Dr. Andreas Wulf, MD
Medico international e, representante en Berlín
Seventy-five years have now passed since the World Health Organization (WHO) was founded in 1948 as the ”directing and coordinating authority” in global health policy. It bases its authority on the membership of almost all states in the world (194 currently). Much has changed in the world after so many years, and the organisation is in need of several reforms. Some of the most relevant of these changes include:
The leading role of countries in the governance of the WHO has long been jeopardised by the process of “multistakeholderism”, as people like to call the modern form of political governance that involves all interest groups, so “stakeholders”, in decision-making processes. Often excluded are the fundamental conflicts of interest that exist between stakeholders whose (private) interests require regulation and stakeholders who are supposed to put such (public) rules into place.
The most recent example of a conflict of this kind was the inability of states to agree to the temporary suspension of intellectual property rights for health products needed in response to COVID-19. Huge pressure from industry lobbying was a major factor, leveraging the world’s reliance on its products. 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, access to health products and the regulation of intellectual property rights in the event of a pandemic loom large.
The cooperation between the 75-year-old multilateral institution 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 civil society to take the floor on WHO agenda items were already cut back to one minute at previous meetings. The WHO’s current proposal 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.
The position and influence of the WHO Secretariat and the current Director-General (DG) Dr Tedros as the directly elected boss of the organisation are 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. 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.
The WHO is also caught in the middle of geopolitical wrangling, and its members use the WHO stage to argue among 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) and the WHO’s diplomatic response increased the ire of Trump, who threatened to quit the WHO, which was prevented by his failure to secure re-election. 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.
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.
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.
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 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.
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 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.