36. A new vision for WHO

Here is a picture of my dear friend and colleague Dr Ravi Narayan of the Centre for Public Health and Equity, Bangalore. Beginning in 2003, he was the second global secretary of the People’s Health Movement (PHM) which, during his years in the post, started to monitor the activities of the World Health Organization and other relevant UN agencies. (For the PHM’s comments on the appointment of Ann Veneman as executive director of UNICEF, marshalled by Ravi when he was PHM’s global secretary, see the lead news story on the Association’s website this month). A central criticism of WHO has been that, for many years, it abandoned its commitment to the primary health care approach in a number of areas, including nutrition.

PHM’s People’s Charter for Health calls on ‘people of the world to demand a radical transformation of the World Health Organization, so that it responds to health challenges in a manner which benefits the poor, avoids vertical approaches, ensures intersectoral work, involves people’s organisations views in WHO’s annual World Health Assembly, and ensures independence from corporate interests’.

My column this month is drawn from successive People’s Health Movement statements, agreed after extensive consultation. Ravi has always been involved in this work. Said statements have repeatedly criticised WHO for too strong a reliance on so-called ‘public-private partnerships’ with industry for a big part of its budget. This, despite a lack of objective evidence of the effectiveness of this approach in either improving public health and nutrition, or in improving access to care for those who happen to be poor. Despite real and active participation of civil society representatives in WHO’s work being crucial, civil society initiatives designed to work with WHO have become increasingly sidelined. WHO’s attitude has to change from lukewarm to committed and enthusiastic in this respect.

Margaret Chan, Director-General of WHO, speaking in Mexico on the topic of prevention of obesity and chronic diseases, on 25 February 2011. Her point is enjoyed by Mexican President Felipe Calderon, and his Health Minister. Rates of obesity are rocketing in Mexico. One reason, as Mexican politicians know, is unfair terms of trade with the US. These also increase poverty and create destitution among Mexican farming communities.
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The World Health Organisation, the UN agency most responsible for global health decision-making, has so far not fully lived up to the hope expressed in the heading above this section. WHO does not seem to be giving first priority to fairness and justice. To varying degrees, WHO and its leaders in the last decades have not succeeded in encouraging member states in many crucial ways. They have:
• Lacked a commitment (active, beyond pronouncements and some good reports) to equity, social justice and the human right to health and to nutrition.
• Lacked an action-oriented implementation of the principles and public health orientation of the Alma Ata Declaration on comprehensive primary health care, as well as a commitment to manage WHO on the basis of these principles, especially given the current still prevailing trend towards selective and vertical health care and nutrition programs.
• Lacked an ability to establish WHO as the acknowledged leader of global advocacy for the attainment of the universal right to essential health care and nutrition.
• Lacked an ability to forcefully stand behind an agenda based on the principles of equity, integration, inclusiveness and public service ethics.
• Avoided an inappropriate relationships with the corporate sector whose interests conflict with public health, particularly the pharmaceutical, alcohol, and processed foods and drinks manufacturers.
• Lacked the courage and readiness to stand up to the inappropriate influence of the major donor countries.
• Lacked a commitment to strengthening civil society’s involvement within WHO’s decision making process, especially grassroots organisations and particularly from developing countries.
• Lacked a real willingness to follow-up on the recommendations from the Commission on the Social Determinants of Health to tackle the social, political and economic determinants of ill-health, malnutrition and preventable deaths at global and national levels.
• Lacked a commitment to speak up and prevent the negative health and nutrition effects of policies pursued by the World Trade Organisation, the World Bank, the International Monetary Fund and the ‘G8’ richest countries.
• Lacked an ability to support and strengthen the weaker regional offices of the World Health Organisation, in particular the WHO African Regional Office.
• Lacked a commitment to fair in-house labour practices, the advancement of committed and technically competent staff and a more multi-disciplinary staff composition representing all regions of the world.
Following the money
Civil society organisations expect WHO to be the number one international advocate for their most cherished principles, values and approaches. These include the ethics of nutrition and of public health, equity, primary health care, community-based health care and nutrition, community participation and empowerment, use of appropriate technology, and intersectoral cooperation. Civil society organisations also look to WHO as the standard bearer on health and nutrition issues.

But now this role appears to have been usurped by other organisations, particularly the World Bank. WHO comes with technical advice, the World Bank comes with money; national governments usually prefer the money –despite the indebtedness involved.

Many non-governmental organisations have, from many years ago, formal relations with WHO and thus can have a voice at WHO meetings. Unfortunately these tend to be those that are relatively malleable, without a strong social consciousness. They usually do not actively lobby for agendas that more forcefully address the needs of the poor.

What WHO should do
Here is what PHM thinks the World Health Organization should do. The list below is ambitious. Some may say that WHO can do only what its member states instruct it to do. Formally this is true, but WHO still has a duty to set rational and progressive agendas and to guide and help member states to address the social determinants of health, particularly in those countries with least resources. WHO thus should:

• Become a real strong advocate of poverty eradication (or, better, of disparity reduction) particularly in its interactions with the World Trade Organization, the World Bank, and the International Monetary Fund.
• Take a more forceful stand with the above institutions, to make them more responsive to greater equity; cancellation of foreign debt; fairer trade; more just intellectual property rights; promotion of comprehensive primary health care.
• Oppose the privatisation and commoditisation of health care.
• Resist vertical, overwhelmingly technical initiatives.
• Involve community and people’s organisations in evidence seeking and in the drafting and carrying out of action plans.
• Involve people’s organisations in WHO’s work at national, regional and headquarters levels.
• Advise and help member states to strengthen the public sector for health and nutrition.
• Prevent any agenda setting by corporate interests.
• Ensure that transnational corporations (particularly those whose activities impact health and nutrition) are effectively regulated.
• Promote more participatory, relevant and transparent public health and public health nutrition policy processes and initiatives by giving civil society a greater voice in the annual WHO World Health Assembly.

The mighty meet to save the world at the World Economic Forum, Davos, 28 January 2011. Left to right: Josette Sheeran, head of the World Food Programme; Melinda Gates of the Gates Foundation (on-screen); Margaret Chan of WHO; Bono, the pop star and champion of ‘Make Poverty History’; Muhtar Kent, CEO of Coca-Cola; and Lars Sorensen, CEO of Nordisk. They hear one another. Are they listening to the people?
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He also said: ‘It seems so strange for WHO staff in Geneva to be talking about poverty, destitution, misery and hunger, as they pay 2 Swiss francs (equivalent to $US 2) for a cup of coffee, while millions struggle to survive and sustain their families on the equivalent of $US 1.25 a day’.
It is time now for WHO to take a new direction. It currently is moving in the wrong direction, towards its control by corporations. The call to the leaders of WHO, beginning with its current Director-General Dr Margaret Chan, is as follows: (Many more points can really be added…)
• Reaffirm the principles of comprehensive primary health care approaches and translate them into concrete activities in all WHO programmes.
• Review the Millennium Development Goals, and the recommendations of the Commission on Macroeconomics and Health, in terms of their compatibility with the principles of primary health care as stated in the Alma Ata Declaration; moreover, health and nutrition are to be taken for what they are –human rights– rather than primarily inputs to economic development.
• Evaluate different approaches to primary health care by both governments and NGOs in order to improve their implementation worldwide.
• Instruct WHO personnel in WHO headquarters in Geneva, and in WHO regional and in country offices, to engage actively with both government and NGOs primary heath care initiatives, and to determine their capacity gaps so as to face and overcome demographic, epidemiological and socio-economic challenges.
• Continue to support countries that are improving the quality and quantity of health personnel in order to improve access to comprehensive services, especially for people who happen to be poor.
• Emphasise implementation of locally determined models of primary health care that are flexible and well adapted.
• Monitor global policies in trade, development and economic restructuring for their effects on the health and nutrition status of those who happen to be poor.
• Identify and oppose policies that are having an adverse impact on primary health care.
• Organise a series of periodic meetings on future strategic directions for primary health care that capture grass roots experiences, and involve grassroots organisations such as the People’s Health Movement.
Needed: attention to the people at the grassroots

In a meeting with the People’s Health Movement, the immediately past Director General of WHO, Jong-Wook Lee, further said that ‘WHO urgently needs to listen to the people and their movements have to say. Many of these organisations have for too long felt powerless. But by uniting forces, they have now reached a critical mass, in part through the People’s Health Movement. WHO must now listen to voices from communities’. And he was right.

Needed: new accountability and transparency
Today, WHO’s accountability is no longer mainly owed to national governments, who in the UN context are preoccupied with their own status, the trading of favours, and continental rotations of top posts, including that of the director-general. Accountability is primarily owed to the people, legitimately represented by civil society organisations. We in civil society now should demand an open dialogue, to discuss WHO’s policies and programmes in all its areas, including public health nutrition.

Acknowledgement and request

You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.

Please cite as: Schuftan C. Hundreds of millions of people across the world… [Column] Website of the World Public Health Nutrition Association, March 2011. Obtainable at www.wphna.org

The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.

This column is reviewed by Geoffrey Cannon.