Democratizing the world health organization

Assessing the World Health Organization: What does the academic debate reveal and is it democratic?

The World Health Organization (WHO), the leading global authority in public health, routinely attracts loud calls for reform. Although Member States negotiate reform internally, academic debate is more public, and can generate ideas and provide independent accountability. We investigate why authors advocate for WHO reform so commonly. We wondered if this literature had potentially useful themes for WHO, what methods and evidence were used, and we wanted to analyze the geography of participation. We conducted a systematic review using four databases to identify 139 articles assessing WHO or advocating for reform. We discuss these using categories we derived from the management literature on organizational performance. We also analyzed evidence, country of origin, and topic. The literature we reviewed contained 998 claims about WHO's performance or reform, although there were no standard methods for assessing WHO. We developed a framework to analyze WHO's performance and structure a synthesis of the claims, which find WHO imperiled. Its legitimacy and governance are weakened by disagreements about purpose, unequal Member State influence, and inadequate accountability. Contestation of goals and strategies constrain planning. Structure and workforce deficiencies limit coordination, agility, and competence. WHO has technical and normative authority, but insufficient independence and legal power to influence uncooperative states. WHO's identity claims transparency, independence, and courage, but these aspirations are betrayed in times of need. Most articles (88%) were commentaries without specified methods. More than three-quarters (76%) originated from the US, the UK, or Switzerland. A quarter of papers (25%) focused on international infectious disease outbreaks, and another 25% advocated for WHO reform generally. Many criticisms cite wide-ranging performance problems, some of which may relate to obstructive behavior by Member States. This literature is incomplete in the geographic representation of authors, evidence, methods, and topics. We offer ideas for developing more rigorous and inclusive academic debate on WHO.

The constitutional economics of the World Health Organization

This paper brings a constitutional economics perspective to bear on the World Health Organization (WHO), the flagship United Nations intergovernmental health organisation, which is obligated by its Constitution to achieve 'the highest possible level of health' for the world's peoples. The WHO has in the seven decades of its existence used its formidable legislative powers only sparingly. It has been widely chided for being weak in regional coordination and unresponsive to transnational emergencies like the West African Ebola outbreak of 2014-2016. In 2020, it found itself at the centre of the COVID-19 pandemic and in the middle of the Sino-American geopolitical tug-of-war. This paper traces the discordance between the Constitution's stated purposes and the actual track record of the WHO not back to its organisational culture nor to weak leadership but to the design of the Constitution itself. It analytically distinguishes the Constitution's expressive from its instrumental halves, and shows that, whilst the former embodies a 'constitutional moment' of international health solidarity right after the Second World War, the latter embodies a reserved and limited delegation from member-states that are jealous of their sovereignty.

Systematic Review of Human Poisoning and Toxic Exposures in Myanmar

The International Health Regulations (2005) promote national capacity in core institutions so that countries can better detect, respond to and recover from public health emergencies. In accordance with the ‘all hazards’ approach to public health risk, this systematic review examines poisoning and toxic exposures in Myanmar. A systematic literature search was undertaken to find articles pertaining to poisoning in Myanmar published between 1998 and 2020. A number of poisoning risks are identified in this review, including snakebites, heavy metals, drugs of abuse, agrochemicals and traditional medicine. Patterns of poisoning presented in the literature diverge from poisoning priorities reported in other lower-middle income countries in the region. The experience of professionals working in a Yangon-based poison treatment unit also indicate that frequently observed poisoning as a result of pharmaceuticals, methanol, and petroleum products was absent from the literature. Other notable gaps in the available research include assessments of the public health burden of poisoning through self-harm, household exposures to chemicals, paediatric risk and women’s occupational risk of poisoning. There is a limited amount of research available on poisoning outcomes and routes of exposure in Myanmar. Further investigation and research are warranted to provide a more complete assessment of poisoning risk and incidence.

The financial sustainability of the World Health Organization and the political economy of global health governance: a review of funding proposals

The World Health Organization (WHO) continues to experience immense financial stress. The precarious financial situation of the WHO has given rise to extensive dialogue and debate. This dialogue has generated diverse technical proposals to remedy the financial woes of the WHO and is intimately tied to existential questions about the future of the WHO in global health governance. In this paper, we review, categorize, and synthesize the proposals for financial reform of the WHO. It appears that less contentious issues, such as convening financing dialogue and establishing a health emergency programme, received consensus from member states. However, member states are reluctant to increase the assessed annual contributions to the WHO, which weakens the prospect for greater autonomy for the organisation. The WHO remains largely supported by earmarked voluntary contributions from states and non-state actors. We argue that while financial reform requires institutional changes to enhance transparency, accountability and efficiency, it is also deeply tied to the political economy of state sovereignty and ideas about the leadership role of the WHO in a crowded global health governance context.

Don't Discount Societal Value in Cost-Effectiveness Comment on "Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, Not Just More Evidence on Cost-Effectiveness"

As healthcare resources become increasingly scarce due to growing demand and stagnating budgets, the need for effective priority setting and resource allocation will become ever more critical to providing sustainable care to patients. While societal values should certainly play a part in guiding these processes, the methodology used to capture these values need not necessarily be limited to multi-criterion decision analysis (MCDA)-based processes including 'evidence-informed deliberative processes.' However, if decision-makers intend to not only incorporates the values of the public they serve into decisions but have the decisions enacted as well, consideration should be given to more direct involvement of stakeholders. Based on the examples provided by Baltussen et al, MCDA-based processes like 'evidence-informed deliberative processes' could be one way of achieving this laudable goal.

Global Health in the Anthropocene: Moving Beyond Resilience and Capitalism Comment on "Health Promotion in an Age of Normative Equity and Rampant Inequality"

There has been much reflection on the need for a new understanding of global health and the urgency of a paradigm shift to address global health issues. A crucial question is whether this is still possible in current modes of global governance based on capitalist values. Four reflections are provided. (1) Ecological –centered values must become central in any future global health framework. (2) The objectives of ‘sustainability’ and ‘economic growth’ present a profound contradiction. (3) The resilience discourse maintains a gridlock in the functioning of the global health system. (4) The legitimacy of multi-stakeholder governance arrangements in global health requires urgent attention. A dual track approach is suggested. It must be aimed to transform capitalism into something better for global health while in parallel there is an urgent need to imagine a future and pathways to a different world order rooted in the principles of social justice, protecting the commons and a central role for the preservation of ecology.

Public health within the EU policy space: a qualitative study of Organized Civil Society (OCS) and the Health in All Policies (HiAP) approach

OBJECTIVES

This article reviews how Organized Civil Society (OCS) groups in the field of public health work across the boundaries between European institutions and policy areas. In particular, it explores 1) how the Health in All Policies (HiAP) approach is conducted by these groups informally within the formal governance structures, and 2) how this advocacy work creates space for public health within the broader political determinants of health.

STUDY DESIGN

A qualitative mixed-methods framework.

METHODS

Political ethnography, including 20 semi-structured interviews conducted with EU health strategy stakeholders and participant observations in public health events (n = 22) in Brussels over a three-year period (2012-2015), as well as four interviews with EU Member State representatives. Three additional semi-structured interviews were conducted with World Health Organization Regional Office for Europe staff members who had been involved in the drafting of the Health 2020 framework and strategy and the accompanying main implementation pillar, European Action Plan for Strengthening Public Health Capacities and Services (EAP-PHS).

RESULTS

The findings provide an insight into OCS work in the field of European public health, offering an account of the experiences of HiAP work conducted by the research participants. The OCS groups perceive themselves as communicators between policy areas within European institutions and between local and supranational levels.

CONCLUSIONS

The structures and political determinants of health that impose limitations on a public institution can at points be transcended by stakeholders, who conduct HiAP work at supranational level, thus negotiating space for public health within the competitive, globalized policy space.

A Unasul na Assembleia Mundial da Saúde: posicionamentos comuns do Conselho de Saúde Sul-Americano

A União de Nações Sul-Americanas (Unasul), criada em 2008, pretende fortalecer a identidade sul-americana e reduzir inequidades regionais. Com a criação de conselho específico, a saúde ganha destaque como área estratégica. O artigo discute a atuação do Conselho de Saúde da Unasul na Assembleia Mundial da Saúde (AMS), a partir da análise dos posicionamentos comuns do bloco de 2010 a 2014. No período analisado, a Unasul apresentou posições comuns referentes a 26 Resoluções. A atuação da Unasul na AMS ao longo dos últimos cinco anos dá visibilidade ao processo de integração regional na América do Sul e fortalece a própria Unasul como um player na agenda global da saúde.