Absence of leadership is not the only problem — the pandemic shows how the WHO failed to address deeper and chronic issues.
As the health, economic and political impact of COVID-19 unfolds the World Health Organisation (WHO) has been under international glare and scrutiny in ways rarely seen throughout its over 70-year history. The basis of the malaise is focused on its (in)ability to sound the alarm at the right time and demonstrate global leadership in helping countries cope with the pandemic. The delay in alerting the world was China driven as there is evidence that WHO’s head Tedros Adhanom Ghebreyesus sought the green light from Beijing before declaring a global health emergency. Precious weeks were lost leaving over three million people infected and 210,000 dead.
The pressure on the United Nations (UN) leading health body to perform has heightened as compared to other major outbreaks because human and economic toll has disproportionately affected wealthy nations including in the European Union (EU), the USA. Absence of leadership is not the only problem. The pandemic shows how the WHO failed to address three deeper and chronic issues that demand action during this period of recovery, recrimination and reflection.
• The WHO is not set up to address operational aspects of pandemics.
• The WHO’s advisory structures are insufficiently adapted to policies necessary for countries be they in the developed or developing world.
• The organisation’s neglect of essential public health functions for decades and marked shift in recent years to Universal Health Care (UHC) with a strong treatment bias has led to the erosion of the infrastructure many countries require to respond to pandemics and in fact all major public health needs.
Each is briefly discussed.
For decades debates about whether WHO is best suited to address normative versus operational functions have come and gone and have usually fallen between two stools — i.e. WHO should do both. COVID-19 is a time to ask again. WHO’s normative roles (research, guidelines, norms and standards) are unique within the global health world. They require deliberation, hard science and translation into country plans. They should be informed by country reality. When followed, the outputs have been profound and influence all aspects of health policy.
In contrast, the WHO has a rather shaky history in delivering services or running major programmes aimed at prevention and control. The oft-cited small pox was 40 year ago in the middle of the Cold War. The eradication programme was run with military support and oversight. The task was simple compared to later efforts to eradicate polio. For that Rotary International and UN’s children fund (UNICEF) were key partners along with mass mobilisation of health workers. Polio eradication overshot its budget by billions and over time by years. This approach also failed to do what was promised at the beginning — leave primary health care (PHC) and vaccine infrastructure stronger in all countries. Multibillion-dollar NGOs, inexistent earlier, are now active all over the world and they see their mission as executing WHO norms.
It is high time that the WHO’s normative and related functions be strengthened and the operational roles assigned elsewhere. The mindset of people needed to deal with a pandemic differs from those who establish norms. The training of people differs. Yet when a major epidemic or pandemic occurs, WHO reassigns its normative staff to field work they are poorly trained to do. A new alignment of UN agencies is needed to create a reserve force capable of addressing major global health crises. Extreme weather events, refugee crises and pandemics all require such a reserve force that could be created from existing UN agencies supported by governments. That would leave WHO to do what it has done best for 70 years.
During this pandemic, we have seen how policies developed in one country, as the only way forward cannot work for others. Experts and advisory groups driving this are still heavily derived from European and North American countries. They are the accepted “global health elite” whose wisdom is accepted without challenge. That lingering “colonial mentality” drowns out the voices and lived realities of people in the poorest developing countries where economic hardship is the dominant reality, where resources for basic healthcare are well below need and where basic living conditions related to crowding, access to water and toilets fail to meet SDG goals by far.
There is a need for all WHO policies to be pressure-tested in diverse settings before being put out as a “best practice”. So many policies developed in the comfort of Geneva — where the WHO is headquartered — simply fail on the streets of the large sprawling urban areas across Asia, Africa and the Middle East. The reasons have been clear for years. The WHO has focused too much on seeking a one-size-fits all approach and too little on doing the much harder work to co-create solutions from the street up.
In the mid to late 1990s, there were efforts by Directors General Hiroshi Nakajima and Gro Harlem Brundtland to revitalise public health. Essential public health functions were defined which, if fully implemented would protect populations from emerging threats. They emphasised epidemiological surveillance, vaccine programmes, basic laboratory capacity, environmental health and much more. They also built on centuries of experience around the world in tackling the most basic needs that all populations need. Much of this is boring. Success in public health is measured in terms of non-events.
Public health and the core prevention and health promotion programmes the WHO supports though have been displaced by a focus on treatment. Both are needed but while WHO is best placed to be the “owner,” and global advocate, can it also be the activist especially when many private and civil society interests see their main purpose as driving improvements in access to treatment? If so, who is the boss as access and issues related to it are signals to trade, well outside the purview of WHO’s core mandate.
The World Health Assembly (WHA), the WHO’s annual assembly virtually meets in the third week of May 2020. COVID-19 postmortems are on in private and public. The WHO has two options. Either it returns to its basic functions incorporating 21st century technologies in a transparent way — the best assurance now that it is ready for the next pandemic. Or it continues to play victim, bringing down not just the good work done earlier, but also muddying the waters for what is possible in future. COVID-19 has ensured that absence of leadership in public health will no longer go unnoticed.
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Chitra Subramaniam is a media person and entrepreneur.Read More +