p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 7 3 e1 7 8
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
WHO: Past, Present and Future
Great expectations for the World Health Organization: a Framework Convention on Global Health to achieve universal health coverage G. Ooms a,*, R. Marten b, A. Waris c, R. Hammonds a, M. Mulumba d, E.A. Friedman e a
Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium Rockefeller Foundation, New York, USA c Law School, University of Nairobi, Nairobi, Kenya d Center for Health Human Rights & Development, Kampala, Uganda e O’Neill Institute for National and Global Health Law, Georgetown University, Washington D.C., USA b
article info
abstract
Article history:
Establishing a reform agenda for the World Health Organization (WHO) requires under-
Received 7 April 2013
standing its role within the wider global health system and the purposes of that wider
Received in revised form
global health system. In this paper, the focus is on one particular purpose: achieving
20 June 2013
universal health coverage (UHC). The intention is to describe why achieving UHC requires
Accepted 26 June 2013
something like a Framework Convention on Global Health (FCGH) that have been proposed
Available online 9 January 2014
elsewhere,1 why WHO is in a unique position to usher in an FCGH, and what specific reforms would help enable WHO to assume this role.
Keywords:
ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Universal health coverage Human rights Right to health Convention
Introduction Establishing a reform agenda for the World Health Organization (WHO) requires understanding its role within the wider global health system and the purposes of that wider global health system. In this paper, the focus is on one particular purpose: achieving universal health coverage (UHC). The intention is to describe why achieving UHC requires a
Framework Convention on Global Health (FCGH) which have been previously proposed,1 why WHO is in a unique position to usher in an FCGH, and what specific reforms would help enable WHO assume this role. One of the essential objectives of the FCGH e though not the only one e would be to allocate responsibilities for funding UHC to realize this goal globally, contributing to achieving the global health treaty’s central aim of closing persistent, and
* Corresponding author. Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium. E-mail address: [email protected] (G. Ooms). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2013.06.006
174
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 7 3 e1 7 8
increasing, global and national health inequities. FCGH standards and its financing framework would similarly ensure clean water and sanitation, nutritious food, and other underlying determinants of health for all, while also addressing broader determinants of health. Further, the FCGH could incorporate a proposed health research and development convention, bringing this critical health need within the FCGH financing framework.2 The financing framework could even encompass financing for global health organizations including WHO.3 Inadequate and inequitable health financing is a challenge a global health treaty must address. Progress on costing UHC, along with the importance of UHC itself, makes UHC a valuable window into how the FCGH could address this challenge. The authors first discuss what UHC means, or should mean from a right to health perspective, with a focus on the costs. Then they explain why many low-income countries remain unable to finance UHC without external assistance, even with increased investments. In the next section, international assistance is discussed, again from a right to health perspective, and the authors argue that the present content of international human rights law is insufficiently clear on the allocation of domestic and international responsibility, thus building a case for an FCGH, which could create that clarity, thus overcoming a chief barrier to UHC. Finally, some proposed WHO reforms in relation to its potential role as the central broker of an FCGH are discussed.
Universal health coverage: a goal for humanity, requiring a collective effort from humanity Since WHO published its 2010 World Health Report on Health systems financing: the path to universal coverage,4 the issue of UHC has been at the forefront of global health. In the wake of the report, WHO’s Director-General, Margaret Chan, declared, ‘universal health coverage is the single most powerful concept that public health has to offer.’5 Universal coverage for needed health services sustains and improves health. Beyond this, ensuring health enables children to learn and adults to earn. It helps people escape poverty and provides the basis for economic development.6 Given the some 150 million people who face severe financial hardship and 100 million pushed into poverty annually because they fall ill, use health services, or pay out of pocket, the significant links between UHC and sustainable development are clear.7 With this in mind, the United Nations General Assembly unanimously adopted a resolution on UHC in late 2012.8 Subsequently, UHC has been widely understood as a leading candidate for an umbrella goal for health in the post-2015 agenda,9 particularly if anchored in the right to health.10 Given all of this attention, the definition of UHC is critical. What does UHC mean? The 2010 World Health Report defines UHC as ‘health financing systems so that all people have access to services and do not suffer financial hardship paying for them.’4 The UN resolution defined UHC as a system in which ‘people have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative and
rehabilitative basic health services and essential, safe, affordable, effective and quality medicines, while ensuring that the use of these services does not expose the users to financial hardship.’8 This broader definition of UHC accommodates the existing health sector Millennium Development Goals (MDGs) e on child mortality, maternal mortality and combating HIV/AIDS, malaria and other diseases e but also extends beyond present MDGs health sector commitments. Health statistics experts from WHO, the World Bank, and others have already begun developing UHC measurement frameworks that account for MDG gains, and also account for equity and the distribution of health services among the population.11 UHC brings a systems-level focus on access that demands a more equitable approach and is critical for seeing health and access to health care as a human right.12 WHO has explicitly stated that UHC ‘is not about a fixed minimum package.’13 This is in line with the right to health and the concept of progressive realization: states that ratified the International Covenant on Economic, Social and Cultural Rights committed to ‘take steps, individually and through international assistance and co-operation, especially economic and technical, to the maximum of [their] available resources, with a view to achieving progressively the full realization of the rights recognized in the present Covenant by all appropriate means.’ (emphasis added).14 Full realization means ‘the highest attainable standard of physical and mental health,’ but a country’s obligation is limited to using maximum available resources e and if those available resources are very low, the level of health care provided would necessarily be very low as well, too low for effective coverage of a population’s essential health needs. Yet if UHC is to encompass the current health sector MDGs e and extend beyond to capture NCDs including mental health, and more (e.g., injuries), while securing the health workforce and equitable systems required to achieve UHC e it should at the very least include the targets that have been agreed under the current health sector MDGs, such as ‘universal access to reproductive health,’ (target 5.B) and ‘universal access to treatment for HIV/AIDS for all those who need it’ (target 6.B).15 The High-Level Taskforce on Innovative International Financing for Health Systems (Taskforce), launched in September 2008 to help strengthen health systems in 49 lowincome countries (in accordance with the World Bank classification at that time) completed its work in September 2009 and found that, in low-income countries, the annual costs of achieving the current health sector MDGs would be about US$50-55 per person per year.16 The 2010 World Health Report reported that ‘only eight of the 49 countries have any chance of financing the required level of services from domestic resources in 2015’, which WHO estimated to require, on average, $60 per person.4 Does this mean that these forty-nine low-income countries should then adopt ‘UHC light’, or ‘selective UHC’, i.e. a version of UHC that does not even cover what is needed for the current health sector MDGs? Such notions of resource scarcity should be challenged, particularly considering the ethical and legal obligations of international assistance.17 Indeed, in as much as UHC is a new iteration of the WHO’s Alma-Ata ‘health for all’ declaration, it should explicitly challenge the old
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 7 3 e1 7 8
paradigm, according to which domestic financial self-reliance prevailed over access to vital health services.18
The minimum domestic effort, from a human rights perspective International human rights law does not specify what the maximum of states’ available resources encompasses. How did the authors of the 2010 World Health Report reach the conclusion that only eight low-income countries ‘have any chance of’ financing the required level of services themselves e that even their maximum effort would be inadequate? They refer to a costing estimate that WHO prepared for the Taskforce.19 The WHO assumes that under an optimistic scenario, African lowincome countries ‘would increase the proportion of domestically generated general government expenditure allocated to health to 15% by 2015 in line with the Abuja declaration,’ while for other low-income countries, ‘it is projected that they would reach 12% by 2015.’ In the 2001 Abuja Declaration on HIV/AIDS, Tuberculosis, and Other Related Infectious Diseases, all member states of the Organization of Africa Unity e now the African Union e pledged ‘to set a target of 15% of [their] annual budget to the improvement of the health sector.’20 Do these estimates correspond with maximum available resources? Some countries do spend 15% of the government budget on health e high-income countries allocate, on average, 17.1% of the government budget to health.21 Middle-income countries, however, generally allocate a much lower proportion of government revenue to health care: between 10.5% (upper middle-income) and 5.5% (lower middle-income). Lowincome countries allocate 8.5% of the government budget to health, on average (9.6% average for all Sub-Saharan countries); this includes some e possibly considerable e level of external resources. Several low-income countries have (or have at times) achieved 15%, such as Rwanda and Zambia.21 For present purposes, the target of allocating 15% of domestically generated government expenditure to the health sector seems a reasonable approximation of the maximum e and thus required e level of the national budget to devote to the health sector, at least for low-income countries. The US$60 per person per year estimate includes both public and private health expenditure. To estimate the minimum level of public health expenditure, one can use WHO’s estimate that out-of-pocket expenditures should not exceed 15e20% of total health spending if the impoverishing effects of health spending are to be avoided.4 It then may be reasonable to estimate the minimum public expenditure to achieve UHC at approximately $50 per person per year in lowincome countries. Furthermore, one may have to add increasing government revenue to the equation. In African low-income countries, government revenue (excluding grants) increased from 15.1% of GDP in 2004 to 18.2% of GDP in 2011; thus it has been assumed that the government revenue will increase to 20% of GDP by 2015.22 But even under all these optimistic assumptions, there is a gap of at least $30 billion. If the international community is serious about UHC, this gap should be acknowledged, and high-income countries should fill it with international assistance.
175
International assistance, from a human rights perspective Is it realistic to expect that high-income countries will, collectively, cover the global UHC financing gap of at least $30 billion? Or must one should accept that in many low-income countries, the best UHC achievable will be below even current health sector MDG standards? One can make a case that covering the global UHC financing gap e whether it is $30 billion or more e is a matter of legal obligation, not of discretionary choice. The case is built on the concept of ‘core content’ of human rights e the minimum essential level for a right to remain meaningful e and corresponding ‘core obligations.’ General Comment 14 on the right to health e issued by the Committee on Economic, Social and Cultural Rights that is tasked with monitoring states’ compliance with the International Covenant on Economic, Social and Cultural Rights e confirms that a state ‘cannot, under any circumstances whatsoever, justify its non-compliance with the core obligations,’ and clarifies that the core obligations arising from the right to health include to ‘ensure the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups,’ to ‘provide essential drugs, as from time to time defined under the WHO Action Programme on Essential Drugs,’ and other aspects that collectively look very much like UHC as described above.23 But how can UHC be a non-derogable obligation if, as discussed above, most low-income countries cannot fulfil it, even if they make a maximum effort? The implicit answer from the Committee lies in its statement that ‘that it is particularly incumbent on States parties and other actors in a position to assist, to provide ‘international assistance and cooperation, especially economic and technical’ which enable developing countries to fulfil their core and other obligations.’23 Several of the Committee’s general comments have explored the nature of extraterritorial obligations with regards to economic, social and cultural rights, as have the recent Maastricht Principles, which confirm the existence of obligations to provide international assistance, adding that ‘[s]tates should coordinate with each other, including in the allocation of responsibilities, in order to cooperate effectively in the universal fulfilment of economic, social and cultural rights.’24 Such coordination, like the maximum resources requirement, is not clearly defined in present international human rights law e not even included as an explicit command, though it is implicit in the obligation of ‘international assistance and cooperation’ (emphasis added). And that is one of the main reasons why people need an FCGH: to coordinate the allocation of responsibilities, in financing and elsewhere. In July 2012, the African Union adopted a Roadmap on Shared Responsibility and Global Solidarity for AIDS, TB and Malaria Response in Africa,25 which affirmed commitments made in the Abuja Declaration, and which also calls upon the international community to keep its prior commitments. The ‘developed’ countries promised, in 1970, to allocate the equivalent of 0.7% of their Gross Domestic Product (GDP) to international assistance.26 If high-income countries met this 0.7% commitment, and even 15% of their international
176
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 7 3 e1 7 8
assistance were allocated to the health sector e mirroring the 15% of domestic government revenue target e the $30 billion gap mentioned above could be covered. Such a sharing of responsibilities could be the beginning of a framework for financing UHC, a framework that an FCGH could expand upon.
A Framework Convention on Global Health and the role of WHO A FCGH could set standards throughout the dimensions of the right to health, including ensuring sufficient and sustained financing for a robust version of UHC, thus guiding government action and bolstering civil society advocacy. Developing and negotiating an FCGH will face challenges in setting these standards, such as state variation in how they fund health care domestically and internationally, burden sharing between states, and expenditure priorities, including among UHC, the underlying determinants of health (e.g., water, sanitation, nutrition, housing), and indeed, the broader social determinants of health. UHC-related costs and investments would be one of several areas in which an FCGH would set standards. Others would relate to inclusive processes to tailor global standards e including for UHC e to national priorities. The FCGH could also have standards related to equity, accountability (e.g., transparency and other elements of national health accountability strategies), participatory policy-making, protecting health in other legal spheres, and more. Countries could incorporate these standards into their own laws and policies and processes. What of the legal pathways to the FCGH itself, to realizing a treaty that effectively allocates responsibility for financing UHC, making it possible in even low-income countries, and does much more as well towards realizing the right to health for all people? While several avenues could be open, including the United Nations General Assembly, WHO must be counted as a leading possibility, following on the International Health Regulations, the Framework Convention on Tobacco Control and WHO powers under article 19 of its Constitution. The International Health Regulations are, essentially, a convention to share the collective burden of infectious disease control; the FCGH would push that logic of shared responsibility to a higher level. In the global health system, the WHO is, as Frenk and Moon argue, ‘the only actor in the global health system that is built on the universal membership of all recognized sovereign nation states,’27 and therefore the only element of it that has both the powers and the legitimacy to make international law. If WHO is to be a credible forum for a FCGH, however, at least three reforms are critical. First, states must greatly increase their untied contributions to WHO. Presently, threequarters of WHO’s budget is voluntary, with most of these funds earmarked,28 making WHO’s agenda driven more by the preferences of its funders than by the organization’s impartial assessment of appropriate priorities. As the People’s Health Movement argues: ‘A high proportion of voluntary contributions by member states undermines the organisation’s independence.’29 How can WHO be e and be perceived as being e impartial under such circumstances? If the high-income countries ‘no longer want to be taking on the full burden of
providing the financing to meet the MDGs’ and expect ‘[s] tronger commitments from.developing countries themselves,’30 they will need to make commitments that reinforce WHO’s independence. Note that ‘taking on the full burden’ is an exaggeration, as even in low-income countries external resources account for only 25.7% of total health expenditure.21 Even so, if high-income countries would like to have an impartial broker of arrangements for allocating health investments, they need to increase unearmarked funding for WHO. Second, with the centrality of the right to health to an FCGH, if WHO wants to be its broker and host, it must increase its work in human rights, equity, and gender. WHO continues to faces challenges in this respect.31 In mainstreaming this work, present reforms must significantly strengthen WHO capacity in these areas, with the legal and policy engagement at all levels to give life to these principles e including how to operationalize UHC from a right to health perspective. Third, to be at the center of the global health system requires ties with other elements of this network. Whereas younger elements of the global health system, like GAVI and the Global Fund to Fight AIDS, Tuberculosis and Malaria, established symbiotic links with civil society organizations,32 civil society typically finds itself sidelined at WHO.33 Reforms proposed to strengthen civil society’s role ought to be carefully considered.34e36 Though the challenges of accurately representing people’s views through select civil society organizations has been recognized, this would contribute to strengthening people’s rights, as part of the right to health, to participate ‘in all health-related decision-making at the community, national and international levels’23 e greater civil society involvement would help compensate for the democratic shortcomings of many states, and potentially strengthen the voice of Southern states, whose populations suffer most from health inequities but many of which have limited capacity in international forums compared to wealthier countries.3 WHO is the natural host and broker of an FCGH. Yet without reform, it may not be seen as the legitimate one.
Author statements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
1. Gostin LO, Friedman EA, Ooms G, Gebauer T, Gupta N, Sridhar D, Chenguang W, Røttingen J-A, Sanders D. The Joint
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 7 3 e1 7 8
2.
3.
4.
5.
6.
7. 8.
9. 10.
11.
12. 13.
14.
15.
16.
Action and Learning Initiative: towards a global agreement on national and global responsibilities for health. PLoS Medicine 2011;8(5):e1001031. Moon S, Bermudez J, ’t Hoen E. Innovation and access to medicines for neglected populations: could a treaty address a broken pharmaceutical R&D system? PLoS Medicine 2012;9(5):e1001218. Friedman EA, Gostin LO, Buse K. Advancing the right to health through global organizations: the potential role of a framework convention on global health. Health and Human Rights: An International Journal 2013;15(1). Available at: http:// www.hhrjournal.org/wp-content/uploads/sites/13/2013/06/ Friedman-FINAL.pdf (Website available approx June 15). World Health Organization. The world health report 2010. Health systems financing: the path to universal coverage. Geneva: World Health Organization. Available at: http://whqlibdoc.who.int/ whr/2010/9789241564021_eng.pdf (accessed 31 March 2013). Chan M. The place of health on the post-2015 development agenda. Opening remarks at an informal Member State consultation on health in the post-2015 development agenda. Available at: http:// www.who.int/dg/speeches/2012/mdgs_post2015/en/index. html; 14 December 2012 (accessed 31 March 2013). World Health Organization. Universal health coverage: five questions. Geneva: World Health Organization. Available at: http://www.who.int/health_financing/universal_health_ coverage_5_questions.pdf; 2012 (accessed 31 March 2013). Evans DB, Marten R, Etienne C. Universal health coverage is a development issue. Lancet 2012;380(9845):864e5. United Nations General Assembly. Global health and foreign policy. U.N. Doc. A/RES/67/81, General Assembly Res. 67/81. Available at:, http://www.un.org/ga/search/view_doc.asp? symbol¼A/67/L.36%26referer¼http://www.un.org/en/ga/info/ draft/index.shtml%26Lang¼E; Dec. 12, 2012 (accessed 31 March 2013). Horton R. Offline: a rainbow on my desolate land. Lancet 2013;381(9870):890. Ooms G, Brolan C, Eggermont N, Eide A, Flores W, Forman L, Friedman EA, Gebauer T, Gostin LO, Hill PS, Hussain S, McKee M, Mulumba M, Siddiqui F, Sridhar D, Van Leemput L, Waris A, Jahn A. Universal health coverage anchored in the right to health. Bulletin of the World Health Organization 2013;91. 2e2A. Boerma T. Measurement of trends and equity in coverage of health interventions in the context of universal health coverage. Meeting report. Bellagio: Rockefeller Foundation Center. Available at:, http://www.worldwewant2015.org/file/279371/download/ 302866; 2012 Sept 17e21 (accessed 31 March 2013). Vega J. Universal health coverage: the post-2015 development agenda. Lancet 2013;381(9862):179e80. World Health Organization. Positioning health in the post-2015 development agenda. WHO Discussion Paper. Available at:, http://www.worldwewant2015.org/bitcache/ 7c4f4f265f3d2dfdfed54c06afee939039865522?vid¼302852% 26disposition¼attachment%26op¼download; October 2012 (accessed 31 March 2013). International Covenant on Economic, Social and Cultural Rights. International Covenant on Economic, Social and Cultural Rights, G.A. res. 2200A(XXI), 21 U.N.GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966). Available at: http://www1.umn. edu/humanrts/instree/b2esc.htm (accessed 31 March 2013). United Nations. MDG list. Available at: http://mdgs.un.org/ unsd/mdg/Resources/Attach/Indicators/OfficialList2008.pdf (accessed 31 March 2013). Taskforce on Innovative International Financing for Health Systems. More money for health, and more health for the money. Available at: http://www.internationalhealthpartnership.net/ fileadmin/uploads/ihp/Documents/Results___Evidence/ HAE__results___lessons/Taskforce_report_EN.2009.pdf (accessed 31 March 2013).
177
17. Schrecker T. Interrogating scarcity: how to think about ‘resource-scarce settings’. Health Policy and Planning; August 16, 2012. Advance access published. 18. Ooms G. Shifting paradigms: how the fight for ‘universal access to AIDS treatment and prevention’ supports achieving ‘comprehensive primary health care for all’. Globalization and Health 2008;4:11. 19. World Health Organization. Background document for the Taskforce on Innovative International Financing for Health Systems. Working group 1: constraints to scaling up and costs. Available at: http://www.internationalhealthpartnership.net/fileadmin/ uploads/ihp/Documents/Results___Evidence/HAE__results___ lessons/Working%20Group%201%20Technical% 20Background%20Report%20(World%20Health% 20Organization).pdf (accessed 31 March 2013). 20. Organization of African Unity. Abuja declaration on HIV/AIDS, tuberculosis, and other related infectious diseases. Available at: http://www.un.org/ga/aids/pdf/abuja_declaration.pdf; 2001 (accessed 31 March 2013). 21. World Health Organization. World health statistics 2012. Geneva: World Health Organization. Available at: http://www. who.int/healthinfo/EN_WHS2012_Part3.pdf; 2012 (accessed 31 March 2013). 22. International Monetary Fund. Regional economic outlook. SubSaharan Africa: maintaining growth in an uncertain world. Available at: http://www.imf.org/external/pubs/ft/reo/2012/ afr/eng/sreo1012.pdf; October 2012 (accessed 31 March 2013). 23. Committee on Economic, Social and Cultural Rights. General comment 14, the right to the highest attainable standard of health (Twenty-second session, 2000). U.N. Doc. E/C.12/2000/4. Available from:, http://www1.umn.edu/humanrts/gencomm/ escgencom14.htm; 2000 (accessed 31 March 2013). 24. Maastricht principles on extraterritorial obligations of states in the area of economic, Social and cultural rights. Available at: http:// www.fian.org/fileadmin/media/publications/2012.02.29_-_ Maastricht_Principles_on_Extraterritorial_Obligations.pdf (accessed 31 March 2013). 25. African Union. Roadmap on shared responsibility and global solidarity for AIDS, TB and malaria response in Africa. Available at: http://www.au.int/en/sites/default/files/Shared_Res_ Roadmap_Rev_F%5b1%5d.pdf; 2012 (accessed 31 March 2013). 26. Fu¨rher H. The story of official development assistance. Paris: Organization for Economic Co-operation and Development. Available at: http://www.oecd.org/dac/1896816.pdf; 1996 (accessed 31 March 2013). 27. Frenk J, Moon S. Governance challenges in global health. New England Journal of Medicine 2013;368(10):936e42. 28. World Health Organization. Programme budget 2012e2013. Geneva: World Health Organization. Available at: http:// whqlibdoc.who.int/pb/2012-2013/PB_2012-2013_eng.pdf; 2011 (accessed 31 March 2013). 29. People’s Health Movement. Comments on ‘The future of financing for WHO’ 64th World Health Assembly (WHA). Available at: http://www.democratisingglobalhealth.org/ sites/www.democratisingglobalhealth.org/files/Future% 20Financing%20of%20the%20WHO%20-%20PHM%20May% 202011.pdf; May 2011 (accessed 31 March 2013). 30. Greenhill R, Prizzon A. WHO foots the bill after 2015? What new trends in development finance mean for the post-MDGs. ODI Working Paper 360. Available at:, http://www.odi.org.uk/sites/ odi.org.uk/files/odi-assets/publications-opinion-files/7905. pdf; 2012 (accessed 31 March 2013). 31. Mason Meier B. The World Health Organization, the evolution of human rights, and the failure to achieve health for all. In: Harrington J, Stuttaford M, editors. Global health and human rights. London: Routledge; 2010. 32. Hawkes N. “Irrelevant” WHO outpaced by younger rivals. BMJ 2011;343:d5012.
178
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 7 3 e1 7 8
33. Schwarz T. A stronger voice for civil society at the World Health Assembly?. Available at: http://www.medicusmundi.org/en/ contributions/reports/2010/a-stronger-voice-of-civil-societyat-the-world-health-assembly; 2010 (accessed 31 March 2013). 34. World Health Organization. WHO reforms for a healthy future: report by the Director-General. Doc. EBSS/2/2. Available at:, http://apps.who.int/gb/ebwha/pdf_files/EBSS/EBSS2_2-en. pdf; October 15, 2011 (accessed 31 March 2013).
35. Sridhar D, Gostin LO. Reforming the World Health Organization. Journal of the American Medical Association 2011;305(15):1585e6. 36. Democratizing Global Health Coalition. Letter by the democratizing global health coalition to the WHO Regional Director for Africa for the sixty-first session of the WHO Regional Committee for Africa. Available at: http://www.ghwatch.org/sites/www. ghwatch.org/files/DGHCoalition_Letter2AFRORegionalDirector. pdf; August 26, 2011 (accessed 31 March 2013).
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
WHO: Past, Present and Future
Great expectations for the World Health Organization: a Framework Convention on Global Health to achieve universal health coverage G. Ooms a,*, R. Marten b, A. Waris c, R. Hammonds a, M. Mulumba d, E.A. Friedman e a
Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium Rockefeller Foundation, New York, USA c Law School, University of Nairobi, Nairobi, Kenya d Center for Health Human Rights & Development, Kampala, Uganda e O’Neill Institute for National and Global Health Law, Georgetown University, Washington D.C., USA b
article info
abstract
Article history:
Establishing a reform agenda for the World Health Organization (WHO) requires under-
Received 7 April 2013
standing its role within the wider global health system and the purposes of that wider
Received in revised form
global health system. In this paper, the focus is on one particular purpose: achieving
20 June 2013
universal health coverage (UHC). The intention is to describe why achieving UHC requires
Accepted 26 June 2013
something like a Framework Convention on Global Health (FCGH) that have been proposed
Available online 9 January 2014
elsewhere,1 why WHO is in a unique position to usher in an FCGH, and what specific reforms would help enable WHO to assume this role.
Keywords:
ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Universal health coverage Human rights Right to health Convention
Introduction Establishing a reform agenda for the World Health Organization (WHO) requires understanding its role within the wider global health system and the purposes of that wider global health system. In this paper, the focus is on one particular purpose: achieving universal health coverage (UHC). The intention is to describe why achieving UHC requires a
Framework Convention on Global Health (FCGH) which have been previously proposed,1 why WHO is in a unique position to usher in an FCGH, and what specific reforms would help enable WHO assume this role. One of the essential objectives of the FCGH e though not the only one e would be to allocate responsibilities for funding UHC to realize this goal globally, contributing to achieving the global health treaty’s central aim of closing persistent, and
* Corresponding author. Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium. E-mail address: [email protected] (G. Ooms). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2013.06.006
174
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 7 3 e1 7 8
increasing, global and national health inequities. FCGH standards and its financing framework would similarly ensure clean water and sanitation, nutritious food, and other underlying determinants of health for all, while also addressing broader determinants of health. Further, the FCGH could incorporate a proposed health research and development convention, bringing this critical health need within the FCGH financing framework.2 The financing framework could even encompass financing for global health organizations including WHO.3 Inadequate and inequitable health financing is a challenge a global health treaty must address. Progress on costing UHC, along with the importance of UHC itself, makes UHC a valuable window into how the FCGH could address this challenge. The authors first discuss what UHC means, or should mean from a right to health perspective, with a focus on the costs. Then they explain why many low-income countries remain unable to finance UHC without external assistance, even with increased investments. In the next section, international assistance is discussed, again from a right to health perspective, and the authors argue that the present content of international human rights law is insufficiently clear on the allocation of domestic and international responsibility, thus building a case for an FCGH, which could create that clarity, thus overcoming a chief barrier to UHC. Finally, some proposed WHO reforms in relation to its potential role as the central broker of an FCGH are discussed.
Universal health coverage: a goal for humanity, requiring a collective effort from humanity Since WHO published its 2010 World Health Report on Health systems financing: the path to universal coverage,4 the issue of UHC has been at the forefront of global health. In the wake of the report, WHO’s Director-General, Margaret Chan, declared, ‘universal health coverage is the single most powerful concept that public health has to offer.’5 Universal coverage for needed health services sustains and improves health. Beyond this, ensuring health enables children to learn and adults to earn. It helps people escape poverty and provides the basis for economic development.6 Given the some 150 million people who face severe financial hardship and 100 million pushed into poverty annually because they fall ill, use health services, or pay out of pocket, the significant links between UHC and sustainable development are clear.7 With this in mind, the United Nations General Assembly unanimously adopted a resolution on UHC in late 2012.8 Subsequently, UHC has been widely understood as a leading candidate for an umbrella goal for health in the post-2015 agenda,9 particularly if anchored in the right to health.10 Given all of this attention, the definition of UHC is critical. What does UHC mean? The 2010 World Health Report defines UHC as ‘health financing systems so that all people have access to services and do not suffer financial hardship paying for them.’4 The UN resolution defined UHC as a system in which ‘people have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative and
rehabilitative basic health services and essential, safe, affordable, effective and quality medicines, while ensuring that the use of these services does not expose the users to financial hardship.’8 This broader definition of UHC accommodates the existing health sector Millennium Development Goals (MDGs) e on child mortality, maternal mortality and combating HIV/AIDS, malaria and other diseases e but also extends beyond present MDGs health sector commitments. Health statistics experts from WHO, the World Bank, and others have already begun developing UHC measurement frameworks that account for MDG gains, and also account for equity and the distribution of health services among the population.11 UHC brings a systems-level focus on access that demands a more equitable approach and is critical for seeing health and access to health care as a human right.12 WHO has explicitly stated that UHC ‘is not about a fixed minimum package.’13 This is in line with the right to health and the concept of progressive realization: states that ratified the International Covenant on Economic, Social and Cultural Rights committed to ‘take steps, individually and through international assistance and co-operation, especially economic and technical, to the maximum of [their] available resources, with a view to achieving progressively the full realization of the rights recognized in the present Covenant by all appropriate means.’ (emphasis added).14 Full realization means ‘the highest attainable standard of physical and mental health,’ but a country’s obligation is limited to using maximum available resources e and if those available resources are very low, the level of health care provided would necessarily be very low as well, too low for effective coverage of a population’s essential health needs. Yet if UHC is to encompass the current health sector MDGs e and extend beyond to capture NCDs including mental health, and more (e.g., injuries), while securing the health workforce and equitable systems required to achieve UHC e it should at the very least include the targets that have been agreed under the current health sector MDGs, such as ‘universal access to reproductive health,’ (target 5.B) and ‘universal access to treatment for HIV/AIDS for all those who need it’ (target 6.B).15 The High-Level Taskforce on Innovative International Financing for Health Systems (Taskforce), launched in September 2008 to help strengthen health systems in 49 lowincome countries (in accordance with the World Bank classification at that time) completed its work in September 2009 and found that, in low-income countries, the annual costs of achieving the current health sector MDGs would be about US$50-55 per person per year.16 The 2010 World Health Report reported that ‘only eight of the 49 countries have any chance of financing the required level of services from domestic resources in 2015’, which WHO estimated to require, on average, $60 per person.4 Does this mean that these forty-nine low-income countries should then adopt ‘UHC light’, or ‘selective UHC’, i.e. a version of UHC that does not even cover what is needed for the current health sector MDGs? Such notions of resource scarcity should be challenged, particularly considering the ethical and legal obligations of international assistance.17 Indeed, in as much as UHC is a new iteration of the WHO’s Alma-Ata ‘health for all’ declaration, it should explicitly challenge the old
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 7 3 e1 7 8
paradigm, according to which domestic financial self-reliance prevailed over access to vital health services.18
The minimum domestic effort, from a human rights perspective International human rights law does not specify what the maximum of states’ available resources encompasses. How did the authors of the 2010 World Health Report reach the conclusion that only eight low-income countries ‘have any chance of’ financing the required level of services themselves e that even their maximum effort would be inadequate? They refer to a costing estimate that WHO prepared for the Taskforce.19 The WHO assumes that under an optimistic scenario, African lowincome countries ‘would increase the proportion of domestically generated general government expenditure allocated to health to 15% by 2015 in line with the Abuja declaration,’ while for other low-income countries, ‘it is projected that they would reach 12% by 2015.’ In the 2001 Abuja Declaration on HIV/AIDS, Tuberculosis, and Other Related Infectious Diseases, all member states of the Organization of Africa Unity e now the African Union e pledged ‘to set a target of 15% of [their] annual budget to the improvement of the health sector.’20 Do these estimates correspond with maximum available resources? Some countries do spend 15% of the government budget on health e high-income countries allocate, on average, 17.1% of the government budget to health.21 Middle-income countries, however, generally allocate a much lower proportion of government revenue to health care: between 10.5% (upper middle-income) and 5.5% (lower middle-income). Lowincome countries allocate 8.5% of the government budget to health, on average (9.6% average for all Sub-Saharan countries); this includes some e possibly considerable e level of external resources. Several low-income countries have (or have at times) achieved 15%, such as Rwanda and Zambia.21 For present purposes, the target of allocating 15% of domestically generated government expenditure to the health sector seems a reasonable approximation of the maximum e and thus required e level of the national budget to devote to the health sector, at least for low-income countries. The US$60 per person per year estimate includes both public and private health expenditure. To estimate the minimum level of public health expenditure, one can use WHO’s estimate that out-of-pocket expenditures should not exceed 15e20% of total health spending if the impoverishing effects of health spending are to be avoided.4 It then may be reasonable to estimate the minimum public expenditure to achieve UHC at approximately $50 per person per year in lowincome countries. Furthermore, one may have to add increasing government revenue to the equation. In African low-income countries, government revenue (excluding grants) increased from 15.1% of GDP in 2004 to 18.2% of GDP in 2011; thus it has been assumed that the government revenue will increase to 20% of GDP by 2015.22 But even under all these optimistic assumptions, there is a gap of at least $30 billion. If the international community is serious about UHC, this gap should be acknowledged, and high-income countries should fill it with international assistance.
175
International assistance, from a human rights perspective Is it realistic to expect that high-income countries will, collectively, cover the global UHC financing gap of at least $30 billion? Or must one should accept that in many low-income countries, the best UHC achievable will be below even current health sector MDG standards? One can make a case that covering the global UHC financing gap e whether it is $30 billion or more e is a matter of legal obligation, not of discretionary choice. The case is built on the concept of ‘core content’ of human rights e the minimum essential level for a right to remain meaningful e and corresponding ‘core obligations.’ General Comment 14 on the right to health e issued by the Committee on Economic, Social and Cultural Rights that is tasked with monitoring states’ compliance with the International Covenant on Economic, Social and Cultural Rights e confirms that a state ‘cannot, under any circumstances whatsoever, justify its non-compliance with the core obligations,’ and clarifies that the core obligations arising from the right to health include to ‘ensure the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalized groups,’ to ‘provide essential drugs, as from time to time defined under the WHO Action Programme on Essential Drugs,’ and other aspects that collectively look very much like UHC as described above.23 But how can UHC be a non-derogable obligation if, as discussed above, most low-income countries cannot fulfil it, even if they make a maximum effort? The implicit answer from the Committee lies in its statement that ‘that it is particularly incumbent on States parties and other actors in a position to assist, to provide ‘international assistance and cooperation, especially economic and technical’ which enable developing countries to fulfil their core and other obligations.’23 Several of the Committee’s general comments have explored the nature of extraterritorial obligations with regards to economic, social and cultural rights, as have the recent Maastricht Principles, which confirm the existence of obligations to provide international assistance, adding that ‘[s]tates should coordinate with each other, including in the allocation of responsibilities, in order to cooperate effectively in the universal fulfilment of economic, social and cultural rights.’24 Such coordination, like the maximum resources requirement, is not clearly defined in present international human rights law e not even included as an explicit command, though it is implicit in the obligation of ‘international assistance and cooperation’ (emphasis added). And that is one of the main reasons why people need an FCGH: to coordinate the allocation of responsibilities, in financing and elsewhere. In July 2012, the African Union adopted a Roadmap on Shared Responsibility and Global Solidarity for AIDS, TB and Malaria Response in Africa,25 which affirmed commitments made in the Abuja Declaration, and which also calls upon the international community to keep its prior commitments. The ‘developed’ countries promised, in 1970, to allocate the equivalent of 0.7% of their Gross Domestic Product (GDP) to international assistance.26 If high-income countries met this 0.7% commitment, and even 15% of their international
176
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 7 3 e1 7 8
assistance were allocated to the health sector e mirroring the 15% of domestic government revenue target e the $30 billion gap mentioned above could be covered. Such a sharing of responsibilities could be the beginning of a framework for financing UHC, a framework that an FCGH could expand upon.
A Framework Convention on Global Health and the role of WHO A FCGH could set standards throughout the dimensions of the right to health, including ensuring sufficient and sustained financing for a robust version of UHC, thus guiding government action and bolstering civil society advocacy. Developing and negotiating an FCGH will face challenges in setting these standards, such as state variation in how they fund health care domestically and internationally, burden sharing between states, and expenditure priorities, including among UHC, the underlying determinants of health (e.g., water, sanitation, nutrition, housing), and indeed, the broader social determinants of health. UHC-related costs and investments would be one of several areas in which an FCGH would set standards. Others would relate to inclusive processes to tailor global standards e including for UHC e to national priorities. The FCGH could also have standards related to equity, accountability (e.g., transparency and other elements of national health accountability strategies), participatory policy-making, protecting health in other legal spheres, and more. Countries could incorporate these standards into their own laws and policies and processes. What of the legal pathways to the FCGH itself, to realizing a treaty that effectively allocates responsibility for financing UHC, making it possible in even low-income countries, and does much more as well towards realizing the right to health for all people? While several avenues could be open, including the United Nations General Assembly, WHO must be counted as a leading possibility, following on the International Health Regulations, the Framework Convention on Tobacco Control and WHO powers under article 19 of its Constitution. The International Health Regulations are, essentially, a convention to share the collective burden of infectious disease control; the FCGH would push that logic of shared responsibility to a higher level. In the global health system, the WHO is, as Frenk and Moon argue, ‘the only actor in the global health system that is built on the universal membership of all recognized sovereign nation states,’27 and therefore the only element of it that has both the powers and the legitimacy to make international law. If WHO is to be a credible forum for a FCGH, however, at least three reforms are critical. First, states must greatly increase their untied contributions to WHO. Presently, threequarters of WHO’s budget is voluntary, with most of these funds earmarked,28 making WHO’s agenda driven more by the preferences of its funders than by the organization’s impartial assessment of appropriate priorities. As the People’s Health Movement argues: ‘A high proportion of voluntary contributions by member states undermines the organisation’s independence.’29 How can WHO be e and be perceived as being e impartial under such circumstances? If the high-income countries ‘no longer want to be taking on the full burden of
providing the financing to meet the MDGs’ and expect ‘[s] tronger commitments from.developing countries themselves,’30 they will need to make commitments that reinforce WHO’s independence. Note that ‘taking on the full burden’ is an exaggeration, as even in low-income countries external resources account for only 25.7% of total health expenditure.21 Even so, if high-income countries would like to have an impartial broker of arrangements for allocating health investments, they need to increase unearmarked funding for WHO. Second, with the centrality of the right to health to an FCGH, if WHO wants to be its broker and host, it must increase its work in human rights, equity, and gender. WHO continues to faces challenges in this respect.31 In mainstreaming this work, present reforms must significantly strengthen WHO capacity in these areas, with the legal and policy engagement at all levels to give life to these principles e including how to operationalize UHC from a right to health perspective. Third, to be at the center of the global health system requires ties with other elements of this network. Whereas younger elements of the global health system, like GAVI and the Global Fund to Fight AIDS, Tuberculosis and Malaria, established symbiotic links with civil society organizations,32 civil society typically finds itself sidelined at WHO.33 Reforms proposed to strengthen civil society’s role ought to be carefully considered.34e36 Though the challenges of accurately representing people’s views through select civil society organizations has been recognized, this would contribute to strengthening people’s rights, as part of the right to health, to participate ‘in all health-related decision-making at the community, national and international levels’23 e greater civil society involvement would help compensate for the democratic shortcomings of many states, and potentially strengthen the voice of Southern states, whose populations suffer most from health inequities but many of which have limited capacity in international forums compared to wealthier countries.3 WHO is the natural host and broker of an FCGH. Yet without reform, it may not be seen as the legitimate one.
Author statements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
1. Gostin LO, Friedman EA, Ooms G, Gebauer T, Gupta N, Sridhar D, Chenguang W, Røttingen J-A, Sanders D. The Joint
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 7 3 e1 7 8
2.
3.
4.
5.
6.
7. 8.
9. 10.
11.
12. 13.
14.
15.
16.
Action and Learning Initiative: towards a global agreement on national and global responsibilities for health. PLoS Medicine 2011;8(5):e1001031. Moon S, Bermudez J, ’t Hoen E. Innovation and access to medicines for neglected populations: could a treaty address a broken pharmaceutical R&D system? PLoS Medicine 2012;9(5):e1001218. Friedman EA, Gostin LO, Buse K. Advancing the right to health through global organizations: the potential role of a framework convention on global health. Health and Human Rights: An International Journal 2013;15(1). Available at: http:// www.hhrjournal.org/wp-content/uploads/sites/13/2013/06/ Friedman-FINAL.pdf (Website available approx June 15). World Health Organization. The world health report 2010. Health systems financing: the path to universal coverage. Geneva: World Health Organization. Available at: http://whqlibdoc.who.int/ whr/2010/9789241564021_eng.pdf (accessed 31 March 2013). Chan M. The place of health on the post-2015 development agenda. Opening remarks at an informal Member State consultation on health in the post-2015 development agenda. Available at: http:// www.who.int/dg/speeches/2012/mdgs_post2015/en/index. html; 14 December 2012 (accessed 31 March 2013). World Health Organization. Universal health coverage: five questions. Geneva: World Health Organization. Available at: http://www.who.int/health_financing/universal_health_ coverage_5_questions.pdf; 2012 (accessed 31 March 2013). Evans DB, Marten R, Etienne C. Universal health coverage is a development issue. Lancet 2012;380(9845):864e5. United Nations General Assembly. Global health and foreign policy. U.N. Doc. A/RES/67/81, General Assembly Res. 67/81. Available at:, http://www.un.org/ga/search/view_doc.asp? symbol¼A/67/L.36%26referer¼http://www.un.org/en/ga/info/ draft/index.shtml%26Lang¼E; Dec. 12, 2012 (accessed 31 March 2013). Horton R. Offline: a rainbow on my desolate land. Lancet 2013;381(9870):890. Ooms G, Brolan C, Eggermont N, Eide A, Flores W, Forman L, Friedman EA, Gebauer T, Gostin LO, Hill PS, Hussain S, McKee M, Mulumba M, Siddiqui F, Sridhar D, Van Leemput L, Waris A, Jahn A. Universal health coverage anchored in the right to health. Bulletin of the World Health Organization 2013;91. 2e2A. Boerma T. Measurement of trends and equity in coverage of health interventions in the context of universal health coverage. Meeting report. Bellagio: Rockefeller Foundation Center. Available at:, http://www.worldwewant2015.org/file/279371/download/ 302866; 2012 Sept 17e21 (accessed 31 March 2013). Vega J. Universal health coverage: the post-2015 development agenda. Lancet 2013;381(9862):179e80. World Health Organization. Positioning health in the post-2015 development agenda. WHO Discussion Paper. Available at:, http://www.worldwewant2015.org/bitcache/ 7c4f4f265f3d2dfdfed54c06afee939039865522?vid¼302852% 26disposition¼attachment%26op¼download; October 2012 (accessed 31 March 2013). International Covenant on Economic, Social and Cultural Rights. International Covenant on Economic, Social and Cultural Rights, G.A. res. 2200A(XXI), 21 U.N.GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966). Available at: http://www1.umn. edu/humanrts/instree/b2esc.htm (accessed 31 March 2013). United Nations. MDG list. Available at: http://mdgs.un.org/ unsd/mdg/Resources/Attach/Indicators/OfficialList2008.pdf (accessed 31 March 2013). Taskforce on Innovative International Financing for Health Systems. More money for health, and more health for the money. Available at: http://www.internationalhealthpartnership.net/ fileadmin/uploads/ihp/Documents/Results___Evidence/ HAE__results___lessons/Taskforce_report_EN.2009.pdf (accessed 31 March 2013).
177
17. Schrecker T. Interrogating scarcity: how to think about ‘resource-scarce settings’. Health Policy and Planning; August 16, 2012. Advance access published. 18. Ooms G. Shifting paradigms: how the fight for ‘universal access to AIDS treatment and prevention’ supports achieving ‘comprehensive primary health care for all’. Globalization and Health 2008;4:11. 19. World Health Organization. Background document for the Taskforce on Innovative International Financing for Health Systems. Working group 1: constraints to scaling up and costs. Available at: http://www.internationalhealthpartnership.net/fileadmin/ uploads/ihp/Documents/Results___Evidence/HAE__results___ lessons/Working%20Group%201%20Technical% 20Background%20Report%20(World%20Health% 20Organization).pdf (accessed 31 March 2013). 20. Organization of African Unity. Abuja declaration on HIV/AIDS, tuberculosis, and other related infectious diseases. Available at: http://www.un.org/ga/aids/pdf/abuja_declaration.pdf; 2001 (accessed 31 March 2013). 21. World Health Organization. World health statistics 2012. Geneva: World Health Organization. Available at: http://www. who.int/healthinfo/EN_WHS2012_Part3.pdf; 2012 (accessed 31 March 2013). 22. International Monetary Fund. Regional economic outlook. SubSaharan Africa: maintaining growth in an uncertain world. Available at: http://www.imf.org/external/pubs/ft/reo/2012/ afr/eng/sreo1012.pdf; October 2012 (accessed 31 March 2013). 23. Committee on Economic, Social and Cultural Rights. General comment 14, the right to the highest attainable standard of health (Twenty-second session, 2000). U.N. Doc. E/C.12/2000/4. Available from:, http://www1.umn.edu/humanrts/gencomm/ escgencom14.htm; 2000 (accessed 31 March 2013). 24. Maastricht principles on extraterritorial obligations of states in the area of economic, Social and cultural rights. Available at: http:// www.fian.org/fileadmin/media/publications/2012.02.29_-_ Maastricht_Principles_on_Extraterritorial_Obligations.pdf (accessed 31 March 2013). 25. African Union. Roadmap on shared responsibility and global solidarity for AIDS, TB and malaria response in Africa. Available at: http://www.au.int/en/sites/default/files/Shared_Res_ Roadmap_Rev_F%5b1%5d.pdf; 2012 (accessed 31 March 2013). 26. Fu¨rher H. The story of official development assistance. Paris: Organization for Economic Co-operation and Development. Available at: http://www.oecd.org/dac/1896816.pdf; 1996 (accessed 31 March 2013). 27. Frenk J, Moon S. Governance challenges in global health. New England Journal of Medicine 2013;368(10):936e42. 28. World Health Organization. Programme budget 2012e2013. Geneva: World Health Organization. Available at: http:// whqlibdoc.who.int/pb/2012-2013/PB_2012-2013_eng.pdf; 2011 (accessed 31 March 2013). 29. People’s Health Movement. Comments on ‘The future of financing for WHO’ 64th World Health Assembly (WHA). Available at: http://www.democratisingglobalhealth.org/ sites/www.democratisingglobalhealth.org/files/Future% 20Financing%20of%20the%20WHO%20-%20PHM%20May% 202011.pdf; May 2011 (accessed 31 March 2013). 30. Greenhill R, Prizzon A. WHO foots the bill after 2015? What new trends in development finance mean for the post-MDGs. ODI Working Paper 360. Available at:, http://www.odi.org.uk/sites/ odi.org.uk/files/odi-assets/publications-opinion-files/7905. pdf; 2012 (accessed 31 March 2013). 31. Mason Meier B. The World Health Organization, the evolution of human rights, and the failure to achieve health for all. In: Harrington J, Stuttaford M, editors. Global health and human rights. London: Routledge; 2010. 32. Hawkes N. “Irrelevant” WHO outpaced by younger rivals. BMJ 2011;343:d5012.
178
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 7 3 e1 7 8
33. Schwarz T. A stronger voice for civil society at the World Health Assembly?. Available at: http://www.medicusmundi.org/en/ contributions/reports/2010/a-stronger-voice-of-civil-societyat-the-world-health-assembly; 2010 (accessed 31 March 2013). 34. World Health Organization. WHO reforms for a healthy future: report by the Director-General. Doc. EBSS/2/2. Available at:, http://apps.who.int/gb/ebwha/pdf_files/EBSS/EBSS2_2-en. pdf; October 15, 2011 (accessed 31 March 2013).
35. Sridhar D, Gostin LO. Reforming the World Health Organization. Journal of the American Medical Association 2011;305(15):1585e6. 36. Democratizing Global Health Coalition. Letter by the democratizing global health coalition to the WHO Regional Director for Africa for the sixty-first session of the WHO Regional Committee for Africa. Available at: http://www.ghwatch.org/sites/www. ghwatch.org/files/DGHCoalition_Letter2AFRORegionalDirector. pdf; August 26, 2011 (accessed 31 March 2013).
