Another World Health Assembly wrapped up on Saturday, 26 May. The WHO Director-General’s opening address, guest speeches and discussions on the basis of a long agenda have all taken place. The halls of the Palais des Nations in Geneva have emptied as the delegations of the 193 member countries of the World Health Organisations and the representatives of the 189 nongovernmental organizations (NGOs) in official relations with the World Health Organization (WHO) have left. Although this year’s assembly was understated, it confirmed an inextricable trend towards health taking a place centre stage in political decision-making.
The 65th World Health Assembly (WHA) agenda covered some of the biggest challenges and opportunities facing public health today; with member countries reaching agreement on a wide range of issues, including research and development (R&D) for diseases that affect poor countries, counterfeit medicines, pandemic influenza preparedness, and a plan for access to vaccines. The agenda also covered non-communicable diseases, ageing, maternal and child health, under- and over- nutrition, the eradication of polio and health demands during humanitarian emergencies. To add to this heady mix, this year’s Assembly highlighted the increasing aspirations of the World Health Organization in shaping the relationship between intellectual property, innovation, and public health. (Full list of specific outcomes from the WHA, Ref: World Health Organization press release: http://www.who.int/mediacentre/news/releases/2012/wha65_closes_20120526/en/index.html)
On first appearance, despite the late-night and even overnight sessions, the frenetic meetings in the Assembly rooms or on the fringes of the event, be it in the Serpent coffee bar, the InterContinental Hotel, this year’s WHA “cru” did not seem to dazzle. There was no launch of the “Decade of Vaccines” by Bill Gates as in 2010, no recent epidemic or natural disaster to focus the minds, no charismatic Desmond Tutu to make the Assembly room resound to the unusual sound of laughter. But, we should not be fooled by the lack of sparkle. This World Health Assembly was noteworthy because of the increasing consensus among the global health community that health, economics and politics are intrinsically linked. What’s more, the old world order of donor countries and recipient countries, North and South, rich and poor countries can no longer be counted on to predict the outcome. This year, more than others, different constellations of countries and regional groups joined forces to propose alternatives resolution texts; it saw the blurring of the lines between positions of NGOs and BINGOs (defined as either business-friendly international NGO/ big international NGOs who are generally viewed with scepticism by mainstream NGOs).
A shift in the balance of health power?
The forces behind this shifting focus are multiple: the World Health Organization (WHO) is naturally seeking to be relevant in a changing world, not least because of a crisis of funding and reform that has to be addressed this year. Emerging and developing countries are eager to position health as a political, economic and social issue. Health activists and NGOs are gaining ground with forceful and well-funded campaigns, which 10 years ago would have been more appropriate for Greenpeace than for Medecins Sans Frontieres (MSF). Last but certainly not least, politicians and other decision-makers are increasingly eager to be seen to be on the side of positive change. This at a time, when they are facing the challenges of limited means, and cuts in their healthcare budgets. And at the same time, the demographics for many countries are putting an even greater strain on healthcare systems.
However, the most powerful driver is the shift in wealth and health. The largest disparities today are within countries and not between countries. Absolute poverty is most present in middle-income countries rather than in low- or high-income countries. These extremes in wealth within a country can be shown to have the most negative impact on health. As explained by authors Richard Wilkinson and Kate Picket in their book The Spirit Level “Inequality causes shorter, unhealthier and unhappier lives; it increases the rate of teenage pregnancy, violence, obesity, imprisonment and addiction; it destroys relationships between individuals born in the same society but into different classes; and its function as a driver of consumption depletes the planet's resources.” This position chimes with the key theme of Dr Margaret Chan’s opening address: “Universal health coverage is the single most powerful concept that public health has to offer…It is a powerful equalizer that abolishes distinctions between the rich and the poor, the privileged and the marginalized, the young and the old, ethnic groups, and women and men. Universal health coverage is the best way to cement the gains made during the previous decade. It is the ultimate expression of fairness. “
The World Health Assembly is a crucial platform for these issues to be addressed and each year the WHA holds up the mirror to politicians and the world to remind us that there is still so much that needs to be done to save or improve the lives of children, women, the sick and dying. But also, increasingly there are calls for prevention – the Framework Convention on Tobacco Control (adopted in 2009 by 175 countries) is a powerful demonstration of what can be achieved in the field of prevention and there is no reason to think that prevention measures in the area of obesity and irresponsible drinking are not going to increase. Prevention in these areas is hugely complex, as changing behaviours is at best, a hit and miss affair. Positive outcomes in improving diet and drinking patterns are closely linked to wealth, jobs and social factors, to name but a few.
The WHA speech of Jonas Gahr Stør, Foreign Minister of Norway, provided a glimpse of the kinds of issues that are increasingly taking hold of the global health debate. He pointed to the Oslo Declaration on Foreign Policy and Global Health as evidence that health, politics and foreign affairs have become intertwined. The Minister said, “Because the purpose of trade is to enhance our economies. Not to harm the health of our people. And there are lessons to be learned when it comes to holding the commercial sector to account in relation to other products and production methods that severely affect public health. In short, we need regulations that can match the forces of globalisation.”
To many of us, who have been following health matters closely, we have witnessed this broadening of the health agenda, and have been pointing out that politicians and civil servants outside of health ministries would do well to take notice of what is going on at the World Health Assembly. We are seeing the G20 start to become active in this field. We have noted the creation of a BRICs minister of health group. And indeed, this year’s focus of the WHA discussion on proposals for R&D coordination and financing, including a binding agreement (i.e., convention) shows how the scope and agenda is broadening. Under such a scheme, all countries would contribute at least 0.01% of their GDPs to government-funded R&D programs to address health needs in the developing world. For developed countries, the contributions would range from 0.15% to 0.2% of GDP. This proposal, which sought to delink the costs of R&D from the price of final products, became the subject of much political wrangling and indeed heated public exchanges (ref: Between Huffington Post’s Zach Carter and Nils Daulaire, US Representative to WHO Executive Board http://www.huffingtonpost.com/2012/05/25/global-health-fund-obama-administration_n_1544399.html?1337949364). Maybe, on this rare occasion, the emails of finance officials took notice of the WHA. Ultimate decision-making authority is the WHA – we will continue to do with the utmost vigour.” At the end of the day, the adopted resolution contained no references to a binding instrument, and discussions on this topic which started 10 years ago will continue and will be presented at the WHA in 2013.
Chan focuses on innovation and health
Although Dr Chan’s Health Assembly opening address was less compelling than previous years, it was noteworthy for her focus on innovation. She said, “As public expectations rise [for universal health coverage], costs soar, and budgets shrink, we must look to innovation as never before. And I mean the right kind of innovation. Innovation does the most good when it responds to societal concerns and needs, and not just to the prospects of making a profit.” She then went on to coin the phrase “frugal innovation” in connection to the cost high-quality clinical care. She explained how the WHO borrowed a simple checklist used by pilots in the airline industry (“one of the safest in the world”), to introduce the WHO Safe Surgery Checklist to address the surgical errors, which were killing around one million people worldwide each year. Despite this focus on innovation in her speech, at a side technical meeting, Oxfam put Margaret Chan under pressure, questioning whether the WHO supported the R&D convention and earmarking money from transaction tax. Dr Chan’s answer was guarded, “The decisions on what to take forward is not the responsibility for WHO. I won’t fall into that trap.”
At the WHA, Dr Margaret Chan was appointed for a second five-year term as Director-General of WHO until 30 June 2017. In her acceptance speech, Dr Chan said that the biggest challenge over the next five years will be to lead WHO in ways that will help maintain the unprecedented momentum for better health that marked the start of this century. The next five years are going making the WHO fit for purpose for the coming generations; it’s remit will be a key issue but pragmatically speaking, at the crux of the reform process will be the issue of how to fund this important institution.
Obviously, the Health Assembly and the WHO that serves member countries will have to cut its cloth to reflect the turbulent global economic situation and unsure outlook. But with a broadening health agenda and a widening net of decision-makers and stakeholders needing to engage with the WHO, it’s going to get complicated, it’s going to call on new, better data for decision-making, it’s going to require other experts to step up to the plate, in short: it’s going to get messy. However, it will also become even more interesting and if it can be made to work, much more powerful and the solutions more sustainable as they will not be just a side show but will be fully integrated into the political process. For many of those who are already well established in the WHO process (health advisors and experts, NGOs), there are constant rumblings about conflict of interest and the need to ensure there is a clear vision of Universal Health Coverage and Equity. These are not unfamiliar calls when there is change in the air and the forces of power might be shifting. The biggest concern is if the WHO is going to have the vision and the means to meet this challenge.
There is plenty to watch and play for until next year’s World Health Assembly; and it is a huge privilege to be able to follow these issues and witness efforts being made to make our world a better place.
By Abigail Jones, Partner