AJPH SPECIAL SECTION: WORLD HEALTH ORGANIZATION
performance metrics.” In a new world populated by a multiplicity of global public health actors, the new director-general will need to have inspiring leadership qualities, noted management abilities, and the strong communication and diplomatic skills necessary for negotiating among and between member countries and competing agencies and interests—a tall order, perhaps, for an individual who must also have extensive national and international public health experience, be committed to evidence-based performance, emphasize access for all people to quality health care, and embody the values of equity and social justice. Gilles Dussault (p1908) tries to explain the election of WHO’s director-general to a visitor from Mars who is expected to find the whole procedure rather peculiar. Dussault argues that the governance structure of WHO makes it almost impossible to achieve its
mission. When regional leaders are elected, they are accountable to those who support them rather than to a central authority. This fragmented structure of WHO makes the job of the director-general extremely difficult. Adding to the problem of attempting to coordinate the public health activities of regions and member states is the need to coordinate the work of other United Nations agencies as well as a proliferating number of stakeholders—development banks, foundations, multinational corporations, and nongovernmental organizations—all seeking to address and influence the health status and public health programs of the world’s population. Dussault also emphasizes the need to help countries establish effective and sustainable health systems and strengthen the health workforce. He urges regional offices to develop their technical capacity and sound management practices.
BACK TO THE ROOTS Suwit Wibulpolprasert and Mushtaque Chowdhury (p1910) ask the dramatic question: should WHO be overhauled or dismantled? They outline many of the most notable successes and failures of WHO— as seen especially from the country perspectives of Thailand and Bangladesh—and again raise the problem of WHO’s financial dependency on outside donors. A new director-general, they assert, must demand more country contributions and ensure exemplary financial management. Furthermore, they suggest abolishing regional offices to save money and claim this would result in no loss of efficiency. By eliminating one layer of bureaucracy, member countries could thus interact directly with the Geneva headquarters. The regional structure of WHO has been a significant source of debate from the organization’s beginning in 1948 and is the subject of a historical
World Health Organization Reform— A Normative or an Operational Organization? In a rapidly changing world, it is not unusual for a major institution to review its mission, whether its organizational structures are appropriate for its purpose, and how it works with major players to advance areas of mutual interest. Since the mid-1990s, the World Health Organization (WHO) has had reform agendas, yet rarely have these yielded the anticipated outcomes. The process of selecting a new WHO directorgeneral has started. I summarize past reform efforts to highlight
1904
Editorial
Yach
how intractable obstacles beset change and propose recommendations on the extent to which WHO functions as a normative or an operational institution, questions that should be addressed by future directorgeneral candidates. Three key WHO reform initiatives were initiated by directors-general over the last two decades. Hiroshi Nakajima (Director-General 1988–1998) was elected after Halfdan Mahler (Director-General 1973–1988) to spearhead substantial revisions
to WHO’s Constitution. He came under pressure from governments to respond to the Ebola and infectious disease outbreaks and the sentiment that WHO was not engaging with
analysis by Fee et al. (p1912). They trace the changing political context of WHO, especially during the early years of the Cold War, when the organization’s basic structure was established, and later, the transformation of the European colonies into independent nations. It may well be time to revisit this form of organization, in addition to the issues of finance and management that the several editorials have so vividly presented. Elizabeth Fee, PhD REFERENCES 1. World Health Organization. News release: process to elect next directorgeneral of WHO begins. Available at: http://www.who.int/mediacentre/ news/releases/2016/election-process/en. Accessed August 30, 2016. 2. Intellectual Property Watch. New rules eyed for election of WHO director general. Available at: http://www.ip-watch. org/2011/01/18/new-rules-eyed-forelection-of-who-director-general. Accessed August 30, 2016. 3. Susser M. Editor’s note: a new director for WHO. Am J Public Health. 1998; 88(5):727.
new initiatives to address global research, HIV/AIDS, and vaccines.1 Gro Harlem Brundtland (Director-General 1998–2003) was elected to “make a difference” in measurable outcomes and undertook substantive restructuring of key programs since WHO’s establishment in 1946. Brundtland focused on reducing the influence of governments in WHO’s work and expanding public–private partnerships.2 Margaret Chan
ABOUT THE AUTHOR Derek Yach is with The Vitality Group, New York, NY (part of Discovery Holdings, South Africa). Correspondence should be sent to Derek Yach, MBChB, MPH, Chief Health Officer, The Vitality Group, 3 Columbus Cir, New York, NY 10019 (e-mail: dyach@thevitalitygroup. com). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted July 6, 2016. Note. Derek Yach is a full-time employee of Vitality/Discovery (a business that promotes healthy lifestyles); has been a full-time employee of PepsiCo; and has provided paid consultancy or advisory services to Mars, PepsiCo, Astra Zeneca, Novo Nordisk, AB Inbev, and Tesco. He is the chairman of the World Economic Forum Global Agenda Council on Ageing. doi: 10.2105/AJPH.2016.303376
AJPH
November 2016, Vol 106, No. 11
AJPH SPECIAL SECTION: WORLD HEALTH ORGANIZATION
(Director-General 2007–2017) was elected after Lee Jongwook’s (Director-General 2003–2006) premature death while in office and responded to the WHO’s inability to address global pandemics. Nakajima, Brundtland, and Chan failed to tackle the reforms needed to ensure that WHO can direct and lead health programs within the United Nations (UN) system. Since WHO’s establishment, there have been debates about its core mission and objectives.3 Governments have called for trimming the list of objectives in WHO’s Constitution.4 Disagreement continues about whether WHO is a normative organization that develops global norms and standards (e.g., international health regulations, the WHO Framework Convention on Tobacco Control, the essential drug list, growth standards for children, and the International Classification of Diseases), leads and coordinates global health research, and acts as a powerful voice for health in development debates; an operational organization that eradicates diseases, controls pandemics, tackles humanitarian crises, and supports health systems development in the least developed countries; or some combination of the two. To date, success has been related mainly to the development of norms and standards, selected advocacy for neglected issues, mental health, and smallpox eradication. Other agencies within the UN, scientific community, and nongovernmental organizational world lead global health research, trade, health systems development, humanitarian support, and aspects of infectious disease control. That should allow WHO to focus on its comparative advantage, success records, and established relationships.
November 2016, Vol 106, No. 11
AJPH
Critiques of Nakajima and Chan have been harsh and blunt. Concern about their ability to provide leadership during infectious disease crises has led the UN, national bodies, and global foundations to establish governance structures that engage WHO, although not as the lead agency. WHO’s inability to target the major risk factors that underlie the global burden of disease rarely receives criticism, despite the consequences for global health. Brundtland’s reforms were positively received and led to new investments in global health. Multistakeholder partnerships were funded with substantive budgets, including The Global Fund to Fight AIDS, Tuberculosis and Malaria; the Global Alliance for Vaccines and Immunizations; and the Global Alliance for Improved Nutrition. These partnerships addressed issues in ways WHO acting alone could not. Areas that had been neglected since WHO’s establishment, including noncommunicable diseases, injury control, and tobacco, received visibility and modest increases in funding. For the first time, estimates of the burden of disease and risk were used in decision-making. After Mahler’s leadership, which led to the Alma-Ata Declaration of 1978 and the launch of primary health care, Nakajima lost ground for WHO in its global effect and influence. Brundtland is credited with placing WHO and global health at the highest level of the development agenda. Chan was criticized for letting that slip when the UN, the World Economic Forum, and new players embraced health in development. The latest reforms agreed to during the May 2016 World Health Assembly may
restore her image but only if they lead to progress. All three WHO reform efforts by Director-Generals Nakajima, Brundtland, and Chan suffered from realities embedded in the structure of WHO’s Constitution. These constitutional structures must be changed by a new director-general if future reform is to endure. First, commentators have had concern that WHO’s regional arrangements would undermine progress since 1946. These have not been seriously revisited since 1946, and any director-general is left with weak leverage to build one strong, coherent organization. The logic of a regional director with dual allegiance to WHO’s director-general and his or her regional countries, combined with a regional office and a physical location, is crying out for review and modification. Current regional arrangements waste resources, encourage political indecisiveness, and impede pandemic control. A future director-general must embrace these to address current and future needs. This involves embracing the power of innovative technologies capable of bridging distance, language, and time to implement twentyfirst century organizational and management capabilities. Second, WHO’s interactions with nonstate partners (a term that is unacceptably derogatory by using a blanket label that fails to acknowledge heterogeneity among partners) demand reform beyond the 2016 WHO Framework of Engagement With Non-State Actors (FENSA) resolution. Although Brundtland opened communications with companies and nongovernmental organizations to tap their knowledge, Chan has warned about these engagements in statements that are hostile to the industry.5
FENSA suggests that progress may happen but needs a directorgeneral who adapts his or her tone and outreach to the spirit of the resolution. FENSA is written primarily to limit conflicts with nonstate actor interactions as opposed to the language of the Addis Ababa, Ethiopia, Third International Conference on Financing for Development; the UN Sustainable Development Goals; and the mission of the UN Global Compact.6 These documents have a vision that development goals can be addressed when players join forces. Climate change, political instability and associated humanitarian crises, and the threat of infections will challenge global health systems. Crises undermine long-term norms, but it is the latter that underpin science-based progress and is where WHO is uniquely placed to lead. This decision is long overdue but may be undermined by the World Health Assembly’s decision to establish the Health Emergencies Programme with explicit operational responsibilities.7 That may draw resources into permanent firefighting at the cost of deliberative norm-setting functions. A future directorgeneral must consider how to enhance WHO’s normative and advocacy roles without being pulled into every health crisis. A future director-general needs to lead discussions on WHO’s role in a world that is so different from 1946. Global health has become the business of many nongovernmental organizations, private foundations, corporations, and academic groups; the World Bank; and other UN bodies. This can be beneficial for global health if role clarification were to emerge and if WHO’s central role as the global health conductor of an emerging health orchestra were
Yach
Editorial
1905
AJPH SPECIAL SECTION: WORLD HEALTH ORGANIZATION
to be reinstated. That requires individual leadership by those who can work with diverse players. It also takes a directorgeneral who will lead governments to tackle norms, standards, and advocacy and, in doing so, spin off operational functions to other organizations within the UN and nongovernmental organizational world that are better qualified to execute them. Derek Yach, MBChB, MPH
REFERENCES 1. Social Science Research Council and Harvard School of Public Health. Pocantico retreat: enhancing the performance of international health institutions. Paper presented at: Rockefeller Foundation’s Pocantico Retreat; February 1–3, 1996; New York, NY. 2. World Health Organization. Executive Board, 102nd Session: Resolutions and Decisions, Summary Records. May 18–19, 1998; Geneva, Switzerland. Available at: http://apps. who.int/iris/bitstream/10665/ 152382/1/WHO_EB_102_1998_ REC1_eng.pdf. Accessed August 14, 2016.
3. World Health Organization. Constitution of the World Health Organization. In: Basic Documents. 45th ed. October 2006. Available at: http://www.who.int/ governance/eb/who_constitution_en. pdf. Accessed May 24, 2016. 4. Gear JH. South Africa and the World Health Organization. S Afr Med J. 1991; 79(1):1. 5. Chan M. WHO director-general addresses Inter-Parliamentary Union Assembly. World Health Organization. 2015. Available at: http://www.who.int/ dg/speeches/2015/inter-parliamentaryunion/en. Accessed May 24, 2016.
1906
Editorial
Frenk
of its quintessential roles: the deployment of instruments for controlling the international transfer of risks and ensuring a timely response to threats that spread across borders.2 Epidemiological crises have brought into focus the pressing need to improve the way in which the agency handles global health emergencies. At the same time, it has become increasingly clear that there is a broader reform agenda that WHO must pursue if it wants to remain relevant in an increasingly complex, diversified, and interconnected world. The most important strategic imperative faced by the next director-general of WHO will be to reorganize the agency by functions. The global health system performs four essential functions: 1. Production of global public goods, such as research and development, standards and guidelines, and comparative evidence and analyses;
7. World Health Assembly agrees new Health Emergencies Programme [news release]. Geneva, Switzerland: World Health Organization. May 25, 2016. Available at: http://www.who.int/ mediacentre/news/releases/2016/ wha69-25-may-2016/en. Accessed May 31, 2016.
6. United Nations Global Compact Web site. Available
Finance and Governance: Critical Challenges for the Next WHO Director-General The 70th anniversary of the World Health Organization (WHO) is drawing near and so is the election of its next director-general, which will take place at a critical juncture. The 2008 global crisis uncovered the financial vulnerability of the agency, a product of the adoption in 1993 of a zero nominal growth policy, whereby the assessed contributions of member states have been frozen in absolute terms, failing to compensate even for the effects of inflation.1 In addition, several countries regularly fall into arrears, even at such a modest level of contributions. Budgetary constraints are further aggravated by structural inefficiencies. As a result, the WHO budget has become dependent on voluntary donations, and its operational capacities are undermined. The dangerous consequences of this perfect storm became evident during the 2014 Ebola outbreaks, which exhibited WHO’s inability to perform in an effective way what has always been considered one
at: https://www.unglobalcompact.org. Accessed May 24, 2016.
2. Management of externalities across borders (such as drug resistance, pandemics, and environmental pollutants) through surveillance systems and coordination for preparedness and response; 3. Mobilization of global solidarity through development financing, technical cooperation, and humanitarian assistance; and 4. Stewardship, which includes convening for negotiation and consensus building, priority setting, rule setting, evaluation for mutual accountability, and cross-sector health advocacy.3 Until now, the mix of functions has been unbalanced, since mobilization of global solidarity (specifically, technical
cooperation) has been the predominant focus of WHO at the expense of the three other functions. Yet it is precisely those neglected functions that should be strengthened if WHO is to address its most critical challenges. There is a growing perception among global health actors that finance and governance issues have limited WHO’s effectiveness and legitimacy. In terms of finance, the main restriction has been the erosion of the agency’s budget through the zero nominal growth policy adopted more than two decades ago, along with unpaid contributions by several member states and reluctance by most emerging economies to step up their contributions in line with their growing wealth and influence. The shortfall has been met through voluntary contributions provided mostly by a few member states and by nonstate actors such as global foundations, development banks, and multinational corporations. As long as
ABOUT THE AUTHOR Julio Frenk is the president of the University of Miami, Miami, FL. Correspondence should be sent to Julio Frenk, President, University of Miami, 230 Ashe Bldg, PO Box 248006, Coral Gables, FL 33124-4600 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted July 15, 2016. doi: 10.2105/AJPH.2016.303399
AJPH
November 2016, Vol 106, No. 11
performance metrics.” In a new world populated by a multiplicity of global public health actors, the new director-general will need to have inspiring leadership qualities, noted management abilities, and the strong communication and diplomatic skills necessary for negotiating among and between member countries and competing agencies and interests—a tall order, perhaps, for an individual who must also have extensive national and international public health experience, be committed to evidence-based performance, emphasize access for all people to quality health care, and embody the values of equity and social justice. Gilles Dussault (p1908) tries to explain the election of WHO’s director-general to a visitor from Mars who is expected to find the whole procedure rather peculiar. Dussault argues that the governance structure of WHO makes it almost impossible to achieve its
mission. When regional leaders are elected, they are accountable to those who support them rather than to a central authority. This fragmented structure of WHO makes the job of the director-general extremely difficult. Adding to the problem of attempting to coordinate the public health activities of regions and member states is the need to coordinate the work of other United Nations agencies as well as a proliferating number of stakeholders—development banks, foundations, multinational corporations, and nongovernmental organizations—all seeking to address and influence the health status and public health programs of the world’s population. Dussault also emphasizes the need to help countries establish effective and sustainable health systems and strengthen the health workforce. He urges regional offices to develop their technical capacity and sound management practices.
BACK TO THE ROOTS Suwit Wibulpolprasert and Mushtaque Chowdhury (p1910) ask the dramatic question: should WHO be overhauled or dismantled? They outline many of the most notable successes and failures of WHO— as seen especially from the country perspectives of Thailand and Bangladesh—and again raise the problem of WHO’s financial dependency on outside donors. A new director-general, they assert, must demand more country contributions and ensure exemplary financial management. Furthermore, they suggest abolishing regional offices to save money and claim this would result in no loss of efficiency. By eliminating one layer of bureaucracy, member countries could thus interact directly with the Geneva headquarters. The regional structure of WHO has been a significant source of debate from the organization’s beginning in 1948 and is the subject of a historical
World Health Organization Reform— A Normative or an Operational Organization? In a rapidly changing world, it is not unusual for a major institution to review its mission, whether its organizational structures are appropriate for its purpose, and how it works with major players to advance areas of mutual interest. Since the mid-1990s, the World Health Organization (WHO) has had reform agendas, yet rarely have these yielded the anticipated outcomes. The process of selecting a new WHO directorgeneral has started. I summarize past reform efforts to highlight
1904
Editorial
Yach
how intractable obstacles beset change and propose recommendations on the extent to which WHO functions as a normative or an operational institution, questions that should be addressed by future directorgeneral candidates. Three key WHO reform initiatives were initiated by directors-general over the last two decades. Hiroshi Nakajima (Director-General 1988–1998) was elected after Halfdan Mahler (Director-General 1973–1988) to spearhead substantial revisions
to WHO’s Constitution. He came under pressure from governments to respond to the Ebola and infectious disease outbreaks and the sentiment that WHO was not engaging with
analysis by Fee et al. (p1912). They trace the changing political context of WHO, especially during the early years of the Cold War, when the organization’s basic structure was established, and later, the transformation of the European colonies into independent nations. It may well be time to revisit this form of organization, in addition to the issues of finance and management that the several editorials have so vividly presented. Elizabeth Fee, PhD REFERENCES 1. World Health Organization. News release: process to elect next directorgeneral of WHO begins. Available at: http://www.who.int/mediacentre/ news/releases/2016/election-process/en. Accessed August 30, 2016. 2. Intellectual Property Watch. New rules eyed for election of WHO director general. Available at: http://www.ip-watch. org/2011/01/18/new-rules-eyed-forelection-of-who-director-general. Accessed August 30, 2016. 3. Susser M. Editor’s note: a new director for WHO. Am J Public Health. 1998; 88(5):727.
new initiatives to address global research, HIV/AIDS, and vaccines.1 Gro Harlem Brundtland (Director-General 1998–2003) was elected to “make a difference” in measurable outcomes and undertook substantive restructuring of key programs since WHO’s establishment in 1946. Brundtland focused on reducing the influence of governments in WHO’s work and expanding public–private partnerships.2 Margaret Chan
ABOUT THE AUTHOR Derek Yach is with The Vitality Group, New York, NY (part of Discovery Holdings, South Africa). Correspondence should be sent to Derek Yach, MBChB, MPH, Chief Health Officer, The Vitality Group, 3 Columbus Cir, New York, NY 10019 (e-mail: dyach@thevitalitygroup. com). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted July 6, 2016. Note. Derek Yach is a full-time employee of Vitality/Discovery (a business that promotes healthy lifestyles); has been a full-time employee of PepsiCo; and has provided paid consultancy or advisory services to Mars, PepsiCo, Astra Zeneca, Novo Nordisk, AB Inbev, and Tesco. He is the chairman of the World Economic Forum Global Agenda Council on Ageing. doi: 10.2105/AJPH.2016.303376
AJPH
November 2016, Vol 106, No. 11
AJPH SPECIAL SECTION: WORLD HEALTH ORGANIZATION
(Director-General 2007–2017) was elected after Lee Jongwook’s (Director-General 2003–2006) premature death while in office and responded to the WHO’s inability to address global pandemics. Nakajima, Brundtland, and Chan failed to tackle the reforms needed to ensure that WHO can direct and lead health programs within the United Nations (UN) system. Since WHO’s establishment, there have been debates about its core mission and objectives.3 Governments have called for trimming the list of objectives in WHO’s Constitution.4 Disagreement continues about whether WHO is a normative organization that develops global norms and standards (e.g., international health regulations, the WHO Framework Convention on Tobacco Control, the essential drug list, growth standards for children, and the International Classification of Diseases), leads and coordinates global health research, and acts as a powerful voice for health in development debates; an operational organization that eradicates diseases, controls pandemics, tackles humanitarian crises, and supports health systems development in the least developed countries; or some combination of the two. To date, success has been related mainly to the development of norms and standards, selected advocacy for neglected issues, mental health, and smallpox eradication. Other agencies within the UN, scientific community, and nongovernmental organizational world lead global health research, trade, health systems development, humanitarian support, and aspects of infectious disease control. That should allow WHO to focus on its comparative advantage, success records, and established relationships.
November 2016, Vol 106, No. 11
AJPH
Critiques of Nakajima and Chan have been harsh and blunt. Concern about their ability to provide leadership during infectious disease crises has led the UN, national bodies, and global foundations to establish governance structures that engage WHO, although not as the lead agency. WHO’s inability to target the major risk factors that underlie the global burden of disease rarely receives criticism, despite the consequences for global health. Brundtland’s reforms were positively received and led to new investments in global health. Multistakeholder partnerships were funded with substantive budgets, including The Global Fund to Fight AIDS, Tuberculosis and Malaria; the Global Alliance for Vaccines and Immunizations; and the Global Alliance for Improved Nutrition. These partnerships addressed issues in ways WHO acting alone could not. Areas that had been neglected since WHO’s establishment, including noncommunicable diseases, injury control, and tobacco, received visibility and modest increases in funding. For the first time, estimates of the burden of disease and risk were used in decision-making. After Mahler’s leadership, which led to the Alma-Ata Declaration of 1978 and the launch of primary health care, Nakajima lost ground for WHO in its global effect and influence. Brundtland is credited with placing WHO and global health at the highest level of the development agenda. Chan was criticized for letting that slip when the UN, the World Economic Forum, and new players embraced health in development. The latest reforms agreed to during the May 2016 World Health Assembly may
restore her image but only if they lead to progress. All three WHO reform efforts by Director-Generals Nakajima, Brundtland, and Chan suffered from realities embedded in the structure of WHO’s Constitution. These constitutional structures must be changed by a new director-general if future reform is to endure. First, commentators have had concern that WHO’s regional arrangements would undermine progress since 1946. These have not been seriously revisited since 1946, and any director-general is left with weak leverage to build one strong, coherent organization. The logic of a regional director with dual allegiance to WHO’s director-general and his or her regional countries, combined with a regional office and a physical location, is crying out for review and modification. Current regional arrangements waste resources, encourage political indecisiveness, and impede pandemic control. A future director-general must embrace these to address current and future needs. This involves embracing the power of innovative technologies capable of bridging distance, language, and time to implement twentyfirst century organizational and management capabilities. Second, WHO’s interactions with nonstate partners (a term that is unacceptably derogatory by using a blanket label that fails to acknowledge heterogeneity among partners) demand reform beyond the 2016 WHO Framework of Engagement With Non-State Actors (FENSA) resolution. Although Brundtland opened communications with companies and nongovernmental organizations to tap their knowledge, Chan has warned about these engagements in statements that are hostile to the industry.5
FENSA suggests that progress may happen but needs a directorgeneral who adapts his or her tone and outreach to the spirit of the resolution. FENSA is written primarily to limit conflicts with nonstate actor interactions as opposed to the language of the Addis Ababa, Ethiopia, Third International Conference on Financing for Development; the UN Sustainable Development Goals; and the mission of the UN Global Compact.6 These documents have a vision that development goals can be addressed when players join forces. Climate change, political instability and associated humanitarian crises, and the threat of infections will challenge global health systems. Crises undermine long-term norms, but it is the latter that underpin science-based progress and is where WHO is uniquely placed to lead. This decision is long overdue but may be undermined by the World Health Assembly’s decision to establish the Health Emergencies Programme with explicit operational responsibilities.7 That may draw resources into permanent firefighting at the cost of deliberative norm-setting functions. A future directorgeneral must consider how to enhance WHO’s normative and advocacy roles without being pulled into every health crisis. A future director-general needs to lead discussions on WHO’s role in a world that is so different from 1946. Global health has become the business of many nongovernmental organizations, private foundations, corporations, and academic groups; the World Bank; and other UN bodies. This can be beneficial for global health if role clarification were to emerge and if WHO’s central role as the global health conductor of an emerging health orchestra were
Yach
Editorial
1905
AJPH SPECIAL SECTION: WORLD HEALTH ORGANIZATION
to be reinstated. That requires individual leadership by those who can work with diverse players. It also takes a directorgeneral who will lead governments to tackle norms, standards, and advocacy and, in doing so, spin off operational functions to other organizations within the UN and nongovernmental organizational world that are better qualified to execute them. Derek Yach, MBChB, MPH
REFERENCES 1. Social Science Research Council and Harvard School of Public Health. Pocantico retreat: enhancing the performance of international health institutions. Paper presented at: Rockefeller Foundation’s Pocantico Retreat; February 1–3, 1996; New York, NY. 2. World Health Organization. Executive Board, 102nd Session: Resolutions and Decisions, Summary Records. May 18–19, 1998; Geneva, Switzerland. Available at: http://apps. who.int/iris/bitstream/10665/ 152382/1/WHO_EB_102_1998_ REC1_eng.pdf. Accessed August 14, 2016.
3. World Health Organization. Constitution of the World Health Organization. In: Basic Documents. 45th ed. October 2006. Available at: http://www.who.int/ governance/eb/who_constitution_en. pdf. Accessed May 24, 2016. 4. Gear JH. South Africa and the World Health Organization. S Afr Med J. 1991; 79(1):1. 5. Chan M. WHO director-general addresses Inter-Parliamentary Union Assembly. World Health Organization. 2015. Available at: http://www.who.int/ dg/speeches/2015/inter-parliamentaryunion/en. Accessed May 24, 2016.
1906
Editorial
Frenk
of its quintessential roles: the deployment of instruments for controlling the international transfer of risks and ensuring a timely response to threats that spread across borders.2 Epidemiological crises have brought into focus the pressing need to improve the way in which the agency handles global health emergencies. At the same time, it has become increasingly clear that there is a broader reform agenda that WHO must pursue if it wants to remain relevant in an increasingly complex, diversified, and interconnected world. The most important strategic imperative faced by the next director-general of WHO will be to reorganize the agency by functions. The global health system performs four essential functions: 1. Production of global public goods, such as research and development, standards and guidelines, and comparative evidence and analyses;
7. World Health Assembly agrees new Health Emergencies Programme [news release]. Geneva, Switzerland: World Health Organization. May 25, 2016. Available at: http://www.who.int/ mediacentre/news/releases/2016/ wha69-25-may-2016/en. Accessed May 31, 2016.
6. United Nations Global Compact Web site. Available
Finance and Governance: Critical Challenges for the Next WHO Director-General The 70th anniversary of the World Health Organization (WHO) is drawing near and so is the election of its next director-general, which will take place at a critical juncture. The 2008 global crisis uncovered the financial vulnerability of the agency, a product of the adoption in 1993 of a zero nominal growth policy, whereby the assessed contributions of member states have been frozen in absolute terms, failing to compensate even for the effects of inflation.1 In addition, several countries regularly fall into arrears, even at such a modest level of contributions. Budgetary constraints are further aggravated by structural inefficiencies. As a result, the WHO budget has become dependent on voluntary donations, and its operational capacities are undermined. The dangerous consequences of this perfect storm became evident during the 2014 Ebola outbreaks, which exhibited WHO’s inability to perform in an effective way what has always been considered one
at: https://www.unglobalcompact.org. Accessed May 24, 2016.
2. Management of externalities across borders (such as drug resistance, pandemics, and environmental pollutants) through surveillance systems and coordination for preparedness and response; 3. Mobilization of global solidarity through development financing, technical cooperation, and humanitarian assistance; and 4. Stewardship, which includes convening for negotiation and consensus building, priority setting, rule setting, evaluation for mutual accountability, and cross-sector health advocacy.3 Until now, the mix of functions has been unbalanced, since mobilization of global solidarity (specifically, technical
cooperation) has been the predominant focus of WHO at the expense of the three other functions. Yet it is precisely those neglected functions that should be strengthened if WHO is to address its most critical challenges. There is a growing perception among global health actors that finance and governance issues have limited WHO’s effectiveness and legitimacy. In terms of finance, the main restriction has been the erosion of the agency’s budget through the zero nominal growth policy adopted more than two decades ago, along with unpaid contributions by several member states and reluctance by most emerging economies to step up their contributions in line with their growing wealth and influence. The shortfall has been met through voluntary contributions provided mostly by a few member states and by nonstate actors such as global foundations, development banks, and multinational corporations. As long as
ABOUT THE AUTHOR Julio Frenk is the president of the University of Miami, Miami, FL. Correspondence should be sent to Julio Frenk, President, University of Miami, 230 Ashe Bldg, PO Box 248006, Coral Gables, FL 33124-4600 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted July 15, 2016. doi: 10.2105/AJPH.2016.303399
AJPH
November 2016, Vol 106, No. 11
