic food corporations like Unilever, Nestlé and Coca-Cola, whose fast food and sugar drinks are in the firing line as contributing to major chronic diseases, are not ruled out categorically.

The WHO has experienced many dilemmas and dependencies like this over its history. The legendary “Alma Ata Conference” in 1978, at which the Primary Health Care (PHC) concept was adopted, only took place there because the USSR wanted to inflict a blow on China in the struggle for control of the narrative in the socialist world and so provided the funding for the conference. At least the WHO was able to ensure that the conference was not held in Moscow and instead in the regional capital of poor Kazakhstan, where there had been positive experiences with PHC programmes.

The effort can be worthwhile

So is there anything at all to celebrate on the 75th anniversary of this World Health Organization? The WHO remains as good and bad as the world it exists in. That is the simple answer. What we make of it is key is the complicated answer. Without the WHO, there would be nothing to check and balance the pragmatic PPP movers and shakers and no forum to continue to argue and debate about health system strengthening, equitable resource distribution between countries and the necessary support for countries especially hard hit by the global realities of exploitation. Rights of minorities and discriminated groups do not always secure the majority in WHO resolutions, but the stage that Member States use for their geopolitical battles must also be made available to those who otherwise have even less of a voice in their own countries.

This means developing alliances of a critical civil society and like-minded governments at the WHO level. The new Brazilian government has already presented an initiative for a resolution on the health of indigenous groups and peoples. Fighting for the spaces where global policy is made is worthwhile - despite the efforts and difficulties to be overcome.

Translation: Rajosvah Mamisoa

Published: 30. March 2023

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