Written by: Daniel Knights (Joint National Coordinator, Medsin-UK, firstname.lastname@example.org), Jonathan Meldrum (Vice Coordinator, Medsin-UK, email@example.com), Michael Kalmus Eliasz (Global Health Education Director, Medsin-UK, firstname.lastname@example.org)
The World Health Assembly is a special event. With delegations from all of the 194 Member States of WHO, pursued by a plethora of press and civil society, the WHA represents the highest decision-making body of WHO and is an annual opportunity for debate, decision and resolve to action on anything and everything to do with international public health. The International Federation of Medical Students’ Associations (IFMSA) was one of these civil society organisations, taking every opportunity to make our voice and opinions heard. Maybe young people are idealistic, but we are the ones who will inherit the health structures, institutions and systems that today’s global health leaders are debating at WHA – and after a week of lengthy discussions, we were left wondering whether such an opportune forum is failing to deliver as it could and should.
The WHO needs reform - and credit should be given to the secretariat for recognising this. There’s been an extensive consultation process that should have culminated in important decisions at this WHA, but Member States were clearly reluctant to tackle the underlying problems necessitating reform. Here is the nub of the issue: Member States provide the majority of funding to WHO, but only 20% of the total budget comes from core obligatory contributions that WHO is free to spend according to the priorities of the Health Assembly. Any further financing comes in the form of strictly earmarked donations. This means priorities have been pushed into the clutches of those who can pay (countries, philanthropic foundations, and the private sector), rather than being democratically and objectively determined. In her opening speech, Director-General Dr Margaret Chan said, “results build trust and with trust commitment escalates.” It seems clear that Dr Chan knows WHO cannot fully set its own agenda without an increase in core-funding, but Member States showed no resolve to really put their trust in a ‘reformed’ WHO by increasing their core contributions. It’s a vicious circle: WHO needs to provide the results to persuade Member States to fund them more generously, but Member States need to give the WHO secretariat the financial freedom to provide these results to foster that mutual trust. It has to be the Member States that break this cycle, but appetite for real change is distinctly lacking.
A prime example of a critical area that is being neglected due to Member State underfunding is the Social Determinants of Health (SDH). At the WHA they contentiously opted to maintain SDH as an overarching theme, rather than nominating it as a sixth priority area. Dr Chan admirably asserted that she would step down if WHO failed to deliver on SDH, but without a dedicated and well-funded body within the Organisation, her task to permeate SDH through each and every department seems a tall order. Guest speaker Norwegian Foreign Minister Jonas Støre highlighted, “We need to remind presidents, prime ministers and finance ministers...that they too are health ministers.” It is equally true that other UN agencies are also health agencies, and this shows that beyond hammering SDH into the fabric of WHO, the Organisation needs to stand up for these issues on the wider global political stage. Fundamentally there seems to be a disconnect between what Member States say in their speeches at the WHA about a strong, outspoken WHO and where they ultimately choose to put their funding. But money talks – and it comes down to us to stand up and protect the right of WHO to speak out in favour of health-friendly policies at the highest and broadest level.
WHO relations with industry pose another set of uncomfortable questions for the Organisation’s financial predicament. Dr Chan further said, “no government seeking to...protect the health of its citizens should be intimidated by an industry.” She was referring to Big Tobacco, but what about the food, alcohol and pharmaceutical industries, all of which enjoy a comfortable position in policy-making? These giants are similarly driven by their duty to maximise shareholders’ profits, yet it’s proposed that the private sector will play a key role in WHO’s new Global Non-Communicable Disease Coordinating Body. There are plans for an ‘Ethics Office’ within the Reform resolution, designed to ‘manage conflicts of interest’ - and indeed a general concern about conflicts of interest was frequently voiced by Member States at the Assembly. However there was little by way of concrete action decided - and it seems to us that the very use of the term ‘manage’ rather than ‘eliminate’ shows a lack of ambition for real change.
As health professionals of tomorrow, we need to push WHO towards a new, bold, and aspirational approach. The IFMSA and its National Member Organisations such as our own - Medsin-UK - are already being bold in tackling health inequities on a local, national and global scale. Within WHO, various and conflicting interests are stifling aspiration. This is our tomorrow and we challenge health leaders to channel our idealism into pragmatic solutions.
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