WHO reform: opening the floodgates to the private sector?

It is in the name of 'reform', against a backdrop of a funding crisis, that a greater collaboration between WHO and big business is being justified.  Judith Richter provides a historical overview of the process which began in 1992 with the drive for UN 'reforms', a euphemism for the neoliberal restructuring of the world body.

'Many of WHO's traditional donors face their own budgetary pressures. WHO will therefore seek to attract new donors and explore new sources of funding ... [T]he aim will be to widen WHO's resource base, for example, by drawing on ... foundations and the private and commercial sector, without compromising independence or adding to organisational fragmentation.'

'Global health policy is shaped by a wide range of stakeholders from the public, private and voluntary sectors. It is of growing importance that these voices are also heard in WHO. Being more inclusive can contribute to a stronger leadership for WHO by gathering broader-based support.'

- from 'The future of financing for WHO', a report by the WHO Director-General  (December 2010)

THE following reflections were sparked by the concern that WHO's Director-General (DG) has embarked on a 'reform' of our highest authority in international public health. This might ultimately result in trading off the 'soul' of the World Health Organisation - its decision-making processes in the public interest - against the hope of attracting more funds from profit- or neoliberal-ideology-driven actors.

I have focused much of my professional life on issues of corporate accountability and regulation, with a particular focus on the transnational pharmaceutical and infant food industries. Starting in 1998, I served as a consultant for UNICEF's Children in a Globalising World project. In the course of this project, I became increasingly concerned over the lack of attention given to conflicts of interest, and to the predictable harmful effects of public-private partnerships (PPPs) and multi-stakeholder initiatives on global health policymaking and architecture.

Several public interest NGOs and the Finnish government provided me with an opportunity to explore these issues and outline some possible solutions. In 2005, I was commissioned to summarise concerns about global health partnerships for WHO's Director-General, the late Dr Jong-wook Lee, and his Assistant Directors-General (ADGs). From 1998 until 2005, the focus of my work shifted increasingly to what is now termed 'global health governance'.

This entails questions of how to:

*   Maintain democratic principles;

*   Establish adequate and effective accountability mechanisms;

*   Safeguard public interests in 'global health governance'.

These are the issues I would like to explore in this article.

Linking private sector financing with a reform of WHO

Debates around how to fund WHO in a more predictable and sustainable way started in 2009 amidst alerts that WHO was in 'a funding crisis'. I joined these debates in May 2011, when health and pro-democracy activists drew my attention to proposals by Dr Margaret Chan, the current WHO Director-General, which threatened to make WHO even more dependent on funding from foundations and the private sector.

Particularly alarming was the fact that Chan's reports to WHO's governing bodies had begun to link fundraising from private sector sources with an 'ambitious agenda for reform'. Reform plans included a proposal to 'supplement' WHO's existing intergovernmental governing structure through 'a new forum that will bring together Member States, global health funds, development banks, partnerships, nongovernmental organisations, civil society organisations, and the private sector to address issues critical to global health'.

In March 2011, a background paper for an advisory meeting on WHO and Global Health Governance stated that: 'The Director-General has committed to convening a regular multi-stakeholder forum, which will bring together Member States, global health funds, development banks, partnerships, NGOs, civil society organisations, and the private sector. This initiative recognises the need for a more inclusive debate on all aspects of global health . Discussions at the Forum may identify new priorities, highlight neglected issues or suggest actions that might be taken by different stakeholders. Its role will be in helping to shape the future global health agenda in a way that is relevant to all, with WHO as its convener. It is therefore a mechanism for improving global health governance, without being a formal part of the governance of WHO.' (emphasis added)

At the time of the World Health Assembly in May 2011, this proposed multi-stakeholder World Health Forum had become one of the centrepieces of WHO's reform agenda. Subject to approval by this Assembly, WHO's secretariat planned to hold the first World Health Forum in late 2012 in Geneva.

WHO's member states were not enthusiastic about this plan. A number of member states complained about the lack of time to fully evaluate the Director-General's financing and reform proposals. This complaint reflected broader concerns about the way the process was being carried out. WHO Executive Board members, in their regular meeting immediately following the World Health Assembly, insisted that WHO reforms have a more 'transparent, Member-State driven and inclusive consultative process'. Civil society actors, such as the People's Health Movement (PHM) and the Democratising Global Health Coalition (DGH), pointed out that the Director-General had not adequately justified the need for a reform through a convincing contextual analysis of the problems WHO was allegedly facing.

In November 2011, at a Special Session of the Executive Board, the Director-General announced that she was abandoning the idea of the regular World Health Forum due to lack of support from member states. Nonetheless, a massive restructuring of WHO and its relationships with private sector actors continues to be promoted under terms such as 'inclusiveness' and 'widening engagement' with 'stakeholders'.

Member states can pursue alternative strategies if they want to ensure that WHO unambiguously and effectively fulfils its constitutional mandate and core functions. I will outline some of these strategies in the closing part of this article.

The WHO reform: a justified move or a continuation of neoliberal global restructuring of the UN at all costs?

WHO's proposed 'reform' is just the latest manifestation of an increasing cosiness between the UN and big business. This trend is often said to have started at the 1992 UN Conference on the Environment and Development in Rio de Janeiro. At that time, Dr Gro Harlem Brundtland influenced environmental policies in her capacity as chairperson of the World Commission on Environment and Development. Ever since, closer UN-business relationships seem to have become a leitmotif in UN reforms.

In 1997, the newly elected UN Secretary-General Kofi Annan advocated strengthening ties with the business community as a particular focus of his UN reform proposal. He launched the Global Compact initiative as the flagship of this trend at the 1999 World Economic Forum in Davos. This multi-stakeholder initiative was presented as a means to increase corporations' social responsibility with respect to nine selected principles in the field of human rights, labour and the environment.

In 1998, Brundtland, newly elected as Director-General of WHO, told member states that one of the hallmarks of her term would also be increased cooperation with the private sector under the name of public-private partnerships.

UNICEF's Executive Director at that time, Carol Bellamy, launched the Global Alliance for Vaccines and Immunisation (GAVI) at the World Economic Forum in 2000 and the Global Alliance for Improved Nutrition (GAIN) during the UN General Assembly Special Session on Children in May 2002. Both launches occurred in the presence of major financial sponsor Bill Gates, also chairman of Microsoft Corporation. Bellamy did not seem to mind the introduction of a new feature of global health initiatives under the Gates venture-philanthropy PPP model: the presence of private sector representatives on their decision-making boards from the global to the national levels.

UN leaders pushed aside any concerns over potential harmful effects of this trend towards greater collaboration with big business by issuing decrees of their inevitability. For example, Brundtland justified the restructuring of the global health arena at the 2002 World Health Assembly with the claim that there was no way to solve 'complex health problems' except through these new partnerships. She asserted, 'Whether we like it or not, we are dependent on our partners . to achieve health for all.'

WHO's current Director-General Chan promotes her reform in similar terms:

*      In common with other UN leaders, Chan first initiated a reform plan, which involves fundamental changes in the relations between the UN agency for which she is responsible and the private sector, and only later sought to gain approval from WHO's member states for her initiative. One could say, somewhat provocatively, that the agenda was set and member states were asked to rubber-stamp it.

*      Yet Chan's proposal to establish a regular global multi-stakeholder forum for health went a step beyond Brundtland's introduction of the PPP paradigm. To consider the possible implications, imagine the following scenarios: (1) Your health minister announces bankruptcy, invites the private sector to co-fund your ministry of public health and, simultaneously, announces a vague restructuring of the ministry as well as of national public health decision-making. The only clear component of the restructuring is a multi-stakeholder forum permitting private sector actors to actively shape public health affairs. (2) What would happen if the UN Secretary-General announced serious funding problems for the UN Security Council and suggested that the remedy was to raise more funds from the private sector? This would be accompanied by a 'reform' of the Security Council, which would include the creation of a regular multi-stakeholder security forum. The arms industry would be invited as one of the key 'stakeholders' to this Global Security Forum to help shape matters of peace and war.

*      In common with Brundtland, Chan sidelines concerns over predictable negative impacts of these moves with promises to establish safeguards to hedge them.

Safeguards for public interest: myth and reality

In 2000, Kofi Annan issued 'Guidelines on Cooperation between the United Nations and the Business Sector'. Among the Guidelines' General Principles regarding cooperative arrangements with business were that these arrangements should 'advance UN goals as laid out in the Charter', be based on a 'clear delineation of responsibilities and roles' and 'not diminish the UN's integrity, independence, and impartiality'. The principle on transparency stated: 'Cooperation with the business community must be transparent. Information on the nature and scope of cooperative arrangements should be available within the Organisation and to the public at large.'

In 2001, Brundtland also promised public interest safeguards. They included:

*     Documentation of private sector interactions, which would be made available to the Executive Board, the World Health Assembly and the public at large;

*     Creation of guidelines for staff on how to handle such interactions, which would be updated regularly and include texts to recognise and avoid conflicts of interest;

*     Establishment of a tool to assess the good standing of companies with which interactions are envisaged;

*     Facilitation of civil society organisations' input on issues pertaining to public-private interactions.

In 2003, when I was asked by the Finnish government to assess WHO's safeguards for public interest, I found out that many of them had never been established or made effective. Until very recently, I could not share my findings from the internal consultancy with WHO's leadership, since the 2005 report had been classified as confidential. Not enough information is available to evaluate whether the situation has fundamentally changed in 2011-12, when member states are again being urged to approve a path towards closer interactions with the private sector.

A number of member states and public interest NGOs expressed concerns that the intensified resource mobilisation from private foundations and the commercial sector and the current pro-business reform are steps in the wrong direction. Promises are made about safeguards for public interest to allay these concerns, but we have heard these promises before.

Chan dismissed concerns over conflicts of interest and undue industry influence on several occasions. She argued that she is 'transparent' about industry representatives on particular advisory committees and told NGOs who criticised multi-stakeholder approaches (for example, in  the obesity/non-communicable diseases  prevention  arena)  that  'her' member states have told her to do this.

Official WHO documents asserted that resource mobilisation from private foundations and the commercial sector can be implemented 'without compromising [WHO's] independence'. We also read that the projected multi-stakeholder forum for global health 'may help shape decisions and agendas, but will not usurp the decision-making prerogative of WHO's own governance, which will remain intergovernmental'. Above all, it was claimed that the proposed regular multi-stakeholder dialogue on global health issues would '[strengthen] WHO's role in global health governance'.

A careful inspection of the close relationship between the UN and the private sector (including the Bill and Melinda Gates Foundation) does not support the assertions that were made in the Director-General's reports to the member states. Both the idea of attracting more funding from private foundations and the commercial sector and the notion of dealing with global health and nutrition matters through multi-stakeholder approaches carry major risks to WHO's role as the highest authority in international public health. Even though the regular World Health Forum is abandoned at the moment, the notion of greater involvement of the private sector as legitimate 'stakeholders' in public health affairs is not. There is an urgent need to reflect on whether this path should be pursued.

An alternative vision of WHO reform

The English word 'reform' comes from the Latin term 'reformare', which means 'to form something again'. It often refers to correcting wrongs or even to returning something 'back to the original condition'. The term implies that this original condition was better and therefore there is no need for a complete overhaul (revolution).

Let us remember what WHO and the United Nations and its agencies originally stood for. They were meant to work for us ('the peoples') and not for corporations. From that perspective, one can argue that UN leaders have initiated not so much a 'reform' of our UN agencies as their neoliberal restructuring.

This restructuring process includes what some refer to as 'privatisation' of our public agencies and spaces. Privatisation in this sense refers to a greater reliance on private sector funding, as well as inviting profit-motivated actors into public decision-making forums, and sometimes removing specific public issues from the public sphere altogether. It is the opposite of ensuring financial independence of our public institutions and safeguarding and enlarging spaces for public debate.

The Merriam-Webster Dictionary mentions the word 'reclaim' as a synonym to the verb 'reform'. It is heartening to see people standing up and reclaiming democracy and democratic institutions worldwide. Many have been influenced by the short essay 'Indignez-vous!' (English translation: 'Time for Outrage!'), written by 93-year-old Stephane Hessel, a former resistance fighter against Nazism who had subsequently been involved in the drafting of the Universal Declaration of Human Rights.

In the debate around a reform of WHO, it may be useful to remember a few tenets of democracy. 'Democracy' is a term coined in ancient Greece and refers to rule by the people for the people. 'Plutocracy' is rule by money; it is what UN agencies and their member states should refrain from fostering.

Trying to prevent money from ruling has always been difficult. More than 2,000 years ago, the Greek philosopher Aristotle advocated a clear separation of the public square from the market to ensure a free and unpolluted exchange of ideas.

Those who believe that it is possible to increase 'voluntary funding' by the private sector (or neoliberal-ideology-driven development agencies such as the UK Department for International Development) and to 'widen engagement' via multi-stakeholder arrangements without risk of losing independence, integrity and public trust may be faced with resistance by citizens who remember folk sayings such as 'he who pays the piper plays the tune' and 'don't let the fox guard the chicken coop.'

The fundamental problem is that WHO has lost control over its budget. Currently, less than 20% of its budget comes from regularly assessed member states' contributions. Apparently member states show little willingness to change the situation. This is why there is an urgent need to bring the financing debate back to the forefront of the agenda.

Discussions around financing, evaluation and reform of WHO should be based on the 'shape' enshrined in the principles and values of WHO's constitution and Health For All declarations and strategies (reaffirmed in the 1995 and 1998 World Health Assembly resolutions on health in the 21st century), as well as in the International Covenant on Economic, Social and Cultural Rights and other relevant human rights documents and reports.

How to steer WHO's reform in a healthier direction

What can be done when those at the helm of our UN agencies try to push significant changes without leaving the space or time for appropriate discussion?

Member states and civil society organisations can influence the 'reform' agenda and process in various ways. For example, they can:

*      Resist attempts at manipulation, silencing or sidelining, e.g., by insisting on discussion of the points they raise and by demanding transparency as a first step to prevent undue industry influence.

*      Insist that transparency about the presence of commercial sector actors in public forums and expert committees is not the same as addressing concerns about conflicts of interest.

*      Redirect the debate towards the need to establish broader public interest safeguards in financial and other interactions with the private sector, which include not just the establishment of clear, comprehensive and effective conflict-of-interest policies but also the creation of an enabling environment for informed public debate by a vibrant civic community.

*      Remind WHO's Director-General that 'her' member states are in fact 'our' states, and that public officials are meant to act in the interest of their citizens. Some member states might be offended by the way they are being used to silence the critical voices of public interest NGOs and citizen networks.

*      Point out that the Director-General often seems to practise 'selective listening' to member states. She refers principally to those member states who support her proposals and/or who have the financial clout concerning WHO funding, such as the US and the UK.

*      Point to the ideology behind the current proposals. The DG's reform plans follow the neoliberal agenda that has fundamentally changed the global governance architecture. Those promoting neoliberal policies have weakened and defunded nation states and UN agencies for more than 30 years; the neoliberal champions have increased the influence of for-profit actors and those who have accepted their funding and uncritically participated in the initiatives which are symptomatic of this restructuring. At the same time, they have silenced and sidelined the more critical voices within UN agencies, NGOs and civil society organisations. Global neoliberal restructuring - often in the form of 'multi-stakeholder' and public-private 'partnership' initiatives - has undermined efforts to establish binding international regulatory frameworks for harmful practices of transnational corporations, redirected and fragmented global and national health, social and economic policy efforts, and eroded public trust in the UN and other organisations which have allowed unethical corporations and rich individuals to use such initiatives to influence public decision-making processes and to 'bluewash' their names. ('Bluewash' is a term referring to whitewashing tarnished images by association with the UN's blue logo.)

*      Request a delinking of the discussions on the funding crisis of WHO and the 'reform' of WHO.

*      Prioritise and fast-track the work of ensuring independent and sustainable funding of WHO on the agenda of WHO's governing bodies and secretariat.

*      If financial cuts have to be made, prevent the displacement of public-spirited WHO staff by those who work for the neoliberal agenda and by costly PR staff who work for reputation management.

*      Ask for a halt to the moves towards greater funding of WHO by private foundations and the commercial sector, and further expansion of 'multi-stakeholder' dialogues and initiatives. There should be a thorough assessment of both moves from broad democracy, human-rights-centred and political economy perspectives.

*      Draw attention to the fundamental arguments against both moves: they can potentially undermine WHO's independence and integrity in decision-making, as well as public trust that WHO works for Health for All and not for corporate interest.  

Judith Richter, MA Pharm. Sc., PhD Soc. Sc., is the author of two books and numerous articles, most of which centre on mapping out possibilities to work for Health for All and to resist the corporate takeover of our world. She is a member of Health Action International and the Global Policy Forum Europe. She has also served on the Advisory Committee of the BUKO Pharma-Kampagne (the model for Hippo in John Le Carre's The Constant Gardener). The above is extracted from her 2012 article 'WHO reform and public interest safeguards: An historical perspective', which was published in full (with notes and references) in Social Medicine (Vol. 6, No. 3, March 2012).

*Third World Resurgence No. 298/299, June/July 2015, pp 20-23