Health Policy 119 (2015) 395–404
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Health Policy journal homepage: www.elsevier.com/locate/healthpol
Governance within the World Health Assembly: A 13-year analysis of WHO Member States’ contribution to global health governance Tess van der Rijt ∗ , Tikki Pang (Pangestu) Lee Kuan Yew School of Public Policy, National University of Singapore, 469C Bukit Timah Road, Singapore 259772, Singapore
a r t i c l e
i n f o
Article history: Received 4 November 2013 Received in revised form 2 December 2014 Accepted 6 December 2014 Keywords: WHO governance Policy development Global health policy
a b s t r a c t There is a widespread perception that developed countries in the Western world dictate the shaping and governance of global health. While there are many bodies that engage in global health governance, the World Health Organisation (WHO) is the only entity whereby 194 countries are invited to congregate together and engage in global health governance on an equal playing field. This paper examines the diversity of governance within the World Health Assembly (WHA), the supreme decision-making body of the WHO. It explores the degree and balance of policy influence between high, middle and low-income countries and the relevance of the WHO as a platform to exercise global governance. It finds that governance within the WHA is indeed diverse: relative to the number of Member States within the regions, all regions are well represented. While developed countries still dominate WHA governance, Western world countries do not overshadow decision-making, but rather there is evidence of strong engagement from the emerging economies. It is apparent that the WHO is still a relevant platform whereby all Member States can and do participate in the shaping of global health governance. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction It is broadly acknowledged that deliberations surrounding global health are dominated by developed countries and that the voices of lesser-developed nations are not as loudly heard. Such a perception was proven by a previous study conducted by the authors, which showed that the majority of people influencing and defining the priorities of global health represent institutions based on the developed world – global health is not being shaped by those who are most affected by it [1]. This paper aims to examine whether governance of the WHO is also dominated by
∗ Corresponding author at: 469C Bukit Timah Rd, Singapore 259772. E-mail address: [email protected] (T. van der Rijt). http://dx.doi.org/10.1016/j.healthpol.2014.12.008 0168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.
the developed Western world, or whether the WHO provides a more balanced forum whereby the voices of all Member States are heard and influence decision-making. A previous study analysed the subject matter of WHA resolutions and examined the trends and characteristics of international health issues through agenda items of the WHA [2]. It concluded that the WHA agendas cover a variety of items, but do not always reflect international health issues in terms of disease burden. However HIV/AIDS, non-communicable diseases in general, health for all, the Millennium Development Goals (MDGs) and the International Health Regulations (IHR) appeared associated with the public health milestones [2]. This paper utilises a different approach and analyses the diversity of Member States’ contributions to decision-making. WHO is the directing and coordinating authority for health within the United Nations system [3]. While there
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are many influential foundations and institutions that engage in global health, the WHO is the only forum that allows 194 countries to actively determine global health governance on an equal footing. The World Health Assembly (WHA) is the supreme decision-making body for WHO [4]. It meets annually and delegates from all 194 Member States are invited to attend. This paper provides a snapshot of the contribution of Member States to the World Health Assembly. It analyses the resolutions debated at each of the World Health Assemblies from 2000 to 2012 and notes how many times each Member State spoke and the subject matter of the resolution on which they spoke. The paper then explores these results, examining the contribution of Member States according to their region, their income level and the subject matter of the resolutions. 1.1. Definition of global health Although a consensus on a definition of global health is yet to be obtained, key underlying concepts of what global health constitutes have emerged. In 2009 Koplan et al. [5] called for a common definition of global health. In the paper, Koplan et al. consider various definitions previously proposed and accordingly propose their own definition: “Global health is an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care.” [5] Since the publication of this paper, new ideas and issues have become apparent, including those outlined in Bozorgmehr’s paper [6]. Bozorgmehr questions the ‘global’ in ‘global health’ and argues that global-as-supraterritorial provides ‘new’ objects for research, education and practice while avoiding redundancy. Nevertheless, for the purposes of this paper, Koplan et al.’s definition will be observed. 2. Aim To explore and determine the diversity of countries that shape global health governance and decision-making within the WHO. Areas of analysis include regional variety, economic diversity and the subject matter of resolutions. 3. Method In May each year, the WHA meets to hold a plenary session, followed by two main committee sessions: Committee A discusses program matters and determines policy of the organisation; Committee B deals predominantly with administrative, financial and legal matters. This paper only examines resolutions adopted in Committee A of the WHA. WHA resolutions are usually proposed based on dialogue between Member States that are interested in a particular issue. Along with the Secretariat, the specific issues
and contents of the resolution are decided upon. A resolution is firstly put to the WHO Executive Board and on their approval, it is put to the World Health Assembly. Member States are able to influence and participate in decision-making not only through discussing resolutions at the World Health Assembly, but also through proposing resolutions. The source of information used to write this paper came from the World Health Assembly Summary Records of Committees (REC/3 documents), printed annually by the WHO. These documents were used to note any time a delegate representing a Member State spoke to a resolution that was eventually approved. The Member State the delegate represented, the region in which the Member State is based (according to the WHO regional groups) and its income group (according to the World Bank) [7] was noted. The title and subject matter of the resolution was also observed. Each resolution was classified into health matter categories. The first five categories were drawn from one of the 65th WHA agendas entitled ‘WHO Reform’ [8]. The authors constructed the further categories in accordance with the resolutions debated in the study. A list of the WHO Member States was written into Microsoft Excel and each time a delegate spoke on a resolution, it was noted. A separate tab also listed the resolution the Member State spoke to according to the classification of its subject matter. Each time a delegate spoke was listed, even if they spoke to the same resolution more than once. The authors decided to use this approach, as arguably the more engaged a delegate is with a resolution, the more influence they had over its creation. Delegates that represent non-Member States were not included in the analysis. Only adopted resolutions were included; discussions that resulted in the Committee ‘noting a report’ or progress reports on previously adopted resolutions and reports were not included in the study.
4. Results 4.1. Involvement of Member States in the debate of resolutions within Committee A of the WHA One hundred and thirty-eight (138) resolutions were debated and approved within Committee A of the WHA from 2000 to 2012. Five thousand and six (5006) interventions were made on these 138 resolutions. Table 1 lists the 20 most engaged Member States (that being, the Member States which spoke to resolutions the most). Table 2 outlines the Member States that did not address Committee A of the WHA from 2000 to 2012. The newest Member State to the WHO is South Sudan, which became a member in 2011. Since then, the South Sudanese delegation has addressed the Assembly 21 times. Although it is the WHO’s newest Member State to join the Assembly, it is already one of the 70 most active participants at the WHA. Furthermore, Chinese Taipei has been an observer of the WHA since 2009 (but only addressed the WHA since 2010) and since then has addressed the Assembly 26 times, making it one of the top 60 most active participants at the WHA.
T. van der Rijt, T. Pang (Pangestu) / Health Policy 119 (2015) 395–404 Table 1 Number of times a Member State addressed Committee A of the World Health Assembly (2000–2012).
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Member State
Number of times member state spoke at WHA 2000–2012
United States of America Thailand China Canada Japan India Brazil South Africa Russian Federation Cuba Australia Botswana Iran Kenya Mexico Iraq Switzerland Turkey Venezuela United Kingdom
239 214 144 134 121 110 109 100 96 78 77 76 74 74 72 68 66 65 64 63
4.2. Involvement of regions in the debate of resolutions within Committee A of the WHA It is important to note that not all regions have the same number of Member States: the African Region (AFRO) consists of 46 Member States (population – 904 million); the Americas region (AMRO) consists of 35 Member States (population – 958 million); the South-East Asia region (SEARO) has 11 Member States (population – 1.8 billion); the European region (EURO) has 53 Member States (population – 904 million); the Eastern Mediterranean region (EMRO) has 22 Member States (population – 601 million); and the Western Pacific region (WPRO) has 27 Member States (population – 1.9 billion) [9]. The regions that have the larger number of Member States in the region have a greater opportunity to address the Assembly.
Table 2 Member States who did not address Committee A of the World Health Assembly (2000–2012). Region
Member State(s)
WPRO EMRO AMRO
Niue Sudan Dominica Antigua and Barbuda
EURO
Albania Andorra Belarus Georgia Kyrgyzstan Montenegro San Marino Serbia Tajikistan Macedonia Turkmenistan
AFRO SEARO
– –
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For example, 27% of the Member States are within the EURO region and therefore it could be expected they address the Assembly more times than SEARO, which only make up 6% of the WHO Member States. Interestingly, this presumption does not correlate to the findings; 12 Member States from the EURO region (the largest region) did not address the Assembly from 2000 to 2012 (see Table 2). Of the 20 most engaged Member States at the WHA, six were from the Americas, four from Europe, three from the Western Pacific region, three from Africa, two from SouthEast Asia and two from the Eastern Mediterranean. Of the 50 Member States that addressed the Assembly the greatest number of times, ten were from the Americas, twelve from Europe, eleven from Africa, seven from the Western Pacific region, four from South-East Asia, and six from the Eastern Mediterranean. On examination of the results, AMRO, EURO and AFRO regions are most greatly represented on face value. This could be self-explanatory due to the fact that there are more Member States from these regions. Fig. 1 shows the 20 most engaged and 50 most engaged Member States, relative to the amount of Member States that come from that region. Although only 4 of the 50 most engaged Member States at the WHA came from the SEARO region, relative to the number of Member States within the region, it was the most highly represented. For example, 36% of SEARO Members were in the top 50 most engaged Member States, while comparatively only 29% of AMRO Members were in the top 50 most engaged Member States, even though 10 of its Members were in the top 50. The EMRO region was the least represented; with 14% of its Members (6 of 22) being in the top 50 most engaged Member States. Fig. 2 is a visual representation of how often Member States contributed compared to the average number of contributions. Both AMRO and EURO were highly represented in the 20 most engaged Member States. SEARO, WPRO and EMRO’s contributions to the WHA from 2000 to 2012 were below average. SEARO was the least represented. While there were less AFRO representatives in the 20 most engaged Member States, their engagement was above average when examining the top 50 most engaged Member States. As opposed to examining the most engaged Member States, Table 3 examines the number of speeches made at the WHA from 2000 to 2012. The table illustrates that 1 in 4.3 speeches made at the WHA from 2000 to 2012 were delegates representing Member States from the AMRO region. Comparatively, 1 in 9.2 speeches made were representatives from the SEARO region. Although there are more Member States in the EURO region compared to the AFRO region, and a greater number of EURO States were represented in the top 20 most engaged States, as a whole more speeches were made from Member States in the AFRO region. This is due to the fact that all AFRO Member States spoke at the WHA; although there were less AFRO than EURO states in the top 20 most engaged, AFRO delegates’ contributions en masse was greater than EURO delegates.
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Fig. 1. The 20 most engaged and 50 most engaged Member States at the WHA categorised into regions, relative to the number of Member States in the region.
Fig. 2. A comparison of regional engagement at the WHA of the 20 and 50 most engaged Member States. Statistic representation is as follows: 20 most engaged Member States, n = 20, mean = 3.3, std = 1.5. 50 most engaged Member States: n = 50, mean = 8.3, std = 3.1.
4.3. Involvement of Member States in the WHA according to income level Table 4 demonstrates that 85% of the 20 most engaged Member States were from high income or
upper-middle income countries [10] and 70% of the 50 most engaged Member States were from high or upper-middle income countries. Table 5 highlights the most engaged lower-income and low-income countries.
Table 3 Rankings of regions based on engagement at WHA. Total number of speeches made at WHA from 2000 to 2012 equalled 5006. Region
Number of speeches made by MS at WHA from region
Ratio of engagement
Rank
AMRO AFRO EURO WPRO EMRO SEARO
1162 1015 955 745 586 543
1:4.3 1:4.9 1:5.2 1:6.7 1:8.5 1:9.2
1 2 3 4 5 6
T. van der Rijt, T. Pang (Pangestu) / Health Policy 119 (2015) 395–404 Table 4 Representation of the most engaged Member States at the WHA according to income level. Income level
Number of MS in top 20 most engaged at WHA
Number of MS in top 50 most engaged at WHA
High income Upper-middle income Lower-middle income Low income
6 11
18 17
2
12
1
3
Of the lower-middle income countries and low-income countries that were the top 50 most engaged at the WHA, seven were from AFRO, four from EMRO, three from SEARO and one from WPRO. It is interesting to observe the level of engagement of the top 20 economies according to GNI World Bank rankings, as displayed in Fig. 3. Of the top 20 economies in the world, 13 of these were ranked as the 20 most engaged Member States at the WHA; 18 of the top 20 economies ranked as the top 50 most engaged Member States at the WHA. Although 8 of the top 20 economies are from Western Europe, they were some of the less engaged of the countries with the highest economies. The only countries that are the top 20 contributors to the WHO budget, but are not one of the 20 most engaged Member States, are all from Western Europe, except the Republic of Korea. 4.4. Involvement of Member States in the WHA according to subject matter of resolutions Nine different subject matters were used to classify the subject of resolutions. Fig. 4 shows that the greatest number of speeches made at the WHA concerned resolutions on communicable diseases (23.1%). Preparedness surveillance and response was the second most discussed subject, with 14% of speeches addressing the issue. Non-communicable diseases, health systems, health through the life course and social determinants of health were also more or less equally discussed. Table 5 Member States classified as a lower-middle or low income country that were one of the top 50 most engaged Member States at the WHA. Member State
Rank level of engagement
Income level
India Kenya Iraq Philippines Indonesia Morocco Bangladesh Pakistan Nigeria Egypt Cote d’Ivoire Senegal Zambia Mozambique Swaziland
6 14 16 22 23 25 26 27 30 32 34 36 40 41 49
Lower-middle Low Lower-middle Lower-middle Lower-middle Lower-middle Low Lower-middle Lower-middle Lower-middle Lower-middle Lower-middle Lower-middle Low Lower-middle
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Fig. 5 displays the main issues that were raised according to each region. The majority of speeches made by AFRO Member States (29.4%) were on the topic of communicable diseases. Preparedness surveillance and response and health through the life course were the second and third most spoken about topics by delegates from the AFRO region (12.5% and 11.1% of speeches respectively). Overall, the topics of communicable diseases, non-communicable diseases, health systems and preparedness surveillance and response made up the majority of all speeches made by each region. Social determinants of health were also a popular topic. AMRO was the region most concerned with public health, innovation and intellectual property. Preparedness, surveillance and response was a popular topic in the WPRO region due to Australia, China, Japan, Thailand and Indonesia’s contributions.
5. Discussion 5.1. Limitations of the study This study recognises that the World Health Assembly is just the tip of the iceberg regarding governance of the WHO; there are many more avenues that would be necessary to examine in order to wholly encapsulate governance and decision-making within the WHO. The Executive Board is composed of 34 members technically qualified in the field of health and are elected for three-year terms [11]. The Board is responsible for implementing decisions and policies of the WHA and acts as the WHO’s executive organ. There are also sub-committees and six WHO regional offices. The regional offices generally meet once a year and discuss and implement their own resolutions. Arguably, some Member States could be more vocal and influential in these other governance structures and less prominent at the WHA. The work and priorities of the WHO are shaped to a very significant extent by Member States additional voluntary contributions to particular health programs and initiatives. These account now for a very large proportion of WHO’s global budget. Nonetheless, the WHA was chosen as the focus of this paper, as it is the final decision making platform of the WHO and the only platform where all Member States of the WHO are invited to attend and engage in decision-making. Each Member State has the same weighted vote and each Member State has equal access to the floor. It is also important to note that when the WHA convenes, all negotiations and influential decisions do not take place within the open recorded debates of resolutions within the Assembly itself. Back room negotiations and the influence of lobby groups are invisible within the formal Assembly process. Smaller working groups are commonly convened during the WHA, especially around controversial issues. Power plays and pre-formed alliances are also rampant. Some Member States may speak to a resolution for political reasons and other Member States may not speak to a resolution even though it is an issue important in their country. Political interests, international affairs, policies or civil service cultures also influence the degree of Member States’ engagement. Some Member States may choose
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Fig. 3. Top 20 GNI countries compared to top 20 most engaged Member States. The countries capitalised and bold were not one of the top 20 most engaged Member States at the WHA.
to coordinate other Member States to argue their point of view. One Member State may also speak to a resolution on behalf of a regional group (e.g. South Africa may speak on behalf of the African nations and Germany may speak on behalf of the European Community) and so using the method in this paper, only South Africa and Germany would be noted for its contribution, even though other Member States may have contributed to the argument or speech. Nonetheless, it was interesting to observe that even though South Africa would speak on behalf of the African nations, it did not deter other African nations speaking to the resolution also. In examining the involvement of Member States and their contributions to resolution discussions, it is valuable to note that not all Member States have been a part of the WHO since its creation in 1948. Consequently, all Member States have not had the same opportunity to address the WHA and therefore these results may be skewed to favour those Member States who have been a member of
the WHO for a greater period. Furthermore, on examining the involvement of Members States according to income level, it must be mentioned that the income level of some countries has changed over time. 5.2. Emerging economies’ engagement at the WHA There has been concern expressed that the agenda of the ‘Western world’ dominates governance of global health. Interestingly, while the high income and uppermiddle income countries are the majority of the 20 most engaged Member States, only the USA, Canada, Australia and Switzerland are from the ‘Western world.’ Instead, many of the most engaged high income and upper-middle income countries are the emerging economies. The emerging economies of BRICS (Brazil, Russia, India, China, South Africa) and MIST (Mexico, Indonesia, South Korea, Turkey) were highly represented at the WHA, with 7 of the 9 countries being the top 20 most engaged Member States. The emerging markets that were not in the top 20 were
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Fig. 4. Subject matter of resolutions debated at WHA (2000–2012).
Indonesia (which was 23rd) and South Korea (which was 38th). There has been strong interest in the shift of power within global governance due to the rise of emerging economies, with Drezner referring to ‘the new new world
order’ [12]. Cooper and Alexandroff argue that the global order is shifting in an appreciable but awkward fashion and that the centre of gravity of the global power structure is arguably no longer the United States, which is
Fig. 5. Subject matter and number of speeches made by Member States according to region.
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a result of the emergence of new powers [13]. Interestingly, it has been more recently argued that the shift in power from the G7 to the BRICS countries has been ‘much smaller than the headlines or the private alarm bells suggest’ [14]. Wade [14] argues that the United States remains the dominant state and the G7 states together continue to exercise primacy, but now more fearfully and defensively. On examining governance within the WHA, it is clear that the USA still greatly contributes to and influences decision-making. However it also clear to see that the emerging markets are indeed increasing their presence. While 7 of the 9 BRICS and MIST countries are in the top 20, only four of the G7 are the top 20 most engaged at the WHA. While the G7 are still the highest contributors to the WHO financially, they are not the greatest contributors to governance and decision-making. It will be interesting to observe if the BRICS and MIST continue to increase their presence in global health governance at the WHA.
5.3. Regional engagement While appreciating that the regional structures set up within the WHO are sometimes dictated by geopolitical considerations and that some Member States arguably should be placed in different regional groups, it is nonetheless useful to examine the engagement of the Member States within the regional structure setting. Although there are only 11 Member States in the South East Asian region, two were in the top 20 most engaged and five of the top 20 would be considered from the Asian region generally (Thailand, China, Japan, India, Australia). The greater contributions of these Asian countries is in line with findings in a paper examining how global is global health, which found that of the lesser developed regions, Asia is a strong contributor to the shaping of global health [1]. Just as the paper found that authors and professionals from Asian institutions are reasonable contributors to global health journals, conferences and institutions, so too were they found in this paper to be fairly represented at the WHA, relative to other regions. Countries from the African region were also well represented, with 11 Member States in the top 50 most engaged. If examining the African continent (as opposed to the WHO AFRO region), 9 African countries were in the top 50 most engaged that are lower-income or lowincome countries (Kenya, Morocco, Nigeria, Egypt, Cote d’Ivoire, Senegal, Zambia, Mozambique and Swaziland). These lesser-developed African countries are increasing their engagement in global health governance within the WHA. Relative to the number of Member States in the European region, fewer chose to contribute at the WHA. Of the top 20 Member States that financially contribute to the WHO, 11 are from the EURO region, yet only 2 of these countries are the top 20 most engaged in governance and decision-making. Why are European Member States willing to financially provide to the WHO, but are less engaged in its governance? Perhaps they are more active in the WHO
EURO regional office, or choose to engage more bilaterally through development agencies such as DFID, NORAD and GTZ. Further analysis of regional engagement also provides ‘case study’ examples of resolutions where there has been a major split between high and low income countries and of the ‘what’ and ‘why’ of different interests and priorities between regions and countries. The number of speeches and contributions by Member States measures engagement and is limited in measuring influence, and as such is a proxy for interest on particular topics. One example of the subject matter of a resolution being split between high and low income countries concerns the contentious issue of the ‘geographical rotation’ for the Director General’s position. Member states from the Eastern Mediterranean, African and South-East Asian Regions of WHO, citing the need for equity and fairness, proposed a resolution during the 120th session of the Executive Board in 2006 to address the rotation issue, including necessary changes in the Rules of Procedure of the World Health Assembly to implement such rotations [13]. The three regions cited the fact that WHO had elected seven Directors-General from three of the Organisation’s six regions. No candidate from the African, South-East Asian or Eastern Mediterranean Regions had as yet been successful, despite these regions containing more than half the world’s population and there being qualified health professionals in those regions. These professionals were capable of managing WHO and would meet the paramount criterion of the highest standard of efficiency and integrity, as called for in Article 35 of WHO’s Constitution. Geographical rotation was also cited as having been practised in the selection of Secretary-General of the United Nations. Contending that the criterion of geographical representation was secondary to the paramount criterion of the highest standards of ability, capacity, efficiency and integrity, the resolution was opposed – mainly by high-income countries such as the USA, Japan, Australia, Luxembourg, and Singapore [15]. The proposed resolution to be carried to the World Health Assembly and to contain the words “as well as the issue of regional rotation” was thus not passed and diluted to the effect that the Board “REQUESTS the Director-General to prepare a report on the geographical rotation of the post of Director-General, taking into account the views expressed by members of the Executive Board, and to report back to the 121st session of the Executive Board.” The debate thus continued at the 121st Session of the Executive Board in 2007. While the countries from the three aforementioned regions stood their ground, opposition to the rotation resolution from high-income countries continued, with New Zealand, United Kingdom, Denmark, and the Bahamas [16] opposing the idea of rotation. Predictably the resolution was not passed and the matter postponed yet again for discussion at the next meeting of the Board. During the 122nd Session of the Board in 2008 a document was prepared to describe various options for rotation of the Director-General [17] with an invitation to the Board “to consider the possible options proposed.” The matter, however, was not even discussed at the Board session [18] and no definitive resolution was passed. The stalemate continues until today with the ‘rotation’ issue
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disappearing off the agenda of WHO’s governing bodies after 2008. 5.4. Subject matter of resolutions Discussions on diseases dominated the WHA from 2000 to 2012, with 33.6% of speeches focusing on the topic. In particular, communicable disease was the subject most greatly discussed. The topic of non-communicable diseases increased from 2007. African Member States were much more engaged in the topic of communicable diseases compared to non-communicable diseases. Although climate change only became a topic of concern in 2008, China, the greatest emitter of greenhouse gases, was the 4th most engaged Member State on the topic.
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are becoming more popular to debate, such as social determinants of health. As the unique entity that assembles Member States from all over the world to discuss global health matters, it appears that the WHO has maintained its relevance. For indeed, Member States from a variety of economic and regional backgrounds are continuing to use the WHA as the forum to set the agenda and determine global health governance. Acknowledgement The authors would like to acknowledge the support of the Lee Kuan Yew School of Public Policy for funding the research leading to the article.
5.5. Relevance of the WHO
References
Other papers have found that although there may be a shift in influence, global health is still dominated by countries in the Western world [1,19]. This paper reinforces the importance of the WHO as a platform where all countries are able to participate, as indeed, the Member States who contribute to discussions are geographically and economically diverse. Only 16 of the 194 Member States of the WHO have never addressed the WHA. Although 70% of the 50 most engaged Member States were from high or upper-middle income countries, many of these were emerging economies that have increased their contribution to global health governance at the WHA. Furthermore, 15 of the top 50 most engaged Member States were lower-middle income or low-income countries. There is great regional diversity of Member States at the WHA, with reasonable representation from all regional areas. SEARO and EMRO had the least regional engagement, but they also consist of the least number of Member States. Although some subjects were more heavily discussed than others, the WHA is a forum whereby any important health matter can be put on the table and debated. Consequently, the WHO is still relevant and necessary to ensuring that all Member States can engage on an equal platform and contribute to global health governance.
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6. Conclusion Global health governance within the WHO is diverse. While high-income and upper-middle income countries are the top twenty most engaged Member States within the WHA, a limited number of them are culturally from the ‘Western world’. Instead, it is the emerging economies that are utilising the World Health Assembly to set the global health agenda. While lower-middle income and lowincome countries are less represented, they still have a reasonable presence and influence within the WHA. Contributions to the Assembly are also regionally diverse; relative to the number of countries within each region, regional representation is relatively even. The subject matter of diseases, particularly communicable diseases, and preparedness surveillance and response were the most discussed topics at the WHA from 2000 to 2012. Certain topics
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[19] Harmer A, Xiao Y, Missoni E, Tediosi F. ‘BRICS without straw?’ A systematic literature review of newly emerging economies’ influence in global health. Globalization and Health 2013;9:15.
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Health Policy journal homepage: www.elsevier.com/locate/healthpol
Governance within the World Health Assembly: A 13-year analysis of WHO Member States’ contribution to global health governance Tess van der Rijt ∗ , Tikki Pang (Pangestu) Lee Kuan Yew School of Public Policy, National University of Singapore, 469C Bukit Timah Road, Singapore 259772, Singapore
a r t i c l e
i n f o
Article history: Received 4 November 2013 Received in revised form 2 December 2014 Accepted 6 December 2014 Keywords: WHO governance Policy development Global health policy
a b s t r a c t There is a widespread perception that developed countries in the Western world dictate the shaping and governance of global health. While there are many bodies that engage in global health governance, the World Health Organisation (WHO) is the only entity whereby 194 countries are invited to congregate together and engage in global health governance on an equal playing field. This paper examines the diversity of governance within the World Health Assembly (WHA), the supreme decision-making body of the WHO. It explores the degree and balance of policy influence between high, middle and low-income countries and the relevance of the WHO as a platform to exercise global governance. It finds that governance within the WHA is indeed diverse: relative to the number of Member States within the regions, all regions are well represented. While developed countries still dominate WHA governance, Western world countries do not overshadow decision-making, but rather there is evidence of strong engagement from the emerging economies. It is apparent that the WHO is still a relevant platform whereby all Member States can and do participate in the shaping of global health governance. © 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction It is broadly acknowledged that deliberations surrounding global health are dominated by developed countries and that the voices of lesser-developed nations are not as loudly heard. Such a perception was proven by a previous study conducted by the authors, which showed that the majority of people influencing and defining the priorities of global health represent institutions based on the developed world – global health is not being shaped by those who are most affected by it [1]. This paper aims to examine whether governance of the WHO is also dominated by
∗ Corresponding author at: 469C Bukit Timah Rd, Singapore 259772. E-mail address: [email protected] (T. van der Rijt). http://dx.doi.org/10.1016/j.healthpol.2014.12.008 0168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.
the developed Western world, or whether the WHO provides a more balanced forum whereby the voices of all Member States are heard and influence decision-making. A previous study analysed the subject matter of WHA resolutions and examined the trends and characteristics of international health issues through agenda items of the WHA [2]. It concluded that the WHA agendas cover a variety of items, but do not always reflect international health issues in terms of disease burden. However HIV/AIDS, non-communicable diseases in general, health for all, the Millennium Development Goals (MDGs) and the International Health Regulations (IHR) appeared associated with the public health milestones [2]. This paper utilises a different approach and analyses the diversity of Member States’ contributions to decision-making. WHO is the directing and coordinating authority for health within the United Nations system [3]. While there
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are many influential foundations and institutions that engage in global health, the WHO is the only forum that allows 194 countries to actively determine global health governance on an equal footing. The World Health Assembly (WHA) is the supreme decision-making body for WHO [4]. It meets annually and delegates from all 194 Member States are invited to attend. This paper provides a snapshot of the contribution of Member States to the World Health Assembly. It analyses the resolutions debated at each of the World Health Assemblies from 2000 to 2012 and notes how many times each Member State spoke and the subject matter of the resolution on which they spoke. The paper then explores these results, examining the contribution of Member States according to their region, their income level and the subject matter of the resolutions. 1.1. Definition of global health Although a consensus on a definition of global health is yet to be obtained, key underlying concepts of what global health constitutes have emerged. In 2009 Koplan et al. [5] called for a common definition of global health. In the paper, Koplan et al. consider various definitions previously proposed and accordingly propose their own definition: “Global health is an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population-based prevention with individual-level clinical care.” [5] Since the publication of this paper, new ideas and issues have become apparent, including those outlined in Bozorgmehr’s paper [6]. Bozorgmehr questions the ‘global’ in ‘global health’ and argues that global-as-supraterritorial provides ‘new’ objects for research, education and practice while avoiding redundancy. Nevertheless, for the purposes of this paper, Koplan et al.’s definition will be observed. 2. Aim To explore and determine the diversity of countries that shape global health governance and decision-making within the WHO. Areas of analysis include regional variety, economic diversity and the subject matter of resolutions. 3. Method In May each year, the WHA meets to hold a plenary session, followed by two main committee sessions: Committee A discusses program matters and determines policy of the organisation; Committee B deals predominantly with administrative, financial and legal matters. This paper only examines resolutions adopted in Committee A of the WHA. WHA resolutions are usually proposed based on dialogue between Member States that are interested in a particular issue. Along with the Secretariat, the specific issues
and contents of the resolution are decided upon. A resolution is firstly put to the WHO Executive Board and on their approval, it is put to the World Health Assembly. Member States are able to influence and participate in decision-making not only through discussing resolutions at the World Health Assembly, but also through proposing resolutions. The source of information used to write this paper came from the World Health Assembly Summary Records of Committees (REC/3 documents), printed annually by the WHO. These documents were used to note any time a delegate representing a Member State spoke to a resolution that was eventually approved. The Member State the delegate represented, the region in which the Member State is based (according to the WHO regional groups) and its income group (according to the World Bank) [7] was noted. The title and subject matter of the resolution was also observed. Each resolution was classified into health matter categories. The first five categories were drawn from one of the 65th WHA agendas entitled ‘WHO Reform’ [8]. The authors constructed the further categories in accordance with the resolutions debated in the study. A list of the WHO Member States was written into Microsoft Excel and each time a delegate spoke on a resolution, it was noted. A separate tab also listed the resolution the Member State spoke to according to the classification of its subject matter. Each time a delegate spoke was listed, even if they spoke to the same resolution more than once. The authors decided to use this approach, as arguably the more engaged a delegate is with a resolution, the more influence they had over its creation. Delegates that represent non-Member States were not included in the analysis. Only adopted resolutions were included; discussions that resulted in the Committee ‘noting a report’ or progress reports on previously adopted resolutions and reports were not included in the study.
4. Results 4.1. Involvement of Member States in the debate of resolutions within Committee A of the WHA One hundred and thirty-eight (138) resolutions were debated and approved within Committee A of the WHA from 2000 to 2012. Five thousand and six (5006) interventions were made on these 138 resolutions. Table 1 lists the 20 most engaged Member States (that being, the Member States which spoke to resolutions the most). Table 2 outlines the Member States that did not address Committee A of the WHA from 2000 to 2012. The newest Member State to the WHO is South Sudan, which became a member in 2011. Since then, the South Sudanese delegation has addressed the Assembly 21 times. Although it is the WHO’s newest Member State to join the Assembly, it is already one of the 70 most active participants at the WHA. Furthermore, Chinese Taipei has been an observer of the WHA since 2009 (but only addressed the WHA since 2010) and since then has addressed the Assembly 26 times, making it one of the top 60 most active participants at the WHA.
T. van der Rijt, T. Pang (Pangestu) / Health Policy 119 (2015) 395–404 Table 1 Number of times a Member State addressed Committee A of the World Health Assembly (2000–2012).
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Member State
Number of times member state spoke at WHA 2000–2012
United States of America Thailand China Canada Japan India Brazil South Africa Russian Federation Cuba Australia Botswana Iran Kenya Mexico Iraq Switzerland Turkey Venezuela United Kingdom
239 214 144 134 121 110 109 100 96 78 77 76 74 74 72 68 66 65 64 63
4.2. Involvement of regions in the debate of resolutions within Committee A of the WHA It is important to note that not all regions have the same number of Member States: the African Region (AFRO) consists of 46 Member States (population – 904 million); the Americas region (AMRO) consists of 35 Member States (population – 958 million); the South-East Asia region (SEARO) has 11 Member States (population – 1.8 billion); the European region (EURO) has 53 Member States (population – 904 million); the Eastern Mediterranean region (EMRO) has 22 Member States (population – 601 million); and the Western Pacific region (WPRO) has 27 Member States (population – 1.9 billion) [9]. The regions that have the larger number of Member States in the region have a greater opportunity to address the Assembly.
Table 2 Member States who did not address Committee A of the World Health Assembly (2000–2012). Region
Member State(s)
WPRO EMRO AMRO
Niue Sudan Dominica Antigua and Barbuda
EURO
Albania Andorra Belarus Georgia Kyrgyzstan Montenegro San Marino Serbia Tajikistan Macedonia Turkmenistan
AFRO SEARO
– –
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For example, 27% of the Member States are within the EURO region and therefore it could be expected they address the Assembly more times than SEARO, which only make up 6% of the WHO Member States. Interestingly, this presumption does not correlate to the findings; 12 Member States from the EURO region (the largest region) did not address the Assembly from 2000 to 2012 (see Table 2). Of the 20 most engaged Member States at the WHA, six were from the Americas, four from Europe, three from the Western Pacific region, three from Africa, two from SouthEast Asia and two from the Eastern Mediterranean. Of the 50 Member States that addressed the Assembly the greatest number of times, ten were from the Americas, twelve from Europe, eleven from Africa, seven from the Western Pacific region, four from South-East Asia, and six from the Eastern Mediterranean. On examination of the results, AMRO, EURO and AFRO regions are most greatly represented on face value. This could be self-explanatory due to the fact that there are more Member States from these regions. Fig. 1 shows the 20 most engaged and 50 most engaged Member States, relative to the amount of Member States that come from that region. Although only 4 of the 50 most engaged Member States at the WHA came from the SEARO region, relative to the number of Member States within the region, it was the most highly represented. For example, 36% of SEARO Members were in the top 50 most engaged Member States, while comparatively only 29% of AMRO Members were in the top 50 most engaged Member States, even though 10 of its Members were in the top 50. The EMRO region was the least represented; with 14% of its Members (6 of 22) being in the top 50 most engaged Member States. Fig. 2 is a visual representation of how often Member States contributed compared to the average number of contributions. Both AMRO and EURO were highly represented in the 20 most engaged Member States. SEARO, WPRO and EMRO’s contributions to the WHA from 2000 to 2012 were below average. SEARO was the least represented. While there were less AFRO representatives in the 20 most engaged Member States, their engagement was above average when examining the top 50 most engaged Member States. As opposed to examining the most engaged Member States, Table 3 examines the number of speeches made at the WHA from 2000 to 2012. The table illustrates that 1 in 4.3 speeches made at the WHA from 2000 to 2012 were delegates representing Member States from the AMRO region. Comparatively, 1 in 9.2 speeches made were representatives from the SEARO region. Although there are more Member States in the EURO region compared to the AFRO region, and a greater number of EURO States were represented in the top 20 most engaged States, as a whole more speeches were made from Member States in the AFRO region. This is due to the fact that all AFRO Member States spoke at the WHA; although there were less AFRO than EURO states in the top 20 most engaged, AFRO delegates’ contributions en masse was greater than EURO delegates.
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Fig. 1. The 20 most engaged and 50 most engaged Member States at the WHA categorised into regions, relative to the number of Member States in the region.
Fig. 2. A comparison of regional engagement at the WHA of the 20 and 50 most engaged Member States. Statistic representation is as follows: 20 most engaged Member States, n = 20, mean = 3.3, std = 1.5. 50 most engaged Member States: n = 50, mean = 8.3, std = 3.1.
4.3. Involvement of Member States in the WHA according to income level Table 4 demonstrates that 85% of the 20 most engaged Member States were from high income or
upper-middle income countries [10] and 70% of the 50 most engaged Member States were from high or upper-middle income countries. Table 5 highlights the most engaged lower-income and low-income countries.
Table 3 Rankings of regions based on engagement at WHA. Total number of speeches made at WHA from 2000 to 2012 equalled 5006. Region
Number of speeches made by MS at WHA from region
Ratio of engagement
Rank
AMRO AFRO EURO WPRO EMRO SEARO
1162 1015 955 745 586 543
1:4.3 1:4.9 1:5.2 1:6.7 1:8.5 1:9.2
1 2 3 4 5 6
T. van der Rijt, T. Pang (Pangestu) / Health Policy 119 (2015) 395–404 Table 4 Representation of the most engaged Member States at the WHA according to income level. Income level
Number of MS in top 20 most engaged at WHA
Number of MS in top 50 most engaged at WHA
High income Upper-middle income Lower-middle income Low income
6 11
18 17
2
12
1
3
Of the lower-middle income countries and low-income countries that were the top 50 most engaged at the WHA, seven were from AFRO, four from EMRO, three from SEARO and one from WPRO. It is interesting to observe the level of engagement of the top 20 economies according to GNI World Bank rankings, as displayed in Fig. 3. Of the top 20 economies in the world, 13 of these were ranked as the 20 most engaged Member States at the WHA; 18 of the top 20 economies ranked as the top 50 most engaged Member States at the WHA. Although 8 of the top 20 economies are from Western Europe, they were some of the less engaged of the countries with the highest economies. The only countries that are the top 20 contributors to the WHO budget, but are not one of the 20 most engaged Member States, are all from Western Europe, except the Republic of Korea. 4.4. Involvement of Member States in the WHA according to subject matter of resolutions Nine different subject matters were used to classify the subject of resolutions. Fig. 4 shows that the greatest number of speeches made at the WHA concerned resolutions on communicable diseases (23.1%). Preparedness surveillance and response was the second most discussed subject, with 14% of speeches addressing the issue. Non-communicable diseases, health systems, health through the life course and social determinants of health were also more or less equally discussed. Table 5 Member States classified as a lower-middle or low income country that were one of the top 50 most engaged Member States at the WHA. Member State
Rank level of engagement
Income level
India Kenya Iraq Philippines Indonesia Morocco Bangladesh Pakistan Nigeria Egypt Cote d’Ivoire Senegal Zambia Mozambique Swaziland
6 14 16 22 23 25 26 27 30 32 34 36 40 41 49
Lower-middle Low Lower-middle Lower-middle Lower-middle Lower-middle Low Lower-middle Lower-middle Lower-middle Lower-middle Lower-middle Lower-middle Low Lower-middle
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Fig. 5 displays the main issues that were raised according to each region. The majority of speeches made by AFRO Member States (29.4%) were on the topic of communicable diseases. Preparedness surveillance and response and health through the life course were the second and third most spoken about topics by delegates from the AFRO region (12.5% and 11.1% of speeches respectively). Overall, the topics of communicable diseases, non-communicable diseases, health systems and preparedness surveillance and response made up the majority of all speeches made by each region. Social determinants of health were also a popular topic. AMRO was the region most concerned with public health, innovation and intellectual property. Preparedness, surveillance and response was a popular topic in the WPRO region due to Australia, China, Japan, Thailand and Indonesia’s contributions.
5. Discussion 5.1. Limitations of the study This study recognises that the World Health Assembly is just the tip of the iceberg regarding governance of the WHO; there are many more avenues that would be necessary to examine in order to wholly encapsulate governance and decision-making within the WHO. The Executive Board is composed of 34 members technically qualified in the field of health and are elected for three-year terms [11]. The Board is responsible for implementing decisions and policies of the WHA and acts as the WHO’s executive organ. There are also sub-committees and six WHO regional offices. The regional offices generally meet once a year and discuss and implement their own resolutions. Arguably, some Member States could be more vocal and influential in these other governance structures and less prominent at the WHA. The work and priorities of the WHO are shaped to a very significant extent by Member States additional voluntary contributions to particular health programs and initiatives. These account now for a very large proportion of WHO’s global budget. Nonetheless, the WHA was chosen as the focus of this paper, as it is the final decision making platform of the WHO and the only platform where all Member States of the WHO are invited to attend and engage in decision-making. Each Member State has the same weighted vote and each Member State has equal access to the floor. It is also important to note that when the WHA convenes, all negotiations and influential decisions do not take place within the open recorded debates of resolutions within the Assembly itself. Back room negotiations and the influence of lobby groups are invisible within the formal Assembly process. Smaller working groups are commonly convened during the WHA, especially around controversial issues. Power plays and pre-formed alliances are also rampant. Some Member States may speak to a resolution for political reasons and other Member States may not speak to a resolution even though it is an issue important in their country. Political interests, international affairs, policies or civil service cultures also influence the degree of Member States’ engagement. Some Member States may choose
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Fig. 3. Top 20 GNI countries compared to top 20 most engaged Member States. The countries capitalised and bold were not one of the top 20 most engaged Member States at the WHA.
to coordinate other Member States to argue their point of view. One Member State may also speak to a resolution on behalf of a regional group (e.g. South Africa may speak on behalf of the African nations and Germany may speak on behalf of the European Community) and so using the method in this paper, only South Africa and Germany would be noted for its contribution, even though other Member States may have contributed to the argument or speech. Nonetheless, it was interesting to observe that even though South Africa would speak on behalf of the African nations, it did not deter other African nations speaking to the resolution also. In examining the involvement of Member States and their contributions to resolution discussions, it is valuable to note that not all Member States have been a part of the WHO since its creation in 1948. Consequently, all Member States have not had the same opportunity to address the WHA and therefore these results may be skewed to favour those Member States who have been a member of
the WHO for a greater period. Furthermore, on examining the involvement of Members States according to income level, it must be mentioned that the income level of some countries has changed over time. 5.2. Emerging economies’ engagement at the WHA There has been concern expressed that the agenda of the ‘Western world’ dominates governance of global health. Interestingly, while the high income and uppermiddle income countries are the majority of the 20 most engaged Member States, only the USA, Canada, Australia and Switzerland are from the ‘Western world.’ Instead, many of the most engaged high income and upper-middle income countries are the emerging economies. The emerging economies of BRICS (Brazil, Russia, India, China, South Africa) and MIST (Mexico, Indonesia, South Korea, Turkey) were highly represented at the WHA, with 7 of the 9 countries being the top 20 most engaged Member States. The emerging markets that were not in the top 20 were
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Fig. 4. Subject matter of resolutions debated at WHA (2000–2012).
Indonesia (which was 23rd) and South Korea (which was 38th). There has been strong interest in the shift of power within global governance due to the rise of emerging economies, with Drezner referring to ‘the new new world
order’ [12]. Cooper and Alexandroff argue that the global order is shifting in an appreciable but awkward fashion and that the centre of gravity of the global power structure is arguably no longer the United States, which is
Fig. 5. Subject matter and number of speeches made by Member States according to region.
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a result of the emergence of new powers [13]. Interestingly, it has been more recently argued that the shift in power from the G7 to the BRICS countries has been ‘much smaller than the headlines or the private alarm bells suggest’ [14]. Wade [14] argues that the United States remains the dominant state and the G7 states together continue to exercise primacy, but now more fearfully and defensively. On examining governance within the WHA, it is clear that the USA still greatly contributes to and influences decision-making. However it also clear to see that the emerging markets are indeed increasing their presence. While 7 of the 9 BRICS and MIST countries are in the top 20, only four of the G7 are the top 20 most engaged at the WHA. While the G7 are still the highest contributors to the WHO financially, they are not the greatest contributors to governance and decision-making. It will be interesting to observe if the BRICS and MIST continue to increase their presence in global health governance at the WHA.
5.3. Regional engagement While appreciating that the regional structures set up within the WHO are sometimes dictated by geopolitical considerations and that some Member States arguably should be placed in different regional groups, it is nonetheless useful to examine the engagement of the Member States within the regional structure setting. Although there are only 11 Member States in the South East Asian region, two were in the top 20 most engaged and five of the top 20 would be considered from the Asian region generally (Thailand, China, Japan, India, Australia). The greater contributions of these Asian countries is in line with findings in a paper examining how global is global health, which found that of the lesser developed regions, Asia is a strong contributor to the shaping of global health [1]. Just as the paper found that authors and professionals from Asian institutions are reasonable contributors to global health journals, conferences and institutions, so too were they found in this paper to be fairly represented at the WHA, relative to other regions. Countries from the African region were also well represented, with 11 Member States in the top 50 most engaged. If examining the African continent (as opposed to the WHO AFRO region), 9 African countries were in the top 50 most engaged that are lower-income or lowincome countries (Kenya, Morocco, Nigeria, Egypt, Cote d’Ivoire, Senegal, Zambia, Mozambique and Swaziland). These lesser-developed African countries are increasing their engagement in global health governance within the WHA. Relative to the number of Member States in the European region, fewer chose to contribute at the WHA. Of the top 20 Member States that financially contribute to the WHO, 11 are from the EURO region, yet only 2 of these countries are the top 20 most engaged in governance and decision-making. Why are European Member States willing to financially provide to the WHO, but are less engaged in its governance? Perhaps they are more active in the WHO
EURO regional office, or choose to engage more bilaterally through development agencies such as DFID, NORAD and GTZ. Further analysis of regional engagement also provides ‘case study’ examples of resolutions where there has been a major split between high and low income countries and of the ‘what’ and ‘why’ of different interests and priorities between regions and countries. The number of speeches and contributions by Member States measures engagement and is limited in measuring influence, and as such is a proxy for interest on particular topics. One example of the subject matter of a resolution being split between high and low income countries concerns the contentious issue of the ‘geographical rotation’ for the Director General’s position. Member states from the Eastern Mediterranean, African and South-East Asian Regions of WHO, citing the need for equity and fairness, proposed a resolution during the 120th session of the Executive Board in 2006 to address the rotation issue, including necessary changes in the Rules of Procedure of the World Health Assembly to implement such rotations [13]. The three regions cited the fact that WHO had elected seven Directors-General from three of the Organisation’s six regions. No candidate from the African, South-East Asian or Eastern Mediterranean Regions had as yet been successful, despite these regions containing more than half the world’s population and there being qualified health professionals in those regions. These professionals were capable of managing WHO and would meet the paramount criterion of the highest standard of efficiency and integrity, as called for in Article 35 of WHO’s Constitution. Geographical rotation was also cited as having been practised in the selection of Secretary-General of the United Nations. Contending that the criterion of geographical representation was secondary to the paramount criterion of the highest standards of ability, capacity, efficiency and integrity, the resolution was opposed – mainly by high-income countries such as the USA, Japan, Australia, Luxembourg, and Singapore [15]. The proposed resolution to be carried to the World Health Assembly and to contain the words “as well as the issue of regional rotation” was thus not passed and diluted to the effect that the Board “REQUESTS the Director-General to prepare a report on the geographical rotation of the post of Director-General, taking into account the views expressed by members of the Executive Board, and to report back to the 121st session of the Executive Board.” The debate thus continued at the 121st Session of the Executive Board in 2007. While the countries from the three aforementioned regions stood their ground, opposition to the rotation resolution from high-income countries continued, with New Zealand, United Kingdom, Denmark, and the Bahamas [16] opposing the idea of rotation. Predictably the resolution was not passed and the matter postponed yet again for discussion at the next meeting of the Board. During the 122nd Session of the Board in 2008 a document was prepared to describe various options for rotation of the Director-General [17] with an invitation to the Board “to consider the possible options proposed.” The matter, however, was not even discussed at the Board session [18] and no definitive resolution was passed. The stalemate continues until today with the ‘rotation’ issue
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disappearing off the agenda of WHO’s governing bodies after 2008. 5.4. Subject matter of resolutions Discussions on diseases dominated the WHA from 2000 to 2012, with 33.6% of speeches focusing on the topic. In particular, communicable disease was the subject most greatly discussed. The topic of non-communicable diseases increased from 2007. African Member States were much more engaged in the topic of communicable diseases compared to non-communicable diseases. Although climate change only became a topic of concern in 2008, China, the greatest emitter of greenhouse gases, was the 4th most engaged Member State on the topic.
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are becoming more popular to debate, such as social determinants of health. As the unique entity that assembles Member States from all over the world to discuss global health matters, it appears that the WHO has maintained its relevance. For indeed, Member States from a variety of economic and regional backgrounds are continuing to use the WHA as the forum to set the agenda and determine global health governance. Acknowledgement The authors would like to acknowledge the support of the Lee Kuan Yew School of Public Policy for funding the research leading to the article.
5.5. Relevance of the WHO
References
Other papers have found that although there may be a shift in influence, global health is still dominated by countries in the Western world [1,19]. This paper reinforces the importance of the WHO as a platform where all countries are able to participate, as indeed, the Member States who contribute to discussions are geographically and economically diverse. Only 16 of the 194 Member States of the WHO have never addressed the WHA. Although 70% of the 50 most engaged Member States were from high or upper-middle income countries, many of these were emerging economies that have increased their contribution to global health governance at the WHA. Furthermore, 15 of the top 50 most engaged Member States were lower-middle income or low-income countries. There is great regional diversity of Member States at the WHA, with reasonable representation from all regional areas. SEARO and EMRO had the least regional engagement, but they also consist of the least number of Member States. Although some subjects were more heavily discussed than others, the WHA is a forum whereby any important health matter can be put on the table and debated. Consequently, the WHO is still relevant and necessary to ensuring that all Member States can engage on an equal platform and contribute to global health governance.
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6. Conclusion Global health governance within the WHO is diverse. While high-income and upper-middle income countries are the top twenty most engaged Member States within the WHA, a limited number of them are culturally from the ‘Western world’. Instead, it is the emerging economies that are utilising the World Health Assembly to set the global health agenda. While lower-middle income and lowincome countries are less represented, they still have a reasonable presence and influence within the WHA. Contributions to the Assembly are also regionally diverse; relative to the number of countries within each region, regional representation is relatively even. The subject matter of diseases, particularly communicable diseases, and preparedness surveillance and response were the most discussed topics at the WHA from 2000 to 2012. Certain topics
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