Last month, Geneva Global Health Hub (G2H2) reached out to civil society colleagues and collected some key questions for the candidates running for the position of WHO Director-General. Throughout my career, I have also worked closely with civil society to address global health challenges and recognize the critical roles that they play in advancing global health, including their work at country level, their advocacy work, and their important contribution to accountability. I welcome their engagement in this process, and am pleased to share my answers below. - Dr Flavia Bustreo
Q1: Increased core funding of WHO
During the last financing dialogue in November 2016 there was a heated debate on the proposal by WHO’s Director-General Margaret Chan to increase the assessed contributions (ACs) by WHO member states by 10%. This increase has been proposed to fund WHO’s core capacities and ensure its normative work can be sustained, and is part of a longer ongoing reform of the organization. Germany and some other member states support this 10% increase in ACs, but other countries hesitate due to their stated doubts about the efficiency of WHO’s work. What would you, as WHO’s new DG, do to convince the member states of the crucial importance of increasing the core funding of WHO?
Flavia Bustreo: As WHO DG, I would work closely with Member States and partners to develop a strong, inclusive programme budget with continuing management reforms to deliver efficient and effective results. Establishing this firm foundation, I will position the WHO Secretariat to work with its Members States to expand how voluntary contributions can be used in an 'unearmarked' manner. It has been my experience that Member States are willing to increase the resources they commit to WHO when the organization provides a significant added value through demonstrated, measurable results. In addition, I will continue to draw on my experience with innovative financing mechanisms, which has been accumulated work both at WHO and at the World Bank, to highlight blended financing options that include a range of partners from foundations to other private sector actors. Finally, WHO's convening power can be leveraged to secure in-kind contributions for shared programmes of work in partnership with NGOs, research institutions, and other actors.
Q2: Public financing for UHC
Given that 120 million people fall below the poverty line each year because of paying for health services, how would you lead member states to adopt public financing for delivering Universal Health Coverage?
Flavia Bustreo: It is among the world's greatest injustices of our time that millions of adults, adolescents and children are dying of illnesses for which we have the knowledge and interventions available to save their lives. Millions more fail to reach their full potential for health and wellbeing, which also constrains their contributions to social and economic development. Many of the millions of refugees and internally displaced people in the world do not have access to basic services.
WHO urgently needs to translate its commitment to universal health coverage (UHC) into reality by greatly expanding the number of people with access to UHC, which is a target under SDG 3. WHO has already made a case for UHC as an important concept in public health but we cannot only talk about UHC as a concept; I will drive an extension of this coverage and particularly to the "one left behind". As well as building on the progress made against HIV, malaria, tuberculosis and maternal and child deaths, I will work to expand the definition of UHC by adding critical services that are currently unavailable in many low-income countries, especially for non-communicable diseases. I will work with the newly launched International Health Partnership for UHC 2030, especially under it renewed governance, as it provides the best platform for the coordination of other agencies and initiatives related to UHC.
These efforts can be financed within countries through several means which will be within the discretion of the State. Here are three of several ways that this can be done. First, income tax revenues are shown to exponentially increase from a healthier work force. This has been documented with reliable evidence by studies in which I was involved when working at the World Bank. Just as important is the recognition of the converse relationship, whereby there are detrimental impacts when the health of the working population is poor. Second, WHO can assist countries in establishing public-private partnerships which provide revenue to States as well as benefits to private partners. As noted above, in my answer to Question 1, WHO work with partners such as the World Bank and other financial institutions to provide information about blended financing options that include a range of partners from foundations to other private sector actors. And third, WHO can work with Parliamentarians to explore budget options that secure the highest attainable level of physical and mental health for the people they represent.
Q3: Framework of WHO Engagement with non-State Actors (FENSA)
There is a widely held perception that the Framework of Engagement with non-State Actors (FENSA) uses a lot of verbiage related to conflicts of interest, but actually confers considerable discretion on WHO staff to weaken safeguards against undue influence by multi-billion-dollar corporations that manufacture, sell, or invest in products and services related to WHO’s mandate and guidance, especially, food, alcohol, pharmaceutical, and medical technology products. Skepticism has been fueled by the fact that FENSA negotiations were repeatedly held in camera, with no access, even as observers, to public interest NGOs. While some WHO staff insist that conflict of interest safeguards will be robust or even stronger than before, they have been conspicuously silent on whether such industry associations will be eligible for WHO Official relations, technical collaboration, or as donors. If you are elected Director-General, would you ensure that these industries are kept at arm’s length from the WHO in the same way that tobacco companies and the arms industries current are?
Flavia Bustreo: In implementing FENSA, WHO needs to be proactive in engaging with non-State actors within the framework agreed by Member States. In my more than 20 years of experience with WHO, the work under my responsibility has actively engaged non-State actors to unprecedented levels that have significantly strengthened the Member State-led processes in which we are engaged to contribute to improving global health. Under my leadership, the cluster on Family, Women's and Children's Health supported the first citizens’ hearings at the World Health Assembly and I support making WHO more transparent and accessible. Ensuring that the manner in which we engage non-State actors contributes to improving peoples’ health is the essential key to our engagement under FENSA. WHO is equipped to measure health impacts, we must apply expertise in measurement as well as encourage independent actors to measure the quality of our engagement with non-State actors. Partnership is one of the five key ideas driving my candidature and I am well versed in coordinating the activities of multiple international and regional stakeholders to combat threats to global health, including in response to Ebola and Zika. In addition to my numerous roles within WHO, I have worked extensively and constructively with partners outside of WHO, for example, I set up and developed the Partnership for Maternal, Newborn and Child Health (PMNCH), which is now established as an alliance of more than 700 diverse organizations in 77 countries. I also was vice-chair of Gavi, the Vaccine Alliance, through which WHO coordinates the countries’ analysis and plans and monitors the results of the financial investments. WHO could provide such services at regional and country levels for Member States. My engagement and advocacy with non-State actors has included partnerships with members of parliament, non-governmental organizations, foundations, think-tanks, academic institutions, the private sector, women, young people, civic organizations, and other civil society actors. Importantly, I have also promoted strong and transparent accountability frameworks and accompanying mechanisms to implement them, such as the Commission on Information and Accountability and the accompanying independent accountability mechanisms. Engagement guided by transparency and accountability efforts can enhance WHO’s ability to achieve the mandate given to it by its Member States.
Q4: WHO division to address Social Determinants of Health
In 2008, the Commission on the Social Determinants of Health reported to the WHO DG. The WHO responded by co-organising a World Conference on the Social Determinants of Health with the Brazilian Government. This resulted in the Rio Political Declaration on the Social Determinants of Health (2010). Since then there has been very little follow-up on this Declaration and there is no dedicated staffed division on the social determinants within WHO and few WHO staff have a dedicated role to advance the social determinants agenda. This is despite the evidence that the world is growing less equal and health less equitably distributed and that social determinants are largely responsible for driving these inequities.
What actions will you, if elected Director-General, take with regard to the social determinants of health? Will you establish a dedicated division within the organisation to address the social determinants of health? If yes, at what level will you staff this division? To what extent will you work with other United Nations agencies on the social determinants of health and health equity agenda?
Flavia Bustreo: As ADG at WHO, I lead our work on the social and environmental determinants, with a small, but committed team focused on taking forward the work on social determinants of health. Based on the evidence, social determinants are also central to key global strategies including on women’s, children’s and adolescents’ health and on healthy ageing. However, overall it is true that the work on the social determinates of health has not been given the attention it deserves within WHO. In part this has been because of the unwillingness of donors to focus voluntary contribution on this work and the fact that the World Health Assembly has not apportioned more adequate resources out of assessed funds to these activities.
In the era of the Sustainable Development Goals this cannot continue - integration across health and other sectors and multisector action is central to achieving the 2030 vision. The biggest challenges to the implementation off the 2030 Agenda relate to putting pledges into action based on the evidence. To put the pledges related to health that have been made in the 2030 Agenda into action WHO needs to be proactive in mobilizing resources and supporting evidence-based investments. I believe this can be done by linking resources mobilization to results and by ensuring collaboration across the different sectors that are important social, economic, and environmental determinants for health. I firmly believe that Member States and other partners are willing to invest in public health policies that show results. My cluster at WHO has been an example of the sustained funding that WHO can generate by providing results to its Member States and the people who benefit from improved health care.
The global health community has been slow to recognize the strong links between health and social determinants such as climate change, but I have encouraged us to provide the evidence for this link where it exists. In my work, I have emphasized that WHO improve its understanding the social, economic and environmental determinants of health in all settings.
Q5: Framework Convention on Global Health
Persisting deep health inequalities, insufficient accountability, and incoherence between health goals and non-health sectors continue to impede national and global efforts towards securing the right to health for all people. A Framework Convention on Global Health has been proposed by a wide range of civil society organizations and national and global health leaders as one critical component of responding to these challenges. United Nations Secretary-General Ban Ki-moon has encouraged the international community to recognize the value of and consider this proposal. The treaty would foster the national and global governance for health that will better enable all people to realize their right to health.
If you are elected to be the next Director General, what might you do to help advance this proposed treaty?
Flavia Bustreo: Human rights are the foundation of the vision I have for the WHO and those rights apply to all people, everywhere. Rights are also at the center of Sustainable Development Goals. Moreover, the right to health is the cornerstone for achieving good health outcomes. Every country in the world has committed to the right to health in numerous treaties, including in the preamble of WHO’s own Constitution. These commitments should drive the policies and actions of both Member States and the WHO Secretariat.
I have been a longtime champion of the human-rights based approach to health. As such a key tenant of my candidature for DG is defense of the human right to health. I have demonstrated my commitment to justice, fighting for gender equality, and by advocating that ensuring the right to health for all is imperative. Both as an experienced health practitioner and as contributor to policy making, I will continue to advocate for human rights to support and inform all our work. As the ADG responsible for health and human rights I have cooperated with the first United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health to produce a study entitled ‘Women’s and Children’s Health: Evidence of Impact of Human Rights.’ The study highlighted how governments that included the right to health in their legislation were better able to achieve concrete health outcomes for their people. If we are serious about achieving the Sustainable Development Goals (SDGs), especially SDG 3 concerning global health, we must unite around rights and equity. We must use the unparalleled global influence of WHO to bring together the people, partners and scientific evidence needed to challenge inequities in access to health care and to realize the central promise of the SDGs: that we leave no one behind.
WHO’s work to secure the right to health must be evidence based. It is important that WHO look at the evidence of what kinds of discrimination hamper access to health care. WHO is an organization founded on evidence, we are not a human rights council in which more political discussions of rights take place. WHO can be a forum for negotiating a treaty in the field of global health, as the successful negotiation and adoption of the Tobacco treaty and the International Health Regulations have shown, but such processes much be transparent and inclusive for all Member States concerned.
The Framework Convention on Global Health is an initiative by non-State actors. It is laudable initiative, but it initially ran into problems because it proposed a ‘one size fits all’ approach to the right to health and was not seen as having been the fruit of an inclusive process. Such an initiative needs to be negotiated by, and enjoy the consent of, as many countries as possible and stakeholders from all parts of the world to enjoy success. It must also build on the right to health that is established in the numerous existing universal and regional treaties. I am committed to working with an inclusive and transparent process to reiterate and build on the existing right to health, if it enjoys the wide support of WHO Member States. I do believe that non-States actors, particularly from civil society, can, and have done, a good job of starting this process.
Q6: Promote the voice of civil society
What would you, as new WHO DG, do to make sure that the voice of civil society—in a broad sense, including people, patients, communities, workers, and their organizations—will be better heard in the shaping of health policies and health-related standards and regulations at all levels?
Flavia Bustreo: As noted above, as the ADG for Family, Women's and Children's Health I supported the first citizens’ hearings at the World Health Assembly and I support making WHO more transparent and accessible to civil society actors. I have also promoted accountability mechanisms. But perhaps as important as my will to engage civil society is the absolute necessity of doing so.
“Leave no one behind” is a core tenet of the SDGs, and this is a guiding principle for WHO in all its work. As a priority, WHO must work with civil society partners to develop new methods of monitoring and data analysis to identify and target the most marginalized and underserved groups, including people living in poverty, internally displaced people, refugees and migrants, adolescents and unaccompanied children, and other vulnerable people.
Another area in which WHO must engage civil society is in its response to emergencies. Engagement with partners in dealing with health emergencies and outbreaks, especially PHEICs, while governed by FENSA also requires the streamlined application of this framework. WHO must be proactive in engaging with non-State actors in emergency situations. WHO must be able to exercise its convening authority in a rapid and effective manner. The new WHO Health Emergencies Programme is a good first step that needs to be accelerated and enhanced as we learn from its operation in practice and from the best practices of our Member States.
WHO’s Member States have provided FENSA is the basis of WHO’s engagement with non-State actors. Also as noted above in my response to Question 3, I have engaged non-State actors including partnerships with members of parliament, non-governmental organizations, foundations, think-tanks, academic institutions, the private sector, women, young people, civic organizations, and other civil society actors.
We can only achieve the Sustainable Development Goals of the 2030 Agenda through cooperation with a wide range of partners including Member States and their multilateral agencies, and non-State actors such as foundations, non-governmental and civil society organizations, private enterprises, existing partnerships, members of legislative assemblies, academics, and affected populations such as migrants, women, and youth. WHO is already engaging these actors, but must intensify this engagement to ensure it is transparent and that all partners are accountable.
I am fully committed to engaging civil society both in our policy making processes and in our contributions in the field. Civil society reflects the people we serve at country level and can often provide us with valuable insight into the challenges we face and the means of addressing them.