The Survival of “Global Health” - Part One: WHO's Margaret Chan Sets the Stage
This week the nations of the world are gathered in Geneva for the sixty-sixth session of the World Health Assembly (WHA). The eight-day gathering can be thought of as the legislative proceedings of the World Health Organization (WHO), during which Ministries of Health, donors and NGOs haggle over individual words located within barely penetrable documents, often arguing through all-night sessions fueled by Swiss pizzas. The WHA is a notoriously painful experience, but it is a sort of democracy in action. Far from proportional representation, each country, from miniscule Vanuatu to behemoth China, has an equal vote. Behind the scenes lobbyists – in the form of major donors, civil society groups, various UN agencies and affiliates – urge official country delegations to consider their perspectives. And in the end, grand compromises may be reached, forcing a donor as significant as the U.S. government to buckle under to the demands of an alliance of left-leaning NGOs, BRICS countries, and perhaps an obscure group of physicians. Such things have happened.
It is the job of the WHO Director-General’s (DG) office to set the stage and tone of the WHA through carefully prepared advance documents, especially the agency’s proposed two-year budget. The political directions the DG hopes to tilt WHA members towards are best reflected in her budget outline.
Yesterday the WHA officially opened, and DG Margaret Chan entered with a strong hand. She recently started her second term of office, having run virtually unopposed – only token unsupported candidates ran in her reelection. Chan enjoys strong backing from the three most powerful members of the WHO: the U.S., U.K., and China. And though the budget of WHO is woeful, as I will show in this and subsequent blog posts this week, Chan has the power to persuade the WHA to approve new directions in Global Health through her choices in apportioning funds.
Overall, Chan’s options are limited by two factors. First, it has been more than 28 years since the members of the WHA have voted in favor of an increase in their base assessments. Essentially dues for membership, the assessments are determined through a basic algorithm nation-by-nation, roughly based on GDP. Since the member states refuse to allow their basic dues to increase, the WHO’s core budget has steadily decreased in size over the last two decades when adjusted for inflation. Moreover, the assessments are paid in US dollars, but the WHO’s Geneva operations and salaries are paid out in much-inflated Swiss francs. The second challenge to Chan’s budget stems from the 2008 financial crisis and on-going world recession: her voluntary donation pool has plummeted. Major donors, especially the U.S., have always supplemented their assessments with far more substantive donations that target specific programs or agendas. This out-sized influence on the part of key donors has always been a source of tension within both the WHA and Global Health, writ large: Most have viewed it as a necessary evil. That “evil” diminished significantly in the post-2008 economic climate and by 2010 the WHO was in dire straits. (More on that below and in subsequent blog posts.)
According to the WHO’s budget documents submitted this week to the WHA, the agency’s expenditures actually started to eclipse its revenues in 2007, and by 2010 DG Chan faced a significant deficit. About $1 billion was cut from 2011-12 spending, and the agency laid off or left unfilled about 20 percent of staff positions, mostly in its Geneva headquarters.
Chan initiated a series of reform measures against this financial background. Her reforms – long needed in general, but debated in detail – have yet to measure up to the far more sweeping changes suggested by outsiders, especially in the Chatham House process. Chan’s initiatives unfolded not only against the background of stiff financial difficulties for the WHO, but scandals surrounding the other large Geneva-based health programs, GAVI (the Global Alliance of Vaccines and Immunizers) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. Both of those organizations faced donor anger amid allegations of corruption and incompetence. Over the last five years, both have undergone significant reform in their financing and function. GAVI is now in such strong shape that its budget well exceeds that of the WHO, and the Global Fund is facing a replenishment round this fall, calling for a $15 billion package of donor support.
In her budget proposal to the WHA this week Chan reflects on the need for reform, aimed at enhancing the agency’s credibility, by promising accountability and outcomes measurement, as delineated in this flow chart:
Overall, the proposed WHO 2014-15 budget offers startling changes in the mission and direction of the agency, pushing it significantly away from infectious diseases, HIV, TB, malaria, and outbreaks, and towards addressing disabilities, diabetes, heart disease, cancer, and aging.
Chan seeks to:
- Cut infectious diseases spending by 7.9%, with HIV dropping -5.1%, TB by -10.9% and overall tropical diseases R&D (the TDR program) plummeting -52.4%.
- Increase spending on noncommunicable disease programs by +20.5%, with disabilities and rehabilitation getting the largest boost, +60%.
- Institute a programmatic approach dubbed, “Promoting Health Through the Life-Course,” which is an educational/prevention package, garnering almost a +10% increase, with the largest boost going to aging and health – an enormous +125% budget increase.
- Support health systems development and improvement – counseling governments on actions to benefit their care-giving – gets a +8.4% boost.
- Support a variety of management and leadership efforts, garnering a +10% increase.
Perhaps the most confusing budgetary dichotomy is that between preparedness and response for crises:
- The overall preparedness, surveillance and crisis management budget increases by +31.7%.
- The lion’s share of that is directed at supporting countries in their efforts to meet the surveillance and disease alert capacities outlined in the 2005 International Health Regulations (IHR). Countries were supposed to meet those guidelines by 2012, but 117 nations formally requested more time, and only thirteen fully reached all criteria on deadline. WHO would spend about $287 million to assist countries in training and development necessary to abide by the IHR.
- But the WHO will greatly reduce its own institutional capacity to respond to outbreaks, epidemics and humanitarian crises, cutting its crisis response budget by -51.4%.
The text of the proposed DG budget does little to explain why these shifts in spending, and therefore in the entire mission of the WHO, are recommended. Presumably the enormous boost in noncommunicable diseases foci reflects last year’s resolutions on the matter passed by the UN General Assembly.
But it is curious that in this final countdown to the 2015 deadline for the Millennium Development Goals the DG seeks to radically reduce spending on HIV and TB, has no specific maternal health or child development line in the primary budget (though they are in appendices), and seems confident that the MDGs can be attained without significant spending. Presumably this confidence reflects assumptions that other entities (Global Fund, GAVI, UNICEF, World Bank, USAID, Roll Back Malaria, PEPFAR) will pick up the slack.
The tuberculosis cuts are especially mysterious, as the numbers of individuals worldwide getting treatment have increased substantially over the decade, but so has incidence of multi-drug resistant TB. Worse, XDR-TB, a virtually untreatable form of the bacterial disease, can now be found all over the world, though it was nonexistent (or at least unknown) ten years ago. WHO is drastically reducing its spending on TB, and so is the world's other major donor, USAID. Due to sequestration, all US global health programs are currently experiencing a -5.1% reduction in spending, and Congress has yet to agree on a FY2014 budget. President Obama's proposed 2014 budget would cut TB programs at USAID by -19% and leaves PEPFAR-based spending stagnant. The Global Fund will not know how much money it has available to direct to TB until after its fall replenishment summit with donors. Even if the Fund attains its $15 billion target, most of its resources will go to HIV treatment, and none of the funds would be dispersed until late 2014, leaving a large potential hole in backing for TB efforts. Drug stock-outs are being experienced all over the world for TB meds, in part due to manufacturing problems. Without sufficient funds, it seems likely TB programs will muddle through with less-than-perfect drug cocktails, breeding still more strains of MDR and XDR tuberculosis. We could reach 2016 with the dismal recognition that budget shifts made this year had devastating impact on Humanity's centuries-old fight with the mycobacterium.
The budget would also seem to assume that countries, rich and poor, will meet the surveillance and response capacities of the International Health Regulations, and handle outbreaks largely on their own. The WHO response budget is slashed. In her speech opening the WHA this week Chan noted that the H7N9 influenza outbreak in China came dangerously close to pandemic stage, and that “nobody can predict” what that virus will do over the coming months. The Kingdom of Saudi Arabia has requested special discussion of the novel coronavirus (MERS) outbreak in that country, spawning a SARS-like epidemic that continues to swell at this writing. Both China and Saudi Arabia have systems in place that meet the IHR, yet each country requested outbreak assistance from the WHO.
It seems to this writer that the WHO’s decision to increase spending in noncommunicable diseases at the apparent expense of its own capacity to respond to outbreaks and epidemics is hasty. The world is not yet ready to walk away from Humanity’s war with the microbes.
Tomorrow’s Post: The Future of Global Health Funding