David Sanders
Emeritus Professor of Public Health, University of the Western Cape, South Africa And Global Co-Chair Peoples Health Movement
Although there is no single accepted definition of the term Global Health Governance (GHG), it is generally agreed that it refers mainly to those institutions and processes of governance which are related to an explicit health mandate, such as that of the World Health Organization (WHO).
In addition to global governance of health the phenomenon of Global Governance for Health has been recognised as globalisation and the institutions shaping it have become more prominent: this term refers mainly to those institutions and processes of global governance that have a direct and indirect health impact, such as the World Trade Organisation – mainly through affecting the social determinants of health.
Finally, Governance for Global Health refers to the institutions and mechanisms at national and regional levels that contribute to global health governance and/or to governance for global health – such as national global health strategies or regional strategies for global health. Such strategies may promote action of health and non-health sectors, of public and private actors and of citizens for a common health-related interest.
While WHO is officially recognised as the multilateral agency primarily charged with political and technical leadership in global health, its pre-eminent role in GHG has been reduced by the increasing involvement of other multilaterals such as the World Bank, new private-public partnership organisations such as the Global Fund to Fight AIDS, TB and Malaria (GFATM), and the rise of philanthrocapitalism in the form of foundations, the largest of which is the Bill and Melinda Gates Foundation.
WHO’s role in GHG has been progressively weakened over the past two decades. It is experiencing its greatest crisis since its founding in 1948. There are three areas where WHO faces its biggest challenges:
For the past few decades the organisation has increasingly relied on donor funds because member states – particularly richer member states – have been reducing their contributions. A full 80% of organisation’s funding is now ‘extra-budgetary’. Donors such as the Bill and Melinda Gates Foundation are making major contributions. Although there was a call at the recent World Health Assembly (WHA) for a 10% increase in member states’ contributions, the Assembly finally only agreed on a 3% increase.
This sometimes makes it difficult for the WHO to carry out the policies identified by its member states as the priorities of donors tend to dominate. Certain key programmes have had their budgets significantly reduced. One example is the control programme for non-communicable diseases which are now the top cause of morbidity and mortality globally and in low and middle-income countries.
Some vital work programmes that are central to the WHO’s mandate remain underfunded. Sometimes this is due to the fact that they conflict with the interests of rich countries and big donors, particularly those with links with industry. For example, governments have consistently opposed putting in place regulations that would affect big corporations to address the rise in consumption of unhealthy food.
Drastic human resource shortages, especially in Africa and South Asia. Huge investments are required in human resources - the most expensive and important component of health systems. Africa in particular has an extreme shortage of health workers, and their numbers are further threatened by inadequate training programmes and external migration ('brain drain') to rich countries. A WHO Voluntary Code of Practice on International Recruitment of Health Personnel has failed to impact positively on such losses. The clear challenge remains for health human resource shortages to be urgently and effectively addressed. And interventions to increase the availability and affordability of essential medicines are required.
The above weaknesses have resulted in WHO’s leadership role in global health being undermined – with some arguing that this has been a deliberate strategy by the rich and powerful nations to limit the impact on health policy of poorer countries in the Global South.
At its recent WHA Dr Tedros Ghebreyesus was elected as the Director -General of the World Health Organisation and is the first African to head it in its 70 year history.
This was the first time the entire 192-strong WHO assembly has voted for the position by secret ballot. Previously the Executive Board selected the DG. The massive margin for Tedros – 133 votes for Tedros vs 50 for the UK’s candidate David Nabarro – suggests that the entire global south voted for him. The size of the landslide had not been expected.
The vote almost certainly represents a vote against big power domination and machinations in the WHO which has been accused of ignoring the main challenges and aspirations of low and middle income countries.
As Ethiopia’s former Minister of Health Ghebreyesus spearheaded major reforms to the health system. This included a massive expansion of primary health care infrastructure and a dramatic increase in health human resources at all levels. He oversaw a rapid increase in the training of doctors, a shift in responsibility for key interventions such as caesarean sections to mid-level workers, and the introduction of community-level workers. All contributed to impressive improvements in health outcomes – especially in child health.
This track record is certainly behind his election. However, there were some objections to his candidacy as a result of alleged human rights violations by the Ethiopian Government while he was a cabinet minister.
Ghebreyesus needs to use his strong mandate – notably from the South – to truly reform the World Health Organisation and its operations in favour of the world’s poor majority, South and North. To do this, he needs to push strongly for member states to honour their commitments to the WHO and to rapidly and significantly increase their financial contributions.
He also needs to ensure that the influence of the food, beverage, alcohol and tobacco industries on the WHO – and thus global health policy – to control non communicable diseases is resisted. This will be difficult given that a framework (FENSA) has been passed that allows non-state actors, including industry, to participate in WHO policy-making processes.
In addition, Ghebreyesus must ensure that the health systems of low and middle income countries are strengthened so health emergencies like infectious disease outbreaks can be contained.
The current investments in building surveillance capacity for infectious disease are welcomed. But without sustained investment in building the health systems, these efforts will remain inadequate. Only the strengthening of health systems of countries in the Global South will ensure that the ‘health security agenda’ is not focused on securing the health of rich country populations against contagion from the poor, but rather on protecting all, particularly the most vulnerable.
But what will be most interesting to watch over the next five years is whether the evident solidarity between low and middle income counties in voting in Ghebreyesus as 'their’ candidate is maintained during the debates and decisions about world health during meetings where until now, rich countries have been dominant.