| 摘要 | The U.N.’s World Health Organization (WHO) has a unique role to play in global health. As the only membership U.N. entity concerned exclusively with health, it can theoretically provide a forum for health ministers to share information on rapidly transmitted and dangerous infectious diseases, such as avian flu and severe acute respiratory syndrome (SARS). Through its World Health Assembly, WHO can call attention to global health problems and help to establish global health standards.
WHO can facilitate data sharing, although this process has been hobbled by distrust from developing countries, many of which erroneously view the organization as too close to Western business interests. It can also provide approved product lists for medicines, bed nets, condoms, and other health products purchased with public funds, especially for poor countries that lack capacity. Yet historically, it has failed to control quality on drugs and has acted as a bottleneck for other products. While other public and private actors might perform some of these roles more efficiently, WHO, as a multilateral organization, can garner more trust from all states, especially those wary of “Western-guided” development.
Given its lack of accountability and poor performance, WHO desperately needs to reform. WHO has often failed to fulfill its assigned mandates and has been unable to implement the initiatives it has begun. It has sometimes allowed political concerns to undermine its technical expertise. It is no longer equipped to directly implement measures to combat disease because it lacks sufficient staff, the skill set, the correct incentive structure, and adequate financing. Other implementing organs–bilateral initiatives, such as the U.S. President’s Malaria Initiative, and private actors, such as the Bill and Melinda Gates Foundation–have grown in number and influence over the past 20 years and are better suited to combating disease than WHO is. The organization should focus on roles in which it enjoys a comparative advantage (e.g., technical coordinator, health advocate or “cheerleader,” and secretariat for various private and public agencies) and divest responsibilities not directly related to these roles.
As WHO’s single largest financier, the U.S. government has a powerful role to play in WHO reform. It can publicly pressure the organization to stop letting “politics get in the way of fundamental health needs,” as it is doing with WHO’s continued refusal to grant membership to Taiwan. It can partner with like-minded states to withhold assessed contributions and push for more voluntary ones, making payment contingent on strong performance in WHO’s areas of comparative advantage. When WHO fails to measure up, the U.S. government can and should invest its money elsewhere, with the plethora of other actors that now populate the international health arena.
The International Health Arena
Today’s international health arena is complex and sprawling, with myriad interconnected actors. At the pinnacle is the World Health Organization. Its policy organ, the World Health Assembly, includes representatives from the 193 WHO member states and meets every year, usually in May. Policies are coordinated by headquarters in Geneva and carried out by six regional offices, 147 country offices, and more than 8,000 staff.
WHO’s regional offices operate as the implementing organs for the global body, but often have a high degree of autonomy and their own policy-organ assemblies. For example, WHO’s regional office for the Americas goes by the independent-sounding moniker Pan American Health Organization (PAHO) and receives some funding directly from the U.S. government ($56.6 million in assessed contributions in 2007 plus voluntary funding) over which WHO has virtually no control.
WHO members are expected to donate a specified percentage of the overall budget, known as “assessed contributions,” based on a formula designed to determine a country’s ability to pay. Although members are technically obligated to provide assessed funds, they have often made such contributions contingent on policy reforms.
WHO’s $4.2 billion budget for 2008–2009, approved at the May 2007 World Health Assembly, included $959 million for the regular assessed budget (an approximately 5 percent increase over 2006–2007) and $3.3 billion in projected voluntary contributions. Overall, this is a 15 percent increase over 2006–2007. In 2006, the United States’ assessed contribution was $101.4 million (set at 22 percent of WHO’s total regular budget), and the President’s total request for fiscal year 2009 was $106.6 million. The U.S. also provides substantial voluntary contributions annually, including more than $130 million in 2006. By comparison, in 2006, the U.S. government contributed $108.9 million to the United Nations Development Programme (UNDP) and $125.7 million to the United Nations International Children’s Emergency Fund (UNICEF), which are more “implementation-driven.”
WHO is the most prominent and important international health organization, but it was not the first. When it was launched in 1945, it entered an arena already populated by several multilateral and bilateral institutions, including the Office International d’Hygiene Publique (founded in 1907), the mostly defunct League of Nations Health Organization (1923), the U.N. Relief and Rehabilitation Administration, the Pan American Sanitary Bureau (1902), and the U.S. Malaria Control in War Areas (1942), which later became the Centers for Disease Control and Prevention (CDC), as well as quasi-governmental health organizations such as the International Red Cross (1863) and private charities including the Rockefeller Foundation (1913).
Within the U.N., WHO was later joined by several agencies that included health issues within their mandates. UNICEF was made a permanent agency in 1953, and UNDP was created in 1965, followed by the United Nations Population Fund (UNFPA) in 1969. The U.N. has also created special programs and offices, such as the United Nations Joint Programme on HIV/AIDS (UNAIDS) in 1994 and the Global Fund to fight AIDS, Tuberculosis and Malaria in 2002. The structures of these special programs tend to reflect their focus on implementation. Most include governing boards, but lack representative assemblies. Contributions are generally voluntary, rather than assessed.
Other international agencies also consider “health” within their purview. For example, the World Bank provides loans to developing countries for health-related projects. While the International Monetary Fund does not involve itself in specifics or priorities of health spending, it supports national poverty-reduction strategies that allocate additional spending to HIV/AIDS and other health programs.
The size and scope of bilateral health initiatives have increased significantly over the past decade, primarily with targeted disease-specific programs such as the President’s Malaria Initiative (PMI) and the President’s Emergency Plan for AIDS Relief. U.S. programs are funded through one or more of the following: the U.S. Department of Health and Human Services, U.S. Agency for International Development (USAID), Department of State, National Institutes of Health, and CDC, and increasingly through the Department of Defense because of cross-connections between health and security. For example, the President’s Malaria Initiative is led by the U.S. Agency for International Development but is overseen by a coordinator appointed by the president and an Interagency Steering Group with representatives from USAID, CDC, U.S. Department of Health and Human Services, Department of State, Department of Defense, National Security Council, and Office of Management and Budget.
Outside of the strictly bilateral and multilateral governmental sphere, the picture becomes even more complex. Quasi-governmental organizations (e.g., the International Red Cross), large nonprofit private foundations (e.g., the Bill and Melinda Gates Foundation), nongovernmental organizations (e.g., Oxfam and Médecins Sans Frontières) finance and implement health programs; businesses provide pharmaceutical drugs, medical devices, and health care services at cost or as charitable donations. These nongovernmental actors are becoming more influential and powerful. According to the Hudson Institute’s Center for Global Prosperity, private resources (investment, remittances, and philanthropy) account for “over 75 percent of donor countries’ entire economic dealings with developing nations.” While health aid has been historically dominated by governments, private sector participation is increasing. In 2007, corporations spent more than $5 billion on in-kind medical donations. Since 1994, the Bill and Melinda Gates Foundation has pledged some $9.3 billion for global health out of $17.3 billion in total development aid.
Within the international health arena, actors might be classified as financiers, implementers, vendors, or recipients. Sometimes an organization falls neatly into one category. For example, the Global Fund is a U.N.-coordinated partnership of “governments, civil society, the private sector and affected communities” concerned exclusively with financing efforts against three diseases–AIDS, tuberculosis, and malaria. However, organizations more frequently fall into several categories and play numerous roles. Although each theoretically has its own comparative advantage, mandates and tasks often overlap.
Because it is the principal international agency concerned exclusively with health, we anchor our analysis on the World Health Organization, explaining how it has interacted with myriad agencies and venturing to propose how it could do its job better.
The New International Health Organization
In April 1945, delegates from around the world gathered in San Francisco to hammer out a postwar order and launch the United Nations. Because few countries had the capacity to finance and organize broad-based international health operations and programs, an international body was appealing and seemed necessary. A proposal by the Brazilian and Chinese delegations for a new World Health Organization quickly gained support. In June 1948, delegates from 53 of the U.N.’s 55 member states convened the first World Health Assembly and proclaimed as its mission “the attainment by all peoples of the highest possible level of health.” Slogans proclaiming that “germs know no frontiers” and “carry no passports” echoed throughout the first assembly.
WHO’s Original Mission. Negotiations over the structure and authority of the new health organization borrowed from the mandate of the Health Organization of the League of Nations. Because participants deemed it to have been too weak to meet many of the world’s health needs, they designed WHO with a far more comprehensive role and greater authority to fulfill its mission. Among the 21 functions in its constitution, WHO would:
Direct and coordinate international health work;
Establish and maintain collaboration with all international health actors, public and private, deemed “appropriate”;
Provide assistance for emergencies and for “strengthening health services”;
Work to eradicate, not only “epidemic” diseases, but also “endemic and other diseases”;
Establish international nomenclature and standards for health;
Provide administrative and technical services, including epidemiological data; and
Even “promote and conduct research.”
These functions were supposed to be performed only “upon the request or acceptance of governments” of member states, the organization’s financiers and clients. As with any large organization, principal–agent problems quickly arose.
In its early years, the organization strayed little from what most member states considered to be its primary function: eradicating epidemic diseases. This approach of focusing on mass disease prevention and control campaigns is generally categorized as “vertical,” rather than “horizontal,” which focuses on improving general health.
WHO launched a series of disease-specific programs, which achieved varying degrees of success: the 1952–1964 program against Yaws (a bacterial infection), a 1974 effort against onchocerciasis, the celebrated eradication of smallpox by 1979 (in just over a decade), and a campaign against polio in 1988. The organization’s early campaigns against malaria were launched in the mid-1950s in the Americas, Europe, Asia, and Oceania with pilot programs in Africa and were highly effective. By 1970, an estimated 1 billion people no longer lived in malaria-endemic areas, and malaria had been eradicated from 14 wealthier tropical and sub-tropical countries.
These programs succeeded for several reasons. For smallpox and malaria, the nature of the disease had been clearly identified, and methods for prevention and treatment were obvious. Funding was forthcoming from donor countries, at least initially. National governments in recipient countries were eager to participate.
Because paternalistic attitudes overtly pervaded much international aid policy (and WHO was no exception), it was politically acceptable for rich countries to both fund and carry out health campaigns in poorer countries without consulting much with the countries’ health leaders. With strong political support from donor and often from recipient nations, WHO did not hesitate to pursue aggressive, vertical strategies with firm timelines and tight management. Expert personnel were recruited from other private and public organizations, and protocols were borrowed from and built upon the strategies implemented by these other organizations.
For example, Brazilian Marcolino Candau, WHO’s second director-general, who launched WHO’s first major malaria eradication campaigns in 1955, had previously worked under Fred L. Soper, who directed many of the vertical disease control programs at the Rockefeller Foundation and later the Pan American Sanitary Bureau. In the smallpox eradication campaigns of 1966–1979, WHO borrowed scientists from the CDC, the Institute of Sera and Vaccines in Prague, and the Pasteur Institute in Paris, among others.
The strategy yielded positive results, at least initially. Between the early 1960s and the early 1980s, infant mortality and under-five mortality rates fell in sub-Saharan Africa, partly due to successful vertical campaigns. The decline in the infant mortality rate (2.9 deaths per thousand per year) was less than in East Asia/China (3.8 deaths) and the Arab countries (3.4), but greater than in South Asia (2.2).
Even in South Asia, the limited success owed largely to “global initiatives and vertical national programs” against diarrhea and acute respiratory infections. Still, sustaining success critically hinged on the recipient country’s economic growth and specifically on governmental and private support for health interventions.
Failure to achieve these goals is a key reason why improvements ultimately languished in sub-Saharan Africa. Economic development in Africa stagnated, with direct implications for future health. By 1999, 32 countries in sub-Saharan Africa were poorer than they had been in 1980, even while countries in other regions were enjoying rapid economic growth.
New Goals and Mission Creep. Despite a reasonable number of successes, questions and criticisms of WHO’s approach to international health gathered momentum in the 1970s. Donor countries began to question the wisdom and sustainability of large foreign aid transfers. Newly independent states in Africa were demanding a role in crafting policy. WHO’s top-down, “paternalistic” campaigns of the past were growing increasingly unpalatable. These trends crystallized into policy at the September 1978 International Conference on Primary Care held in Alma-Ata (now Almaty), Kazakhstan, where “health for all” and “primary health care” were proclaimed as WHO’s new goals. Both goals were subsequently endorsed by the U.N. General Assembly in December 1979.
These two goals revolved around the principles of “equity, community involvement, appropriate technology, and a multisectoral approach.” Their practical effect was to broaden WHO’s mandate significantly. WHO would no longer focus primarily on disease-specific programs, but would now promote health “development” more broadly by improving health systems, building infrastructure, and fighting chronic diseases.
The Health for All and Primary Health Care initiatives made several important contributions to development discourse and practice. They identified the need to strengthen underlying health systems and thereby improve health capacity, which is essential for any sustainable, long-term development beyond epidemic disease control. They also emphasized the interconnection between health and other development issues, including economic growth and education, and identified the importance of country-level, local ownership. WHO leadership had long recognized the need for such policies, but most WHO member countries had done little to fill policy gaps. In 1948, for example, WHO’s Regional Director for South-East Asia, Dr. C. Mani, noted that reducing morbidity from communicable diseases would not be possible “until basic health services [were] strengthened and adequately supervised so as to play their part.”
However, given the paucity of competent health care practitioners and the lack of good governance in many nations, the new Health for All ethos enabled, even encouraged, mission creep. WHO expanded into many highly politicized areas where it had less technical ability, managerial competence, or experience, duplicating the efforts of other organizations including the well-funded and managerially more competent World Bank. WHO was often unable to secure adequate funding for success. WHO also failed to recognize or at least acknowledge that the radical changes to existing health-care delivery systems required to achieve “health for all” were ultimately the responsibility of health ministries of national governments, not a global body. Indeed, research by Alex Preker of the World Bank would later show that efforts to provide resources for horizontal health initiatives were far less effective than predicted, partly because they crowded out domestic (national government) health expenditures.
In the wake of the global financial woes of the 1970s and amidst growing distrust of the WHO’s ability to allocate funding effectively, the World Health Organization began to lose funding. In 1982, the World Health Assembly voted to freeze the organization’s budget. In 1984, the Guttmacher Institute noted that WHO’s Special Programme of Research Development and Research Training in Human Reproduction had downsized its goals in response to its reduced funding, including eight budget reductions since 1980. In 1985, the U.S. withheld its entire pledged contribution to WHO’s regular budget, partly to protest WHO’s recent launch of an essential drugs program partly designed to encourage countries to develop their own pharmaceutical production. The U.S. actively encouraged the director-general to make cuts to the organization’s budget.
Meanwhile, supporters of the organization were bemoaning what appeared to be growing politicization of the “sort that [had] plagued other United Nations agencies.” For example, following the retirement of director-general Dr. Halfdan Mahler in 1988, a political squabble ensued. Health agency officials alleged that Japan had pressed “third-world governments” to support the candidacy of Dr. Hiroshi Nakajima as Mahler’s replacement, “in some cases offering foreign aid projects as inducements.”
By the end of 1995, unpaid contributions from all member states had reached $243 million. The organization had been forced to borrow its entire internal reserve of over $175 million, foregoing its ability to respond quickly to health crises and the interest on its reserve. Meanwhile, WHO’s extrabudgetary funding, which allowed donors to track the use of their funds more closely, increased from 25 percent of WHO’s total budget in the 1970s to 40 percent in 1980 and over 50 percent in 1990.
Even as financial constraints made it increasingly impractical, WHO did little to focus its activities and remained committed to a “full-menu” programming approach. Critics routinely lambasted the organization for spending too much on its own bureaucracy. In 2002, only 40 percent of WHO resources went to countries and regions. Money that did make it to the regions was not being spent efficiently. In many countries, national governments demonstrated little willingness to invest in necessary health resources and infrastructure, and endemic corruption meant that even well-intentioned WHO-directed aid had little impact.
WHO’s strong, semi-autonomous regional offices often could more clearly identify and respond to each region’s unique problems and were generally perceived to be more representative of local peoples. Yet they also duplicated efforts of the WHO Secretariat and offered little accountability. Because regional directors were elected by member states, they were not directly accountable to the director-general of WHO, were not necessarily subject to the same technical scrutiny as secretariat staff, and tended to be less insulated from local politics.
Recent Reform Efforts. When Dr. Gro Harlem Brundtland, a former prime minister of Norway, became director-general in 1998, the organization was in desperate need of reform. She raised performance standards at WHO’s Geneva headquarters, placed more than half of the staff on short-term contracts, and tightened the chain of command between the executive board and what had been “powerful and largely independent units” within the Geneva office. Although WHO did not acknowledge the outright failure of its Health for All campaign, its 1998 evaluation report recognized the initiative’s numerous shortcomings. By the end of the report, the phrasing “health for all” had been abandoned for the more qualified language of “health development,” with emphasis on ownership by countries themselves. This change in phrasing signaled a subtle, but important clarification of WHO’s goals.
Brundtland also renewed WHO’s focus on public–private partnerships. Emboldened by resources brought to the table by private NGOs and foundations, as well as donor confidence in these partnerships’ responsiveness and flexibility, WHO helped launch several new public–private partnerships within the U.N. system, including Roll Back Malaria, the Global Alliance for Vaccines and Immunization (GAVI), and Stop TB partnership. Brundtland also boosted the organization’s long isolated and underfunded Special Programme for Research and Training in Tropical Diseases (TDR) to a more prominent position. WHO helped to create–and joined the boards of–several independent initiatives, including the International AIDS Vaccine Initiative and Medicines for Malaria Venture.
While not without problems, such partnerships allowed WHO to focus on its comparative advantages. In its public–private partnerships, WHO hosted at most a secretariat and in many cases played merely a technical or advisory role. In the Multilateral Initiative on Malaria, a global alliance launched in 1997 to “maximize the impact of scientific research against malaria in Africa,” TDR’s role (and by extension WHO’s role) was limited to helping to “assess the scientific needs and take responsibility for strengthening research capacities.” In the Medicines for Malaria Venture, WHO’s role was to offer “technical and public health guidance.” Management and implementation were left to private and other nongovernmental actors better suited to the tasks.
Dr. Lee Jong-Wook, Brundtland’s successor, also corrected some of WHO’s many problems when he assumed office in 2003. His recruitment of strong, technically qualified personnel dramatically improved WHO’s focus and effectiveness in several key programs. He also continued internal management and finance reforms, with the aim of “putting most of the budget where it was needed–in countries–and building strong accountability mechanisms.” By 2005, 60 percent of WHO resources was going directly to countries and regions. Better internal management (WHO reduced administrative costs by 15 percent in 1999) and greater transparency in spending improved donor trust. In 2005, member states increased WHO’s regular budget by 4 percent, reversing earlier declines. Extrabudgetary funding continued to increase, accounting for 71 percent of the budget in 2004-2005.
Following Dr. Lee’s untimely death in May 2006, Dr. Margaret Chan, a former assistant director for the organization’s Communicable Diseases cluster was elected director-general. It is still perhaps too early in Chan’s tenure to assess her record. Yet while she publicly acknowledges the need for reform, she at times seems reluctant to tailor WHO’s activities to its strengths.
For instance, Chan pledged to assess the performance of WHO’s assistant director-generals, introduced travel restrictions for senior staff, and affirmed the need to streamline the number of publications produced by the agency. She also reaffirmed the need for WHO to focus its efforts and work with other actors in international health. Shortly after her election, she signaled strong willingness to coordinate WHO efforts with other agencies and NGOs by spending several weeks meeting with Bill and Melinda Gates and “high-ranking officials at all the major international health agencies” to “identify priorities and decide who is doing what.”
In her 2008 address to the World Health Assembly, Chan said that she rejects the full-menu approach for WHO programming and has “a duty to steer the work of this Organization into areas where [its] leadership offers a unique advantage.” Yet she has also expressed a desire to resurrect the vision of primary health care articulated in the 1978 Alma-Ata Health for All declaration. Health of All is a bold cheerleading vision, but only individual states can address delivery. Two of the three “global crises”–food security, climate change, and a global influenza epidemic–that she identified in her address lie outside of WHO’s expertise or mandate. While lack of food has serious health consequences, it may be better addressed by other U.N. entities, such as the U.N.’s Food and Agriculture Program, World Food Program, UNDP, and World Bank. While climate change may lead to deleterious impacts on health, policy solutions would be outside WHO’s sphere of influence.
Recurrent Challenges and Needed Reforms
The World Health Organization has begun a reform process that will hopefully direct it toward roles in which it complements–rather than competes with–the activities of other international health institutions, national health institutions, and private-sector health efforts. Still, the organization faces a long road ahead. Specifically, WHO and its member states need to correct the organization’s:
Ambiguous mandate and overambitious rhetoric,
Duplication of other agencies’ efforts,
Susceptibility to political influence,
Failure to focus on results,
Tendency to exceed its mandate and capabilities, and
Statist bias.
Ambiguous Mandate and Overambitious Rhetoric. WHO’s ambiguous mandate and overambitious rhetoric have translated into a poorly defined, overambitious role. “The almost limitless scope of the international medical field,” Melville MacKensie warned in an address at Chatham House in 1950, meant that there were “certain problems that [lent] themselves to international collaboration and others which [did] not.” Malaria and cholera–for which the causes, treatments, and preventions were known–were “ripe for international collaboration.”
However, research on cancer and leprosy might best be done nationally. It would be difficult, MacKensie acknowledged, “to keep the work of the organization on the right lines…to prevent the development of projects in which we cannot hope to produce adequate results.” A pertinent example is WHO’s continued focus on chronic diseases and other “lifestyle” issues, such as substance abuse, high blood pressure, cholesterol, tobacco use, and obesity. These programs divert attention, time, and money from other, more immediate priorities such as epidemic diseases. In 1998, the organization launched the Global Initiative on Primary Prevention of Substance Abuse. In 2002, the World Health Assembly issued a resolution urging member states to collaborate with WHO and calling on the director-general to “develop a global strategy on diet, physical activity and health…for the prevention and control of noncommunicable diseases,” which the director-general later fleshed out to include high blood pressure, cholesterol, tobacco use, alcohol abuse, and obesity.
In 2002, WHO also convened an international meeting of medical experts, airline companies, and consumer groups to probe the potential causal link between air travel and venous thromboembolism. The group concluded that the “the risk was not quantifiable because of a lack of data” and “was likely to be small and mainly affect passengers with additional risk factors for venous thromboembolism.” Yet the group agreed that WHO and the International Civil Aviation Organization would conduct a series of large clinical studies to consider its impact.
Problems such as diabetes and heart disease predominantly afflict older people in more developed countries: the United States, European countries, and increasingly, countries such as India and China. In less developed countries, many people simply do not live long enough to experience such health problems. Therefore, these problems can be addressed more effectively by (generally wealthier) developed-country governments or nongovernmental agencies. Instead of worrying about “economy-class syndrome (when passengers on long flights develop blood clots in their legs)” and international tobacco control, WHO should “concentrate on the biggest killers in the countries least able to cope without assistance”: AIDS, tuberculosis, and malaria, especially in Africa.
Even when formal mandates are complementary, overlapping authorities lead to “an unclear delineation of activities.” A relevant example is WHO’s decision to reestablish its own HIV Department at the beginning of 2001 –only a year after it helped to found the Accelerated Access Initiative, a public–private partnership of five pharmaceutical companies, WHO, UNAIDS, World Bank, and other U.N. agencies to accelerate and improve access to HIV/AIDS-related care and treatment in the developing world.
This problem is not exclusive to WHO. A third of U.N. initiatives involve more than 10 U.N. agencies, inevitably duplicating administrative efforts and creating overlapping mandates. The World Bank has also been faulted for expanding into areas outside its traditional ambit. By 2001, it had acquired tasks as disparate as Balkan reconstruction, education for girls in Muslim countries, and the fight against AIDS, making its mission so complex as to be unwieldy.
WHO’s early efforts at malaria eradication ultimately fell short because donors grew tired of supporting what turned out to be decades-long initiatives. In September 1971, WHO admitted that it had “not been possible to pursue a vigorous campaign to eradicate malaria because of deficiencies in planning, management, administrative problems and particularly lack of government funds.” Eradication in all countries, many of which lacked the necessary infrastructure to mount ongoing malaria control measures, proved to be an overambitious, unsustainable goal–much like many of the targets set in later decades.
In some cases, WHO has even launched unfunded programs with the hope that the subsequent media blitz would generate the necessary support. Its drug prequalification program was launched hurriedly, even though it was underresourced and underdeveloped. Yet funding was not forthcoming because the program lacked credibility, and the program languished, poorly funded and poorly implemented. Duplication of Efforts. At the outset, WHO experienced difficulty in defining its relationship with nonmembers, both states and non-states, including earlier regional initiatives and other U.N. funds, programs, and efforts. Considering their disparate origins and different political imperatives, the difficulty of coordinating efforts between Geneva headquarters and regional offices is not surprising. At its founding, WHO absorbed a host of longstanding regional health p |
