Live from Rio and recalling his experience in Manila, Renzo Guinto reflects on the unseen links between WHO reform and social determinants of health.
Last Tuesday, Cristobal, Pablo, Taavi, and I attended the stakeholder’s event organized by the People’s Health Movement (PHM). For more than a decade, PHM has been a leader in championing health as a fundamental human right and in pointing out the many defects in the current global health regime. The Movement finds its inspiration in the 1978 Alma Ata Declaration on Primary Health Care, which speaks of intersectoral cooperation, people’s participation, focus on prevention and promotion, and community development as vital approaches in achieving “health for all.”
Entitled “Protecting the Right to Health through an Action on Social Determinants,” the session looked into the different issues relating to social determinants of health such as power relations, the right to health, primary health care, and climate change. But one subtopic that caught my attention was the ongoing global debate on reforming the WHO and the future of global health governance.
This major issue has been rarely discussed in connection with social determinants of health. This is saddening, as WHO pushes for both reforming the organization and at the same time giving special attention on social determinants, but it failed to see the marriage between the two. And so, one of the speakers, Nicoletta Dentico from Italy, who is the coordinator of ‘Democratizing Global Health Coalition,’ during her presentation asked the question: Will the current reform enable the WHO to better address SDH?
I can’t avoid remembering my experience at the WHO meeting of the Western Pacific Regional Committee in Manila last week. On the first day of the meeting, Member States spent an entire afternoon discussing WHO reform without raising the aforementioned question, or any question that somehow implies this point. Even the Director General failed to bring SDH to the table. This has happened many times – WHO priorities are rarely seen under one huge umbrella, but are presented as disparate concerns and therefore are competing for political attention from Member States. I think this is one major area that WHO needs to reform: the ability to integrate the different issues that it tries to address, and to make explicit the links between them, for example WHO reform and SDH. Such framing of priorities will be helpful for Member States as they try to understand why these issues are raised and thus merit immediate action.
Going to the link between WHO reform and SDH, I believe the campaign for action on SDH will not move forward, within WHO and among Member States, if the principles that govern the SDH approach will not be explicitly adopted by WHO, for example as one of their “core businesses.” Nicoletta shared that in the original document on WHO reform, “Health and Development” was not actually identified as one of the core businesses of the future WHO. WHO’s reasoning behind this is that many other international organizations, such as UN agencies and health foundations, are already doing tremendous work in this area. However, this non-inclusion of development in the WHO reform agenda ignited opposition and criticism among some Member States. “Health and Development” was later added in the revised document.
I think WHO can do more than that, if it really aims to achieve substantial and genuine reform. Looking back at history, international health actually started as a charity work for religious groups and nongovernmental organizations, and later turned into a development issue, hence the participation of many new global health actors, even international development banks such as World Bank and Asian Development Bank. However, recent history and current global health data will clearly tell us that development alone is not sufficient anymore to improve health outcomes AND at the same time to reduce and even eliminate health inequalities within and between countries. Development can happen without justice and equity, and we have witnessed how many countries greatly improved their economies and communities with the help of development agencies while many segments of society are still left behind, totally forgotten by development. Development work even widened some gaps in health. Take for example the many development projects established in my country, the Philippines – despite existing development efforts, six of 10 Filipinos still die without seeing a doctor, and 150 out of 1000 mothers die of pregnancy-related deaths in the provinces, while the number is just one-tenth in urban cities.
In general, the situation is much better, but the inequalities remain.
Instead of development, WHO should enshrine “global health justice,” not just as one of its core businesses, but its CORE business. I can’t think of any other global health organization that has the capacity as well as the mandate to fulfill this role. This World Conference aims to put equity at the center of global health through action on social determinants of health, but we have a WHO that, despite its initiating a commission on SDH and now a conference, is ill-prepared to provide guidance and leadership in this area. The overall structure of WHO remains incompatible to global health justice work, as it continues to divide its work into disease silos and to align its priorities with available funding and not country needs. I remember even talking about SDH with WHO staff from other departments who are either unaware of the whole concept of SDH or even pessimistic about its full realization. I hope WHO will use this opportunity to see the connection of its desired internal reform with its equally desired vision of achieving global health equity, and align these two goals in the process.
Finally, I remember again the Director General scolding the Member States for not fully participating in the discussion on WHO reform. She said that Member States expect too much from the organization, but they contribute too little, especially in terms of assessed and voluntary contributions. Moreover, she called the attention of Member States who also sit in the boards of health foundations, for saying one thing during World Health Assemblies and for saying another thing during board meetings. She pointed out that WHO is divided into two – the Secretariat, whom she calls the “servants,” and the Member States, the “bosses,” and so she asked the plenary to “tell me the priorities.”
I agree that Member States have to be more assertive this time – and so we in civil society should not forget targeting our advocacy work towards governments, because they are the ones who make the decisions in Geneva every May and who implement (or not implement) them back home. If WHO has to be reformed, Member States should begin taking ownership of WHO.
However, and since the Director General pointed out the dual nature of WHO, the Secretariat cannot totally point fingers to Member States for the responsibility of global health leadership. I believe the Secretariat exists to serve as the guiding light of all Member States, and during times when Member States are confused or indecisive, the Secretariat should be providing not just the technical assistance but also the moral impetus for decision and action. WHO should make use of this role in pushing action on social determinants, and ultimately the achievement of global health justice. I think this is one of the reasons why the vision of Alma Ata somehow failed, when WHO reverted back to its disease-oriented programs and forgot about the horizontal, multisectoral approaches they advocated for in the Declaration, sending the wrong signal to Member States and other global health players.
In conclusion, to answer the question, it is clear that the ongoing debate on WHO reform has not touched social determinants, or SDH has not touched WHO reform yet. I hope that after the World Conference, especially during the Special Executive Board Meeting on WHO reform that will happen on the last week of October in Geneva, this critical question will be asked.