A new Director General for the World Health Organisation - an opportunity for bold and inspirational leadership

published in The Lancet
1. Introduction
The sudden and sad death of Dr Lee Jong-wook, the former Director-General (DG) of the World Health Organisation (WHO), has already prompted several articles in this journal about WHO. , , But further discussion is needed over the next two months in the run up to the election of a new DG.

What will be the challenges facing WHO and its new DG? And how can individuals and institutions strengthen WHO’s capacity to respond effectively to the world’s health challenges? These are not idle questions, for all is not well at WHO. And for millions of people, the prospect of a basic level of health security remains a distant hope. Furthermore, as global and supra-national determinants of health become increasingly important, the performance of global public health institutions becomes ever more important.

In this article, the People’s Health Movement (PHM), a worldwide network of individuals and civil society organisations committed to the vision and principles of the 1978 Alma Ata Declaration, identifies three sets of global health challenges and the kind of response it would want from WHO. It also discusses the constraints and barriers faced by WHO itself, and suggests actions that must be taken by WHO and its new DG, as well as by governments and civil society.

2. Key global health challenges
Poverty and the global political economy

Poverty remains the world’s biggest health epidemic, underlying the HIV/AIDS crisis, the high mortality attributed to TB and malaria, and the 30,000 child deaths every day from preventable and treatable causes. It also results in governments being unable to foster socio-economic development and invest in effective health, welfare and education systems.

Frequent references are made to the World Bank calculation that a smaller number and proportion of people live in poverty on less than $1 / day. However, less is said about the methodology used to make this calculation, and its systematic under-estimation of the full extent of human impoverishment.

Furthermore, when a more appropriate $2 / day threshold of income poverty is used, even by the World Bank’s calculations, the number of people living in poverty increased between 1981 and 2001 to about 2.7 billion people.

This growth in poverty has been accompanied by a growth in wealth. While the number of people living in poverty in sub-Saharan Africa (SSA) increased from 289 million to 514 million between 1981 and 2001, world GDP increased by $18,691billion. Forty percent of the world’s poorest people account for 5% of global income, while the richest 10%, mostly in high-income countries, account for 54%.

Wealth generation is supposed to lead to ‘trickle down’ poverty alleviation, but in reality, it has disproportionately benefited a minority of the world’s population whilst impoverishing others. According to the World Commission on the Social Dimensions of Globalisation, the governance of the global economy is “prejudicial to the interests of most developing countries, especially the poor within them”. The deregulation of finance, the global property rights regime and a ‘winner takes all’ liberalization of trade are different aspects of a form of globalization that traps many countries and households in poverty. In spite of slowly increasing levels of development assistance and some debt cancellation, net resource flows from poor to rich countries still work against global health challenges.

Although some would argue that issues such as trade and global financial markets fall outside the remit of WHO, PHM believes that WHO must play a role in advocating for changes to the macro-economic and political determinants of ill health if we are to reduce child and maternal mortality, achieve universal access to antiretroviral treatment and allow all countries to pay their health care workforce an adequate living wage. While there are interventions that can be implemented by Ministries of Health to tackle the health worker crisis, it is as clear as daylight, that ultimate solutions for many countries will require changes to macro-economic policies in order to increase health sector spending.

WHO could advocate for global, regional and bilateral trade-agreements to be subject to comprehensive health and health systems impact assessments, and develop a well-resourced unit to carry out such work. As it becomes evident that the growth-led paradigm of poverty eradication is failing and untenable without an explicit redistribution strategy, WHO must demand further discussion on the establishment of new, stable and sustainable sources of global public financing for health such as the airline levy introduced by France, which is estimated to be capable of raising about 200 million euros a year for health. Others have suggested focussing attention on the development of an international system to reduce the tax evasion which results in an estimated $350 billion being lost from public accounts.

The launch of a Commission on the Social Determinants of Health in March 2005 offers the hope that WHO will play a more active role in assessing the health impact of the structures and rules of the global political economy. However, WHO’s new DG must push the Commission to go beyond assessment and recommend what WHO can do to engage with economic and social policy.

It will also be important for the new DG to make human rights a pillar of WHO’s work, by for example, giving visible and tangible support towards the work of the UN’s Special Rapporteur on the Right to Health. However, WHO will need to elaborate its human rights principles to stress the trans-national obligations and duties of rich country governments, international finance institutions, individuals and private corporations towards citizens of developing countries, and highlight the human rights transgressions that result from global rules and systems that cause or perpetuate poverty.

The development and restitution of national health care systems

The past few decades have seen many health care systems become weak to the point of collapse, disintegrated, more inequitable and increasingly commercialised. Under Dr. Lee, WHO began to reassert its commitment to the principles of the Alma Ata Declaration. It now needs to commit to health systems development policies that are consonant with the Alma Ata Declaration.

This should incorporate an evidence-based challenge to prevailing neoliberal reforms of the health sector, coupled with a coherent agenda to strengthen the capacity of Ministries of Health and public health care systems. The former would require WHO to assist countries to introduce reforms aimed at integrating fragmented pools of public and private health care finance, reversing commercialisation and shaping the private sector to meet social health objectives. The latter would require WHO to strengthen its own health systems departments and develop the public management expertise required to provide effective support to Ministries of Health.

In addition, WHO must help to bring order to the chaotic proliferation of global health initiatives (GHIs), many of which are characterised by selective, vertical health programmes within countries. Not only has this undermined WHO, it has also undermined Ministries of Health and coherent health systems planning by multiplying the number of donor-related conditionalities, increasing the transaction costs associated with having to liaise with multiple stakeholders and accentuating the fragmentation of health care systems. WHO could help facilitate the establishment of a cross-cutting health systems development strategy to which selective GHIs can commit.

Another practical step would be to resurrect the 2000 World Health Report initiative to measure and collate health care systems indicators country by country. Although there were serious conceptual and methodological weaknesses with WHR 2000, the underlying concept remains applicable and would enable better monitoring of progressive health care financing, equitable health care expenditure and determine whether governments are investing an adequate proportion of government revenue to health.

Protecting people from the hazard merchants

WHO’s role in responding to SARS, coordinating preparations for an avian flu epidemic and establishing a set of international health regulations to assist the control of disease outbreaks demonstrates its importance as a global public health agency. WHO’s role in helping to formulate evidence-based guidelines, norms and standards on various aspects of clinical and public health practice demonstrates another valuable function. The new DG must continue to strengthen these core functions of WHO.

What must also be stressed is the challenge of protecting people from non-biological hazards, including various forms of commercial activity. The International Code of Marketing of Breastmilk Substitutes and the Framework Convention on Tobacco Control represent partially positive outcomes of struggles between public health and powerful commercial, corporate actors.

The inter-connections between commercially-generated hazards, their merchants and ill-health involve both direct and indirect pathways. For example, although oil extraction can have direct negative health impacts on surrounding communities as a result of environmental pollution, it is also part of a global industry that has undermined the science of climate change and retarded action to the detriment of health. The automobile industry is an influential commercial sector that has successfully lobbied against sensible action to reduce the direct and indirect negative health impacts of current transport and travel patterns.

Pharmaceutical corporations are not often referred to as hazard merchants. However, the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), which was conceptualised and brokered largely by Big Pharma working through the official delegations of the United States, Japan and European Union at the World Trade Organisation, has reduced the affordability and availability of many medicines and entrenched an intellectual property (IP) regime that is inefficient at encouraging pharmaceutical research and development, unconducive to safe and ethical practice and incapable of addressing the needs of poor patients. Regional and bilateral trade agreements are further expanding the cope for unsafe and unethical practice by reducing the capacity to regulate the marketing and sale of medicines.

Relations between governments, the corporate sector and citizens have become increasingly unequal over recent decades, accentuated by globalisation and the abridgement of national sovereignty and democratic accountability that accompanies it. The relative weakness of public health institutions is illustrated by the 2004 Global Strategy on Diet, Physical Activity and Health which was watered down because of opposition from the food and beverages industry (whose financial resources far exceed those of WHO and whose interests were strongly represented by US representatives at WHO). One of WHO’s challenges will be to help correct the current imbalance between the liberal, pro-market economic dimension of globalisation with a public safety and social dimension.

2. Barriers to a more effective WHO

One of WHO’s key priorities is an organisational development strategy for itself. Several challenges stand out. One is the need to strengthen WHO’s regional and country offices, particularly in Sub-Saharan Africa (SSA), a region that demands the best that WHO can offer. Under Lee, there was a shift of resources from Geneva to the periphery, but as this journal pointed out, many WHO regional and country offices lack the capacity to put greater resources to good use.

This is a particularly acute problem in weak countries and regions where there is a ‘spaghetti bowl’ of multiple actors from the UN, donor community, NGO sector and research community, competing with each other for scarce resources and the ear of the Ministry. Rather than providing a focal point for improved coordination and integrated leadership, WHO offices in Africa can appear as small-time players in the field.

To rectify this, WHO needs to define more clearly the strategic functions and activities that its regional and country offices can play, based on the local health policy landscape and then recruit (without eroding the skills base of local public and non-government organisations) and retain staff with the appropriate experience and competencies. At the same time, it should initiate public discussions of its regional and country plans as a mechanism to strengthen public support and public monitoring of its performance.

Another comment made by this journal is that too many of WHO’s programmes are inadequately appraised and allowed to perform sub-optimally. However, WHO does not stand alone in this criticism. In relative terms, many of WHO’s outputs and impacts have been cost-effective and impressive. However, the Lancet hits the nail on the head by calling for WHO “to act systematically as an accountability instrument for the work of other institutions” including the World Bank, the Global Fund to fight AIDS, TB and Malaria and the US president’s Emergency Plan for AIDS Relief.

Perhaps WHO can raise the bar for improving the transparency and independent monitoring of key international agencies involved in promoting health by funding and encouraging academic and non-government organisations to act as ‘critical friends’, capable of simultaneously monitoring and supporting the performance of WHO in a transparent manner.

WHO must also address the various documented examples of internal management and administrative weaknesses such as the lack of coordination between its different departments and programmes; the over-abundance of doctors relative to nurses, social scientists, economists, lawyers and political scientists; the tolerance of non-performing senior executives; arcane bureaucratic procedures; and poor personnel management practices that have resulted in considerable staff demoralisation.

An equally challenging set of barriers relate to WHO’s operating environment. One is its funding arrangements. WHO’s core funding has remained static for many years and is currently inadequate, amounting to a tiny fraction of the health spending of high-income member states. Furthermore, over two thirds of WHO expenditure arises from conditional, extra-budgetary funds that are earmarked for specific projects by contributing countries and other donors. Thus governments and other donors sustain a funding system that makes it difficult for WHO to plan and fund a coherent programme of work, whilst forcing WHO departments and divisions to compete with each other (and other organizations) and be susceptible to fragmented, donor-driven agendas.

As government contributions stagnate, WHO has been forced to be increasingly reliant upon private sources of financing and ‘public-private partnerships’. This however has resulted in a subtle erosion of public accountability and public health principles to accommodate the interests and orientation of new donors. For example, one outcome has been a further over-emphasis on the development of new medical technologies relative to strengthening the capacity to deliver existing technologies and the more integrated socio-developmental approach of the Primary Health Care philosophy.

Budgetary control is one mechanism by which some actors constrain the performance of WHO. But there is also direct political pressure on WHO. For example, some member country delegations have warned WHO to steer clear of "macroeconomics" and "trade issues" and avoid reference to terminology such as "the right to health". As a result, WHO has taken a weak position on important economic issues. Its guide to the health implications of multilateral trade agreements was watered down following pressure from some governments and the World Trade Organization. And as reported in this journal, the US forced WHO to sanction and recall a WHO professional from Thailand for drawing attention to a negative aspect of the Free Trade Agreement between the USA and Thailand.3

Another barrier is the multitude of GHIs and agencies with various funding and governance arrangements, contributing to a chaotic operating environment for WHO. The time has come for a significant rationalisation of the global health landscape. At the very least, developing country member states should lobby to capacitate WHO with the mandate and resources to play a stewardship role in coordinating the work of official donor agencies and GHIs.

Finally, no discussion about the future of WHO would be credible without a comment on the current state of global governance and the United Nations in general. According to the World Commission on the Social Dimensions of Globalisation, there are “serious problems with the current structure and processes of global governance”. The propensity of some nation states to flout international law and undermine the UN makes the task of any new DG for WHO harder. But it also makes the election of a new DG vital because of the potential for WHO to act as a conduit towards a more effective and just system of global governance. The global health community, with its knowledge and understanding of the borderless nature of health threats, can play a vanguard role.

3. The right Director General for the right manifesto

WHO already has a positive manifesto, embodied in its constitution and the Alma Ata Declaration – one that reflects fairness, global solidarity, effective health care for all, public accountability and a strong socio-developmental orientation. In recent decades this manifesto has been subverted.

The aspiration of ‘health for all’ has been replaced by a tacit acceptance of growing health inequalities and the timid aspiration to provide a minimum package for the poor. Strong global health leadership capable of acting as a ‘health conscience’ for the world has been replaced by a fragmented landscape of selective global health initiatives designed to mitigate the underlying determinants of health rather than to challenge them head on. The social dimensions of health systems that stand out in the Alma Ata Declaration and District Health Systems model have weakened in the face of a narrow, neoliberal conceptualisation of cost-effectiveness and an uncritical faith in market-based incentives.

In order to adopt a bolder, broader and more progressive public health agenda, WHO will need charismatic, wise and courageous leadership. The hundreds of millions of people with the least access to health care deserve a DG capable of providing decisive intellectual leadership and withstanding political pressure aimed at constraining the ability of WHO to implement its positive manifesto.

A shortlist of thirteen candidates has just been announced with little or no public discussion amongst the health community. To encourage a more transparent and democratic process for the final selection of the DG, PHM has asked all candidates to respond to a set of questions (Box 1) which it will then publish for all to see. PHM will also be compiling profiles of the candidates to facilitate a more public examination of the strengths and weaknesses of each candidate.

However, the final selection of the DG will be the result of opaque, behind-the scenes power-brokerage involving 34 members of the Executive Board. Behind completely closed doors, they will interview and then select from amongst a shortlist of candidates. Structured criteria to assess the relative strengths and weaknesses of the candidates and how each individual scored against them, will not be made public. The untransparent process is entirely unacceptable.

After the election, PHM will lobby to reform this process for future DG appointments. There are also other actions that civil society organisations could undertake to make WHO an organization of the people as well as of governments. Civil society organisations could develop a joint initiative to monitor the discussions, debates and decisions taken at WHO Executive Board meetings. A stronger civil society presence at the meetings, coupled with a facility to report on proceedings, would improve transparency and the scrutiny of policy development as well as create a counterweight to the propensity of certain member states and other actors to bully WHO. The civil society initiative established under Brundtland could be revived to allow a wider range of voices to be heard and heeded, particularly those of marginalized and impoverished communities.

Civil society could and should also prevail upon governments and donors to improve the quantity and quality of funding to WHO. The formula for determining the level of contributions should be reviewed and a report card generated to rank countries according to the amount of funding as well as the proportion of funding that is un-tied. Civil society should also demand that the amount, nature and conditionalities of any private sources of financing be fully disclosed to the public.

The forthcoming election of a new DG marks a crucial opportunity for WHO and a critical juncture for an examination of global health governance more broadly. The PHM hopes that the new DG will position WHO as an organisation capable of catalysing a radical and progressive public health agenda fundamental to improving the health of the world’s poor.

Box 1: Inquiries from the People’s Health Movement to the candidates for the position of WHO’s Director General.

1. What will be your top priorities for WHO over the next five years?
2. Will the development of a global strategy to strength Primary Health Care be a priority for you? If so what will you propose to strengthen CPHC?
3. Where do you stand on the need to repair the damage to public health care systems caused by the inefficiencies and inequities brought about by the privatisation of such systems?
4. There has been a rapid proliferation of Global Health Initiatives and disease-specific initiatives. How will you seek WHO oversight and control of this situation?
5. How will you ensure that WHO’s plays a more assertive role in protecting public health interests in the face of trade agreements (e.g. TRIPS) that would appear to be harmful?
6. Given the pressures from various corporate interests and their allies for WHO to endorse health promoting practices what steps would you take to ensure that WHO is able to resist these pressures?
7. How will you counter balance the disproportionate influence of the rich country governments, particularly the United States, on policy development within WHO?
8. What do you propose to increase the voice and influence of civil society groups in WHO?
9. WHO has been criticized for many years for being dominated by doctors, and lacking professionals from the social sciences, legal, economic and non-medical disciplines. What is your view on this and what will you do to rectify the imbalance in disciplines and expertise within WHO?
10. The phrase "Staff are our most important resource" is commonly stated by leaders when they take office. How will you maximise this most important resource in terms of WHO's work and in relation to staff representation in dealing with management
11. Many argue that there is a particular need to build the capacity of the WHO Regional Office in Africa? Do you agree and if so, how would you go about this?
12. How will you support and promote the work of the Commission on the Social Determinants of Health from now until it reports in May 2008 and then ensure its recommendations are implemented?

Authors

David McCoy, Ravi Narayan, Fran Baum, David Sanders, Hani Serag, Jane Salvage, Mike Rowson, Ted Schrecker, David Woodward, Ron Labonte, Amit Sengupta, Arturo Qizphe, Claudio Schuftan, Dev Ray
Authors' contributions and conflict of interest statement All authors contributed to the text of this article. Each of us declare that we have seen and approved the final version. There are no conflicts of interest involved in this article. No external source of funding contributed to the writing of this article.

References

Horton R. WHO: strengthening the road to renewal. Lancet 2006; 367: 1993-5.
Editorial. Remembering Dr Lee. Lancet 2006; 367:1704. Benkimoun P. How Lee Jong-wook changed the WHO. Lancet; 367:1806-1808.
Reddy S and Pogge T. 2006. How not to count the poor. http://www.columbia.edu/~sr793/count.pdf
Chen S and Ravallion M. How have the world’s poorest fared since the early 1980s? World Bank Research Observer; 19: 141-69. Washington: World Bank.
Woodward D and Simms A. Growth isn’t working: the unbalanced distribution of benefits and costs from economic growth. London: New Economics Foundation, 2006.
http://www.neweconomics.org/gen/z_sys_publicationdetail.aspx?pid=219 United Nations Development Programme. Human Development Report 2005. Geneva: United Nations Development Programme, 2005, pp. 4.
World Commission on the Social Dimensions of Globalisation. A fair globalisation: Creating opportunities for all. Geneva: International Labour Organization, 2004.
United Nations. World Economic and Social Survey 2005: Financing for Development, E/2005/51/Rev.1, ST/ESA/298. New York: United Nations Department of Economic and Social Affairs; 2005.
Ministry of Economics, Finance and Industry and Ministry of Foreign Affairs, Government of France. Innovative development financing mechanisms: building a consensus. Available from http://www.diplomatie.gouv.fr/en/IMG/pdf/avionbis_a4_en.pdf#search=%22airline%20levy%20france%20health%22
Murphy R, Christensen J and Kimmis J. Tax us if you can: the true story of a global failure. London: Tax Justice Network, 2005.
Peoples Health Movement, Medact and Global Equity Gauge Alliance. Health care systems and approaches to health care. In Global Health Watch 2005-06. London: Zed books, 2005.
Buse, K & Harmer A. “Power to the Partners? The Politics of Public-Private Health Partnerships” Development. 2004; 47(2): 43-48.
Drahos P and Braithwaite J. Who owns the knowledge economy: political organizing behinds TRIPS. Corner House briefing 32, 2004.
http://www.thecornerhouse.org.uk/item.shtml?x=85821. Accessed March 6 2005.
Baker D and Chatani N. Promoting good ideas on drugs: are patents the best way? Briefing paper. Washington DC, Center For Economic And Policy Research, 2002.
Drahos P and Henry D. The free trade agreement between Australia and the United States. British Medical Journal, 328:1271-2, 2004.
Cannon G. Why the Bush administration and the global sugar industry are determined to demolish the 2004 WHO global strategy on diet, physical activity and health Public Health Nutrition, 7: 369-80, 2004.
Editorial. WHO’s African regional office must evolve or die. Lancet, 364:475-6, 2004.
World Health Organisation. Proposed Programme Budget 2006/07. Geneva, WHO, 2006.
http://www.who.int/gb/e/e_pb2006.html Peoples Health Movement, Medact and Global Equity Gauge Alliance. World Health Organisation. In Global Health Watch 2005-06. London: Zed books, 2005.
Department for International Development. Working in partnership with the World Health Organization. Institutional Strategy Paper. London: DFID, 2002.
Jawara F and Kwa A. Behind the Scenes at the WTO: the real world of international trade negotiations. London: Zed Books, 2004, pp. 211-5.