UNASUR
South American Institute of Government in Health
Rio de Janeiro, may 2012
Report
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65TH WORLD HEALTH ASSEMBLY DEBATED WHO REFORM WITH UNASUR´S OUTSTANDING PARTICIPATION The 65th World Health Assembly closed on May 26th with the emergency of WHO reforms being emphasized. Other highlights included Margaret Chan, Director General of the organization, being reappointed for a second term, and more than 20 resolutions being approved by the 194 member-countries. They were represented by almost 3000 delegates. During the 6-day debates, the Union of South American Nations had an outstanding performance as a bloc. It presented common proposals and managed to elect the President Pro Tempore of Unasur’s Health Council, Minister Esperanza Martínez, as one of the five vice-presidents of the World Health Assembly. Due to Unasur members’ coordinated participation, it was accorded that a broader . Reform of the WHO would be sought.
The previous proposal included solely funding reforms. In her closing speech, Margaret Chan highlighted the Reform as one of her priorities for the next 5 years. At the closing of the 65th WHA, 21 resolutions and 3 decisions were adopted. A variety of issues were addressed, such as humanitarian emergencies, international regulation, Millennium Development Goals review, polio eradication, nutrition, maternal and child health, ageing, non-communicable diseases, influenza, schistosomiasis, social determinants of health and progress reports. UNASUL AT THE 65TH AMS Unasur, represented by its Health Council, prioritized a performance as a bloc, strengthening the positions accorded among the member-countries’ representatives in Geneva. The main lines of action were decided during the Extraordinary Meeting of the Health Council that took place in parallel to WHA’s first day. Representatives from Argentina, Brazil, Bolivia, Chile, Colombia, Ecuador, Paraguay, Peru and Uruguay participated and they have also approved the Annual Operative Plan (POA) alongside with the Isags’ Detailed Budget for the year 2013, through the resolution CSS 07/12. On the following day, Minister Esperanza Martínez, as President Pro Tempore of Unasur’s Health Council, presided the General Session of the WHA for the debates coordination. On the behalf of Unasur, she fostered the discussion on a Unasur’s resolution proposal to the “Consultative Expert Working Group on Research and Development: Financing and Coordination” - CEWG. She also intervened as a bloc in the WHO Reform debate. At this moment, some of the countries that were scheduled to have their speech offered their time so that the speech prepared by the Pro Tempore Presidency could be read entirely. The Paraguayan delegation highlighted that the discussions focus has been directed to disease as opposed to the promotion of health, which could represent a step back concerning the
Social Determinants of Health principles currently adopted by the member-countries of WHO. She suggested that another category be included about “Equity in Health, Sustainable Development and Social, Economic and Cultural Determinants”. Argentina has defended the strengthening of the World Health Governance as a priority of the WHO Reform. The country highlighted the issue has not been debated fully. As to the schedule of the discussions, Argentina has suggested that the Regional Committees issue be the starting point of the meeting, in order to make sure a bottom-up process is carried out. The country also suggested that Information technology and communication be used. The Argentine intervention highlighted the need for a careful discussion about the interaction with NGOs, private entities and other organizations, so WHO’s fundamental principles and its intergovernmental character are preserved. According to the country’s representative, this is what precisely legitimizes WHO as the maximum authority in health. Chile and Ecuador also highlighted this issue. The delegation of Chile expressed its concern with the mechanisms for managing conflicts of interest, especially those of an institutional nature. In Unasur’s intervention before the “Consultative Expert Working Group on Research and Development: Financing and Coordination”, the bloc celebrated the
conclusion that the intellectual property system does not generate incentives to the research and development needs of medicines that are used in treating illnesses affecting developing countries. It also supported the Expert Group proposal of negotiating an agreement to meet these necessities. In the speech, Unasur requested the Director-General to convene member-countries to put into practice the Expert Group proposals, to seek consensus and to present a progress report of the Executive Board at the next World Health Assembly. Unasur also encouraged the implementation of hedging mechanisms in order to foster research and development. Also on the behalf of Unasur, the Paraguayan Delegation presented a project to ensure global access to safe and effective drugs, a dimension of the fundamental right to health. It also made an intervention in the Non-Communicable Diseases debate, defending that a priority be set to this kind of disease in health public policies. According to Ivan Allende, Paraguayan representative and a member of the Unasur’s Ministers’ Council Technical Group of Health Surveillance, the Non-Communicable diseases are a priority to South American countries. The Paraguayan delegation also made interventions in the debates about women and children´s health, visual disability and mental disorders. Argentina was praised by Dr. Margaret Chan for its leadership in regulation and control of medical and pharmaceutical products. “It is an
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experience that will be, doubtlessly, replicated by other countries”, she said. Argentina’s Vice-Health Minister Eduardo Bustos Villar thanked the acknowledgement and required that his country be considered to host an international meeting about this issue. In April, Unasur’s Health Council had endorsed the Argentine proposal to the creation of an integrated mechanism within WHO to address the prevention and combat low quality or counterfeit medical products. In his speech, Brazil’s Minister of Health, Alexandre Padilha, also addressed 65th WHA as a representative of a Unasur country. He appealed to the Director-General in favor of the WHO Reform. Padilha invited the WHA participants to join the UN Conference on Sustainable Development, Rio+20. WHO REFORM The current World Health Organization Reform process was triggered in 2010 when the Director-General Margaret Chan consulted a group of experts about the new role of the organization. However, the discussion only reached the World Health Assembly a year later, in its 64th edition. A consensus was attained among member-countries about the need to Reform. In November 2011 and January 2012, the Executive Board gathered to discuss the proposals that should be considered at the 65th WHA. The entry of new actors and initiatives as stakeholders in the WHO has stimulated the Reform discussion, because of the expansion of the organization’s role without a corresponding increase in its budget. The situation was aggravated by the financial crisis since 2008. Key Points of the Reform Various key points of the Reform were on the 65th WHA agenda. These points were based in documents like “WHO Reform: DirectorGeneral Consolidated Report” (Document A65/05), that present the proposal’s general terms. In the reference documents, 3 pivoting points were presented: 1) Programmes and Priority Setting The categories and criteria to evaluate the first pivoting point will be also used to elaborate the 12th General Programme of Work and the programmes’ budget. It will define a group of high-level results to be attained between 2014 and 2019. The Assembly would be in charge of defining positions to prepare the mentioned programme. CRITERIA 1- The current Health Situation 2- Needs of individual countries for WHO support 3- Internationally agreed Instruments 4- Evidence-based and cost-effective interventions 5- The comparative advantage of WHO
CATEGORIES 1- Communicable diseases 2- Noncommunicable diseases 3- Health Promotion through the life course 4- Health Systems 5- Preparedness, surveillance and response 2) Governance In its extraordinary meeting in November 2011, the Executive Board established principles about the governance issue: a) multilateral and inclusive process; b) maximum usage of WHO’s existing mechanisms and structures; c) The General Programme of Work must provide guidance to the decision-making bodies; d) collaboration with third-parties must consider the importance of intergovernmental decisions and that WHO activities must be protected from conflicts of interest. Moreover, it established the search for democratizing means of governance as a priority. Changes in the annual meeting’s schedule of the decision-making bodies were also considered important in order to enhance governance and improve the performance of each one. The Regional Committees are key components of governance. However, there are no efficient communication mechanisms between them and the Board. In order to inform regional positions and to expose issues of their agenda, summed up reports are necessary. Harmonizing aspects of regional governance is also relevant, because it allows for solid legal practices, accountability and transparency. Decision point 5 is precisely about the relationship between the Regional Committees and the nomination of its directors; the examination of their credentials and the participation of observers. The new PBAC (Programme, Budget and Administration Committee of the Executive Board) mandate was also discussed. The intention is that it deals not only with administrative matters, but also overseeing and analyzing information, and proposing guidelines and recommendations to the Executive Board about planning, monitoring and the evaluation of programmes. Moreover, the management of resolutions is Important: to prioritize points of the General Programme of Work; to diminish resolutions production; to diminish requirements concerning the presentation of resolutions report; and also to appeal more frequently to the President’s summary in case a formal resolution is necessary. The collaboration with third parties, like civil society, private entities and other governmental organizations is another point, so as to enhance the institutionalization of rules concerning the relations through consultations about the relationship between WHO and private entities, and NGOs. An assessment of agreements and proposals concerning the harmonization of works with the established
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WHO The WHO Constitution was adopted in 1946 by 61 countries during the International Health Conference, held in New York City. It came into effect in 1948, when the 1st WHA was held and the member-countries established the priorities of the new organization: malaria, maternal-child health, tuberculosis, venereal diseases, nutrition and environmental sanitation. Since then, the organization has been acting upon these and many other issues – like HIV/AIDS, tobacco control and revision of the International Health Regulations – meaning to make sure every person obtains the best level of health possible. In its Constitution, there are 9 principles and 22 functions that are hardly questioned of their present relevance, though they were established in the 1940s. Some amendments were made in 1977, 1984, 1994 and 2005. They can be found in the Basic Documents series of 2006. The principles of WHO include, among others: a) the inclusion of a broader definition of health; b) health as a fundamental right of the human being and the role of the State in ensuring it; c) the importance of peace and safety for health; d) the importance of information to achieve health. One of its most important functions is its mandate as an international health authority. It also collaborates with governments and specialized agencies; provides technical assistance; proposes conventions, agreements, regulations and recommendations in international health. Structure WHO’s structure is composed by the World Health Assembly, the Executive Board and the Secretariat. The Assembly consists of the member-countries’ delegates and meets annually. Extra sessions are possible in case it is necessary. Its main functions are: a) to determine WHO policies; b) to make recommendations to the Board and the Director-General about health issues; c) to oversee WHO’s financial policy, review and approve its budget; to consider recommendations of the General Assembly and other UN Councils. WHA is allowed to establish regional organizations, which are part of WHO and are composed of a Regional Committee and a Regional Office, which functions are, among others, to formulate regional policies; to propose conferences; and to cooperate with regional committees from the UN, specialized institutions and international regional organizations. The Executive Board meets twice a year and is made of 34 representatives assigned by the member-States. An equitable geographic distribution is taken into consideration. Moreover, the Board is able to create and abolish Committees serving any of the Organization’s purpose. This forum is responsible for: a) carrying out the decisions and policies approved by the Assembly; b) acting as an executive body of the Assembly; c) preparing its agenda; b) providing guidance to the Assembly in issues concerning the conventions, agreements and regulations. The third instance is the Secretariat, which includes the Director-General and the technical and administrative personnel. The Director-General prepares and submits independent and impartial financial reports and budgetary estimates to the Board.
alliances will be elaborated and considered by the Board in January 2013. Maria Luísa Escorel, Brazilian diplomat to Geneva that spoke about the WHO Reform at the Workshop on Global Health and Health Diplomacy in Isags, mentioned the central role Global Governance plays in the debates.
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According to her, there are proposals like the creation of a Committee C at WHA to establish dialog with third parties; and the creation of a World Health Forum that would count with the participation of NGOs, the private sector, foundations, etc. Many countries resist to these proposals. Escorel understands the modernization cannot take place in detriment to the values and principles that guided WHO’s foundation. The Reform should result in the empowerment of the organization as an a UN agency of excellence in conducting, articulating and integrating health initiatives. 3) Management Reform In relation to management, the Executive Board has established the following guidelines: a) efficiency, alignment, and institutional effectiveness; b) finance; c) politics and management of human resources; d) planning, management and accountability based on results; and e) strategic communication. The necessities present in this subject are the increase of predictability and flexibility of resources; the setting of a fund regarding unpredictable spending; a project to set an official policy of evaluation, etc. There is also a demand that the work of WHO give more importance to actions related the Social Determinants of Health. Another point that should be discussed is the technical and normative support to member states. One of the strategies is to improve the selection process of the regional office directors and implement periodic evaluation and qualification. Another point involves actions on three levels of the organization, with technical support and cooperation; implementation of strategies and norms; political, administrative and management exchange assessment, and knowledge development, among others. Besides that, there is a proposal of investment in personnel so it meets the necessities of the organization and that presents flexibility regarding budget contingency, enhancing the hiring methods and impartiality, transparency and equality of conditions; as well as bettering existing contracts. It is also proposed that the organization should extend the mobility of the personnel in order to serve a wider range of areas, to better serve with human resources areas that show more necessity. The financial planning should be articulated with actions and expected results – a mechanism of resource designation to be used by the budget project of programs to enhance the agreement between the objectives and financial resources. Another proposal is the creation of an internal control framework to direct all activities that involve financial consequences, with the documentation of norms and procedures, by defining the norms and responsibilities, surveillance of the application of such norms, and the creation of a solid culture of accountability. What was previously attained at the 65th WHA was an updated version of the WHO manuals
and a new spreadsheet of internal administration and management procedures. Moreover, after the selection of priority cases, a new panel bound to the Global Management System was created to attend to the procedures. A framework of financial accountability will also be elaborated, interlacing authorities, end-results and responsibilities. Risk management will set frameworks in areas such as institutional risks, financial loss, and loss of trust in a member-state or incidents that may disturb the functioning of the Organization. Another important aspect regards conflict of interest, and is approached by three aspects: employees; specialists; and interaction with third parties. The latter must be coordinated and supervised by the Ethics Office – established to empower the ethical supervision of personnel conduct. This office will centralize functions and assessments that currently are divided into different departments. It will have the duty of producing knowledge related the norms of ethical conduct and commercial practice; elaborating a Code of Ethics; assessing and orienting all levels of the organization by promoting the Code of Ethics; and will be responsible for management planning, execution and presentation of the investigation informs related to possible breach of conduct and infractions. Besides that, a project of a policy of information dissemination will be presented on the next Executive Board meeting scheduled for January 2013. This evaluation policy will encourage the creation of a ‘culture’ and its implementation in all the Organization, which includes the constitution of a unified institutional framework that evaluates all three levels of the WHO. To be established, the evaluation must: a) become an essential component – properly funded – of the planning of the operational headquarters, regional offices and teams of each country; b) enhance and promote the application of a quality control system capable of using auxiliary instruments such as solid guidelines regarding evaluations and methods based on data, results, recommendations, lists of external specialist, and the analysis of experiences and extracted teachings; c) be a coordinated method that eases the promotion of evaluation in all levels of the organization. Results of the 1st phase of Independent Evaluation One of the management reform issues, the independent evaluation had its first phase presented at the 65th WHA. A draft of the 12th general programme of work was also presented. The document, elaborated to be presented at the 65th WHA, considered satisfactory the methodology used to approach new financial challenges and the organizations challenges of adaptation to a new global situation. Even though the reform was initiated due to financial problems, it has expanded towards other areas of the institution.
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It has been identified that the strengthening of government mechanisms and financial adaptation needs widening. The identified financial challenges and the approach were considered adequate, but points such as financial flexibility and protection of WHO regarding the fluctuation of currency need more work, making it necessary the creation of a well-designed mechanism of resource mobilization in the general programme of work. The report considers the area of accountability and transparency as the driving force of the reform, which means enhancing the level of detailment in responses regarding the identified synergy challenges among different levels of governance. Regarding global health governance, the proposals were considered ambitious. Therefore, more work has to be done prior to its presentation before the Executive Board in 2013. The evaluation found it necessary that WHO organizes a map of areas that were in accordance to the Executive Board, such as to the establishment of priorities. The potential challenges and components must be considered to set the appropriate strategies, and results and goals should be identified to make decisions. Other recommendations made by the evaluators: a) Create links between the headquarter governance mechanisms and the offices b) Redesign the structures of accountability and responsibility c) Detail strategies focused on each country in the Plan of Action d) Elaborate a Plan of Advocacy and a detailed Plan of Management after receiving the authorities proposals e) Identify expected results, select indicators and elaborate a monitoring and feedback mechanism f) Construct a plan set by priorities to allow a gradual reform g) Take into consideration Human Resource policies of organizations similar to the WHO h) Maintain regular flow of communication with those interested in the reform i) Create independence between the Reform components, avoiding its compartimentalization The next phase of evaluation will serve as a subsidy to the next reform, predicted to be presented at the 66th WHA, in 2013, when the 12th Programme of Work will be discussed. GLOBAL HEALTH AND HEALTH DIPLOMACY WORKSHOPS – ISAGS/UNASUR Various aspects of WHO’s reform were also discussed during the Global Health and Health Diplomacy Workshop, held at the South American Institute of Government in Health (ISAGS) headquarter in Rio de Janeiro, Brazil, between the 7th and 11th of May 2012. Representatives of International Advisories of diverse Health Ministries and diplomats of member countries of Unasur participated in the discussions. Maria Luisa Escorel approached the funding problem faced by WHO. According to her, only
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25% of the organizations budget comes from countries’ regular contributions. And most of it is directed to personnel expenses. The other 75% are made of voluntary contributions such as the Bill and Melinda Foundation, the biggest WHO doners. According to Patricia Gonzales, International Advisor of Ecuador’s Health Ministry, it is necessary to align the voluntary contributions alongside WHO’s guidelines – taking care not to instigate the opposite. Juan Garay, Health Coordinator of the European General Development Committee, added: “It is impossible to consider governability with only 25% of fixed contributions”, alerting that this characteristic tends to drive these voluntary donations of NGOs and individual donors towards previously oriented themes and programmes of the WHO. Henri Jouval alerted that the funding, after the 90’s, was mostly directed to single issue funds such as UNAIDS and in detriment of multilateral agencies. Escorel also criticized the rush regarding the conduction of the reform. According to her, the attempts to include the word “gradual” were rejected. “It’s a power struggle” says Escorel, pointing out that the countries that donate the most, and that already have an articulated position, are the ones that are most interested in the reform. Another point she criticizes is the diminishment of the concept of “health and development” from the table of discussions. Brazil’s National Coordinator of Unasur, Paulo Buss, has commented that social health production is being contemplated within the prioritized categories – only the rupture of biological normality. He suggests that category 1, 2, and 5 should fuse into one under the name of Health Surveillance, and that a 6th category should be added addressing the theme of health, development and social health determinants. Cesar Cabral, Paraguayan representative of the Pro-Tempore presidency, understands the reform as shallow, a simple makeover. He points out to the fact that the 12th General Plan’s 2014 budget was approved before the evaluation of the Millennium Goals, in 2015. In the end, the necessity of placing in the WHO’s reform issues that take into consideration actions regarding health determinants emerged as a consensus between the participants. The position of other international actors Other international actors have also positioned themselves regarding WHO’s reform. In the 51th Directing Council meeting of PAHO in 2011, Minister Esperanza Martinez indicated that the reform should focus on its leadership role and on the enhancement of its performance as a global sanitary authority. On the 2011 Report of Médicos Del Mundo – an organization set in Spain that works with populations in critical conditions of poverty, inequity of gender, and social exclusion – it is pointed out that the reform begun before the conclusion of the independent evaluation.
According to the NGO’s report, the funding of WHO by for-profit organizations could generate a conflict of interests incompatible with WHO’s objectives. Ilona Kickbusch, programme director of the Global Health Institute of International Higher Studies of the University of Geneva, in a interview with Le Temps, pointed out that the organization has neglected innumerous non transmissible diseases such as diabetes and mental illness’. According to her, the support of the private sector is very important, but must be transparent. Regarding the creation of a Global Health Forum, the researcher believes that it is a possibility that the member-states should know where each of the other parties stands in relation to sanitary issues. At the Global Health Europe Workshop that took place in the European Health Forum, in 2011, Dr. Mihàly Kökény, member of the Executive Board of WHO, stated that the support towards the Reform by member-countries only takes place when their interest is not affected. To him, there must be a balance in the manner that non-government third parties participate in the organization, but does not believe in the creation of a World Health Forum. According to the Forum’s final report, Dr. Kökény recognized that it will be a long process of Reform, a process of adaptation to an environment in constant change. To Buss, the UN system lacks in transparency as a whole, and WHO is no exception. “We don’t want it to be, and it can’t be, a cosmetic reform”, says Buss in an interview to the ENSP (National School of Public Health, Brazil) report. The BRICS, in the Beijing Declaration, also mentioned transparency as an objective to aim for in the organization, side by side with efficiency and responsibility. Measures that serve to such objectives, according to the bloc, should include “a focus in core business, strengthening of the mobilization in financing resources, and the reinforcement of communication strategies”. At an interview to IPS, specialist Germán Velásquez, who worked in the executive branch of WHO two years ago, suggested the application of a progressive plan to recover the public aspect of the agency so that all Health ministers could regain power and establish priorities. The Strategic Director of WHO, Andrew Cassels, by its turn, gave credit to the fact that “all member-countries fixated objectives but only responded to 20% of the budget, which are part of their shared quota.” The Delhi Declaration, subscribed by 21 non-governmental organizations related to health, stated that “the fast emergence of new actors highlighted the health issues and shaped the global agenda, but also contributed to the fragmentation of the agenda”, influencing the “injection of market principles in areas estrange to it”. According to the Declaration, this move contributed to the institutional weakening of the World Health Organization, with controversial implications. In this order, the
MANAGEMENT OF INFORMATION AND KNOWLEDGE Coordinator: André Lobato. Advisors: Amaro Grassi, Flávia Bueno, João Inada e Manoel Giffoni comunicacao@isags-unasur.org
organization should “rediscover its fundamental multilateral identity and rise to the role of global actor with a wider scope of governance in the health sector”, although it alerts to the fact that member-countries should also do their homework, enhancing the way they govern their own health systems.
ISAGS Isags’ Annual Operative Plan and the Detailed Budget was approved during the Health Council’s Extraordinary Meeting, that took place parallel to the 65th WHA, through resolution CSS 07/12. In the meeting, Chief of Staff Mariana Faria was representing Isags’ Director, José Gomes Temporão, and said that “it is clearer and clearer that Isags is no longer a project fostered by Brazil, but an institute with a South American identity”. In the Plan presentation before the ministers of the member-countries, Faria reminded them that “Isags is an institute of 12 countries” since the Health Council’s 6th Meeting carried out on April 20th. According to her, this partnership “is dedicated to the construction of a more equitable world, based in the concepts of trust, mutual respect and solidarity”. Isags’ technical staff was praised by Uruguay’s Health Minister Jorge Venegas for “the excellent job done”. Venegas stated still that the institute is “a massive achievement for all the countries” and found the Plan in absolute conformance with what the countries are developing as a goal of public and universal health. Eduardo Bustos Villar, Argentine Health Vice-Minister, stated that Isags’ Operative Plan is not “a responsibility of Isags only, but of us all, in order to achieve the totality of objectives”. In addition, he warned that the Operative Plan is limited to 2013, so it is necessary to think of the institute’s sustainability beyond this timeframe. He invited Isags to “convene us to regular meetings and to appoint setbacks and advancements”. To complete its process of institutionalization, Isags has to undergo two different processes: one in Brazil and another within Unasur’s structure. In Brazil, the President and the National Congress must approve the agreement signed by Health Minister Alexandre Padilha and Unasur’s Secretary-General Maria Emma Mejía. Within Unasur, the Delegates Council must still submit all of Isags’ documentation to the consideration of the Foreign Affairs Ministers Council.