WHO Reform Mandate, Pandemic Report Clear Hurdles

A committee of member governments of the World Health Organization this week adopted a resolution on the future financing of the organisation and a broad set of reforms, as well as a resolution on the WHO’s management of a recent influenza pandemic showing no evidence of wrongdoing.

The financially strapped United Nations institution was given the green light to begin changes to staffing – including a move to more short-term staffing, and concentration of policy priorities on health systems, cost of healthcare, noncommunicable diseases, and involvement in global issues such as trade and climate change. It also foresees the establishment of a multi-stakeholder platform.

The multi-stakeholder idea, called the World Health Forum, has provoked concerns among WHO observers who fear it may push the agency too far into the hands of its financial supporters.

The annual World Health Assembly is taking place from 16-24 May. Still to come is a discussion of substandard and counterfeit medicines. No resolutions will be final until the full assembly approves them at the end of the week.

The reforms were embodied in a resolution member states adopted on WHO director general’s proposed programme for the future of financing for WHO [pdf], despite lacking many details on how these will be carried out.

Member states also adopted a resolution on the report of a review committee in charge of evaluating the functioning and implementation of the International Health Regulations (IHR), and the WHO response to the H1N1 pandemic. The IHRs are a binding legal instrument to help prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide.

The resolution included approval of the WHO response to the H1N1 “swine” flu pandemic, which turned out to be milder than expected and caused some member states to raise questions about unduly enriching the pharmaceutical industry by declaring a pandemic.

The review committee offered three main conclusions and a set of recommendations. The first conclusion is that the IHR “helped make the world better prepared to cope with public- health emergencies,” but the core national and local capacities called for in the IHR are not yet fully operational. The second conclusion reached by the committee said that it found no evidence of malfeasance in the management of the H1N1 pandemic by WHO, and the third conclusion is that the world is ill-prepared to respond to a severe influenza pandemic.

The recommendations included: the accelerated implementation of core capacities required from countries by the IHR, the strengthening of WHO internal capacity for sustained response to a public health emergency, and the development of measures to assess the severity of the problem. The report also recommends to encourage advance agreements for vaccine distribution and delivery, and to create a contingency fund for public-health emergencies.

Developing countries such as Argentina and Uruguay asked for capacity building to implement the recommendations presented in the review committee’s report.

The first draft report of the WHA committee (Committee A), in charge of discussing technical health matters, that worked on those two issues is available here [pdf].

Chan’s Campaign Plan

With the end of her term as director general on the horizon and the election process on this week’s agenda, WHO Director General Margaret Chan appeared to be positioning herself for candidacy for re-election.

Chan told the committee that the programme of reforms was “just the beginning of the process, not even the end of the beginning.” The document, she said, sets a broad and ambitious agenda that has the potential to change WHO for the better.

WHO’s financial difficulties are not tied to the need for change, as in a rapidly changing health environment, the organisation needs to be ready to meet the needs of all its member states, she said. The financial crisis merely adds urgency to what was started.

“I will lead this programme of reforms myself,” she said.

Some concerns were heard among member states, in particular from Brazil about the future role of WHO, the priorities of the reformed agency, the allocation of resources, the costs of the reforms, and a wider participation of stakeholders including the private sector.

Governments said WHO had to concentrate on areas where the organisation had expertise and were enshrined in its mandate, such as the setting of international standards and norms, the development of policies for national health systems, and an appropriate, quick and effective response in case of global health emergencies. All of these are among Chan’s proposed reforms.

Thailand, in a lively statement, said the WHO inherited the UN bureaucratic system developed after the Second World War. “It is the lawyers who really rule the organisation,” the delegate said. A large part of the WHO budget comes from donors, he said. “WHO is a donor-driven organisation,” he said, contrary to the usual statement by WHO that it is “member-driven.” The Thai delegate welcomed the decision to reduce many departments and programmes but wondered which ones and how. There is a need to rethink global health organisation under a new governing structure.

Algeria, on behalf of the 46 countries of the African region, said that they would like to see “greater flexibility in the allocation of resources of the organisation to regions and country offices taking into account their specific context,” according to their statement [pdf].

“Reforms aimed at improving the quality of funding should not mean reducing the commitment of WHO in favour of African countries in particular and more generally, of developing countries,” the Algerian delegate added.

“It is essential that the reform process to be state-driven in all its aspects. It should not in any way undermine the exclusive role of the decision-making bodies of the organisation in the field of normative action and standard-setting, which should remain one of the WHO’s core functions,” the delegate said.

Hungary, on behalf of the European Union, also emphasised the importance of the involvement of member states. Sri Lanka said, “clear guidelines or a criteria need to be defined on the impact on the intended reforms will have on the WHO governance in consultation with the member states,” according to its statement [pdf].

The United Kingdom called for the WHO to be more efficient, results-driven and cost-conscious. Germany said a better understanding is needed of WHO work in the clusters at headquarters and in the regions. Only with evidence can a choice can be made on which areas to prioritise, the German delegate said.

The United States said “the further development of a detailed implementation plan will be an important piece of this effort, both for elaborating details around partially fleshed out concepts like the World Health Forum, and for bringing greater clarity concerning some of the interesting ideas that still need more work.”

Listen More to Civil Society, Brazil Says

In a strong statement [pdf], Brazil said the reform must encompass a few basic principles: It must be member-state driven, it must be based on consensus and it must be incremental.

“It is also urgent to listen more and more attentively to what civil society has to say and less to private donors,” Brazil said in its written statement. “WHO needs to prioritise collective interests and better manage conflict of interests and corporate demands. If we are sincere about a reform for a healthier future, the main goal of the Organization must be social justice and equality and fairness in access to health for all.”

Brazil also expressed concerns about a document on the “development plan” which “was circulated quite late,” in particular the reference to a “mechanism to pool funds from private entities.” The country said it was not ready to approve the document [pdf]. In response later, Chan said that the document was just an information document.

World Health Forum

Among Chan’s proposed reforms, the multi-stakeholder World Health Forum has attracted significant attention. It intended to include member states, civil society, private sector, academia and other international organisations, according to the WHO reform document. The forum would “have a role in identifying, from the different perspectives of its participants, future priorities in global health,” according to the document presented to delegates [pdf].

Several countries expressed concerns about the forum, with the United Kingdom saying that the forum should fill a clear gap to justify the cost of a new consultative mechanism. Australia asked to make sure that that the forum is necessary and a cost-effective and transparent mechanism.

Chan today reassured member states that the decisions would be solely in their hands “under her watch.” “I will consult, consult, and consult, until you are happy,” she said.

Industry Satisfied with Adoption of IHR Report

Industry expressed satisfaction with the adoption of the report of the review committee on the IHR and the management of the H1N1 pandemic by WHO.

The International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) told Intellectual Property Watch that it “applauds the WHO’s efforts to ensure that it is an organisation that is able to meet the health challenges of tomorrow. The IHR report findings are the most recent confirmation that even in a desperately pressing health crisis, the WHO is able to bring together the best minds, whilst maintaining its independence from commercial interests.”

The issue of conflict of interest, they said, whether it be of academics, researchers, scientists, businessmen or groups representing health professionals, is an “important and legitimate” issue for the WHO to consider under its governance discussions.

“It is important to ensure that all potential conflicts are recognised and that a robust Conflict of Interest policy be put in place which should be applied equally to all stakeholders,” IFPMA said. “Conflict of interest issues must be addressed in an open and transparent manner, but should not be used as a reason to exclude any stakeholders in a wholesale manner.”

The IFPMA issued a press release welcoming the adoption of the report on the H1N1 management.

Concerns over WHO Financing, Reforms

Several non-governmental organisations (NGOs) on 17 May issued a statement urging member countries to oppose the World Health Forum, warning that commercial interests should not be part of policy and decisions on norm-setting. It is important to dismiss “the unrealistic and empirically unsupported assumption that all stakeholders will collaborate to advance the public interest.”

The International Baby Food Action Network (IBFAN) and the People’s Health Movement, two global networks of organisations, jointly opposed the WHO director general’s report on the future of WHO financing and reforms to the organisation, in a press release. They said they “consider that the new proposal undermines the principles of democratic governance, and the independence and effectiveness of WHO.”

The report “increases the power of the already disproportionately powerful for-profit sector,” they said. The two groups also called for a rejection of the World Health Forum, as “it is the WHA’s responsibility to set health priorities, benchmarks and standards which will effectively protect health for all. Previous experience with multi-stakeholder initiatives has shown that health priorities are distorted when they have to be agreed by for-profit actors.”

In the release, IBFAN said their experience with baby foods “illustrates how the baby food industry systematically undermines member states’ efforts to regulate marketing in line with WHA’s resolutions.”