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Saturday 10 May 1997 1407,1409 WHO reform and global health Radical restructuring is the only way ahead The world has changed since the World Health Organisation was founded nearly 50 years ago, and the pressure on WHO to change in response has never been greater. Gontinuing fmandal constraints, growing demands on the international health system, the approach of the millennium (the deadline for the Health for All initiative), and the certainty of new leadership (see p 1367)t in 1998, when WHO celebrates its own half century, all add to the urgency and timeliness of the debate. But what would a reformed WHO look like, and will reform mean di~..mantling the existing organisation and starting again? The meeting this week of the World Health Assembly in Geneva marks the beginning of a crucial year for the future of international health. The past five years have seen the emergence of an impressive consensus about the problems of the world's health system. Analysts talk of a crisis in international health, with increasing inequities and worsening access to health care for the world's most ~xflnerable populations. The moves towards privatisation and terti- ary care are mirrored by reduced emphasis on and pro- vision of primary "and preventive care_ Lack of coordination between international agendes has meant duplication of effort, confusion, and waste of resources. . With its narrow, top down, service oriented 'approach to health and its centralised, hierarchical bureaucracy, WHO has proved unequal to the new challenges. Its once clear calls for equity and universal primary care have been drowned out by the World Bank's conflicting emphasis on economic growth and e~iciency. Much of this can be blamed on WHO's lack of leadership and inadequate commitment from mem- ber states. In trying to please all its political constituents WHO has spread itself too thin and lost direcfionY The first formal car for reform came from within WHO in 1993,3 but since then tittle has changed. In response to increasing financial constraints, the director general announced earlier this year that WHO would concentrate its resources on a smaller number of health issues,4 but there have been only halfhearted efforts towards the constitutional reform that would make such a change in priorities possible. And there has been no high level discussion of changes to the organisafion's sn-ucture or processes. In the words of one WHO director, the changes have amounted simply to "rearranging the furniture." But if the leadership's response to calls for reform has__been little more than symbolic, elsewhere the 18 months have seen at least five influential inter- national gatherings to discuss the future of inter- national health and to explore what a reconiigured world health organisation might look like. Two of these groups report their condnsions in this week's BMJ (pp 1404, 1407)? 6 The BMJ has also obtained some notes on poss~le reforms from a recent informal meet- hag Of WHO directors and programme managers (see below). Finally, this week's BMJ carries a call for a change to WHO's definition of health (p 1409), which ha its current form may, the author suggests, be prevent- ing the organisation from functioning effectively.7 The reports take the same general approach to their taska analysing ctwrent and future health needs, detailing the failings of the existing system, and trying to identify the main functions of'an international health organisation as a guide for deciding the su:ucture and mechanisms of a new world health system. In this issue Frenk et al report the conclusions from a meeting of 21 health experts in Cuenaveva, Mexico, earlier this year, sponsored by the Rockefeller Founda- tion (p 1404)? They identified five essential core functions: surveillance and control ofcliseases that rep- resent a regional or giobal threat; promotion of research and technological development related to problems of global importance, including mechanisms for sharing information; development of standards and norms for international certification; protection of international refugees; and providing assistance and advocacy for extremely vulnerable populations. The report's authors hope that a consensus about the core functions will emerge. Two reports from Sweden--both sharing the same main author, Professor Goran Sterky--suggest that one of the main roles of a global health organisation should be to coordinate international health initiatives and to set international health policy? ~ The first report, from the Dag Hammerskjold Foundation, identifies three basic functions for a reformed organisation: pro- riding integrated health policy guidance; providing "normative" information on what we know and what we don't; and supporting multidisciplinary research into health and health services,s The second report, commissioned by Sweden's ministry of foreign affairs, concludes that the best way to achieve international cooperation in health would be through a decentralised network? It suggests that this could consist of sinai/independent organisations set up for linfited periods to perform specified functions. These wotfld tackle specific diseases 6~; riskfa~t6rs a~d- -

such issues as healthcare reform. They would have their own boards and their own finances, but they would be set up, overseen, and dissolved as necessary by the assembly of member states and its secretariat. Unlike ~,~.~'~:'~: t tin am, ent Secretariat, this would have a purely supportive role rather than a political one. The advantage of such a system would be, say the authors, flex~ility in response to changing demands and dear separation of the political side of the Organisation (the assembly and the secretariat, where problems would be identified and analysed and solutions derided on) and the action side (the independent bodies which would put solutions into practice). There would be no re~onal structure and no mandatory representation in individual countries as at present, and no executive board--the director general would report directly to the assembly. All of this would release funds for use dsewhere. Funding would come, as now, from membership fees and voluntary contribu- tions for special projects, but also from new forms of taxation of global resources (such as oceanic seabeds, the air, or the genetic diversity in natnral resources) and global activities (such as foreign trade, research, and intellectual property rights).The organisational culture would encourage high staff remover, openness, risk laking, and high professional standards and autonomy. An equally concrete though less detailed proposal was presented recently at an internal meeting of WHO directors and programme managers. This suggested restructuring the organisation into three centres A global health intelligence centre would collect, analyse, and disseminate information on burden of disease, epidemic surveillance, forecasting, cost-effectiveness of interventions (about which there is currently little high quality information), global health expenditures, and norms and standards A global health policy centre would develop, test, and disseminate policy guidance on health system reform, finance and management, sustainable development, and equity. A global disease and risk factor reduction centre would consist of targeted programmes to reduce specific diseases and risk factors, focusing on the world's 15 or 20 major health problems. These would be selected on the basis of global burden of disease and would therefore relate mainly to the developing world, with tobacco being a top priority. These would be the only areas where WHO would be actively involved. For other diseases and risk factors, WHO would simply refer people to other providers of high quality information and assist- ance. The activities of the three centres would be coor- dinated by a global health strategy unit, which would focus on common functions such as planning and evaluation, training, drug quality and supply, technol- ogy, and emergency response. While these suggested reconiigurations differ in their details, several key themes emerge. The new health challenges are global and so need a global solution. A reconfigured organisation should take the leadership role in coordinating international health initiatives and in setting the direction of international health policy. The system should incorporate a broader mix of gkills and move away from the narrow biomedical model of the current organisation. It should be decentralised not only (or at all) by region but by functior~ Structurally it should be made up of flexible, time limited units ~ather than perm~yidn~ pi:ffgi:a~arnes I(should be made more democratically accountable, both through more active partidpation fi'om member states and through supervi- sion, as originally intended, by the general assembly and the UN Economic and Social Council Importantly, these suggestiom mean recommitfing to, not discard- ing, the prindples laid down in WHO's comtitution. These reports show that the debate has moved well beyond simply looking for solutions for the problems of the existing World Health Organisatior~ People are now asking the more fundamental question: what type of organisation is needed to meet the world's health needs now and in the next century. Whether WHO will be able, under new leadership, to uansform itself into this slimmed down, multidisciplinary, flexible animal remains to be seen. It will depend on the political will of the member states and the ability of the new leadership to identify and mobilise people committed to reform. Success may also depend on removing much of the organisadon's old guard. This will be a painful process requiring a dear vision of the future, strong leadership, a,~. disinterested support from member state~ So where should we go from here? A meeting in Pocantico, New York, in February 1996, also sponsored by the Rockefeller Foundation, suggested creating an independent, international expert commission to develop and advocate a series of immediate and long term reforms.~° This seems a good idea. Such a commission would need to be multidisciplinary and to consult widely within and beyond WHO. All of the reports agree that the debate must be wide ranging, involving key individuals from each country-- politicians interested in health, administrators, mem- bers of the research community, non-governmental organisations, and representatives of funding agencies and industry. They also emphasise that proposals should not be linked to any one candidate and should be flee from national political posturing. The next year will be cruciaL It is a unique chance for the wider world to influence the future of international health. And when the World Health Assembly meets in May 1998 it should be not only to confirm the appoint- ment of a new director general, but also to announce a commitment tivm all member states to radical reform of WHO's structure and processes Fiona Godlee Assistant editor BM.], London WC1H 9JR 1 Walgate IL World Health Organisati~n leader to step down. BMJ 1997;314:1367. 2 Godlee E WHO in crisis. BMJ 1994;309:1424-8. World Heal th Organisation. Repot t of the Ex~ut/w Board W~rrk/ng Group on th~ $~1"I0 response to glol~d dumg~ Executive Board 92rid ~ Genev~ WHO, 1993. 4 Godlee E WHO director general fac¢~ leade~hip challenge. BMJ 1997;314: 998. 5 Frenk J, Sepulveda J, Gomez-Dante~ O, McGuinne~ MJ, Knaul E The new world orde~ and the future of international health. BMJ 1997;314:1404-7. 6 Seventh Comultative Committee on Primary Health Care Systems for the 2Pt Cen~ Health care systern~ for the 21st century. BMJ 197;314:1407-9. 7 Saracd R. WHO may need to reconsider its definition of health. BMJ 197;314:1409-10. 8 Sterky G, Bidwai P, Trung Tr, Childer~ E, Chtmhax-a~ S, Dan Y, et a~ G/o- bal heall~ woperatio~ in the twenty.~t cmgury and tl~ rale of th~ UN'Ostem. Uppsala: Dag Hammerskjold Foundation, 1996 9 Sterky G, Forss IL Stemon B. Tomom~ gfoba/htadth orga~at~a."/d~s and opt/ore. Stockholm; Mini.say of Foreiga Affairs, 1996. 10 Rockefeller Foundation. Pocantico retreat. Enhancing tht performoaw.e of /nternat/onM h.ta/th/m'/'/tu//ons. Cambridge, MA:. Rockefeller Foundation. So&al Science Research Council Harvard School of Public Health, 1996.