Whither the World Health Organization?

These are worrying times for the World Health Organization (WHO). The unexpected announcement in August this year by Gro Harlem Brundtland, WHO's Director-General, of her intention not to stand for re-election has resulted in considerable uncertainty within the organisation. It has also sparked intense lobbying for her position by, or on behalf of, nine aspirants. The Executive Board of WHO will make a recommendation on Brundtland's replacement in January 2003 for endorsement by the World Health Assembly in May 2003 (see Box 1).

During her four years in office, Brundtland successfully put the issue of health, especially health for the poor, back into the international arena. She focused the efforts of WHO into four areas — building health communities; combating communicable and non-communicable diseases; promoting more transparent, equitable and accountable health systems; and improving relationships of WHO with other organisations.1

Despite these achievements, the incoming Director-General will head a WHO weakened by two decades of zero growth in core budgets, diminished influence over the deployment of new sources of funding, and with ongoing challenges to its constitutional mandate. How he or she responds to the relationship of WHO with the private and non-government organisation sectors, and the promotion of the organisation's breadth of mandate, will determine his or her success. Some of the problems faced by the new Director-General can be addressed from within WHO; others reflect broader issues of globalisation and the role of organisations such as the World Trade Organization, the World Bank and the International Monetary Fund. There are different perceptions of what is the right path for WHO to take.

The past 50 years have witnessed significant improvement in life expectancy. In 1955, global average life expectancy at birth was just 48 years; in 1995, it was 65 years and it is estimated to increase to 73 years by 2025.2 For these advances, WHO can claim success as a global participant in promoting better health.

However, these positive trends mask the inequalities between countries. More than 50 million people live in countries where life expectancy is less than 45 years. Indeed, 300 million live in 16 countries where life expectancies over the past 25 years have declined.2 Many of these countries are in Africa, where the impact of HIV/AIDS has been most severe.

Since the HIV/AIDS epidemic began two decades ago, more than 60 million people have been infected with HIV, and up to 2001 an estimated three million had died.3 Over the next 20 years, an estimated 68 million people will die prematurely as a result of AIDS in the 45 most affected countries. For example, in Botswana (which has the highest adult prevalence of HIV/AIDS in the world: 39%), life expectancy at birth has dropped below 40 years — a level not seen in that country since before 1950.3

Variations in health status are reflected in variations in economic status. The economic gap between the richest and the poorest nations widened between 1961 and 1997, from 12-fold to an astonishing 30-fold difference, and even more so between 1994 and 2000 as differences in life expectancy and infant mortality also further widened.4 These problems can hardly be sheeted home to WHO; nevertheless, they create a climate in which the pursuit of its goals (Box 2) has been made harder.

Critics argue that WHO has been imbued by an ever-increasing focus on disease eradication to the detriment of health promotion, environmental health, standards setting and country capacity-building. This focus on individual diseases has promoted "vertical silos" in health program responses, and is antithetical to health system responses.

WHO budgeting has reflected this trend. The regular budget funding that WHO has received from countries has had zero real growth since the early 1980s. On the other hand, there has been an increase in extra-budgetary funds received from countries, other United Nations organisations, and private donors. These funds, which now make up 62% of WHO's total funding, tend to be earmarked for specific programs — usually disease-specific programs.

The large influx of philanthropic funding to groups outside WHO has also tended to be disease-specific. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), funded by the Bill and Melinda Gates Foundation, is one example. The Fund claims it will "address the three diseases in ways that will contribute to health systems",6 but concern remains that "it has the potential to weaken fragile health systems, by diverting resources and staff from other activities".7 The extent to which GFATM and other philanthropic foundations recognise that appropriate infrastructure, trained, motivated and suitably remunerated health personnel and adequate supplies of basic drugs are necessary prerequisites to fight diseases will be critical.

A recent report on WHO by the United Kingdom Department for International Development (DFID), which provides the third-largest extra-budgetary funding to WHO, also defines WHO's mandate narrowly.8 The report repeatedly emphasises the need for WHO to focus on the achievement of the Millennium Development Goals: specific goals adopted by the General Assembly of the United Nations in September 2000 to address poverty and hunger, education, gender inequities, health and environmental sustainability. The health goals focus on HIV/AIDS, tuberculosis and malaria. Richard Horton, Editor of The Lancet, has argued that "DFID excludes discussion of maternal and child health, nutrition and food safety, non-communicable disease (mental health, violence, injuries, and the impact of tobacco), and many other important infections. Above all, while making much (rightly) of WHO's sometimes poor work within countries, DFID ignores the agency's global role in building health programmes and health systems, and in setting norms and standards".9

In her first speech after her 1998 election, Dr Brundtland argued for "open and constructive relations with the private sector".10 At that time, her speech caused some uneasiness both with major non-government organisations and within WHO.

Although partnerships between UN agencies and the private sector existed before her appointment, more recently public–private partnerships (PPPs) have become the method of choice to address a large component of international public health efforts. This has occasioned a reassessment of the strengths and limitations of public/governmental, private/commercial, and civil society institutions in grappling with world problems.11 There is considerable debate between the proponents of such partnerships and opponents who worry deeply about the negative consequences.

These partnerships commonly involve at least one private for-profit organisation and one public organisation with shared objectives; the partners share the risks and benefits.12 Major pharmaceutical companies such as Merck, Pfizer, Roche and Bristol Myers-Squibb are involved, as are many US private foundations — not a surprise, considering that the combined annual income of the world's three richest people (Bill Gates, Warren Buffet and Paul Allen) is greater than the combined GNP of the 43 poorest nations.13

Coupled with the growth of influence of these transnational companies has been the expectation that they demonstrate not just philanthropy, but good corporate citizenship and corporate responsibility. Kent Buse, of the Division of International Health, Department of Epidemiology and Public Health at Yale University of Medicine, and Gill Walt, of the Health Policy Unit, Department of Public Health and Policy at the London School of Hygiene and Tropical Medicine, concluded that the growth in PPPs ". . . is in part due to the fact that the commercial sector has been increasingly challenged to show greater social responsibility, to invest in the well being of populations, to adhere to global labour and environmental standards, and to invest in research and development that benefits the poorest".14

The role of countries' development aid agencies in strengthening the capacity of WHO is critical. The current Director-General has sponsored work to define more clearly the relationship between economic development and health development, in particular through establishing the Commission on Macroeconomics and Health. The Commission's report, issued in 2001, makes a strong case for health development as an essential and early element in comprehensive strategies designed to achieve economic uplift in the poorer five-sixths of the world's nations. The report was cognizant of the need for local political commitment and effective governance as a prerequisite for gains in health. The Commission estimated that expanding coverage for a small number of effective interventions targeted at conditions that contribute significantly to the burden of disease across the world would cost US$14 per person per year in low-income countries and US$22 per person in the least-developed countries.4

Expansion of access to these interventions, including treatment of tuberculosis, treatment and prevention of malaria and HIV, immunisation, and antenatal care, would contribute to "a decisive drop, a major reduction in avoidable deaths", and in turn have significant economic and development benefits for these countries. The Commission concluded that, while the lowest-income countries needed to increase local resources for these programs, there was a need for an increase in donor contributions from the wealthiest nations. The Commission estimated that additional investments in health by donor countries equating to one-tenth of one per cent of their national income would, by 2010, result in eight million lives saved per year, providing these monies were wisely spent. The report emphasises the importance of primary, close-to-client care as the essential health system requirement to achieve these targets.

The new Director-General of WHO thus faces massive political, financial and technical challenges, and these without considering the grim spectre of international biowarfare. Global health needs are substantial. The need for WHO to retain and implement its broad mandate is even more important to bring a better balance to the more disease-specific and vertically implemented mechanisms promoted by donors outside the UN system. Lessons from the indisputable successes of recent years need to be learned, sponsored and applied. Australia can play an important part in this enterprise.