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The World Health Organization (WHO) in a Shifting Global Governance Landscape

Speakers: Jack Chow, Distinguished Service Professor, Carnegie Mellon University, Former Assistant General, World Health Organization, and Jennifer Ruger, Associate Professor, Yale School Of Public Health
Presider: Yanzhong Huang, Senior Fellow For Global Health, Council On Foreign Relations
November 16, 2010
Council on Foreign Relations

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YANZHONG HUANG:  Well, let's get started.  It's always the Council policy to start on time.

Good evening, everybody.  Welcome to the Council on Foreign Relations.  I'm Yanzhong Huang, senior fellow for Global Health at the Council on Foreign Relations.  And this is the second meeting of the Global Health Governance Roundtable Series.  And we are excited to see many of you again and very excited also to see some new faces.  Today's session will focus on the role of WHO in global health governance.  We know that over the past decade or two, changes in the political and biological worlds have profoundly changed the landscape of global health governance, resulting in, quote-unquote, overlapping and sometimes competing regime clusters that involve multiple players addressing different health problems through diverse processes and principles.

But in the meantime, new health challenges, such as global warming and rising noncommunicable chronic diseases -- we just had the first session focusing on this issue -- they also loom on the horizon. So how does the changing landscape in global health governance affect WHO's role as a specialized agency that is responsible for, quote- unquote, "providing leadership on global health matter, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries, and monitoring and assessing health trends"?

So it is my great pleasure today to introduce our two distinguished speakers, who have in-depth knowledge on this issue: Jack Chow -- he's not here yet, and -- (chuckles) -- I don't know -- we don't know what happened, but we hope he will be here soon.  But on my left is Jennifer.  Jennifer Ruger is -- she's a professor at Yale. She was co-director of the Yale World Health Organization Collaborating Center for Health Promotion, Policy and Research.  She also had served on the health and development satellite secretariat of WHO Director General Gro Brundtland's transition team.

She then worked as a health economist at the World Bank and later served as speechwriter to James Wolfensohn, my -- the former president of World Bank.  And she had authored numerous articles, some leading public health journals, including Lancet, AJPH, Health Affairs and BMJ.  And her book, "Health and Social Justice," was recently published, in 2009.

So while we're still -- we continue waiting for Jack, we're going to begin with remarks from Professor Ruger.  And Jennifer, you have 15 minutes, and then we're going to figure out what's the next step. (Laughter.)

JENNIFER RUGER:  Well, thank you, Andrew, for -- and to the council for inviting me to come speak to you about the WHO and its role in global health governance.  And thank you particularly for putting global health governance on the agenda for the things that you're interested in and you want to learn more about and do something about in terms of global and foreign policy.

I'm going to -- I only have about 15 minutes, so I'm going to structure my initial remarks --

HUANG:  But if Jack doesn't come, you will double it. (Laughter.)

RUGER:  (Chuckling.)  Then I'll have double time.

I'll structure my remarks around four particular areas.  The first is a theoretical framework for global health governance, because I think that that's an essential first place to start.

The second is categories of work for global health institutions in general.  And here I'm really sort of pushing the idea that, you know, the World Health Organization is sitting in an infrastructure and an architecture of these multiple and different institutions and actors and what are the different categories of work.

The third is the core functions of the World Health Organization, what makes it unique in this global health architecture.  And I've argued for focusing particularly on the global functions of the World Health Organization vis-a-vis its other regional and local functions.

And then, finally, going to talk a little bit about the importance of the World Health Organization director general, and underscore the importance and influence that the WHO leader and the leadership and the administration has and particularly talk about the Brundtland administration, of which I know a great deal about but I also feel is a particular example of implementing the types of principles and ideas that I'll be talking about.  So that's sort of the structure of it.

So by way of theoretical grounding and framework, I'm averse, so to speak, of sort of things dropping out of the sky.  And I think that there's a -- there's a real importance in global health and global health -- (the ?) governance, in particular to present a theoretical framework to justify why we think we need to be interested in these governance issues, why particular institutions may have a role and sort of where we are in terms of other different theoretical approaches to global health.

And so first and foremost, so I've sort of written about this quite a bit and made arguments for this, but just in a nutshell -- and I won't be able to go through a lot of the nuances of the different arguments I put forth -- but first of all, I've sort of argued for and would underscore here what I think is important, which is that international health relations are actually more than strategic interactions among self-interested nation states.  And there -- that's -- there's a lot there.   

There's a whole theoretical body of work, and there's a whole sort of set of baseline, or sort of a priori ideas about what the role of international health relations are, and that's one of them.  And so I've argued against that.  I've challenged that particular view.

And I've challenged it in a way that I've sort of tried to put forth a larger moral order, or normative existence for justifying the global health governance architecture, and saying that the moral order should exist.  And that is what elucidates the principles and guidelines for governing interstate actors, and also non-state behavior as well.  So that's where we get from international to global in terms of our governance structure.

The next thing I would say is that in this moral -- this moral framework, or normative framework, I've put forth two particular problems in global health that are most pressing, or categories of problems.  And the first is global health inequalities; and this is inequalities among countries, and also inequalities within countries. And the second is global health externalities.  These are the aspects of global that know no national boundaries, that cross states.  And both sets of problems, I've argued, are morally compelling, and we have moral reasons to respond to them.

Then within the framework that I've put forth, the moral theory delineates who is responsible for dealing with these types of problems.  Is it -- is it wealthy countries, industrialized countries? Is it developing countries?  Is it the U.N. system?  Is it other international actors, civil society?  Sort of what -- you know, what -- how do we think about allocating responsibility for addressing these types of problems?

And I've basically put forth the, you know, theory of social cooperation and collective action that's based on trying to delineate and allocate responsibility to these institutions and actors -- governments -- bilaterally, and institutions and governments multilaterally, to address these two problems based on their roles, their abilities and functions, and their effectiveness.  And I was delighted to see that the effectiveness of WHO is put on the agenda.

So that's sort of the theoretical background.  I don't have time to go into the different aspects of that, but there's some reading and there's also some further work that I've done that I certainly could make available.

So that's important, because when we think about allocating responsibility in these different actions to global health institutions, we think about what types of categories of work map onto the roles and functions that these different actors and institutions might play.  And here, I'm still talking global health.  I'm still talking about the global health governance and the global health architecture.  I haven't narrowed in on WHO.  So I'm trying to give a sense of sort of how we zoom in on the WHO in particular in its role in this.

And here, I've said that there are sort of four different functions and categories of work for global health institutions.  And the first is this idea of generating and disseminating knowledge and information.  This is the public goods argument that these are -- the goods that can be created and disseminated through this type -- these types of actors are ones for which the market, for example, or self- interested entities are not going to have the motivation to do, so we need these actors and this global cooperation.

The second is more in terms of empowerment and these differential power relations among individuals and groups in national and global fora, and that there's a -- there's an asymmetry there; that again, if you just take a sort of realist perspective on international health relations, we're not bothered by that terribly much so, that we accept that sort of as given.

But if you have more of a normative framework, you find that sort of troublesome if you think that there's an important role to play in being part of the environment, in being part of the game, so to speak, in terms of creating global policy.

The third is a very important area and I think is minimized because it has a scientific basis to it rather -- more than a geopolitical or politics orientation.  And that's providing technical assistance.  And I think that's very, very critical.  And I'm going to talk about surveillance in a minute.  Also within this category is applying financial aid.  And then global advocacy, particularly around one area, and that's health systems development, an equitable and efficient health systems development.

And then the fourth sort of area or category of work for these global health institutions is coordination, and around different areas of expertise, different comparative advantages, reducing redundancies among the work of these different organizations and trying to make it easier rather than more difficult, especially, at the country level, to interact with the global health framework.

So just in terms of examples, some examples of global health goods include, actually, global advocacy, include the public goods of research, best practices, for example, around health systems, looking at the different health systems in different countries, what works, what doesn't work, and these types of public goods that can provide the information to help countries grow and develop their health systems.  Surveillance for diseases and risks, this is quite critical. And then basically the -- also the promotion of norms and standards.

So, now let me get into sort of what core functions the World Health Organization can play in this sort of environment.  One I can take off the table immediately is financial aid and providing funding and investment.  That's not the role of the World Health Organization. It's not a funding agency.  It's not a development bank.  It has very limited funds itself.  It certainly doesn't use its funds to invest in any particular country or any particular set of services.  So it works very well, for example, with the Global Fund in terms of global -- the Global Fund being a financier of HIV/AIDS, malaria and TB.  So it doesn't fund.

And I think that's actually a very important limitation also to the effectiveness and the role of the World Health Organization.  So in these sort of global health categories of work, that's not one where the World Health Organization is going to play a major role.

It's also not going to play as big a role in the health system's functioning.  Now, we saw under the recent administration that there was an effort to do that.  And Chris Murray and a whole group has developed around health-system strengthening, building up the health systems, the financing and the sort of management of health systems. And what we found is that once that group left the World Health Organization, the World Health Organization didn't have very much of an expertise.  They -- and it's still there.   

And it also didn't have as much of a(n) argument vis-a-vis its comparative advantage with the World Bank and other organizations that tend to have much more of a stronghold in that area, based on the expertise.  So, for example, in health financing, the World Bank tends to be the organization that has more expertise, more experience.   

It has the -- again, the financial investment that's able to go along with their technical assistance in that particular area to support its work.  So that's another area where the World Health Organization is not -- is not focused in these categories of work.

And then a third area, I would say, sort of just the opt-out or what's not sort of relevant, I think, as much, is -- and I've argued for this with -- in -- particularly with Derek Yach in an article that's distributed -- but at the country level.  I think that the support at the country level and the regional level is important, and it's useful.  But I've argued for taking a much more -- stronger role in the global and the global functions of the World Health Organization.

So in terms of the core functions, I think that there is particular emphasis on these three areas in the article that you've received.  Derek Yach and I argue particularly for focusing -- going -- what we call "going back to basics," going back to sort of the core functions, the global role of the World Health Organization, and focusing particularly on these areas of, number one, the normative functions and setting norms and standards.

In particular, the role that the World Health Organization has played recently in creating agreements and using international law, even if international law is used in a norm-setting, in norm- internalizing capacity -- so here I'm thinking about the FCTC, the Framework Convention on Tobacco Control, for example, reinvigorating and revising the international health regulations, these types of agreements and regulations, and then putting forth the non-binding standards and recommendations.

And, of course, you know, the World Health Organization has no -- has no enforcement power, so the WHO is not going to be able to enforce any of the -- of the recommendations or standards that it puts forth. So the nonbinding aspect of it, combined with the norms that it sets in terms of global policy, is quite critical.

The second area is the coordination.  And I've argued for this. I mean, I -- I'm -- it's with -- and this is the area that we're talking about with respect to the pluralism that you mentioned in your introductory letter; that, you know, we have a wonderful and exciting period of things that are going on in global health.  And that's basically the expansion of financing and initiatives, programs, institutions.  And we -- so we have this pluralism in global health, where they've -- we've got more groups coming in, foundations, the global fund, individuals; we have -- and more programs with vertical, and even some across the health system.

But the problem is that for -- at the country level, they've had a very difficult time in what I call managing up.  And so coordinating these entities and trying to get around a global policy that makes sense at the country level with these global institutions is something that the WHO has a -- has a unique role in.

And then I think technical cooperation and technical assistance around particular areas, now that -- the world -- you know, it's always interesting.  I've worked with the World Health Organization and the World Bank, and people say, well, what's the difference?  And one of -- one of the differences, I say, is the World Bank is full of economists and the World Health Organization is full of doctors.

So the -- you know, the technical assistance around particular diseases and conditions is very useful, although it's becoming outdated, and it also creates an incentive for the World Health Organization to keep programs around, even though it should be incentivized to actually eradicate and reduce some of these diseases because it's so reliant upon that.

Okay.  I'm running out of time.  I've got three minutes.

So this is something that the technical assistance is very important, and particularly around these areas of diseases and categories of, hopefully, eradicating or addressing some particular diseases, that tend to be (very vertically ?) focused or on a particular disease, and that's a strong area of emphasis.  And really moving into these other areas -- economics and finance -- is really not a good move for the World Health Organization because it doesn't tend to maintain the excellence in terms of its technical abilities.

So lastly, I want to emphasize the role, I think, of the WHO director general and the leadership that can be -- and the role of the leader in heading up that institution.  And just let me emphasize the Brundtland administration and talk a little bit about some of the things that I think she was able to do with her administration that brought the World Health Organization back to basics, aligned more closely with some of the things i was just talking about, helped the World Health Organization align itself more with the other organizations and institutions in the global health architecture and become more effective.  And there are a couple things.

The first thing I would emphasize with the Brundtland administration, her leadership in particular, was how she tried and emphasized putting health centrally on the development agenda.  So she had come from a background, as you know, as a prime minister and a finance minister.  Her main emphasis was making the argument to prime ministers and finance ministers of how important health is as an investment in the development business, in the development agenda.   

And that was very important to Hirsh (sp).  He was very committed to it.  And I think it was very -- it was very effective in these different domains, and in just the institution itself, in the institution and its role in the development agenda, and also with these other global health institutions.

Secondly, she focused on global governance.  She was very focused and interested in international treaties and norms.  Again, the FCTC, I think, is a perfect example.

The third was she emphasized global surveillance and systems of epidemic alert and response in the thinking about transnational health threats.  That was a strong emphasis of hers, and I think it really fits with the strengths of the WHO vis-a-vis these other institutions, its effectiveness, and also, back to the theoretical frameworks, dealing with the externalities that are very problematic.

The fourth was building and maintaining a strong base of technical expertise.  And I think she really focused on that.  And then I just want to emphasize -- because I know I need to end.  I want to emphasize the particular role of the convening and coordinating function around the issue of health and development that the macroeconomics and health commission focused on.  And that was a squarely -- (inaudible) -- idea and emphasis.  And it was very -- many (have felt ?) --

Now, have we done a study on how effective it was?  I'm talking about effectiveness of the institution and what it does.  No.  But if you talk to people, people even like Bill Gates, they would say that the information that came out of that, the arguments that were made in terms of the economic arguments for why health is a good investment, but also why there is a bidirectional relationship between health and economic development, these were very influential.  People thought that they made a lot of sense.

And then the second thing and the last thing I want to emphasize is the analysis that went into that in terms of the -- basically the cost-effectiveness of investing in global health.

And, you know, many people say that there's -- again, there's no study of the direct linkage, but many people comment on how this is influential in helping to keep part of this whole stimulation and this exercise of increasing interest and financing in global health that we're facing now in terms of the reality of pluralism.

HUANG:  Thank you, Jennifer, for providing us the theoretical background to analyze the role of the WHO, and also providing, using her experience, the role of leadership in the global health governance.

I hope -- whether this is going to be (the time on the front line ?) is good all day, so it's debatable.  But we are fortunate that we have Jack, Ambassador Chow, here.  And Jack -- I think he doesn't need to be introduced, but -- (chuckles) -- I know that you have many hats. You are a medical doctor, a former public health official, a former U.S. diplomat, and currently a university professor, entrepreneur and NGO leader.

Dr. Chow served on pioneering roles in public service and global health diplomacy.  He was the first assistant DG of WHO on HIV/AIDS, tuberculosis and malaria.  He was also the first U.S. diplomat of ambassador rank appointed to a public health mission.  And in that capacity, he led American diplomatic efforts in the establishment of the Global Fund.  He also authorized -- authored the path-breaking article, "Health and International Security," in 1996 -- which I have actually used as required reading over the past seven years.  The students were intrigued by the terms you coined, like "war by privation," "war by starvation."

And I forgot what exactly that means.  (Laughter.)  But let's start with Jack.

JACK CHOW:  Thank you very much.  (Says thanks to moderator in Chinese.)  And delighted to be here, and I'm sorry I'm late.  I've learned a lesson about taking the New York City subway, that old verbiage "trust but verify."  I took the sixth line and didn't realize it was the express, so I had to come around.  (Laughter.)  So next time, look for the local.

Thank you, Yanzhong and Dan Barker, Laurie Garret.  It's -- I'm delighted to be back at the Council on Foreign Relations.  I appreciate Jennifer's leading off, and I can certainly build off of her comments, her platform, of her points.  See many former colleagues and allies.  And I'm sure I'll be making new friends and colleagues tonight.

If I may, I'd like to dedicate my remarks in the memory of a staff member of mine who tragically died in the line of duty during my time at WHO several years back.  Lisa Veron was a Swiss national on my tuberculosis team who volunteered to go to Harare, Zimbabwe, where she was killed under mysterious circumstances soon after her arrival.  Her murder remains unsolved.  And I and my colleagues honor her bravery and her dedication to helping the underprivileged through health diplomacy.

It is certainly a tall honor -- tall order to convey my thoughts in 15 minutes.   

So I'd like to build on Jennifer's points and I'd like to take a catalytic, provocative, broad-stroke approach to the issues confronting WHO, in order to simulate our collective thinking and enrich our conversation tonight.

I'm heartened by the turnout.  I think it reflects your respect and appreciation and concern for an agency that is the central pillar for the global health architecture.  And if I could just extend that metaphor just a tad, we're all concerned that this pillar of WHO, which upholds the work of others, is becoming increasingly strained and burdened, and is at risk of crumbling and leaving others to shoulder that burden, shouldering the vital work of providing standards and coordination.

Those of us in this room need no further explanation that the global health landscape has been dramatically reshaped over the past 10 years, upon which actions -- positive actions, I would assert -- have been accelerating:  the U.N. Millennium Development Goals, several of which are heavy in health; PEPFAR, the Global Fund, Gates Foundation, the Presidential Malaria Initiative, the Global Health Initiative; the blossoming of NGOs and corporations that have been advancing health; and certainly the sister agencies of WHO at the U.N. -- UNAIDS, UNHCR, UNICEF and several others.   

There's been unprecedented political support on the world stage. The G-8 created a trajectory, the diplomatic trajectory that led to the Global Fund's creation.  The G-20 now is working on development and the health -- intersection with health.   

I've been heartened to see more countries appoint ambassadors on HIV/AIDS and health in addition to the USA, Sweden, France and Holland -- and there are probably a couple others.  There's a higher -- much higher degree of respect for an investment in health as a pathway towards vibrant economies and vibrant cultures.

So, as I frequently describe it, there's now a convergence of resources and good will combining and intersecting at both the country level and at the community level.  And the next chapter of this story is assuring that health outcomes are realized.  And in that chapter, WHO is vital to the content and the cadence of that -- of that chapter.

I think Jennifer went through it, the WHO 101.  Just to bring us all up to -- up to -- up to date, WHO is basically a union of national health ministers supporting a network of health experts at Geneva, regional offices and its country offices.  WHO is a standard-setting body.  It acts as a health consultancy but stops short of direct implementation.  It provides quality assurances, certain essential medicines.  It negotiates and administers the international health regulations.  It participates and hosts many health alliances and operating partnerships.  It commands media attention during health crisises (sic), with the director general's pronouncements and judgments highly scrutinized for its content and policy direction.

Even with these critical functions, the WHO, I would assert, has been -- being left behind in the acceleration of the global health dynamic over the past decade, making the investments and gains vulnerable to setbacks and reversals.

One indicator of concern is its budget.  For all of the tasks it is asked to do worldwide or the ambitious goals it seeks to attain and contributes to the goals of others, WHO's combined assessed and voluntary budget is at the same level as the operating budget for the Massachusetts General Hospital, just one American hospital.  So confronting H1N1, avian flu, AIDS, TB and malaria, I would assert they are thinly resourced.

Further compounding the lack of resources is that donors are now heavily earmarking funds for their favorite causes instead of broad health -- building priorities called for by WHO.  About 80 percent of WHO's budget is voluntary funding.  At the -- my old cluster, AIDS, TB and malaria, it's 95 percent.

I met with my successor.  He basically lives on an airplane going around the world to fundraise.  This makes WHO respond to the preference of a few donors rather than that of the wider membership. And with its paltry budget, WHO is caught in a trap of responding, even appealing to donors' specific interests in fighting specific diseases, such as polio, AIDS and so forth, while broader health systematic priorities remain underfunded.

Its human capital, its talent base is also eroding away.  When I was there, as many of you know, we embarked on the AIDS "3 by 5" treatment campaign.  And through a generous grant from Canada, we were able to enlist a strong list, a strong cohort of HIV/AIDS technical advisers deployed that we deployed to help ministries.

Now, that money has dried up and the hard-won gains by these advisers may literally walk out the door over the next few weeks.   

I was in Geneva just last week and touched base with many of my former colleagues.  One department director told me he went from having $3 million in discretionary funding, when I was there, to just $55,000 this year, and other offices have hit him up for money.  And he said this is -- this is a painful situation for him.  And I've been told that, from lack of funding in other departments at WHO; for example, that there is now just two staff members who cover cancer and one staff member who covers diabetes, which is miniscule compared to the tangible epidemiology.   

Even if WHO were to fund a new programmatic campaign, its ability to quickly mount an effort with its greatest resources -- its objective expertise -- can be frustrated by the U.N. personnel system, which aims for language and a geographic balance.  While diversity is a strength -- and I have benefitted from and contributed to that diversity at WHO -- I've just seen that the personnel system requirements and procedures, the hoops that they make people go through, can frustrate and delay the hiring of key experts.   

Furthermore, the administrative centralization initiatives to outsource functions to a complex in Kuala Lumpur has complicated simple tasks, such as getting your airplane ticket fixed.  It used to be you could just walk down to the lobby and get it fixed.  Now you have to go through this elaborate system and hope that you catch the person, in Malaysian time, to fix your airplane ticket.  So this has generated much grumbling among the staff and has eroded the morale base.   

Now, the litany of problems and complaints could go -- could go on and on, so instead of my rostering more of these and fall into what I call "the culture of complaint," I'd like to pivot to my next theme. Rather than pick on the flaws and bemoan them, I would -- we need to envision ways in which WHO can be reinvigorated so that its tasks and mission is apace with the cadence and is aligned with the trajectory of the global-health work streams and idea streams.   

In other words, I believe the time has come for us to reimagine WHO -- reimagine WHO amid the landscape in which the restless tide of diseases continue to exact a heavy toll; amid a proliferating constellation, a fleet of new and powerful and well-funded organizations; amid a financially stressed environment in which thetraditional donors are depleted themselves; and amid a political ecology that is the most favorable toward health and development in history.   

Now, by reimagining WHO, we aim for the freedom and latitude to articulate ideals and "must haves" that reinforce the work of partners, and to inject some fresh thinking into how WHO operates and governs itself.  To embark on this reimagination pathway, I suggest that WHO aim for a three-goal mantra:  Prove, improve and approve. Prove, improve and approve.   

More specifically:  Prove itself.  WHO has to prove itself.  In order to demonstrate its resolve and its ability, it should constantly work on establishing clear goals, goals that have three elements: having a finish line, a timeline, and a deadline -- a timeline with a deadline; a headline that enunciates the declarative value of the project or line of work.   

Now, by illustration, we did that during Dr. Lee's -- J.W. Lee's administration with the three-by-five initiative.  It's a -- it's meant to treat 3 million people on -- who have HIV by the year 2005. We started this in 2003.  So it was an accelerated, catalytic event meant to embolden our client countries to roll out ARVs rapidly.  Now, WHO has had an accomplished history -- the eradication of smallpox as an example, but WHO should not, and has not, rested on its laurels. And asking it to keep proving itself may seem burdensome, but doing so at this time will rekindle confidence and attract further investment.   

WHO has to also improve itself.  It must have the ambition to be better, wiser and stronger.  I know Margaret Chan takes this to heart. And from proving and improving itself, WHO is in a much stronger position to do the third task, which is approve the critical needs and the critical interventions, being the preeminent standard bearer.  And to do this judiciously, WHO, Margaret Chan and her team needs to -- needs to look at its work streams and identify its absolute advantage, its comparative advantage comparative advantage, and, honestly, where it has no advantage.  And where it has no advantage, it should cede those functions and share those functions with those in the constellation of global-health operators.   

Operationally, I have several starter, provocative ideas that -- if I may have five minutes --  

HUANG:  No, you don't -- you only have two minutes. (Laughter.)   

CHOW:  Two minutes.  Okay.   

Number one -- and maybe in the Q&A, I'll raise them up.   

HUANG:  Yeah, yeah.  You also have like -- both of you have two minutes.

CHOW:  Okay, so we can draw on that reserve.   

To diversify WHO's ability to access expertise, one option is to establish an independent global institute of medicine, apart from the WHO and apart from the U.N. personnel system, that has the freedom to recruit and retain scientific staff.  It's analogous to the American IOM and the American Senior Biomedical Research Service.   

Number two, WHO ought to prune its complex office system.  "WHO" is actually a misnomer.  It is really World Health "Organizations" of six regional offices and the Geneva headquarters.  Each of those regional offices elect -- politically elect a director.  So you have seven independently-directed leaders who are supposed to be in synchronization.  This is a very challenging, challenging task.   

I'm calling for WHO to transition away from that system to a system of regional coordinators appointed by Geneva, and that the director general have a discretionary fund to implement programs rapidly in response to an emergency.  During H1N1, Margaret Chan, in the first few weeks, basically went on a fundraising tour to try to get money in order to fight H1N1.  Any director general should not be in that position.   

So with those primer ideas, again, I remember what Lisa Veron did for me in Africa -- WHO.  She gave us her enthusiasm and her belief in the force of global health.  And when I reflect upon what she did for us, that global health is really a special -- campaign of liberation. It's a campaign of liberation because, by defeating AIDS, TB, polio, we liberate many generations from now, into perpetuity, to help them live their lives freer, openly and even joyfully.   

So, thank you very much, and I look forward to our conversation tonight.   

HUANG:  Thank you, Jack.   

Certainly, you are not the only one who -- who are convinced that WHO has been left behind in this accelerated dynamics in global health.  Two weeks ago when I was in D.C., an official -- an official at USAID said, and I quote, that "WHO has lost a lot of its leadership and influence."   

And also with the rise of other actors, initiatives, and with a limited budget, the WHO's role has been quite limited.  According to my colleague, Laurie, it's chaos.  Basically, the WHO's job is sometimes akin to corralling kittens.  So you are not only one who believe(s) that there is a lot of potential -- unrealized potential for WHO to strengthen its leadership.   

But I have a question for you, while using my privilege as presider to ask a provocative question.  The good news is that we don't have any current WHO officials here, so they won't be embarrassed.  (Laughter.)  This question is about the relevancy andeffectiveness of the World Health Organization.  I use just a case to support my point, basically.   

Basically, this is about WHO's ability to handle large-scale disease outbreaks.  We know that during the SARS outbreak in 2003, WHO proved to be the only authoritative actor capable of containing the virus.  During the outbreak, the WHO, through the Global Outbreak Alert and Response Network, assembled some of the world's best laboratory -- lab scientists, clinicians, epidemiologists and virtual networks that provided real-time information about the causative agent, modes of transmission and other epidemiological features that allowed the organization to provide specific guidance and recommendations regarding international travel, clinical management and protective measures.   

And also, during the campaign against SARS, in many countries, including China and Canada, WHO acted in the capacity of being -- refereeing as opposed to being just a junior partner.  Countries like Canada complained about the travel advisory, but they obeyed nevertheless.  China, reluctantly, also acquiesced to the WHO's leadership role.  This led a -- actually, a renown international law scholar to hail the arrival of the so-called -- (inaudible) -- wherein state sovereignty of a public health governance has been undermined by the increasingly assertive power role of the NGOs, international institutions such as WHO.   

But the story turned out to be dramatically different during the 2009 H1N1 pandemic.  While there seems to be a little stronger evidence to support that WHO played a effective, a strong leadership role in addressing the outbreak, several criticisms of the WHO's response emerged, including:  WHO's links with pharmaceutical manufacturers; the phase-based pandemic alert system; its lack of transparency.   

And also the WHO appeared to have no mechanism or resources to expand public health capacities within individual countries.  That is evidenced in the global distribution of vaccines.  We know that, industrialized countries, they ordered, produced, distributed vaccines that exceeded the actual demand or need of their own people, while low-income countries had little access to those vaccines.   

And also, compared to the SARS episode, there seems to be significant drop in the confidence, in the advice given by the organization during the H1N1 pandemic.  Against WHO recommendations, many countries imposed unnecessary, sometimes excessive, aggressive travel-trade restrictions to halt the advance of the virus.  So that led to another also reknowned international law scholar to claim that the WHO has no real power.   

So maybe I will ask both Jennifer and Jack's opinion on this.  To what extent can we attribute this capability or credibility gap to a different virus, or a different leadership?  What lessons can the WHO draw from the handling of the recent H1N1 pandemic?Jennifer, do you want to --  

(Cross talk.)   

CHOW:  Well, I'll -- I'll go up to bat here.   

Just from extrapolation, from my own experience, WHO's advisory process is -- while it may convey a systematic process, in reality, how it sometimes it's done, there's an ad hoc flavor to it.  It then intersects with a complex, legal environment, a procedural environment, even a political environment where sometimes steps are not taken, or, while well-intentioned, the outcome looks nontransparent.  And if things go okay, nobody really pokes around. But if it's something high-profile, or somebody has a chip on their shoulder and they start to dig in, there's probably plenty of procedural flaws that could be attacked, and I think that is a case here.   

So that's why -- that contributes to the thread of my thinking of creating an independent body who has time and resources to vet individuals for their conflict -- any potential conflicts of interest; having clear established procedures that can be worked out over time; reducing the ad hoc nature of some of these decisions.  That is certainly one facet.   

There is an added facet of this under-resourcing.  And one of my other points is that WHO should basically open itself up to other funding styles.  UNICEF, you know, they have their holiday cards; and the GAVI has aggregated their pledges into bonds; The Global Fund, et cetera, et cetera.  So, why can't WHO go out and have something like a project -- a "project red" campaign?  It seems to have been fossilized into being suspicious of these other sources.  But we've -- (audio break) -- AIDS and Global Fund that having civil society participation and private-sector participation adds to the legitimacy, adds to the vibrancy of these programs.   

HUANG:  Jennifer?

RUGER:  Well, I would say that a lot of what you said was also said about the CDC, okay, in its handling particularly of H1N1. And was the CDC afoul and wrong and poorly managing the situation also?  Maybe.   

So I actually -- I actually think that, as I mentioned in my introductory remarks, I think surveillance and alert systems are actually a main function of the WHO.  I actually think -- I haven't defended the WHO and the CDC publicly, but I think they handled those things fairly well,   

And I think here's what's going on there.  The issue is whether or not you want to make it -- it's what type of error does an institution like this want to make?  Does it want to make what we call a "type 1" error, which is overblowing an epidemic that wasn't as bad as we thought it was going to be, or minimizing an epidemic that ended up being a lot worse than we presented it as?  And I think that basically they don't want to be in the second category of mistakes.   

And so to the extent that the WHO -- and I would even -- I really would couple it with the CDC -- erred on the side of -- you know, what really prompted me to think about this was the travel restrictions and the very aggressive nature of what was going on.  And with the CDC handling the H1N1, people said they manipulated the media and theywere really overblowing all the statistics, and you know, it was just, you know, they're creating hysteria.  And I'm not so sure that that's the case.  I think they were trying to err on the side of not -- of not managing it as effectively as they could have.  Now, we don't know what the counterfactual would be.  We don't know what would have happened.   

So that's -- in terms of surveillance and alert and these types of measures, I actually think both institutions handled those situations fairly well.  Could they have done things better?  I agree. But I think those were pretty good.  And I actually think that that's a very, very strong argument for investing more resources and putting more at stake in WHO and CDC working together, and other organizations like the CDC in-country working together in these situations.   

The second thing, though, is the vaccine production.  Now, that is another -- (laughs) -- situation where that's a perfect example of a systematic errors that were already -- and deficiencies that were already in place before H1N1 hit, okay.  I mean, even in the U.S., the fact that, you know, the production of a vaccine takes so long; and there's this, you know, outdated process, and all these sorts of barriers to doing this; and they had just rolled out the flu vaccine and, you know, how did -- were these going to interact.  I mean, I think there was some guessing here, and there were some, sort of, infrastructural problems that both institutions really had nothing to do with.   

Now, could they be better in their technical assistance, and could there be more funding and support for creating a system that could handle it better in the future -- that they weren't handed a platter, and how were they going to, you know, deal with what they've been given?  Yes.  I think that that's more long term, and thinking about the future.   

And then just also on the vaccines, in terms of the funding of that, again, I said in my remarks I don't think the WHO is in the funding business or should get into the funding business -- and that's other organizations.  So that gets back to the coordination and the cooperation that's necessary, and particularly here around vaccine production and dissemination.  So I wouldn't put it all on the WHO, in terms of that particular set of scenarios.   

HUANG:  Thank you, Jennifer.   

We're going to open the floor up to questions.  Please flip your -- the cards.  If you want to ask a question, identify yourself and your affiliation before responding.  We also allow the one-finger rule if you have any quick follow-up remarks.  But please keep your comments and questions as short as possible.   

So, Laurie.   

QUESTIONER:  Thank you.  Well, first, thanks to Ambassador Chow and Professor Ruger for joining us here at the Council on Foreign Relations.   

I want to really bring this back to governance, because I feel like a lot of the conversation has deviated from actual governance. WHO was set up in 1948.  It was a Cold War institution writ large. None of you have mentioned that it has a health assembly where Vanuatu has an equal vote with China, and where the Marshall Islands have an equal vote with India, and where countries you've never heard of are capable of introducing policy that goes through a voting process and may actually be enacted, and therefore become principals that WHO must move upon.   

When this crazy structure was set up, it made sense in a way, because the world was divided according to the Cold War:  So Vanuatu voted with the United States -- (laughs) -- and the Marshall Islands voted with the United States; and China usually voted with the Soviet Union, and so on.  But today, for those of us that have suffered through many of these World Health Assemblies, it is a hideous process.  It is one of the most horrible, non-governance/governance experiences you could possibly have.  The only thing worse probably would be hanging out in some of the caucus rooms in Congress. (Laughter.)  

And so I'm surprised that you didn't talk about that.  And you didn't talk about how -- Chow has mentioned the extraordinary power of the regional offices, but we haven't -- you haven't really gotten into how that came to be.  And one thing that is absolutely certain is, none of those regional offices are going to shut down.  I mean, they're absolutely not.  And, indeed, at this time, three regional offices have informed Chan than they're not backing her anymore.  So she's back campaigning again, two years ahead of the election; and this is in airplanes, 24/7, which gets to the next problem of governance:   

How do you govern when you're never in the office?  How do you govern when you spend your whole life in the damned airplane and in a state of jet lag? -- which is Chan and her entire staff is in that situation.  The mice play in Geneva and do whatever the heck they want because the boss is never there, and the boss of the boss, and the second boss, and so on.   

And just a final comment that I'd love you to respond to:  Both of you have mentioned Brundtland as the high-water mark.  And it's interesting that, that's the choice, because, Hiroshi Nakajima came within a hair's breadth of completely destroying WHO.  It was fighting and gasping for its very life when he was about halfway through his second term.  I witnessed bribery carried out by the Japanese government to get votes, and, you know, he was one of the worst leaders we can identify of any U.N. institution.

Brundtland was recruited by Madeleine Albright, and she only agreed to take the job if she would not have to have a second term; if she could go in, kick ass, ruffle feathers, make trouble and then leave.  And that was the understanding up-front with the U.S., and it was on those terms that the U.S. then corralled the necessary votes to get her in that position.  I think it's -- the way WHO exists right now, it's doubtful anyone who actually wants a two-term reign can possibly ever replicate what Brundtland did.   

HUANG:  So, any response?   

CHOW:  Well, thank you.  I actually had remarks on governance.  (Laughter.)  It was --  

HUANG:  Didn't have the time.   

CHOW:  Didn't have the time.   

So let me -- let me read from my notes, if I may, and say that the member states of WHO might revisit the constitution of WHO itself. It came into being 60 years ago at a time when the world was recovering from the wounds of two world wars; when transportation, communication, medicine and public health were at humbler stages than today.   

Now there's much wisdom that's embodied in the text of that pact, but it still falls short in inspiring and connecting with the new ways of thinking and doing.  And the summit of WHO, with the leaders of the agencies and national governments, could affirm or change this formulation and revalidate some of its prime goals and objectives.   

And furthermore, you know, as I mentioned, WHO is basically a "government health club," right.  In many countries, however, health care is delivered by the private sector and NGOs.  When I look at my former -- in my former job, when I looked at my U.N. brethren at UNAIDS and Global Fund, and their governance structure includes members -- voting members from civil society and the private sector, we should, we should challenge WHO's assumption that this has to be a "government health club."   

HUANG:  Jennifer?   

RUGER:  Well, so, you know, I agree with --  

HUANG:  Do you still believe that Brundtland did a better job than Margaret Chan?   

RUGER:  I didn't compare the two.  I just put her up as an example of some -- and noted some characteristics that I thought were useful.So I think there's a couple of ways to think about this.  One is that -- you know, I've argued for, you know, unless you're going to reform the institution, and from -- I agree, from the sort of initial constitution forward, you have to take it as it is.  And one thing to do there is to try to scale it back, and try to curtail the functions; try to have a -- and I've called it, you know, "global minimalist" -- WHO.   

And I think that, that's sort of one way to sort of identify particular areas that the institution should focus on:  pare back the other areas; look at best practices; look at successes in the past -- and I, you know, I do think that there are some; and focus efforts there, and sort of cut away the fat and the rest of it, and just take the institution as it is.  And I have said that we should focus more globally, and reduce -- I think reducing the power of the regional offices is absolutely what needs to be done.  How to go about doing that is a process of internal politics and more internal struggles, and that's a very difficult, as has been pointed out.   

The second thing is to think about how one might change the governance structure, and sort of, "What would the ideal WHO look like?"  And there I think it's useful to look at the other institutions and see what we might do in terms of evaluating them. And then, of course, as you may know, or the people who follow this know, that The Global Fund has been put forth as the -- now, I'm not saying it is, I'm not advocating that -- it has been put forth as an institution whose governance structure is working pretty well.   

And why is it working pretty well?  Well, that's very interesting, because it doesn't have the one-vote/one-member type of style.  It has more of a World Bank-type of style of governance.  So the contributors and the board is basically made up of a certain -- it's a very small number, actually, of countries, of which the United States, for example, is one.  And I think it's the 30 -- the U.S. contributes about 30 percent of the contribution.  I'm not sure exactly of that number, but I know it has a lot.   

So it has more influence, although it even -- it just has one vote.  So it's a hybrid between sort of what you see in a typical one- member/one-vote and what you see at the World Bank in their structure, which is basically tying influence to contributions, which is what you see, for example, at the World Bank.   

So would that be a better structure?  Would that be more effective?  Well, it's smaller.  So we always know that, you know, if you have fewer people to hash it out and to make decisions, and also presumably you have more -- here you have advanced countries which presumably have more (honed ?) interests, then maybe the decisions will be more coherent.   

The problem there is that there's some concern -- now, there are developing-country representatives on the board -- but the concern is that, still, that, you know, this is, this is a lot of influence that these particular countries have.  It does seem to be an open question, though, in terms of that particular structure.  People are putting that forth.   

The other thing that people put forth in terms of a, sort of, comparison of the governance structures, and sort of holding up The Global Fund again -- and, again, I'm not advocating for that, but is this reduction in the, sort of, global and local-level influence?  So The Global Fund doesn't really have a lot of, you know, regional and country-level offices or work.  They don't really do that.  They workthrough the, you know, the CCM, which is a multi-party, you know, multi-stakeholder exercise.   

Now, there's even -- you know, that was sort of seen as a wonderful thing at first.  You brought together government; you brought together all the multilaterals; you brought together the bilaterals; you brought together civil society, and everybody got to work together at the country level, and it's, you know, peace and happiness.  And it's been, you know, put forth as a very positive thing, but then you also see that in that process that the proposals that go to The Global Fund are primarily written by international consultants -- (laughs) -- you know, the beltway bandits.   

So it's working, but how much country ownership, how much real, you know, power at the country level is in place, we don't know.  So, you know, so those are sort of some things to think about when we -- And I think your question is right on, in terms of, you know, how we go about reforming this governance structure.   

HUANG:  Thank you, Jen.   

(Inaudible.)   

QUESTIONER: Thanks.  I'm Jeff Sturchio, from the Global Health Council.   

Well, Laurie actually raised, in general terms, the question that I was going to return to.  I was intrigued, in both Jennifer's and Jack's initial remarks, there was only one mention at all of civil society, and that's when Jennifer said that one of the functions of the WHO is to empower the disenfranchised and actually, represent the interests of the people who really need interventions around the world.   

And I think that, you know, what's intriguing about this dialogue is, and Laurie played to this, you know, one of the things I think we would -- most of us would agree on is that one of the major trends in international relations since the Second World War has been the increasing role of non-state actors.  But here we have an organization that is still based, as Jack said, on the notion of a "government health club."   

And you know, the example of The Global Fund is instructive because it's done much better than the WHO at sort of bringing those voices to the fore.  But still it's not perfect.  You know, the CCMs are captured by health ministries in most countries.  You know, you've already pointed out that it's not actually the people at the country level who are writing these plans.   

And certainly, from the point of view of civil society, the global -- excuse me, the World Health Organization is one in which people find themselves on the outside with their noses pressed against the glass.  I mean, it's almost impossible to have any substantive interaction with the WHO and most of its major functions if you're from an NGO or from a private-sector organization.You know, the few examples that you can point to where there have been partnerships are the exceptions that prove the rule.  And, you know, we can all come up with examples of that.  And, you know, Jack and I have recalled when we both in different roles trying to work through some of that to find ways for the private sector to be engaged in a constructive way in the three-by-five initiative.   

So the question is if we all agree that the WHO has to change and has to be more reflective of a broader set of interests in its governance, what is the best way that the WHO can shift from being run by Vanuatu and other countries that may or may not have the right intentions, and one -- you know, be one in which civil society and the private sector actually are represented adequately and appropriately for the expertise and the resources that they can bring to solving the problems the World Health Organization is there to solve?   

CHOW:  I think Jeff's points are very well taken.   

You know, there is an effort to bring in NGO and private sector in what they call "committee C" proposal -- this is "inside baseball." At the World Health Assembly, there's "committee A" and "committee B" to look at policy and budget issues.  So the idea was to create a "committee C" to allow the participation of the non-state actors, and that is chewing its way through the system.  I mean, I think that's one way.   

I believe that there ought to be spots on the WHO executive board for non-state actors, the exact proportion of which is open to debate. Again, I point to UNAIDS and Global Fund.  They manage any conflicts quite well, and the voice of policy has a deeper, broader range of legitimacy.   

QUESTIONER: uite frankly, I think any major changes of what we were talking about tonight will require shock therapy -- shock therapy by major countries, like the USA, basically, the G-8, G-20.  And you're going to have to have coalition of member states who say this current dynamic doesn't work; it's outdated, a 60-year-old constitution; let's get into the Google era.  And it has to throw its weight around -- through its current votes, the current political ecology and its budget power -- to compel these changes.   

The incrementalism, this sort of quicksand for any idea that it encounters, it's really debilitating.  Those of you who knew me, I was in it.  (Laughs).  I was both in this quicksand and probably contributing to some of that.  (Laughter.)  But I'm wiser now.   

HUANG:  I think that you raised a very interesting issue, that is the role of the civil society, NGOs in global health governance.  So far it seems that the only major institutional change has been the revised IHR that allows the WHO to use the information provided by the NGO in its decisionmaking process.And if you have --  

QUESTIONER: Just related to this, since you're a lot more knowledgeable than I am, but I'm drawn into this conversation because yesterday we launched a public-private partnership on nutrition science at the New York Academy of Sciences with all of the companies that you'd think of, and a lot of the universities and NGOs.  And the WHO staff, particularly for, like, nine months, has struggled to figure out how to be able to make use of this, and have formally agreed that they are going to utilize this to do a formal process of a roadmap on nutrition science.   

Is this a unique -- an oddity that they did as a way to reach out to the NGO community and be able to do -- to get access to the scientists' expertise, both from academia and industry?  Or is it something that does exist in some way within the WHO and could be exploited while you were waiting for these tremendous changes that are probably unlikely to happen in these kinds of institutions?   

HUANG:  Okay, Jennifer, you want to --   

RUGER:  Yeah, well, I -- I combined this response because I think they're both very important questions.   

You know, again, I mean, not to go back to the Brundtland administration, but also mention I think another example, the Commission on the Social Determinants of Health, where there was actually an effort through those processes to involve -- you know, civil society is a broad category, right -- (laughs) -- non- governmental people and institutions -- and, you know, worked fairly effectively in both of those situations.   

I think the problem with the Commission on the Social Determinants of Health isn't that they didn't involve stakeholders and didn't involve countries.  And it was very, very open and inclusive at the, at the country level in particular.  I mean, they traveled around the world to different countries and, you know, tried to work and get feedback from governments and non-governmental organizations, in terms of how this might sort of play out on the ground.   

I think the issue there is that, that's a particularly hard problem -- (laughs) -- figuring out how to implement a social determinants of health strategy in countries.  I think it's just intractable.  It's very, very difficult.  Is it impossible?  No.  But it's very, very difficult.  Whereas the Macroeconomics and Health Commission, and the more scientific involvement -- at least, my experience, what I know is from that -- was very effective; and also was very focused on the -- on analysis, and, in particular, discrete outcomes and products that were based on people's expertise; and also values and involvement, but basically, you know, there was something that could be -- could be done and produced -- I mean, going back to sort of effectiveness, and doing things well, you know, focusing on a discrete project like that, I thought, the involvement was very effective.

HUANG:  Thank you, Jennifer.   

Barney --  

QUESTIONER:  Thank you.   

HUANG:  -- if I may.  (Laughs.)   

QUESTIONER:  Thank you -- (inaudible).  Thank you, Ambassador Chow.   

And thank you, Jennifer.  I'm Yale, 1940.   

RUGER:  My goodness.  Wow.   

QUESTIONER:  I was up there at our biomed campus -- new campus, west campus, which we bought from Bayer.   

RUGER:  Yes.  Impressive -- impressive place, yes.   

QUESTIONER:  (Audio break) -- has been mentioned, more or less.  You mentioned about polio, which is our signature, major corporate program on which we have spent close to a billion dollars.  We work -- and it's funded with Gates Foundation, and our partners are UNICEF, WHO and the Centers for Disease Control.   

We work -- we usually address the World Health Assembly in May, and we're pushing hard for more help -- more work on noncommunicable diseases from WHO.  I was party to part of that.  I introduced a resolution which was passed by the World Health -- by the General Assembly in December four years ago on making diabetes, which is now the fifth-largest killer in the world, World Diabetes Day, November 14th henceforth.   

And I've already mentioned that we have been fighting polio. The Gates Foundation has been fabulous with us.  We work closely with WHO on polio -- Margaret Chan down, Bruce Aylward, and with Gabby (sp) also, of course.   

And I just want to say that we have real focus on so many different things affecting health.  We have rotary action groups, just to name a few, fighting AIDS around the world; diabetes; eliminating malaria; and particularly water and sanitation.  And I think water, after polio, is our next biggest thing, because you can't have good health without clean water.  And that's what we're working on.   

HUANG:  So that -- I take that -- this is a comment, right?   

Well, we only have about 10 minutes, so I'm going to collect the questions.  I still see a lot of the -- (laughs) -- (inaudible) -- card.  So we're going to take the questions.   

And then maybe, Jack and Jennifer, you can select a question --  

CHOW:  I'll answer them all.  (Laughs.)   

(Cross talk.)   

HUANG:  So we can do Natalie and Howard, Mr. Elmendorf and Steve and Suerie.

QUESTIONER:  Thank you very much.  I'm Natalie Hahn.  I worked at --  

HUANG:  Keep your question as short as possible.   

QUESTIONER:  -- the U.N. system for almost 40 years, mostly in Africa with FAO and UNICEF, and IFAD.   

And surely, if we think but global governance, the biggest impact for all of the U.N. system has been the private sector.  And I was struck by the fact, Dr. Chow, that you said that still 95 percent of your staff and -- (inaudible) -- your own unit in WHO-Geneva still had to come from voluntary funds.  Now, to what degree is the private sector funding headquarters staff?  And more importantly, because all of my life has been in the field, primarily I'm interested particularly in the impact of WHO on the private sector.   

As I travel in Africa I see a major influence from the Chinese pharmaceutical companies; a major influence from CEPAL (ph) of India. The standardization of these drugs coming in, the inspection, the collaboration -- are you buying from India and China as part of the essential drug program?  And to what degree is WHO supporting in- country pharmaceutical production?   

QUESTIONER: I'm Ed Elmendorf, from the U.N. Association; formerly, the World Bank.   

I want to go back to the insistence on the issue of governance, and at least to suggest a possible pathway via some form of independent and external evaluation of WHO.  With 75 (percent) to 80 percent voluntary funding, it's pretty clear that WHO's financiers could get together and force this on the organization.  It would be a lot nicer if it weren't just crammed down people's throats.   

And I'm quite convinced that the governments of the Vanuatus of this world would also see their interest in collaborating in this if they were faced with the alternative of getting it rammed down their throats.  And they could -- in this way, one can come up with a mandate that might be responsive, not just to the concerns of the industrial countries, but to the larger global community.  And I think that, in turn, could lead to some pretty profound changes in governance if it's well managed.  Thanks.   

HUANG:  Howard.   

QUESTIONER: Howard Weinberg from Deloitte.   

My interest here was doing pro bono work I'm doing with UNHCR on health care issues for people of concern to UNHCR, chiefly in the camps.   

Jack really suggested revival, all right.  So the program that I -- if you -- to the extent the program is really revival.And I think what you're suggesting, Jennifer, is a pruning back of focus, right.   

At the end of the day, we want good governance, right -- we want to effective governance, and that would be something that would occur after either of those.  Why couldn't those be combined?   

That's I guess mostly for Jack.   

HUANG:  Okay.  Yeah, we have Steve.   

QUESTIONER:  I just wanted to, again, pursue the governance theme and to build on Jack's comments on shock therapy by G-8 or G-20.  By the way, I'm Stephen Phillips from ExxonMobil, sorry.   

I'm just wondering, is WHO beyond fixing and remediation?  And, in terms of the history of the last 10 or 15 years, one interpretation of Jennifer and Jack's presentation is that the -- most of the world has really given up on WHO as an effective instrument for global health matters.  And new institutions, when architected by global health decisionmakers like The Global Fund, like GAVI, can be perceived to be work-arounds WHO, and the only reason is that the architects and the funders lack a fundamental faith in the ability of WHO to carry out that mission.   

Some of us, during the SARS epidemic and H1N1 -- which was perhaps a dress rehearsal for something much more significant -- had the feeling that if it actually had become something more significant, the WHO would have been peremptorily stricken of its authority, and some of its global technical assistance, and surveillance mandate; and that the northern countries would have, by and large, taken matters into their own hands and formed whatever consortia was needed for both monitoring and for an adequate response.   

So some of the issues we've been discussing here tonight -- such as civil-society- and private-sector participation, such as funding levels by the donors, such as internal WHO leadership -- I think are important, but it sounds like it's sort of fine-tuning and incrementalism, versus either a major extensive fix of the type, Jack, that you were alluding to.  But I'm wondering, from your vantage point, how pragmatic is asking the G-8 or G-20 to suit up?  Will they suit up, in whatever combination or permutation?   

Or is the world increasingly marginalizing WHO, and for a small fee of $1 billion-plus a year, saying, "Stay in your sandbox and play with it multilaterally.  But if something is really important, we're going to figure out what the fix is at the time we know when the real issues are?   

HUANG:  Okay last questionQ Thank you.  My name is Suerie Moon.  I'm designing a course currently on global health governance at the Harvard School of Public Health.   

And I want to thank first the Council on Foreign Relations for organizing this event and the two speakers for very interesting presentations.   

I want to try to synthesize a little bit some of the discussions that have taken place this evening, because we've talked, as a previous speaker said, a lot about partisan and representation, as well as about the funding problem, and it seems that the two are very closely interlinked.  And I think many people -- and I'm speaking not only about WHO, but about the U.N. system in general -- have raised the Vanuatu-China problem, or the Vanuatu-India problem and pointed to the lack of legitimacy that, that type of system has.   

But I would argue that one of the reasons why WHO is considered an essential institution is precisely because Vanuatu has a seat -- because poor, small countries have a seat at the table in a institutionalized, formalized way that other global institutions, such as GAVI and Global Fund, don't currently allow.   

So if we want to preserve that legitimacy that WHO has, and although many people may have given up on WHO, I think many other people say, if it didn't exist, we would have to invent it. You know, there's no replacement for WHO.  I think it's one of the reasons we're all here, is because we believe that there's something essential about the institution.  So if we want to preserve the legitimacy of WHO, how do we protect -- this is my question for the speakers -- how do we protect the legitimacy that does come from institutionalizing representation for the poorest, most vulnerable voices, that currently is channeled through national governments, while at the same time giving WHO the independence that's needed to act as an advocate, and a norm and a standard-setting body?  And in order to do that, I would argue it needs financial independence to a much greater degree than it currently has.   

And so how is it possible to achieve both of those at the same, particularly when the institutions -- that are, in fact, providing 80 percent of the funds today that are all earmarked, don't want to give up the power over what happens with their money?  That's precisely why we're in the situation that we're currently in.  So I would love to hear some ideas from the two speakers on how to achieve reform that both protects the system of political representation that currently exists while achieving financial independence --  

HUANG:  (Inaudible.)   

QUESTIONER:  -- or more financial independence.   

HUANG:  It looks like we have many questions -- (laughter) -- and not much time.  And you each will have two minutes --   

CHOW:  Oh, wow, all right.  (Laughter.)  

HUANG:  -- to answer the questions.  And that will also serve as your key takeaways.  (Laughs.)   

CHOW:  Well, it reminds me of those -- (inaudible).   

Natalie, the private sector currently does not fund those type of programs.   

There is a major foundation that wishes to secund a person to WHO, and now the staff is kind of reacting to this idea, all right -- this major foundation that --  

RUGER:  You can't tell us which one.  (Laughs.)   

CHOW:  It starts with the letter G and -- (laughter.)   

RUGER:  It rhymes with "great".  (Laughter.)  

CHOW:  -- the -- on the drug -- indigenous drug production, you know, there is a process that they believe helps support indigenous generic drug production.  I would say it's -- looking at Jeff, fairly debatable whether that really invigorates those processes.  Well, we can talk about that later, but there is that kind of process.   

On Mr. Elmendorf's, I wholeheartedly agree.  I think having an office of the inspector general of that kind of function, with that evaluative power, can really root out and shine a light on some of the processes and be a catalyst for change.  The Global Fund has an office of the inspector general that occupies a wing of the building, and all they is drill into their processes, keep the processes transparent and honest.  They go to countries, through the CCM, and they often find some real problems.  So I think having parallel processes would be very helpful.   

On Howard, I think having that combined "pruning and regrowth," to use the gardening metaphor, is certainly in -- a legitimate play. In my talk, I refer to that.  It needs to truncate, cut loose some functions, and focus on core absolute advantages.  And by accomplishing these absolute -- working from the absolute strength that can get more funding.   

On Stephen's point, you know, there is that sentiment that it's -- WHO is in decline.  The players -- the new players are basically crowding out, and I can cite a number of "inside baseball" crowding out against WHO.  But in the meantime, the media continues to shine the light on WHO when these outbreaks happen.  They go to Margaret; they go in to J.W., they went to Dr. Brundtland, and WHO has to put on the best performance -- the epidemiological performance it can with the resources it has.I think that spotlight is healthy because it -- unfortunately, if we don't reinvest in WHO, there will be a breakdown.  There will be a complete failure to respond to the next SARS emergency outbreak.   

HUANG:  So you agree with Suerie that if we don't have WHO, we'd have to invent it.  (Laughs.)   

Maybe, Jennifer, you could take the remaining questions, or any -- we have to wrap up.   

RUGER:  Okay.  Yeah, right.   

Okay, so I think your question was mostly directed towards Jack.   

I agree that I think an independent evaluation of the WHO would be very useful.  And to the extent that it's a legitimate one that people buy into, and think is credible, I think it would be useful. One will still have the question of sort of what's the evaluation based on?  What is the framework for evaluating it?  What are the functions?  What should it be doing?  Is it doing it well -- those functions well?  Is it effective?  Is it doing too much?  Is it, you know, expanding its mandate into areas that it just --  

So it would still be a -- there still have to be a substantive framework for evaluating the institution, in terms of whether it does, and also in terms of its role in the global health architecture.  So that would still be important.  And so, I think, you know, that's -- I think that would be -- that would be useful.   

I think, in terms of the reform, and sort of -- I think, sort of combining these three comments, all of which were great, but -- and trying to sort of just quickly respond, I mean, this issue of -- I mean, I agree that the democratic nature of the WHA (sic/WHO) is important and is unique.  I mean, I -- you know, it's so interesting to hear the discussion, because, coming from the World Bank where people used to say, "Well, if it was only like the -- you know, the World Health Organization, where, you know, one-member/one-vote; it was more equality."   

And of course you have these issues with any democratic process. You know, there are good ideas, correct ideas, and not-so-good ones. But that's why I think an important executive is critical in any organization, and particularly in the World Health Organization, and the role of that executive in putting forth within that structure a good plan and good ideas that fit with what that institution should be doing and enhancing its effectiveness.  And, you know, I did highlight a few examples of that.   

So the democratic nature, I -- you know, is there.  Does it create problems?  Yes, in terms of streamlining decisions; or, if we were to try to evaluate those decisions in terms of the rightness or wrongness of them, yes, but that's any democratic process, and I think we have to accept that.  So a strong executive can really work with that process.The -- and also I think that, that's where, in terms of the regional influence and regional impact, there is more flexibility there.  I think that, in terms of trying to reduce the influence of the regional and the local within the institution itself, which I think is the right way to go, is something that could be tied more with this executive and the leadership.  But I think that that's -- that's quite important.   

And I think you can do those at the same time.  And, again, you need to sort of focus on those governance issues as well.  But I think leadership is quite important.   

HUANG:  Thank you, Jennifer; thank you, Jack, for that lively and stimulating session.   

And thank you all for coming and attending this session.  And particularly -- (applause) -- I also want to thank Laurie for flying back from D.C. to attend this roundtable.  And thanks also go to Zoe (sp) and Dan for their assistance.   

We look forward to seeing you all at the next session of the Global Health Governance Roundtable Series.  Stay tuned. and have a good night.

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