"All roads lead to Geneva" by Devi Sridhar

By Devi Sridhar | 23 May, 2017

For spectators, the importance of this week extends far beyond the official proceedings shared via livestream. It is about the closed door breakfasts, the high-level side meetings, the sponsored receptions and events, and the general atmosphere in expensive, elite Geneva as it transforms into the centre of the global health world. The stakes are even higher this year with the election of a new Director-General of the WHO at a time when new leadership and vision are sorely needed. Much has been written by Laurie Garrett, Larry Gostin, and others on reforming the WHO. In this blog, I take a step back and focus on three big issues in our current global health system that the new leadership of the WHO will face.

1. Data

Each day brings increased and improved global health centralized data on the global burden of disease – what people suffer and die from – and on development aid for health – what aid money is committed. Over the years, hundreds of millions of dollars have been invested by powerful stakeholders into sophistical analyses, complex models, and high-performance computing. Modelling is especially necessary given that half of all deaths globally do not have a recorded cause.

Is this globally aggregated data useful for poorer communities across the world? The experience of the European Union FP-7 funded consortium Go4Health suggests no, further adding that it may risk riding roughshod over local concerns and priorities. The project undertook community consultations with marginalized groups on the Millennium Development Goals (MDGs) and the post-2015 agenda in Uganda, Bangladesh, Australia, and Guatemala. The common thread was that the communities consulted wanted to determine their own health priorities based on their values and needs and rejected the notion that global metrics should determine what health services they could access. This raises larger questions: why are heavily-modelled numbers exported from Seattle or Geneva taken as the benchmark for what poor people require, over their own voices or even national assessments and has global health moved to such abstraction that statistical models, imputations, and programming no longer resonate with the reality of people’s lives? The consequence is a lack of trust and buy-in from populations across the world in global institutions.

2. Financing

The Sustainable Development Goal agenda marks a progressive move towards universal health coverage and more integrated thinking in global health and development. Capacity-building in robust health systems is required so that countries can deal not only with outbreaks such as Ebola or yellow fever – but also with maternal health, childhood pneumonia, and heart disease. Debates in the US and UK focus on what the health system should deliver, how it should be structured, who shoulders the financial burden, and how to hold politicians to account for these promises. These same debates should occur all over the world.

However, health ministers in low and middle income countries complain of new initiatives and plans that jostle them from one disease priority to another on a yearly or even monthly basis. Additionally, the bulk of development assistance for health still flows vertically towards disease-specific interventions and commodities, and continues to be controlled by a small set of donors. The incentives to finance vertical programmes have not changed, so it is unsurprising that financing flows have largely stayed the same. As a result, the ‘client’ of global health efforts remains the donors with their pet projects, rather than those most in need of support from the global health system – low- and middle-income countries and the poorest quartile of their populations.

3. Governance

Outbreaks of infectious disease such as Ebola have highlighted two important points: how much the world relies on a strong WHO and adherence to global rules such as the International Health Regulations, and the inability of the agency to deliver on its mandate. Numerous reports have been published on how to reform the WHO and a review of these concluded little action has occurred despite ample analysis. This begs the question – is the WHO reformable?

The main place to reform institutions is through their Boards. For example, when the Global Fund to fight HIV/AIDS, TB and Malaria was in crisis due to media coverage of corruption and subsequent withdrawal of donor support, the Board made specific and hard-hitting decisions including the creation of an Office of the Inspector-General. The WHO has an Executive Board comprising 34 individuals who meet twice a year to oversee the daily work of the Secretariat. When first created, the Board was supposed to consist of individuals technically qualified in the field of health and specifically not chosen to represent countries or regions. Over time, the Executive Board has become a mini-World Health Assembly where individuals read prepared statements on behalf of certain constituencies resulting in limited engagement and discussion among the individuals in an informal and productive way. To be effective, boards should be relatively nimble, interactive and forward-looking, and the current Executive Board governance is far from that.

What does all this mean for the next director-general of the WHO and those concerned with the future of the agency? 

First, more engagement with communities and low- and middle-income governments will ensure that the data being produced at the global level fits with their needs. We need more focus on the demand side of the data instead of the supply side – asking what kind of data individuals in government and civil society want rather than assuming that what is produced is useful to them.

Second, stronger leadership from the bully pulpit of the WHO is needed to push donors towards longer-term investments in systems; particularly in the recruitment, training, and compensation of skilled health workers.

Third, to push the institution to reform and adapt. The new Director-General needs to hold him/herself to a higher standard than previously expected and work closely with the Executive Board. For example, negotiating with donors towards more flexible funding and away from earmarked funds (which Peter Piot did successfully at UNAIDS), pushing for an access to information policy and creation of an Inspector-General office, setting clear benchmarks for success in the first year and working to fulfill these in a transparent way.

This entry was first posted on the PLoS Med Global Health blog.