Day Two at the 64th WHA

Highlights from the second day of the 64th World Health Assembly

Geneva, 17.05.11

Invited speaker: Mr. Bill Gates and the “decade of vaccines”

Bill Gates' speech was the highlight of day 2 of the World Health Assembly (WHA). The plenary room was full way before the scheduled beginning of the invited speakers' session, and it was not possible for many representatives of civil society to find place in the (very limited) area reserved to them. In a quite flat intervention, Bill Gates – on behalf of the Bill and Melinda Gates Foundation which he co-chairs – told the story of how he moved from the computer industry to humanitarian action in the health field, deciding to devote the accumulated wealth as well as his full time to the “fight against the inequity” which affects the world. Just like, at the head of Microsoft, he was dreaming of powerful and simple technology that could soon bring every person in the world to own a computer, he later on turned this goal into bringing health to everybody. But his interest in technology was not over, and that's how he particularly fell in love with vaccines, an “extremely elegant, powerful and easy-to-deliver” tool to protect health. Praising the successes obtained by his Foundation with the new vaccines against meningitis and pneumonia, he showed a strong optimism towards the achievement of unprecedented goals in the health indicators of low and middle income countries in the near future. He emphasised the successes in terms of vaccines' cost reduction reached thanks to agreements made with the private sector. He foreshadowed the eradication of poliomyelitis by the end of what he called “the decade of vaccines”. However, on this point his self-confidence slightly wavered, and he urged the Ministries of Health to put immunisation programmes high on the priorities (and budgets) in their countries. The speech was interrupted several times by open applauses from the audience, and everybody seemed enthusiastic to join Bill Gates on his (and Melinda's) successful journey towards a better and healthier world.

There are striking similarities between Bill Gates' talk and the opening speech delivered yesterday by Director General Margaret Chan, which most likely mean that there was a detailed agreement in advance. It is quite sad to see that a person who is strongly pushing for the protection of intellectual property rights – which are in turn responsible of the impossibility for hundreds of millions of people to access essential medicines – is invited (for the second time in five years!) to address the WHA as a saviour of the world. It is even more sad to see the member states (with significant exceptions) welcoming with relief the financial support that will exonerate their governments from increasing the effort and the accountability towards their commitment to serve the health of their citizens. Finally, it is extremely discouraging to see the WHO abdicating its role as the leading institution for the protection and promotion of the world's health – as a collective public good – and placing its fate (and the people's one) in the hands of one among the richest and more powerful persons of the planet.

NCDs

During the afternoon, the general discussion taking member states’ statements about NCDs continued in the main plenary room. Amongst many repetitive statements, mostly restricted to health care interventions to address the need for behavioral changes for a healthy lifestyle, we were happy to hear the voice of Ecuador’s delegate firmly speaking about the social and environmental determinants of NCDs, reminding that it is very insufficient to provide health care to promote lifestyle changes. She brought up the strength of nature and cosmovision and how much we have to learn with our ancestors, where the solution is to be found.

Committee A - The Future of Financing for WHO: the DG Margaret Chan opens the discussion on WHO reform

DG Margaret Chan has opened today the discussion on what is probably the most important issue discussed in this WHA. Under Item 11, called "The Future of Financing for WHO", the Assembly has to discuss and approve a much broader reform plan (see here for related background documents). In her introductory speech, the DG emphasised that the financial crisis is not the only reason for this reform, which has a much broader focus and is greatly needed in order to make WHO "fit-for-purpose". The world has deeply changed since its foundation, health needs are different and have to be timely and effectively addressed, and the field of global health governance is much more crowded than before. Even if there were no economic problems, said the DG, the reform would still be very much needed in order for WHO to regain and maintain the leading role stated in its Constitution. In her speech, the DG highlighted the following aspects that the reform will tackle:
- the bureaucratic nature of WHO, which doesn't allow the flexibility required to timely respond to rapid changes in health needs
- a staff which is too large compared to both the organisation's requirements and its fundings
- the need to better coordinate the three operational levels (global, regional and national) and to strengthen country offices, particularly in low and middle income countries
- the need to strategically regain a leading role in global health governance.
Concerning this last point, the most critical issue is the proposed "World Health Forum", a multi-stakeholder body with "decision-shaping" power in which global health initiatives, civil society organisations, philantropic foundations and the corporate sector should be represented.
In the discussion that followed, the majority of countries aligned themselves with the proposed reform project, at the same time advocating for a stronger, more efficient and effective WHO. A recurrent criticism concerned the lack of detail of the submitted plan and the delay with which the so-called "Development plan" (A64/INF.DOC./5) was submitted. A great deal of discussion also concerned the financing of WHO, particularly the need to develop strategies aimed at increasing flexible funding. The high proportion of earmarked funding has been pointed out by many delegates as being responsible for great inefficiencies within WHO, as well as for a constant threat to its independence. Northern European countries, although declaring their alignment with the EU position brought by Hungary and which was very supportive for the reform, raised some concerns aroung the proposed Forum, explicitly asking for guarantees of transparency and representativeness of its constituencies.
The most outspoken, and frankly "over the top", intervention was made by Thailand. The delegate depicted WHO as being a donor-driven and corporate-driven organisation, with incompetent staff and bureaucratic decision-making processes which puts lawyers in control of all procedures. He then added that the proposed reform will not help and ironically invited all member states to stop financing WHO and boycott the WHA and the EB, so as to really reach a point were a "rebirth" of the organisation is truly possible. Finally, he affirmed that the reform plan will fail but - since Thailand respects his "elder sister" Margaret Chan - they will endorse the reform plan and are "happy to fail together"!

Committee A - Implementation of International Health Regulations (IHR)

In Committee A the report of the Independent Review Committee was welcomed by most countries participating in the discussion (see here for background documents).  Recognition of how much work is required to put in place the capacity for implementation in a future pandemic. In light of the recent nuclear accident in Japan many nations also expressed concern that the IHRs do not adequately address nuclear and chemical hazards.

Committee A - Health System Strengthening

Side meeting: collaboration among Portuguese-speaking countries and the ePORTUGUESEe WHO Programme

A side meeting gathering Portuguese speaking countries took place to discuss about E-Portuguese, a network conceived within the structure of the WHO to enhance the development of human resources for health in these countries. The network is being coordinated by Brazil and has been an important tool to strengthen cooperation among these countries, as well as sharing of resources for knowledge sharing and production and for training of human resources. The meeting was presided by the coordinator of the network, Brazilian Regina Ungerer, and was attended by the ministers of health of Brazil, Angola, Mozambique, Cape Vert, Guiné-Bissau, São Tomé, and Timor Leste. Each one of them said a few words about their participation in the network. The Brazilian delegates reinforced the importance of the participation of all the member states in the Conference about Social Determinants of Health, to be held in Rio in October. Dr. Paulo Buss strongly  encouraged everyone to participate in the public consultation process through the website. He also reiterated that the Brazilian government is looking forward to having a strong participation of civil society organizations (but the only concrete way of participating at the present moment is through the consultation process). Finally, after all, there was no time left for discussion.  For more information about the E-Portuguese network see: http://www.who.int/eportuguese/en/

Side meeting - Movement towards universal coverage: success and challenges

The panel was moderated by Thailand, with the participation of Rwanda, Thailand, China, Germany, as well as the WHO officer David Evans (Director, Department of Health Systems Financing, WHO) and the representative of the NGO sector from Save the Children UK. To begin with, each country explained briefly its health system, highlighting particularly the challenges of implementing universal coverage:

 

• Rwanda: underlined its community insurance system, based on voluntary contributions of the people (of about 2 USD per person per year); this gives access to a very limited package of basic interventions; whereas the better off opt for private insurance, or are covered by public insurance (for formally employed workers) or military schemes. This is a clear case of horizontal stratification of the health system with selective PHC for the poor.
• China: Lives of people are better off than before; however lower income people still do not have access to health care.
• Thailand: it took about 30 years to reach universal coverage.
• Germany: very confusing system, with 160 insurance schemes! 

The session moved on with many questions from the floor. Provocative questions were addressed to the speakers, concerning improving the quality of health care, fragmentation of having multiple insurance schemes, sustainability of the Rwandan community system and so on. All of the questions were only superficially addressed. It was worrisome to hear the speakers say that PHC interventions and community health workers are a cheap alternative for universal coverage, giving the clear sense of poor care for the poor and not acknowledging that PHC is a comprehensive strategy requiring a strong and integrated health system if it is to be effective. Finally, the PHM watcher’s (Judith Kasper) question about excessive workload of care providers and how to assure that SDH will be addressed was not answered, only commented. The moderator tagged PHM as a “barking” NGO.

Side meeting: Climate change, vulnerable population protection and sustainability: from Cancun to Durban and Rio

(meeting organized jointly by the delegation of Mexico and the WHO Secretariat)
The Public Health and Environment (PHE) Department organised the side meeting on Climate Change (CC). The relevance of the issue in the public health context was stressed and an analysis on the health implication of climate change was presented by the speakers. A specific mention of inequalities and the differential impacts of CC on the health of the people in relation with their socio-economic status was discussed by surprisingly few of the panellists. The double approach, incorporating both adaptation and mitigation strategies, is considered the only one potentially successful. The vision of the PHE Department has been presented with the support of the panellists:

 

 

• Adaptation: strategy which aims to minimize the impact of climate change effects on health. Key points are to strengthen health systems, focus on primary prevention of environmental risks (such as clean water and sanitation, management of heat waves, ecc.) and investments. UK pointed out the necessity to reduce the impact on climate change together with the inequalities, in order to be effective. A Bolivian delegate affirmed that we should go far beyond tackling the impact of climate change, and asking to those countries who cause it to stop destroy the earth and the health of the people.
• Mitigation: strategy which aims to minimize the causes of climate change, such as the reduction of greenhouse gas emission.

The strategy of optimization of health co-benefit of climate friendly sustainable development was strongly supported, presented as “win-win” solution able to promote economic development and growth, reduce emissions and at the same time benefit to health. The rational is that what is good for the environment (in term of technology and regulation) is good for the health. Details were not given, just cleaner biomasses, biogas cook stoves and solar panels were hurriedly mentioned as examples of possible technologies to take into account. The strong stress put on “green economy” as mean of climate change mitigation has been supported overall by France, which expressed the will to take the lead of this strategy.

References on co-benefit of low carbon actions on health can been found in the Lancet series “The health benefits of tackling climate change”. The theory behind has been elaborated by the London School of Hygiene and Tropical Medicine and appears to fit perfectly with the World Bank 2010 Environment Strategy (see here for details).

See official summary of Day 2 in Journal No3 (from page 8)