# 4.1 Introduction ## 4.1.1 Objectives - Define what is meant by the term 'global health institution' - Identify and describe the main features and historical origins of the key institutions contributing to global health policy - Understand the strengths and limitations of these institutions ## 4.1.2 Planning Your Study ## 4.1.3 [[Essential readings]] [[@fidlerGlobalizationPublicHealth2001]] Fidler DO (2001). The globalization of public health: the first 100 years of international health diplomacy. Bulletin of the World Health Organization 79(9):842-9. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2566654/pdf/11584732.pdf #to-read Lee K (2009). The World Health Organization. London, New York: Routledge (Chapter 1 and 2). #to-read Cueto M, Brown T, Fee E (2019). The World Health Organization: A History. Cambridge: Cambridge University Press (Chapter 11) ## 4.1.4 [[Recommended reading]] Lisk F (2010). Global Institutions and the HIV/AIDS Epidemic: Responding to an international crisis. Routledge Global Institutions Series. Routledge: Oxon. Chapter 3: 27-42. This chapter, entitled 'The Birth of the Joint United Nations Programme on HIV/AIDS (UNAIDS)', provides students with a comprehensive account of the creation of UNAIDS with a particular focus on the political challenges that were faced. The chapter also provides a useful overview of the structure of UNAIDS and discusses the roles and achievements it has made. Students are encouraged to use this reading to reflect on the role of UNAIDS (as a joint program of the United Nations) in global health policy-making - what is its' mandate, how is it governed, how does it work with other institutions and actors, what are its' benefits and limitations. Students might also wish to look up the following short commentary in The Lancet (Das, P. and Samarasekera, U. (2008). 'What next for UNAIDS?'. The Lancet. Vol.372: pp.2099-2102) as further something to consider on the role of UNAIDS in global health policy. Liverani M, Coker R (2013). Protecting Europe from diseases: from the International Sanitary Conferences to the ECDC. Journal of Health Politics, Policy, and Law 37(6):915-34. doi: 10.1215/03616878-1813772 This article reviews in historical perspective different attempts to protect the European space from diseases, from the early international sanitary conferences in the 19th century to the recent establishment of EU public health institutions. The authors show that changing modes of communicable disease control have not only reflected shifts in public health priorities and institutional developments but have also been important loci where different understandings of Europe and European political identity emerged and have been negotiated. #to-read Moon S, Sridhar D, Pate MA, Jha AK, Clinton C, Delaunay S, et al. (2015) Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response The Lancet 386, 10009: pp. 2204-222 The west African Ebola epidemic that began in 2013 exposed deep inadequacies in the response of national and international institutions raising a crucial question: what reforms are needed to mend the fragile global system for outbreak prevention and response, rebuild confidence, and prevent future disasters? To address this question, the Harvard Global Health Institute and the LSHTM jointly launched the Independent Panel on the Global Response to Ebola, involving academia, think tanks, and the civil society. This paper summarises the key conclusions of this group of experts and stakeholders. # 4.2 International Health Cooperation and Institutions - a History Epidemics have played a much greater role in shaping human existence and societies as described by the geographer and historian Jared Diamond in his popular book Guns, Germs, and Steel. For example, an epidemic of unknown disease contributed to the demise of Athenians in the Peloponnesian War. Malaria is believed to have contributed to the collapse of the Roman Empire. The Black Death that swept across Europe in the 14th century contributed to the demise of the feudal system by raising the value of peasants, who could leave their lords to seek higher wages due to vast labour shortages. Smallpox decimated the Atec empire, allowing the Spanish to subdue the survivors with little resistance. The city-state of Venice has been identified as the first to implement a consistent system of quarantine in 1348. The Venetian authorities prevented ships' captain from unloading their wares and crew for some 40 days after their arrival in the harbour in an attempt to limit the spread of plague. These practices gave rise to the term "quarantine," derived from the Italian *quaranta* (which means "forty"). Other trading states adopted similar approach, but not until the mid-19th century that any formal attempt was made at trying to develop a coordinated system of quarantine. Prompted by a widespread cholera epidemic across Europe, the first [[International Sanitary Conferences]] was convened in paris, France, in 1851. ![[CleanShot 2024-01-07 at 14.03.08.png]] ## 4.2.1 [[International Sanitary Conferences]] (1851-1944) International trade had expanded considerably. The introduction of the steamship and railway in the early 1800s meant that the delays becoming less acceptable, and so pressure was brought to bear on governments to make quarantine practices much more consistent across the board. > Between 1851 and 1938, 14 conferences were held in Paris, Rome, Vienna, Dresden, Washington DC, and Venice, to develop international agreements on how to limit the spread of infectious diseases while minimising disruption to international trade. ==These conferences comprised mostly European states, and the focus of the meetings was usually on trying to prevent the importation of what were widely perceived to be “Asian” diseases== such as cholera, plague, and yellow fever. Ultimately, however, the majority of meetings failed to produce any significant outcomes, and the first international agreement (the first International Sanitary Convention) was adopted only in 1892. Of those agreements that were signed, few were ever implemented. ## 4.2.2 [[International Office of Public Health]] or, [[Office International d'Hygiene Publique]]. Officially established in 1907 following an agreement signed in Rome by the delegates of 13 countries,namely Belgium, Brazil, Egypt, France, Great Britain, Holland, Italy, Portugal, Romania, Russia, Spain, Switzerland, and, importantly, the United States of America. The core function of OIPH was largely epidemic intelligence. The OIHP existed for 39 years until the absorption of its duties by the Interim Commission of the [[World Health Organization (WHO)]] in 1946. Due to the outbreak of the two world wars, the Office was required to temporarily suspend its work on separate occasions. In 1914, for example, the outbreak of hostilities prevented the Office from convening meetings and making progress on developing further international conventions. The Office continued to collect what information it could on disease outbreaks and publish its regular monthly bulletin, but the war understandably had an enormous impact on the quality of information that the Office was able to gather and disseminate. As we will go on to discuss soon, in the aftermath of WW1 a new rival organisation was also created - the [[Health Organisation of the League of Nations]], ==that set out to replicate many of the functions that the Office performed==. These two organisations operated side by side for almost 20 vears in an unhappy alliance. The OIHP was then once again forced to suspend its work following the outbreak of WWII in 1939, and, after the German occupation of Paris, the office temporarily moved its location. [[How does power came to be?]] [[Power asymmetry]] Perhaps the largest criticism that could be made of the OIHP was that it did not maintain a truly international spirit, given that its staff were French, the office was based in Paris, and the publications it produced were only in French. As Neville Goodman noted in his 1952 work, International health organisations and their work, "certainly this contributed to an under-estimate of its value in America and elsewhere". And so, by the time hostilities ended in 1945, moves were already well underway to dissolve the OIHP and the [[Health Organisation of the League of Nations]] in lieu of a new, universal, worldwide health organisation. ## 4.2.3 [[International Sanitary Bureau]] - [[Pan American Health Sanitary Bureau]] The ISB, which was the precursor to what is now known as the [[Pan American Health Organisation (PAHO)]], was established in 1902 following an agreement signed in Washington DC between 11 American countries. The fact that agreement to establish PAHO was originally signed in 1902, some five years before the OIHP was created, it has led some to claim that PAHO was actually the first international health organisation. ==This is inaccurate== though, as while the creation of the International Sanitary Bureau (which was the original name of PAHO) was indeed created five years before the OIHP in 1902, it should rather be described as the first ever regional intergovernmental health organisation (as opposed to an organisation such as the OIHP, which had a wider "international" scope). Importantly, it did not, nor has it ever, sought to have a mandate beyond the Americas and so it is inappropriate to describe PAHO as the first international health organisation. Core focus of ISB when it was established was to facilitate the rapid reporting of disease outbreaks throughout the Americas. To that end, the ISB sought to build technical cooperation links between countries located in north and south America. As time progressed, more and more countries applied to join the ISB, and reflecting its expanded membership, the organisation changed its name to the [[Pan American Health Sanitary Bureau]] in 1923. The following year, the PAS 18 member countries signed their second formal agreement - the [[Pan American Sanitary Code]], which provided a foundation and a set of rules for the sharing of epidemiological information and technical expertise. Given the fact that the United States had joined the OIHP in 1907, the ISB, and the later re-branded PASB, regularly shared information on disease outbreaks and control techniques with the OIHP throughout their existence. Relations with the Health Organisation of the League of Nations were somewhat strained though, principally due to the fact that the United States had refused to join with the League of Nations when it was established in 1920. ## 4.2.4 [[Health Organisation of the League of Nations]] HOLN was established in December 1920. HOLN was designed to become the new international health organisation, but due to political challenges faced by its mother institution, the League of Nations, the Health Organisation always struggled to establish itself. It is important to note that the League of Nations was created in January 1920 as result of Paris Peace Conference, which ended the First World War. In 1971 the 28th President of the United States, [[Woodrow Wilson]], gave a speech outlining a 14-point plan for peace. The final plan was the proposal to establish a league of nations that would prevent the further outbreak of war through negotiation. The premise of the league was that countries would act rationally, and that disputes could be settled reasonably through consultation and arbritration. If a compromise could not be reached, the world's leading governments would impose economic sanctions on the aggresor nation until they ceased hostilities and made reparatioins. Unfortunately, the United States' Congress rejected both Wilson's plan and the invitation to join the League. When Germany invaded Poland in 1939, the League was powerless to stop them, and the organisation collapsed. [[It was thought HOLN would subsume OIHP and become the world's primary international health organisation, but US stance prevented the merger]] Not long after the League was founded in 1919, a decision was taken to establish a health organisation which could assist in preventing the international spread of infectious diseases. It was initially thought that the new health organisation would subsume the OIHP and thereby become the world's primary international health organisation, but the dispute between the United States (US) and the League of Nations prevented this merger from occurring simply because the US was a member of the OIHP but had refused to join the League. It must be said that the OIHP leadership were not particularly thrilled at the prospect of joining HOLN, and actively resisted the proposed merger. As a result, the plans for the structure of HOLN were not finalised until 1923 after it became clear that the OIHP would remain a separate and distinct organisation. [[The structure of the HOLN was a precursor to the World Health Organization]] in that it was comprised of three main bodies - 1) the General Advisory "Health Council," which drew together members of the OIHP and HOLN to advise member states on issues pertaining to health; 2) the "Health Committee," which initially consisted of 20 members appointed by the OIHP and HOLN to serve as technical advisers; and 3) a small Secretariat to help coordinate and conduct epidemiological intelligence, health studies, and develop a range of international standards for the production of biological preparations such as vitamins, minerals, and antibiotics. Since [[HOLN's primary mission was again epidemiological intelligence, and it subsequently developed a number of links with existing offices around the world, in Singapore, Egypt, and the United Kingdom]] to help conduct surveillance and gather information on outbreaks. This work brought HOLN into direct competition with the OIHP, and tensions rose. Needless to say, the fractured nature of international cooperation in health was less than ideal, and it arguably contributed to and strengthened the case for the creation of a new single, universal health organisation. ## 4.2.5 Creation of the [[World Health Organization (WHO)]] > At the close of the Second World War, a second attemptwas made at creating a new world order, this time with the full of support and backing of the United States of America. In April 1945, the United States hosted the UN Conference on International Organisation (UNCIO) in San Francisco. It was this conference where a draft charter was drawn up and approved for a new international organisation, the United Nations. At the UN Conference on International Organisation, a draft charter was drawn up and approved for a new international organisation, the [[United Nations]]. It was at this conference, [[Brazil and China proposed to create a new, universal health organisation, to replace OIHP and HOLN. Thus, WHO was officially founded on 7th April 1948]] with the objective of attaining the highest level of health for all peoples. ## 4.2.6 Quiz 1. In what year did the [[International Sanitary Conferences]] commence? 1851 - The first International Sanitary Convention was held in 1851. The decision to hold this meeting was prompted by an outbreak of cholera that swept across Europe in 1848, and although no formal agreement was reached the meeting did pave the way for further discussions to be held and another 16 conventions and meetings were held before the World Health Organisation was created in 1948. 2. What was the name of the first international organization for health? Answer: [[International Office of Public Health]]. Although based in Europe with its headquarters located in Paris, the first international health organization was the [[Office International d’Hygiene Publique]] or OIHP that was established after the Rome Agreement of 1907. The International Sanitary Bureau, which was later renamed the Pan American Sanitary Bureau, was founded in 1902 but the focus of this organization was not international but regional. It should therefore be more accurately described as the first regional intergovernmental health organization. # 4.3 The Structure and Function of WHO > As mentioned in the last section, the World Health Organisation was officially established on 7 April 1948, when its constitution was ratified by a twenty-sixth signatory member states of the United Nations. Much of the details regarding the new universal health organisation, including its constitution, had been worked out some two years previously at an international health conference that was held in New York between June and July 1946. At that meeting, it was decided that the mandate of the new organisation, which was enshrined in Article of the WHO. The definition of health in the WHO consitution was developed by Dr. [[Brock Chisholm]] from Canada (who later became the first WHO Director-General), Dr [[Gregorio Bermann]] from Argentina, and Dr [[Szeming Sze]] from China. Chisholm was a psychiatrist and so was keen to ensure that the definition of health included mental health, and while the wording was apparently later further refined by Dr H.S. Gear from South Africa prior to its formal inclusion in the constitution, it was agreed that health needed to be more comprehensive than simply the absence of disease. The World Health Organisation is comprised of three main bodies, or organs. They are the World Health Assembly, the Executive Board, and the Secretariat. ## 4.3.1 The [[World Health Assembly (WHA)]] > WHA is the supreme decision-making body of the organisation. In this forum, decisions are made about the policies and the WHO's program of work, and where the budget for the organisation is approved. Only member states are eligible to vote in the Assembly, but other organisations can apply to become observers and may, with the permission of member states, address the Assembly on important issues relating to health. Decisions taken by the Assembly are classified as "Resolutions" and are non-binding on member states. A resolution is, however, binding on the organisation. Said another way, whereas countries have the freedom to decide on whether they will follow the recommendations or not, for the Secretariat resolutions have the same legal effect as a directive. ## 4.3.2 The Executive Board The Executive Board is comprised of 34 technical experts drawn from member states who serve 3-year terms on a rotating basis. The Executive Board is charged with giving effect to the decisions taken by the World Health Assembly. It is also responsible for setting the agenda for the next Assembly, and providing general oversight of the WHO's progress in fulfilling the requests of member states. The Board usually meets twice a year in January and immediately after the World Health Assembly in May, where reports are reviewed and resolutions are issued. ## 4.3.3 The Secretariat > The Secretariat is the name given to the professional and general administrative staff that are responsible for executing the organisation's programs and policies, and includes the general staff and the Director-General. At present, the number of staff employed by the WHO is around 8,000 people. ## 4.3.4 Structure ![[CleanShot 2024-01-07 at 15.13.53.png]] There are also country offices. The regional structure is remnant of the [[Pan American Health Sanitary Bureau]] insisted on remaining autonomous when it was proposed to merge the existing health organisations, into one single worldwide health organisation. The agreement that was struck in the late 1940s was that PASB would become the regional office of the [[World Health Organization (WHO)]] for the Americas, but it was effectively responsible for managing its own operations. This set the precedent for the other regional offices in that autonomy granted to the Americas regional office has also been extended to the other regional offices, with the consequence being that each region has the ability to determine its own policies, work programs, and budget. [[The autonomous regional office of WHO caused criticism of the WHO, that it is not a single organisation, but seven organisations working at odds]] One of the key criticisms of the WHO is that it is not one single health organisation, but rather seven organisations working at odds. In addition to this, due to various political reasons, some member states do not sit within their respective geographical areas. For example, while geographically it would make more sense for Israel to be located within the Eastern Mediterranean Regional Office along with its Arab neighbours, it is instead situated in the European Regional Office. Similarly, while Pakistan could be considered to reside in South East Asia along with India, it is instead a member of the Eastern Mediterranean office that is dominated by Muslim countries. ## 4.3.5 Functions Article 2 of the Constitution, WHO has been charged with fulfilling 22 duties and responsibilities. Because it's so diverse, in 2004, two senior legal officers of the WHO, [[Gian Luca Burci]] and [[Claude-Henri Vignes]] categorised these 22 functions under four broad themes to assist in understanding the WHO's core work: 1. Direction and coordination of international health work 2. Technical assistance in health, including conducting epidemiological and statistical surveys 3. Research in health matters 4. A normative role WHO's budget constraint limits its normative role in global public health. WHO doesn't have the money to be an implementing agency or supplement the provision of healthcare services. Rather, the WHO has played a key role in developing technical standards and regulations, establishing benchmarks, standards and guidelines in best practice and developing treaties and regulations to guide and inform state behaviour. Some of the most obvious examples of the WHO's normative role is the [[Framework Convention on Tobacco Control]], the [[International Health Regulation (IHR)]], and the International Code on marketing of Breast-milk Substitutes. ## 4.3.6 Finances As a consequence of their membership, every year countries are required to make payments to the WHO in order to help fund its activities and programs, and pay the salaries of the secretariat staff through "assessed contributions" based on country's population size and [[Gross Domestic Product (GDP)]] The regular budget has been frozen since 1982, meaning that it was capped at a certain level and has not increased since that time. A second source of income that the WHO has used to finance various programs and projects are voluntary contributions, otherwise known as "extrabudgetary funds." By 1990s, extra budgetary funds have consistently exceeded the regular budget. [[WHO extrabudgetary funds that were directed for vertical problems created coordination problems for the WHO]] While in principles this could be considered a positive development, in reality the practice has created tremendous coordination problems for the WHO. For example, the funds tend to be provided for specific, designated purposes, and this has resulted in creating a number of “vertical” programs that sit outside the WHO’s other established programs. Added to this, while it is understandable that donors would insist on openness and transparency in how their funds are spent, these vertical programs have nevertheless placed an additional administrative burden on the organisation in terms of reporting. Voluntary contributions are also inherently unreliable, dependent upon the satisfaction and/or whims of the donating government. Indeed, there have been instances where certain programs funded via voluntary contributions have had to be terminated as either the funds had dried up, political priorities had changed, or the donors had become dissatisfied in some way. ## 4.3.7 Politics and the WHO Governments have intentionally sought to use the institution as a vehicle to achieve their own strategic objectives and national interests, and as governments are both the directors and customers of the organisation, the organisation has been subject to these whims. As a result, the WHO has fluctuated over the years between demonstrating unparalleled leadership and insight, to an organisation mired in controversy. Indeed, if we look back over the history of the organisation, at various junctures we can see very clearly how power politics and political issues have impacted upon the WHO’s work. Despite this, the WHO Secretariat has continued to insist that the organisation should be considered apolitical, and simply a technical assistance agency. While the secretariat may be keen to maintain this illusion, politics is embedded in every element of the WHO’s work. [[Insulation should be designed in an ideal degree where it will not attract blame and promote effectiveness and transparency, making the IGOs both accountable and protected]] Even when the idea of the WHO was suggested in 1946, as Dr Szeming Sze, one of the initiators of the World Health Organisation later noted, “My part in the founding of WHO was 90% diplomatic and only 10% medical. It was politics all the time” (Anon 1988). We can also see how politics came to be played out in the context of the WHO both immediately prior and after the organisation was founded in 1948. The Cold War, having started in 1947, had an immediate and lasting influence on the WHO and its work for decades. [[WHO is pulled between health ideologies they should promote, between social medicine advocated by UK and Belgium versus United States' focus on individual risk factors]] Moreover, this ideological war that intermittently erupted into open hostilities, had both a series of positive and negative impacts. The first instance where this played out was in the discussion surrounding the type of medicine that the WHO should be involved in promoting. Several countries such as the United Kingdom and Belgium advocated “social medicine”, that emphasised the need to look at broader social determinants of health such as housing, nutrition, sanitation and education, whereas the United States, which had adopted a biomedical model that focused on individual risk factors, resisted the push towards social medicine within the WHO as they equated it with Socialism. Soviet Union once withdrew their membership from UN due to ideological differences. The departure allowed US to exert disproportionate influence on the WHO's agenda and work program. It took almost 15 years before the Soviet Union re-joined the WHO in 1956, but when it did, the Cold War resumed in earnest. Immediately, Soviet Union delegate to the [[World Health Assembly (WHA)]] proposed that the WHO should focus its effort on erradicating smallpox and announced that the WHO should focus its efforts on eradicating smallpox and announced that the Soviet and Cuba would donate 25 million doses of the smallpox vaccine to be used to that end. This challenge was later taken up by the United States, and keen to demonstrate its superiority over the USSR, and the US announced donations that equated to millions of dollars worth in direct funding and equipment. This Cold War-inspired one up-man-ship subsequently permitted the WHO to launch the Intensified Smallpox Eradication Program, and by 1980 was able to declare the successful eradication of one of humanity’s most devastating infectious diseases. Politics has also had a very notable impact on the WHO’s budget and the way it conducts it work. For example, when the WHO first began implementing projects and programs at the request of member states, it tended to adopt a disease-specific approach, launching a variety of programs that focused on addressing only one disease or health condition at a time. These became known as vertical programs, and while they proved beneficial at times in that they helped to build technical expertise in specific disease areas and encouraged rapid action to meet specific targets, they also had several drawbacks. [[Insights]] Vertical programs = disease-specific approach This vertical programs had drawbacks and outweighs the advantages due to administrative and reporting burdens, so WHO shift its approach to horizontal (long-term capacity building), epitomized by Primary Health Care movement that came out of a conference held in [[Alma Ata]] in 1978. The famous catch-phrase that emerged out of this meeting was “Health for All by the Year 2000”. [[Health For All by 2000 was never achieved because several prominent member states viewed the program as unrealistic and unattainable]] Of course, as mentioned on the YouTube clip, we know that this particular objective of Health For All by the Year 2000 was never achieved. In part, some of the blame for this has to be considered to lay with certain member states. As Brown, Cueto and Fee (2006) have observed, the WHO program encountered problems as soon as it was launched, principally because a number of prominent governments, agencies and individuals viewed the primary health care movement as "unrealistic" and "unattainable". The year after it was launched, a group of countries and organisations met in Bellagio, Italy, to develop "Selective Primary Health Care", that emphasised low cost interventions, effectively rolling back some of the grand claims that the WHO had previously advocated, and it was this approach that was then forced on the WHO by means of budgetary levers. As WHO influence grew and "superpower" such as US's influence diminished due to "one state, one vote" policy, low-income countries gained full control over the WHO's regular budget and begand to expand the organisation's program of work to address their interests. The increases in the WHO's regular budget meant that the assessed contributions drawn from member states also had to increase. In response, high-income countries, which were required to pay a larger share of the regular budget, moved to freeze the WHO regular budget in 1982 - a situation that has remained unchanged to the present day. Aside from the financial difficulties this decision caused, by the 1980s, the WHO's role as global health leader also began to be directly challenged on several fronts. The [[World Bank (WB)]], for instance, announced that it was prepared to begin funding health-related initiatives. #to-read Dr. [[Gro Harlem Brundtland]], WHO's 5th Director-General, previously served not only as a medical doctor, but also former Prime Minister of Norway, but also the Commissioner for the World Commission on the Environment and Development. Her work in the Commission in particular, which eventually became known as the Brundtland Commission, was highly regarded and Brudntland's election on a promise of reforming the WHO was widely welcomed. Her term only lasted for five years, but she made a number of very impressive achievements, such as [[Framework Convention on Tobacco Control]], the management of the 2003 SARS outbreak, and the inclusion of health issues in the Millenium Development Goals. Through her efforts, Brundtland restored the WHO's leadership credentials in global public health. Under Brundtland, and partially in response to the reforms she initiated that restored some o the confidence of member states in the organisation, voluntary contributions by member states went through the roof, exceeding all previous years. Somewhat controversially, Brundtland also took the organization in a new direction, building several links with the private sector and industry through the promotion and creation of several major public-private partnerships. You'll be hearing more about these in later lectures, so we won't discuss them further here. Suffice to say, however, that while her tenure as Director-General was not completely free from controversy, Brundtland's reforms of the WHO re-established the confidence of its member states and the wider international community in the leadership of the WHO. More recently, however, the WHO's legitimacy was severely tested again by the epidemic outbreak of Ebola in Africa between 2014 and 2016. During the early stages of the epidemic, the organisation and its Director-General Dr Margaret Chan were criticised for not being able to lead and coordinate efficiently the global response to a complex transnational health issue, which eventually caused more than 11,000 deaths in Guinea, Liberia and Sierra Leone (Kamrad-Scott 2016). In the search for new approaches and institutional authority, in 2017 the WHO appointed as the new director-general Dr Tedros Adhanom Ghebreyesus, a former minister in Ethiopia and the first ever WHO director from the African region. ## 4.3.8 Strengths and weaknesses of the WHO The key strength of the WHO is its normative role, in agenda setting, developing standards and guidelines, and in negotiating international agreements and regulations to guide and inform state behavior. The policies and programs are determined by the [[World Health Assembly (WHA)]] which is comprised entirely of member states. Weakness: Decision-making in the Assembly is by a two-thirds majority, which is now largely controlled by the voting power of low-income countries. But it is high-income countries that largely support the WHO's work financially, and via their control of voluntary contributions, have the power to directly influence the extent of the WHO's activities. Weakness: the autonomy of regional offices of the WHO have caused a number of problems over the years in terms of coordination of activities. This regional structure is a product of history, and it is unlikely that changes will be made as it enjoys considerable political support from countries within each of the regions. # 4.4 Other UN agencies ![[CleanShot 2024-01-07 at 21.48.37.png]] ## 4.4.1 [[UNICEF]] UNICEF was born out of the ashes and destruction of World War II. It was decided that the leftover funds from the United Nations Relief and Rehabilitation Administration would be used to establish an International Children’s Emergency Fund. ==UNICEF was formally established on the 11th December 1946== at the first general assembly meeting of the newly created United Nations. ==The original mandate of UNICEF was to help displaced and refugee children deprived of shelter, health care, and food in the aftermath of World War II==. In the early 1950s, when the time came to shut down UNICEF, a lobby predominately of new nations from the developing world coalesced to save this institution and continue its mandate to help children suffering from sickness and hunger. In 1953 the United Nations general assembly made UNICEF a permanent United Nations agency. ### 4.4.1.1 UNICEF structure and finances Similar to other UN organisations. The executice board of 36 represnetatives of member states is elected every year by the UN Economic and Social Council (ECOSOC). UNICEF budget has increased steadily over time; in 2018 the total revenue was $5,235 million, funded exclusively by voluntary contributions. Two-thirds of this is from government contributions, with the remaining third is from private sector. The Secretariat is based in New York. ### 4.4.1.2 UNICEF and global health UNICEF's support for child health is in keeping with its institutional mission. In the early history, UNICEF health work focused on commodity supply, emergency relief, and specialised disease control and eradication programs. The first campaign which UNICEF was involved was in yaws eradication, which led to a 95% reduction of cases by the end of 1964. [[UNICEF moved away from the comprehensive primary care principles espoused by the Alma Ata declaration, prioritising a selective approach towards primary care interventions which created tensions with the World Health Organisation]] In the 1980s, UNICEF expanded its involvement in public health, under the new Executive Director [[James Grant]], by launching the Child Survival Resolution, which proposed to vanquish common infections of early childhood using simple medical technologies. This focused on four particular interventions labelled GOBI. - "G" growth monitoring to check for under nutrition - "O" oral rehydration to treat childhood diarrhoea - "B" breastfeeding to ensure the health of young children - "I" immunisation for six vaccine preventable deadly childhood diseases, that included tuberculosis, diphtheria, whooping cough, tetanus, polio and measles. [[The GOBI interventions, plus proactive communication work, brought UNICEF into the mainstream of global health policymaking]]. In 1984 a conference in Bellagio, Italy, led to the formation of the task force for child survival, which was a partnership between UNICEF, WHO, UNDP, World Bank and the Rockefeller Foundation. This group agreed that universal child immunisation should be the priority not just for UNICEF’s GOBI campaign but for the whole primary healthcare movement. Yet sceptics have contended that this agenda was as much influenced by UNICEF desire to raise its profile and funding base as by the health needs of children worldwide. The [[Children's Vaccine Initiative (CVI)]] – an alliance of UNICEF and other UN agencies, private foundations, and industry which was subsequently set up to support the child immunisation agenda – further illustrates how cooperation between international institutions in health can be challenging and inherhently political. In April 1990 UNICEF’s executive director James P. Grant submitted a proposal to UNICEF’s executive board, for UNICEF to dedicate 5% of its budget to applied research for vaccine development. But the idea was rejected as the majority of the board felt UNICEF was a field organisation which should concentrate on the delivery of vaccines, not vaccine-related R&D. Grant then worked with Dr James Sherry (UNICEF Chief of Health) and Dr Scott Halstead (Deputy Director of Health Services Division at Rockefeller Foundation), to build support for the proposal amongst the research and policy communities. This was a complicated and messy political process which can be read in full in a 1996 article in the Journal Social Science and Medicine by William Muraskin called ‘Origins of the Children’s Vaccine Initiative: the intellectual foundations’ (Vol.42, Issue.12). Muraskin notes how the structure of the CVI was built on very unstable foundations for various reasons. ==One important issue was that Europe that the CVI was an American initiative which would principally benefit US pharmaceutical companies and research institutes; thus, a majority vote to sign off the initial proposal could not be achieved==. Second, there were widespread perceptions that the CVI was a competitor to the WHO Programme for Vaccine Development seeing and a challenge to their activities and competencies. In particular, the decision to make CVI an independent structure outside the WHO alienated some of CVI’s original supporters who felt there was a need for one institution to have overall direction to prevent a ‘house divided against itself’ collapsing. Ultimately, the CVI is largely seen as a failure which never really got off the ground but laid some of the political groundwork to create [[GAVI]]. Relates: [[Could policymaking ever be apolitical?]], [[policy entrepreneur]], [[global health governance will increasingly be determined by economic institutions with the principle concern not of health but of market liberalisation]]. [[global health governance]] ## 4.4.2 United Nations Development Programme ([[UNDP]]) UNDP was created in 1965 via a merger between United Nations Expanded Programme of Technical Assistance and the United Nations Special Fund. UNDP has a similar governance structure with UNICEF: a Secretariat, 36-member Executive Board and country offices. [[As the lead UN development agency, UNDP is uniquely placed to help countries achieve the SDGs and develop their own solutions to global and national development challenges]]. It also serves an academic/research function with publication of the annual [[Human Development Report]], offering measurement tools and standards, analysis and policy proposals. ### 4.4.2.1 UNDP and global health UNDP plays a significant role in the coordination of UN activities. UNDP administrators chair the United Nations Development Group ([[UNDG]]). The UNDG was established by the Secretary-General in 1997. It unites the 32 UN funds, programmes, agencies, departments, and offices that play a role in development. The group’s common objective is to deliver more coherent, effective and efficient support to countries, seeking to attain internationally agreed development goals, including the Sustainable Development Goals. UNDP campaigns for efforts to achieve the SDGs and works with partners to mobilise the needed resources and capacities and to build awareness. It conducts research and dissemination to share best practices and to track progress on meeting the SDGs. At the country level it supports governments to tailor SDGs to the local contexts and address key implementation challenges. UNDP’s contribution to global health is largely via addressing the developmental aspects of health. One particular way it does this is via formal partnership with health specific actors such as UNAIDS, the Global Fund to fight HIV/AIDS, TB and Malaria, Roll Back Malaria Partnership, GAVI etc. This will be explored in greater depth in a later session of this module. UNDP is a founding cosponsor of UNAIDS and the lead UN agency for addressing the social dimensions of HIV. UNDP has also partnered with the Global Fund for HIV/AIDS, TB and Malaria since 2003 to support implementation of HIV, TB and malaria programmes in low and middle income countries. UNDP’s primary role in the Global Fund is to support national partners to strengthen capacity for making effective use of the Fund’s financing, including by leveraging governance, partnerships, procurement, financing and project management skills. ## 4.3 United Nations Joint Programme on HIV/AIDS ([[UNAIDS]]) WHO launched its Special Programme on AIDS, later renamed the Global Programme on AIDS (GPA) in 1987. However, as [[Michael Merson]] (Head of the GPA 1990-95) noted, in the early 1990s ==there was unhappiness about the performance of WHO as “people felt that the way to deal with HIV== was not just through the health sector or one UN agency, and UNAIDS was the mechanism that was recommended”. Thus, UNAIDS was created in 1996 with the mandate to place HIV/AIDS on the political agenda and to coordinate multi-sectoral response and interventions. The Programme Coordinating Board (PCB) is the main governing body of UNAIDS. Its main functions are to guide UNAIDS through its policies and priorities, to review and approve the plan of action and budget for each financial period and to review and decide upon the planning and execution of UNAIDS. There are 22 member-states grouped into constituencies based on the regional groups used in the UN General Assembly, [[ECOSOC]], and its subsidiary bodies. Specifically, UNAIDS aim to provide global leadership in response to HIV/AIDS, promote global consensus on policies, monitor trends and strengthen the capacity of national governments to develop comprehensive national strategies to promote broad-based political and social mobilisation, prevent and respond to HIV/AIDS within countries, and advocate for greater political commitment to, and adequate resources for, tackling the disease. At the time that UNAIDS was created there was little collaboration between the several UN agencies that had HIV/AIDS programmes, and advocacy and fundraising for the disease was poor. As global health scholar [[Devi Sridhar]] says, “==when UNAIDS was launched in 1996, funding for HIV/AIDS barely reached US$250 million, the disease was of low priority to donor governments, and countries affected by HIV/AIDS suffered a lack of unified institutional response==”. Relates: [[Power asymmetry]] due to HIV/AIDS being a low priority for donor governments and countries affected by HIV/AIDS hadn't had a unified response. [[Peter Piot]] was assigned as Executive Director (a position he held until 2008). As might be expected, there were some early-stage teething problems. UNAIDS was not a direct funder like the WHO Global Program on AIDS but a coordinator.. Trying to get large UN institutions and governments to cooperate was not an easy task. But over the last decade, UNAIDS has developed rapidly and played a large role in getting HIV/AIDS on the political agenda. In addition, [[Peter Piot]] fought hard to have [[NGO]] participation in the PCB. As a result, 5 NGOs (3 from developing countries, 2 from the developed countries or countries with economies in transition), are invited to participate, though they have no voting rights. This created a new norm in global health governance which has subsequently been adopted by newer global health partnerships (such as the Global Fund). [[Broader participation and transparency to enhance accountability must be followed by participation in decision-making, be it to challenge or to remedy issues]] | In this case, Peter Piot made a stride but it wasn't supposed to be enough. UNAIDS has been praised for making NGOs part of its governing body, managing to get UN agencies to work better together, and its contribution to epidemiological surveillance data on HIV/AIDS. It has also been praised for putting HIV/AIDS on the security agenda. The greatest achievement UNAIDS has made has been in raising the profile of HIV/AIDS and putting it firmly on the global political agenda. As [[Elisabeth Pisani]] says, “UNAIDS dramatically raised the profile of the epidemic, and I think it can take most of the credit for dramatically raising the funding available for prevention and treatment” (in Das and Samrasekera 2008). UNAIDS has also faced a number of constraints, some arising from its structure and others from its mandate. [[Peter Piot]] has long made the case of the exceptionalism of HIV/AIDS and the need for a significant response. However, in many ways ==UNAIDS can now be seen as victim of its own success as there are worries over donor fatigue for HIV/AIDS, as the political focus starts to shift towards health systems strengthening and political attention moves towards other global health issues== such as child and maternal health and malaria. HIV/AIDS is also a complicated and multifaceted condition with different medical, social and political factors to address. This can be challenging and some sections of the AIDS community have been critical that UNAIDS didn’t focus enough on prevention and on some sections of affected populations. Global health actors' priorities, rules, etc. are often imposed on and not aligned with the receivers (LMICs) and place a considerable burden on the health systems of those countries. As we have seen in the case above, political focus starts to shift towards other matters. This solidifes the notion that [[global health policy is the product of various material and ideational drivers]], not just who or what wield the power to decide, but how do they frame it. Some have talked of a conflict of interest in UNAIDS mandate to both be an advocate for HIV/AIDS and raise its political profile and to provide unbiased epidemiological data. Its structure also means it lacks independence from the other UN agencies involved (the so called “cosponsors”) it is trying to coordinate. It is not easy coordinating different actors with different agenda and interests and who may at times be resistant to such coordination. As is true for all actors in global health, UNAIDS faces the challenge of how it evolves in the changing landscape in order to remains the leader institutiosn in the global effort to end AIDS as a public health threat by 2030. # 4.5 [[World Trade Organization (WTO)]] After WWII, efforts were made to create an International Trade Organisation but the ==US government declined== to ratify its charter. Therefore, world trade was governed by the [[General Agreement on Tariffs and Trade (GATT)]] which was agreed in 1949. Between 1949 and 1994, GATT served as forum for discussing reductions in tariffs during several rounds of trade negotiations. The last round, the Uruguay Round lasted 8 years (1986-1994) and its conclusion led to the replacement of GATT with the World Trade Organisation (WTO) in 1995. Over time, the WTO has expanded both in membership and scope. Currently, it is an organisation with 164 member states dealing with the rules of trade in goods, services, and [[Intellectual Property Rights (IPR)]]. [[Question]] What are the main functions of the WTO? - Act as a forum for trade negotiations to establish international trade rules; - Oversee and assist member states implementing trade policies; - Settle trade disputes. WTO is slightly different from other institutions we have seen in this lecture as it doesn’t delegate power to a board of directors or the organisation’s head. Instead, the ==WTO is run directly by its member governments==. All major decisions are made by the membership as a whole, either by ministers (who meet at least once every two years – Ministerial Conference) or by their ambassadors or delegates (who meet regularly in Geneva to make decisions in the General Council and other more specific councils). Decisions are normally taken by consensus but given the technical nature of the issues, the variation in country delegation’s capacities, and the potential for side-deals, the more economically powerful countries usually get their way. ## 4.5.1 WTO and global health There are some significant barriers to public health engagement in WTO meetings and decisions. The WHO has observer status in various WOT councils, which allows WHO to contribute to WTO discussions but not to officially influence decision-making. [[Broader participation and transparency to enhance accountability must be followed by participation in decision-making, be it to challenge or to remedy issues]] [[WHO suffers from weak institutional capacity of the complex economic and trade issues negotiated in the WTO|WHO also suffers from weak institutional capacity, both in terms of manpower and technical expertise to address the complex economic and trade issues negotiated in the WTO]]. In addition, there is often limited information sharing between health and trade communities, partly because other than on specific cross-cutting issues, the areas of expertise are quite different and understanding of the links has emerged only recently. In terms of country delegations to WTO, health is not as important an issue as finance and trade and therefore given some countries’ weak delegation capacities health issues may be missed off their agenda. Lastly, there is a scarcity of monitoring and assessment of trade policies from a public-health perspective. # 4.6 Integrative activity _Read the paper 'WHO in 2002: [[Why does the world still need WHO?]]?' in your reading list._  - Write a couple of paragraphs (approximately 500 words) to outline how the changing global health landscape affects the World Health Organisation's ability to carry out its mandate.  - Consider if you think events between 2002 and the present affect the validity of the arguments in the paper. Post your responses in the forum below. After you post you will be able to see the model answer by clicking on the link below.