Geneva Health Forum Archive

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GHF2010 – PS10 – WHO and Global Health Governance

Session Outline

Parallel session PS10, Tuesday, April 20 2010, 16:00-17:30, Room 3
Chair(s):  Sisule F. Musungu, President, IQsensato, Switzerland
Summary: According to the Constitution of WHO, the first function of the Organization is to act as the directing and coordinating authority on international health work. Owing to the gradual influx of various partners in the health arena, WHO, although remaining important, has seemingly lost its preeminent leading role. Several former WHO staff, not excluding others, have pondered about the current situation and would try to indicate some broad policy changes for WHO. These opinions are offered constructively and are based on the deep loyalty they feel towards the Organization.
Towards a Slimmer WHO: Redefining Functions by Concentrating on its Normative Role, Leaving Service Delivery to Others? 
Dev Ray, President, Association of former WHO Staff & previously Chief, WHO Governing Bodies, Switzerland
Tuning WHO Interventions to Needs of Countries: Can Support Be Fine-Tuned Based on Intrinsic Country Differences? 
Fernando Antezana, previously Chairman of WHO Executive Board (2006) & Deputy Director-General of WHO, Switzerland, former Minister of Health of Bolivia
WHO and Public-Private Partnerships: Have Partnerships Proved Beneficial in the Long Run?
Yves Beigbeder, previously WHO Legal Expert in the Human Resources Department, Switzerland

Session Document

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Session Report

Submitted by: Anne Descours (ICVolunteers); Contributors: Christoph Wirth (ICVolunteers)

Public-Private Partnerships are of increasing importance for entities such as the World Health Organization. Exhibition booth at the Geneva Health Forum 2010. Photo by V. Krebs, ICVolunteers.org

The primary mission of the World Health Organisation (WHO) is to provide global health governance. But with an increasing number of powerful stakeholders in the health arena, the WHO has lost its leading role. A panel of former staff members try to analyse why and to propose changes and solutions.

President of the former WHO staff, Dev Ray, thinks that the World Health Organization (WHO) should slim down and revert to its normative role. The size of the WHO’s management staff as well as the volume of paper it publishes has dramatically increased in the last decades, while the influence of a few rich countries has been increased. Yet the WHO’s mission is to serve countries, not itself. Moreover the number of actors in funding health programmes has increased and private donors have poured huge amounts of money into the WHO. Whereas a few decades ago, 20% of funds were coming from voluntary donors and 80% from governments, the reverse is now true. This has led to a lack of transparency and a will to please donors instead of an orientation towards results. To re-establish its leading role in health, the WHO should now concentrate on its primary mission of concentrating on people’s needs and setting international standards and rules. Voluntary contributions should be rejected when they are not flexible. A monitoring and evaluation system should be developed within the organisation to understand where it has failed.

Fernando Antezana has been Chairman of the WHO’s executive Board and Minister of Health of Bolivia. With the benefit of both viewpoints, he raised the question of the adaptability of WHO interventions to the needs of individual countries. Several issues come to his mind. Each country and even each community has its own agenda and has problems adjusting to external agendas imposed by private donors. WHO’s executive board, which meets only twice a year, is busy with an increasing amount of paperwork instead of focusing on taking decisions. Finally, there are huge discrepancies in the specialisation and number of delegates in individual countries. The WHO needs more collaboration centres to come back to its normative function and these should always be based in developed countries. Teams should be limited and represent many sectors.

A former legal expert from the WHO’s human resources department, Yves Beigbeder reported on the recent tendency for the WHO to use Public-Private Partnerships (PPPs). After Kofi Annan opened the UN to the private sector, the WHO saw the number and variety of its partners growing: pharmaceutical companies, the World Bank and business-related foundations have joined the traditional partners of governments and NGOs. Private-public partnerships help to tackle successfully a number of diseases thanks to more funding, a wider expertise, increased R&D and increased production capacity. On the other hand, the primary mission of the WHO has been taken over by others and it is more and more difficult for the WHO to impose public health standardisation onto companies on which it depends. This has cast doubt on the neutrality of the WHO. Public-private partnerships will stay, but to better manage them there is a need for independent assessment and better regulation. The ratio of public/private funds has to come back to a more reasonable one. These efforts are compulsory for the WHO to keep its identity and integrity.

Many questions remain because of the complexity of the problem. Is it even possible for the WHO to regain its leading role? This topic has to be discussed within the WHO itself and solutions have to be found.

GHF2010 – PS30 – Foreign Policy, Trade and Health: Finding The Right Balance

Session Outline

Parallel session PS30, Monday, April 19 2010, 16:00-17:30, Room 13
Chair(s): Nick Drager, Senior Fellow, Global Health Programme, Graduate Institute for International and Development Studies, Switzerland
Discussant: John Hancock, Counsellor, Economic Research Division, World Trade Organization, Switzerland
Summary: There is a growing realization that public health may be affected by trade and the rules set out in international trade agreements. Trade can affect health both positively and negatively. In particular, the increasing liberalization of trade in health services creates new opportunities while posing new challenges for the efficient, equitable and sustainable provision of health services. Many countries have undertaken extensive analysis of these issues, and have gained experience in implementing policies to steer developments in the desired direction. Meanwhile, other countries still struggle to find an entry point for dealing with these often complex and unfamiliar issues that require both knowledge and analytical capacities to understand them. In 2006, the World Health Assembly adopted a resolution on international trade and health, which calls on Member States to ensure that health and trade are balanced. It also highlights the need for capacity building to increase understanding of the health implications of trade and trade agreements. To support national governments in their effort to develop coherent policies on trade and health, WHO, in collaboration with WTO, and country partners are developing a toolkit to assess implications of trade and trade agreements for health. This tool is expected to be available by the end of 2010. Drawing on the experiences of two countries, this session brings together experts actively involved in the development of the toolkit. It presents the new instrument and how it will eventually inform policies and strategies in trade and health, helping countries to identify their capacity building needs in this area.
Shifting Territory: Trade Agreements and the Making of Health Policy in Barbados
Jamila Headley, Department of Public Health, University of Oxford, United Kingdom
Cart before the Horse: A Sri Lankan Experience of Negotiating Trade in Health Services
Manuj Weerasinghe, Senior Lecturer, Department of Community Medicine, Faculty of Medicine, University of Colombo, Sri Lanka
Introduction to the WHO Trade and Health Assessment Tool Kit
Chantal Blouin, Associate Director, Centre for Trade Policy and Law, Carleton University/University of Ottawa, Canada

Session Document

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Session Report

Photo by John Brownlee, ICVolunteers.org

Dr Nick Drager, chair of the Foreign Policy, Trade and Health session led an impromptu seminar on Global Health Diplomacy and Development, as none of the other speakers or presenters could attend the session. The focus of his presentation was on health diplomacy and the health care system. He discussed the changing policy environment, the development of new instruments, national foreign policy and health, and national global health strategies.

Dr. Drager's discussion on the changing policy environment covered the huge economic impact of infectious disease outbreaks; he cited the high economic cost of SARS versus the relatively small medical cost. In the past, the World Health Organization (WHO) had to rely on countries reporting any outbreak of a communicable disease before it could act; now, WHO has the Strategic Health Operations Centre (SHOC). Every morning, the SHOC meets to trawl through rumours, seeking the truth behind statements received from a number of sources from around the world. SHOC's task includes the verification of disease outbreaks.

A London-based school has been tasked with identifying key emerging issues in health care systems, as well as the top five non-health sector priorities that will affect health. Its work identified the key emerging issues as 1) the sharing of viruses and biological specimens for the development of vaccines; 2) diagnostics and medications; 3) anti-biotic resistance; 4) intellectual property, innovation, access to medicines; and 5) trade in health services. Dr. Drager stated that "developing countries are tired of giving up their specimens and having medicines created that they cannot afford". The school also identified the non-health sector issues as water, food, energy, climate change and population growth, factors that the speaker emphasised as key policy challenges for governments.

Dr. Drager then jumped into a discussion on the collaboration between the WHO and World Trade Organization (WTO). When delegations make official visits abroad, they are accompanied by delegates from the WHO and WTO. Initially this promotes greater access to key officials, but in fact complies with the rising crossover between health and trade. To illustrate his point, Dr. Drager presented a case study on Vietnam and its accession to the WTO. He pointed out that Vietnam had had to resolve specific health issues, such as infectious disease control, by complying with WTO trade accords.

The discussion continued about the risks and opportunities associated with trade in health services. The speaker sees trade as a key determinant of health, and the WTO Trade Related Aspects of Intellectual Property Rights Agreement (TRIPS) could exceed the importance of, for example, universal access to drugs. He noted that significant risks are associated with trade in health services, but they could be outweighed if the key questions were satisfied: lower costs, increased quality of care and increased access to care.

Regime design within the global health domain is another important factor for an equitable system. As evidence, Dr. Drager cited Indonesia’s reluctance to hand over specimens of the H5N1 virus. Indonesia, with the support of others, had rightly questioned the pressure to hand over their biological specimens. They knew that no benefit for their country would be derived from doing so, and argued that by putting the risk to global public health first they would be endangering their own population. Since the H5N1 epidemic, three years of negotiation were necessary to establish a more equitable and binding system of instruments. Although the negotiations are ongoing, talks have been stalled on three issues: intellectual property; whether benefits should be mandatory or voluntary; and trade policy.

In his description of the current range of WHO instruments, Dr. Drager questioned how future instruments and governance procedures should look. Drawing an analogy with the World Trade Organization (WTO) complaint procedure, he noted that governance procedures might have to include an enforcement system. He also pointed out the need to understand the interaction between instruments, to research the effectiveness of binding and non-binding instruments, and to develop a set of measurable criteria to evaluate their effectiveness. Negotiations, he added, were the key to developing instruments to stimulate national action and international cooperation.

The last topic addressed was the increasingly collaborative nature of foreign policy and the need to develop a global health policy. Today, global health touches on all the core functions of foreign policy, and some countries are preparing their diplomats to work in the field of global health strategy. A comprehensive United Nations General Assembly resolution has put ‘Global Health Foreign Policy’ on the international agenda.

Several countries are developing their global health strategies, and Dr. Drager presented the benefits at the national level. To identify priority areas for action, he said, would be the first step in the development of a strategy. The process will inevitably be a long one.

GHF2012 – LS06 – National & Global Non-Communicable Diseases Platforms: The Best Way Forward

Session Outline

This session is organized in partnership with Global Health Europe
Lunch session LS06, Friday, April 20 2012, 12:30-14:00, Room 2
The  recent UN High level meeting on non communicable diseases (NCDs) and the  ensuing Political Declaration on the Prevention and Control of NCDs  acknowledged the NCD epidemic and its impact upon both developed and  developing countries.  The WHO has  developed an action plan for NCDs and is establishing a monitoring and  evaluation framework by the end of 2012. Many questions arise as to the best  way forward for the monitoring and accountability of NCD strategies.
The Political Declaration supports the inclusion of civil society including  private industry within NCD strategies and their monitoring. Internationally, there are a number of diet and physical activity ‘platforms’, which include the food and beverage industry, that aim to tackle NCD risk factors. These could provide lessons for a new international platform on NCDs. However, WHO Member States have mixed views regarding the role of the private sector within strategies and governance processes. The question arises as to whether an international platform with an oversight and monitoring role should involve private industry. In addition, many of these platforms are in developed countries and may need to be adjusted for developing country contexts. For example, investment in capacity building and resources of low income countries is necessary in order to develop accountability and monitoring mechanisms. It has also been suggested that a combination oflegislation and voluntary strategies for private industry should be considered when developing an NCD strategy – and that voluntary strategies should be used where legislative and institutional frameworks are weak. This session will consider some examples of NCD platforms and some key questions for debate on the development of NCD platforms.
Some questions to consider during this session are:
  • What are the important components of a global monitoring and accountability framework for NCDs?
  • How can countries be advised and supported to make progress on NCDs?
  • What local (national) and regional level structures need to be in place, e.g. national commissions or agencies responsible for monitoring progress?
  • How should developing countries be supported?
  • How have existing NCD platforms worked? What are some of the key lessons and challenges from these?
  • What are countries views on the involvement of the private sector? Should a platform that has an oversight and monitoring role include private industry?
  • How can private organisations be made accountable to pledges to address NCDs? What is the best way of monitoring private pledges? How can mistrust of the private sector be broken down?
Chair: Samantha Battams, Global Health Europe, Global Health Programme, Graduate Institute of International and Development Studies, Geneva, Switzerland
Gaudenz Silberschmidt, International Affairs Division, Swiss Federal Office of Public Health, Bern, Switzerland
Judith Watt, NCD Alliance, London, UK
Olivier Raynaud, World Economic Forum, Geneva, Switzerland
Ruth Veale, Environment and Safety Department, BEUC (the European Consumers’ Organisation), Brussels, Belgium
Ryoji Noritake, Health and Global Policy Institute, Tokio, Japan

Session Video

GHF2012 – PL05 – Food, Globalization & Chronic Diseases: Overcoming Policy Cacophony?

Session Outline

Plenary session PL05, Friday, April 20 2012, 09:00-10:30, Room 2
Chair: Nicolas Clark, World Health Organization, Geneva, Switzerland
Double Burden of Malnutrition: Hub in French-Speaking Africa
Helene Delisle, Department of Nutrition, University of Montreal, Montreal, Canada
The Right to an Adequate Diet: The Agriculture-Food-Health Nexus
Olivier de Schutter, United Nations Special Rapporteur on the Right to Food, Geneva, Switzerland
The Food and Beverage Industry’s Contribution to The Fight Against NCDs
Janet Voute, Nestlé S.A., Vevey, Switzerland
An Ecological Public Health Model to Reshape Food Systems: Is it still possible?
Geof Rayner, Centre for Food Policy, City University London, UK

Session Documents

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Session Videos

Olivier de Schutter - The Right to an Adequate Diet: The Agriculture-Food-Health Nexus

Front Line Health Accountability – Citizen Voices and Action: Democratizing Health in Communities

Author(s): Stefan Germann1, Jeff Hall1, Thiago Luchesi1, Itunu Kuku2
Affiliation(s): 1World Vision International, Geneva, Switzerland, 2Graduate Institute of International and Development Studies, Geneva, Switzerland
Name your project or intiative: Front line health accountability - Citizen Voices and Action (CVA) - democratizing health in communities
1st country of focus: Uganda
Additional countries of focus: Albania: Armenia: Australia: BiH: Bolivia: Cambodia: Brazil: El Salvador: Georgia:  Haiti:  India: Indonesia: Kenya: Lebanon: Malawi: Mozambique: Pakistan: Peru: Philippines: PNG: Romania: Senegal: Sierra Leone: South Africa: South Sudan: Sri Lank: Tanzania: Zambia
Relevant to the conference theme: Equity and empowerment
Summary: Health related accountability mechanisms are critical to achieve better health outcomes for the money that is spent. There has been increased global attention to this. However, unless accountability efforts occur at the front line, we will not achieve increased health outcomes of well-intended interventions. Citizen Voice and Action is an approach that aims at increasing dialogue between ordinary citizens and organisations that provide services to the public. It also aims at improving accountability from the administrative and political sections of government (both national and local) in order to improve the delivery of public services.
What challenges does your project address and why is it of importance?: Over the past year there has been a significant increase in funding for global health issues such as communicable diseases, maternal, newborn and child health and some other areas. At the same time there has been the recognition that it is not just about ‘more money for health, but as well more health for the money’. Hence, in recent years there has been an increased focus on health related accountability issues and the recent concluded Commission on Information and Accountability is a demonstration of this. Inthe public clinic of many communities the absence of basic drugs and the frequent truancy of nurses and doctors have contributed to the chronic illness and death of dozens of community members. Others travel long, painful, and expensive distances for the most basic care. The cost of lack of front line accountability, with the provision of simple feedback loops for health services, is the loss of lives seen in large numbers of still birth, maternal, neonatal and child mortality over the 60 countries that are off track to achieve the health MDGs. Frontline accountability is critical to achieve health outcomes and ensure that limited resources are delivering good results.
How have you addressed these challenges? Do you see a solution?: CVA is a local level advocacy methodology that transforms the dialogue between communities and government in order to improve services like health and education that impact the daily lives of children and their families. It works by mobilizing citizens, equipping them with tools to monitor government services, and facilitating a process to improve those services. CVA includes one preparatory phase (Organizational and Staff Preparation) and three implementation phases (Enabling Citizen Engagement; Engagement via Community Gathering and Improving Services and Influencing Policy). Before beginning Citizen Voice and Action, the following preparations are needed: • Understanding the political and social context in relation to citizen and governance issues; • Training staff, partners and stakeholders to facilitate Citizen Voice and Action within communities, recognising the broader issues that relate to citizenship and governance within their country; • Contextualizing the CVA materials. We encourage staff to adapt CVA to respond to the civil society spaces that exist and use context analysis tools to better understand the power structures in society.  Phase 2 involves the following: Enabling Citizens Engagement: This Phase builds the capacity of citizens to engage with issues of governance and provides the foundation for subsequent phases. It involves a series of processes that raise awareness on the meaning of citizenship, accountability, good governance, and human rights. Importantly, citizens learn about how human rights translate into concrete commitments by their government under national law. Phase 3: Engagement via Community gathering: ―Community Gathering describes a series of participatory processes that focus on assessing the quality of health services and identifying ways to improve their delivery. Community members who use the service, health service providers and local government officials are all invited to participate. The process is collaborative — not confrontational. Generally, nobody wants an underperforming clinic in their community, and local authorities are often eager to work with citizens to improve these essential facilities. Phase 4: Improving Services and Influencing Policy: In this phase, communities begin to implement the action plan that they created as a result of the Community Gathering process. Citizens and other stakeholders act together to influence policy at both local and higher levels. In effect, communities organize what amounts to a local level campaign, with objectives, targets, tactics, and activities designed to influence the individuals who have the power to change the situations they face at the local level. Often, communities will work with other communities to identify patterns of government failure across large geographic areas.
How do you know whether you have made a difference?: The CVA methodology is a proven approach as was demonstrated by Bjorkman and Svensson (2009) published in the Oxford Quarterly Journal of Economics in an article entitled “Power to the People”. The researchers looked at a social accountability methodology nearly identical to CVA across 50 communities in 9 districts in a randomized field experiment.  In the communities using the CVA-like methodology, they found:• a 33% drop in under-five mortality • a 20% increase in the utilization of outpatient services; • a 58% increase in the number of deliveries at clinics, • a 19% increase in the number of patients seeking antenatal care; and • a 22% increase in the number of patients seeking family planning assistance. It is important to have a strong Monitoring and Evaluation component included in the CVA work. Monitoring and support of community members and groups is necessary in order to achieve the action plans to make sure that services are improved and policy influenced. Creating long term sustainable change is not easy. It is expected that power holders and duty bearers will be responsive to the voice of citizens. Often they respond, but this is not always the case. Monitoring and support serves a number of purposes:• to motivate those carrying out the actions• to see that planned actions are happening• to see that the strategies used are effective and helping to achieve the planned action• to enable problem solving if obstacles prevent the actions from being achieved• to report back progress to the community and users of the service. Monitoring will encourage the use of regular updates, report backs and feedback loops. All of these are useful to maintain citizen interest and commitment, which is often hard to sustain. Perseverance to achieve long term, sustainable change is often difficult to maintain. Starting with ‘quick wins’ – changes that happen easily to improve the services, is a good way to encourage initial citizen action and to build momentum for longer-term action. Documenting actions taken and progress made are very important to the monitoring and support process. Those responsible for carrying out the actions, should be encouraged to keep a record of what they are doing and the responses and results of their action. Regular reporting back of progress encourages other stakeholders, participants and the general community. World Vision conducted a number of CVA evaluations, the most recent one in Uganda (Waswaga, Winterford, Walker, Mugabi &  Otim 2011).
Have you or the project mobilized others and if so, who, why and how?: Citizen Voice and Action began with pilot programmes in Uganda and Brazil in 2005 and was jointly developed between World Vision and the World Bank. In 2008, CVA expanded to additional pilots in Peru, Kenya, Zambia, India, and Armenia. Today, driven by the demand of World Vision Offices, CVA operates in 29 countries in nearly 200 project sites and is recognized as World Vision’s premier local level advocacy approach. Below Map shows the countries and number of CVA project sites per country using colour coding:  Map uploaded Map 1: A number of World Vision partner organization have started to use the CVA or similar approaches, e.g. Professor Lynn Freedman at Columbia University, Mailman School of Public Health uses in several countries similar approaches for front line health accountability.
When your donor funding runs out how will your idea continue to live?: As the approach is a citizen’s empowerment approach, the sustainability is build into the process from the beginning as the only input costs are capacity related. However, it is critical that the process is followed and sufficient time of engagement is applied to ensure that citizen’s use voice and act for change. Whilst the communities that started using CVA over 6 years ago, are still actively engaged as citizen’s to improve their public services and to keep NGOs accountable as well, it is too early to have a definite answer on long term sustainability approaches, although other citizen empowerment approaches in the field of land rights or environmental community empowerment etc have shown to be long term sustainable and do not require donor funding after a solid empowerment process had been undertaken.

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