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YANZHONG HUANG:  I think we're going to get started.

Welcome to the Council on Foreign Relations.  I'm Andrew Huang, senior fellow for global health at the council.  And this is the sixth -- actually, also the final meeting in the Global Health Governance Roundtable Series for this budget year, and also our third in Washington, D.C.  And so we're very excited to see same -- many of you again, and also thrilled to see some new faces.

And we particularly would like to thank the Robina Foundation, the -- through the council's IIGG program and -- which is led by Stewart Patrick -- for the support of this roundtable series.  We'd also like to thank Laurie Garrett, a distinguished colleague, for her support of the roundtable.  And she said she was going to listen to our discussion today, but something just come up on the schedule that make it impossible.

And we'd also like to thank Dan (sp) -- Dan Houston (sp) of the -- he played a critical role in organizing all these roundtables, making all that happen.  And so we very much appreciate that.

So we're going to -- well, before we introduce Larry, I just want to -- just some housekeeping stuff.  We're going to begin with brief remarks from Larry, and we are then -- it's about 15 minutes.  Since you are -- there's only one speaker, so we could afford to have 15 minutes.

LAWRENCE O. GOSTIN:  Good.

HUANG:  We -- for the previous speakers, they only are given 10 minutes.

So we'll then open up the floor to questions and discussions.  And the meeting is on the record, so you can feel free to use and quote today's discussions.  But please turn off your cell phones.

OK, well, this -- the roundtable will focus on the upcoming WHA, the World Health Assembly.  We know that is going to be held next week in Geneva, Switzerland.  And two month ago, the World Health Organization released its provisional agenda highlighting the issues that it intends to make a priority at this session.  Well, this is a laundry list of the issues, including the chronic diseases, noncommunicable diseases, Millennium Development Goals, strengthening health systems, sharing of flu samples, counterfeit and substandard drugs.  So there's a lot of issues to talk about.

In the meantime, as you're going to -- actually, you might have noted in this -- the article that Larry coauthored with Devi Sridhar, this happened at a time when WHO seems to be in a leadership crisis.  Actually, Margaret Chan say -- admitted that WHO has overextended and was unable to respond with speed and agility to today's global health challenges.  So this raises a lot of interesting issues.  What -- for example, what will be -- what issues will be given ample attention at the World Health Assembly?  What progress is expected to be made at the meeting?  Are we going to see some real serious debates, solutions to the challenges, or we're just going to see business as usual?

So we're very fortunate to have Larry, Larry Gostin, which is internationally renowned scholar in global health.  He is the O'Neill professor of global health law at the Georgetown University Law Center, where he directs the O'Neill Institute for National and Global Health Law.  We saw actually some O'Neill fellows here today.

Larry is the director of the WHO Collaborating Center on Public Health Law and Human Rights.  He is also professor of public health at the Johns Hopkins University, and director of the Center for the Law and the Public's Health at Johns Hopkins and Georgetown Universities.

I'm not going to repeat what's on this bio, save to say also in terms of Larry's connections with WHO, Larry serves on the director general's advisory committee on reforming the World Health Organization.  And in 2007, the WHO director general appointed Larry to be -- to the International Health Regulations Roster of Experts and Expert Advisory Panel on Mental Health, and so -- and he is also leading a drafting team on developing a model on public health law for the World Health Organization.

So without further ado, Larry.

GOSTIN:  Thank you very much.  I really appreciate it.

Welcome, everyone.  You can see that I have -- I have deep connections to WHO.  I'm the head of their Human Rights and Public Health Law Collaborating Center, and I'm on Margaret Chan's advisory committee on reforming the WHO.  So when I talk about suggestions for reform of the organization today, you should realize that it's from the position of a very deep friendship and admiration for the organization.  It's only a friend that will tell someone when they really need to change, and I consider myself that.

Eric Friedman and Emily Mok, our two O'Neill fellows, are here, and they can contribute.  I know many of you.  Len Rubenstein is going to be saying something about what he hopes WHO will take up as a major global health issue; Edie Brown Weiss is a world-renowned expert in development and is -- you're not on the board of the World Bank now -- just left the World Bank Board; Steve Morrison, who everyone knows in our field, is one of the great leaders in the field; and many others.  And so I hope you'll all contribute and this will be much more of a discussion.

I wasn't planning -- I only have 10 minutes, so I wasn't really planning on --

HUANG:  You have 15 minutes.  (Laughter.)

GOSTIN:  Fifteen minutes.  I've already used five.  (Laughter.)  Fifteen minutes to -- so I wasn't going to go through the whole WHA agenda.  I thought I would just focus on two areas, and then -- and then we could open it up more broadly.  I'm interested in all of them, particularly the NCD summit in New York in September, and the post-MDG concerns about what we're going to do after the MDGs.

This paper -- you've got two papers.  One is on reforming the WHO, but the other one just came out yesterday in PLoS Medicine, which is really what we're doing at the moment with a broad civil-society coalition, trying to convince states and others to adopt the Framework Convention on Global Health.  And you might want to read this paper, because it really kind of sets out what we consider to be the four critical questions in global health today and into the future.  And this has gotten a great deal of resonance.  In fact, the U.N. secretary general a couple of weeks ago endorsed the Framework Convention on Global Health.  And in Margaret Chan's reform agenda she has talked about a framework for global health which is modeled on it.  Although it wouldn't be a treaty, it would still have many of the ideas and would be a soft norm.

So with that, I'm only going to deal with two of the things on the WHA agenda.  One is the reform agenda; and then secondly, I thought I would talk a little bit about this very recent Indonesia virus-sharing accord that WHO member states agreed to a couple of weeks ago, and the WHA has to approve it.  And it's kind of a very interesting landmark, although it has a lot of flaws.

So I think we all know that there is a crisis in leadership at WHO, as Andrew said.  Nobody who's familiar with the organization is in doubt about that.  There are many reasons for it.  I mean, the most obvious is that it's got a $300 million budget deficit.  And I was at the town meeting when Margaret Chan announced to all the staff in all the regions that there would be massive cutoff -- layoffs of staff.  So there's a great deal of anxiety there.  Many people believe that the 300 million (dollars) is an underestimate and it will be more.

And so there are certainly fiscal sustainability issues that are very important.  But more than that, I think a lot of people worry that WHO hasn't lived up to its role as -- its constitutional role as the national -- international global coordinator of global health, and it hasn't been setting the normative agenda in health; that there's a great deal of fragmentation and skewed priorities out there in the world, and WHO doesn't seem to have much to say about it; that there are other global health organizations have overshadowed WHO, but even worse, there's frostiness among them, between UNAID, WHO, the Global Fund, GAVI alliance and the like.  So it's not a healthy situation for global governance for health.

So what would a future that thought about a good global governance for health do?  Notice I'm using the word "global governance for health" rather than "global health governance."  And the reason for that is, global health governance is really, at least in our minds, thought to be what the national and international health sector can do for health; you know, things like WHO treaties, the International Health Regulation, the Framework Convention on Tobacco Control and the like, whereas global governance for health is much broader than that because it includes many of the international regimes that have profound effects on health, including development, trade, energy, climate change and the like, particularly trade in TRIPS, in intellectual property.  Again, WHO has not figured strongly in these other regimes.  And even in terms of global governance, WHO is thought to have a kind of a lower order of precedence.  It doesn't have the same either normative or enforcement tools that the WTO has.

So if one wanted to change global governance for health, we've recommended five reforms of WHO.  Now, I should say that Margaret Chan has taken many of these on board.  She now has a very broad and fairly robust reform agenda, some of which she's putting before the WHA next week. But we recommended five ideas.

One is to give real voice to multiple stakeholders.  I mean, it's very, very clear that it's not a unilateral world out there and that there are many actors that play a very large role, and not only the big ones, like the Gates Foundation, but many of the NGOs and civil society groups play a very, very profound role, whether in AIDS, tobacco, cancer and the like.

And there's a lot of unrest from below in civil society, dissatisfaction with WHO for failing to include it in its decision-making processes, or as Margaret Chan has said, decision-shaping strategies, since WHO is a member organization.  And this is, I think, quite important, particularly since UNAIDS and the Global Fund have governing structures that do include civil society, maybe not as much as they should, but clearly much more than WHO does.

So WHO is trying to take this on board, and I think the leading idea that's come from this is the -- basically the global stakeholder forum that the director general is recommending.  There's still a lot of work to be done about how that's shaped.  At the moment there is the question of who it will report to, and our advisory committee recommended that it report to the executive board of WHO and that it have a real impact on shaping the agenda.

As one of the first orders of business of the global stakeholder meetings, they're supposed to develop a framework for global health, which is sometimes called the Framework Convention on Global Health Lite because it doesn't involve a treaty but it involves kind of a normative soft accord in global governance for health.

She certainly is more than open, actually welcoming, of the idea of changing it from global health governance to global governance for health.  So the first thing is really to give real voice to multiple stakeholder, including industry, although with industry, conflict-of-interest rules and things would need to be very clearly understood and played out.

Second recommendation is to improve transparency, performance and accountability.  The Paris and Accra accords really ushered in a new -- new era in global health, which has been really embraced by the Global Fund, in particular, and also GAVI, which really is very much performance driven, with monitoring, benchmarks, evaluations, targets to make sure that those are met.

Unfortunately, WHO, by many parameters, hasn't been transparent, haven't been accountable, and hasn't really performed the way that global donors would like it to.  And again, this is something WHO agrees to and is trying very hard to change.  Recent external evaluations that we refer to in this JAMA paper rank WHO among the lowest in performance transparency and accountability.

The third -- and I know PAHO is here, and I love PAHO, but we are suggesting that WHO headquarters have more -- closer oversight and coordination of the regions.  Right now the regions are very autonomous, very diverse.  WHO has very little control over its budget and its performance or its coordination or norms.

I've only got five minutes, so I'm going to rush along.

The third is the -- to exert its legal or normative rulemaking authority.  The WHO constitution gives the agency unparalleled powers to make conventions and treaties, but it's only really adopted them twice, with the IHR and the FCTC.  And there are many other venues where they could do it, including the Framework Convention on Global Health, but that may be too big for now.

Fourth is to ensure predictable, sustainable financing.  At the meetings in Geneva in the last month, it was palpable the distrust between donor states, big donors, foundations, and the WHO.  And the funding sustainability of WHO is really intolerable, in my view.  And it's not only the fault of the WHO; that is, the secretariat.  There is a reluctance on the states -- part of member states to give general funding.  Right now 80 percent of WHO's funding is what is called extra-budgetary funding.

The problem with extra-budgetary funding is multiple.  One is, is that no agency can plan for the future.  The funding is simply unpredictable about whether it's going to be there.  Two, each donor gets to set the agenda, WHO doesn't.  And what you see with extra-budgetary funding is, is that there's a huge mismatch between funding for certain health conditions and actual burdens of disease, so that the burdens of disease, like NCDs, injuries, have, what, 3, 4 percent of WHO extra-budgetary proportions, when they represent much larger problems within the world.

And then finally is global health leadership, really being involved in multiple regimes from trade to intellectual property and climate change and being a coordinator of largely fragmented activities that are going on.

In the end, I think everyone believes or almost everyone believes that we need to have a strong, powerful leader in the WHO and global health.  My own view is, is that if we didn't have a WHO, we would want to invent one.  And, in fact, my friends in the climate change world always think, oh, well, you're so lucky.  You've got a WHO.  We don't have anything.

And that took me aback when they first said that, knowing what WHO's like.  But they're right in very important ways.

So I've run out of time, so why don't I leave the virus-sharing agreement to questions and answers.  And I know Lynn (sp) wants to raise some issues.  Rebecca (sp) and others are here.  So why don't we start?  Because we've got such an amazing audience.

HUANG:  Thank you, Larry.  Well, definitely we could talk more about the issue (actually ?) later.  They're so -- but before we get to the Q&A session, well, this is always the privilege of being moderator:  You get to ask the first question.  You don't need to worry about people stealing your questions.  (Laughs.)  So I'm going to ask the first question.  That is -- something that is going to be covered by the WHO agenda but -- and actually I believe Steve would -- already asked that question.  It's about the NCDs.  The -- we know that the NCD, the noncommunicable disease issue, is gaining momentum.  And, in fact, this past month, the -- there was the first-ever ministerial meetings on healthy lifestyles and NCDS that took place in Moscow.

But interestingly, I found that the issue of mental health was included as NCDs while pushed by the Indian delegation.  So, you know, that reminds me something like the same concept of human security, like you include everything.  Right?  That's an umbrella concept.  

So -- and I'm curious, how is that going to affect the success or the prospect of success of the NCD Summit in September at the U.N. General Assembly?  You know, is that ultimately going to dilute out the entire NCD game?  Well, I hate to say that, but is the Moscow Declaration going to be the death nail of the U.N. NCD Summit in September?

GOSTIN:  Well, it's a multiple question.  It's a good one.  First, I'll deal with the mental health side.

I've been very involved with the NCD Alliance and thinking about the summit.  And I was then asked by the head of mental health at WHO and the head of the National Academy of Sciences forum on neuroscience what the NCD Alliance's position was with respect to mental health.  

And I just -- my first field, my first love, was mental health.  So I just always assumed that it was going to be an important part of it.  When I inquired with the NCD Alliance, they said, no; it had nothing to do with mental health.  And I asked why.  And they said, well, it's simply not an important enough disease.  

And it really took me aback.  And what I've realized is, is that in -- very symptomatic of global health dysfunction, there is a -- there is stresses and tensions between not only within the alliance, with cancer and diabetes, heart disease but more broadly with mental health.  And they were not going to include mental health.  I am glad that that mental health is -- that they're trying to assert it.  I don't think it would dilute it.  I think mental health -- it would be bizarre to me that such an important chronic disease was not in there.

As for the Moscow Summit and the prospects for an effective NCD Summit, I think most people, including myself, are very pessimistic.  And Moscow, a lot of -- a lot of the people there, a lot of the civil society groups, are very dissatisfied.  And there is no clear (ask ?) for the NCD Summit, and there is no clear vision the way the AIDS advocacy groups had for the only other high-level U.N. summit.  And so the high-level U.N. Summit on AID(S) was a game changer.  It changed everything.  And there was very high expectations that that might happen for NCDs.  I'm much more pessimistic about it.

HUANG:  Thank you, Larry.

Now I'm going to open the floor up to questions.  Please identify yourself, if you have a question, and your affiliation before responding.  And also, flip up your -- flip your tent card to indicate that you have a question.  And we also allow, again, the one-finger rule that -- for a quick follow-up remarks.  

So do we have the first?  Maureen?

QUESTIONER:  I'm Maureen Lewis.  I'm from the World Bank.  And I think your (setting that ?) was really an interesting sort of look at somebody who has looked at it very carefully.  I've worked with WHO as a collaborating organization, and I think it has some rather serious problems in terms of how it's structured and what its mandates are.  It seems to have more mandates than it can handle, and so it gets very, very fragmented.  And it doesn't really do its core business as well as it should, because it's so fragmented.  I mean, I don't know your view, but that's sort of my perception as a collaborator.

And they are very important.  And they really, from my perspective -- and as an economist, I sort of think they should be dealing with public goods because nobody else can.  I mean, your point about you would invent WHO if it wasn't there.

But I have a -- I have a question that's sort of -- it's related to that in a -- in a sense, in that this NCD agenda is a little bit like WHO.

GOSTIN:  (Right ?).

QUESTIONER:  And you don't know what NCD is.  It can be about chronic disease, but it can be about injures.  It can be about mental health.  It can be -- you know, it can be about autism.  So in a sense, that's not a very good marketing tool.  I mean, I think you made the point of they haven't really set themselves up to -- for excellence in certain areas, although I think they do stupendously in some areas.  

But the question is whether this NCD as a strategy may be a problem for them, because it's -- it's sort of, I think, reflective of how they're structured.  But also it's very hard to get your hands around it.  And the thing about AIDS is, you had -- not only had a lot of activism, but it's very focused on one disease.  And you can -- you -- they did a little bit of that with tobacco as well.  

But could they unpack NCDs and make it a different set of issues that can be addressed?  And I think it's very hard to address all of those issues simultaneously, because there are more noncommunicable than communicable diseases.  So anyway, I would really be interested in your -- in your views on that, as well as very many other things, but this is really something that's -- that I feel really -- that I've been puzzling over.

GOSTIN:  Well, I mean, you're right, Maureen.  It's a very broad umbrella.  I think the -- I think the instinct behind it was as follows.  If you think about global health, it tends to be packaged along three large packages.  It always been from a public health point of view.  And you mentioned them.  It's basically infectious diseases, noncommunicable diseases and injuries.  Usually mental health kind of either is a stepchild or comes in under -- it -- but it -- so usually it's those three.  

What's happened -- and this is reflective of -- in budget's political will, the G-8, as Stephen (sp) had talked to me about, a side bar.  They've been very focused on infectious diseases, one.  

Two, they've been focused on specific diseases, which are so much easier to politically sell -- AIDS, now TB, malaria; and then very discrete health hazards like tobacco.  Those are the ones that have had the most traction.  

And so I think that the feeling was -- is that neither heart disease, diabetes or cancer alone seemed to have the organization and clout to do anything about it.  And the World Economic Council had made the point that one of -- and Steve, you probably know this -- one of the top three issues in terms of global GDP was NCDs.  And --

QUESTIONER:  That's a big group, right?

GOSTIN:  And so -- and that kind of catalyzed governments, and then the NCD Alliance was formed.

But they -- but all the -- for all the reasons you've suggested -- packaging, politics, selling, but also harmony amongst the different groups, and coordination -- for all those reasons, that makes it really, really hard.  The problem is, what tends to be really hard is usually really most important, and what's not hard is still important, but a lot of health problems get left out.  

I mean, one of the Framework Convention on Global Health's ideas is priority-setting, because we tend to really focus on many of the wrong priorities, in my view.

QUESTIONER:  But just one short follow-up.  One of the things they do -- WHO does, I think, very well is drugs -- setting formularies, setting standards, doing research.  So --

GOSTIN:  Mm-hmm.  It's become -- it's -- I think it's become a quite good scientific technical organization.

QUESTIONER:  Yeah, exactly.  

GOSTIN:  I wouldn't -- I wouldn't lose that, but I would -- I think they need to do more than that.

QUESTIONER:  On their diseases.  OK.

GOSTIN:  Mm.

HUANG:  Quite good scientific organizing -- organization that is subject to political influence and --

QUESTIONER:  Yeah.  (Laughter.)  

GOSTIN:  Huge political influence and pressure.  (Laughter.)

HUANG:  (Chuckles.)  OK.  Rebecca (sp).

QUESTIONER:  I actually -- just to push you back to -- I was really hoping to hear your thoughts about the sample sharing framework and, you know -- well, lots of thoughts, but -- (inaudible) -- also, specifically, if you think WHO is up to the job.

GOSTIN:  Well, it was only WHO that could have forged that agreement, and I think that -- does everybody know about the agreement, or should I just briefly explain it?  Explain it.

QUESTIONER:  Explain it.

GOSTIN:  OK.  So about four years ago, during H5N1, the avian influenza global outbreaks, Indonesia began to refuse to share virus samples with WHO laboratories.  And its reason -- and its reason for doing so is that the WHO laboratories would then share that information with industry to help develop vaccines and antivirals.

This was of enormous concern to the international community, I mean, right up to President Obama, and Bush before him, that -- and the reason was, I guess, twofold.  One, Indonesia was the epicenter of the avian influenza global outbreaks; and two, that if, in the face of a public health emergency of international concern that would probably trigger the IHR, had it -- the revised IHR, had it been around then -- was if -- in the fact of that, if the global community couldn't coalesce and coordinate and be harmonious, it was a problem.  

But it's also a problem for north-south relationships more generally, because although almost everyone from the developed world believed that Indonesia was irresponsible, they did have a point.  And the point was really driven home during the H1N1 pandemic, when you had a really interesting dynamic going on, which is basically, initially, developed countries, like the United States and the European Union, agreeing to share vaccines.  Then, when they got scared, they pulled back -- actually, President Obama reversed himself on it -- and then when the pandemic didn't turn out to be as bad as it was, we couldn't give away the vaccine to our own people.

But had it been bad, the less developed low- and middle-income countries would not have had vaccines, and that would have been a big political problem in terms of north-south political relationships.

So for four years, WHO has tried to broker an agreement, and one of the reasons why people criticize the WHO is that they were never able to do it.  But they were able to do it.  It's a -- it's historic, and it is a landmark, but it's a flawed agreement.  Basically what it does -- and this is an oversimplification, because it's, you know, many pages long -- is that it grants countries sovereignty over viruses in their own territories, as they -- as they actually claimed, legally, but they agree to share the virus.  So everyone's going to share the virus.

Now this wasn't a big change of -- a normative change, because it was only Indonesia, among all countries in the world, that didn't share.  So it was a norm that most people accepted.

In exchange, basically industry has agreed to donate money for developing country purposes and sharing the benefits of vaccines, antivirals and things like that.  What's notably absent is there's not even a soft norm for member states to do anything.

One would have expected, for example, member states to agree to give a certain percentage of their -- of their purchased vaccines to low- and middle-income countries, for example.

Now I know this is of great concern to countries because the Oslo 7 group of countries asked me to draft a paper and to -- and to develop ideas about how we might imagine a world with really true equitable sharing.  And we've been working with them on that.  It's of greater concern to them.  But this agreement doesn't do that; goes a little a way, but not as far as it ought to have.  

And it develops two kinds of contractual forms, one of which has certain legal obligations on industry.  But it's not a treaty, and it's not an international law document.

HUANG:  Well, thank you, Larry.

Well, this is very interesting, because actually WHO grants countries the viral sovereignty, but we know that the virus does not respect territorial borders.  (Laughter.)

GOSTIN:  No, it does not.

HUANG:  (Chuckles.)  OK.  All right.  

The -- Leonard.

QUESTIONER:  Thank you.  I want to raise or share with you a potential for WHO leadership in the way Larry said -- if it didn't exist, we'd have to invent it -- and concerning violence inflicted on health workers and facilities during both armed conflict and civil conflict.  You've seen recently a lot of courage, of the disappearances and arrests of doctors in Bahrain, and the obstruction and beatings of ambulances and ambulance workers.  But that's really quite unusual.  For such a pervasive problem, it gets very little attention, and there's no international organization of any kind that takes any real responsibility for providing leadership on this, except the ICRC, which has a very unique role and has very severe limitations on that role.

So this is an opportunity for WHO to really provide some leadership.  And what it can do is to use its expertise in data and in methodologies for data collection to start creating an evidence base about what is happening in the world regarding these attacks and what prevention strategies may work, develop a research agenda, what protection initiatives can be effective.

And it's really important because these attacks are not just one incident.  It's -- you attack or destroy a hospital and you don't know how many women then lack access to a facility in which to give birth for months or years down the road.  We also don't know but really think and have some evidence that these attacks lead to huge migration of health workers.  We saw that in Iraq.  But we don't really know the extent of it because no one has taken responsibility for developing this.

So it's time for WHO and the international community to provide that leadership.  So this is a plug.  Next week, there will be a session at -- a side event at the -- at the World Health Assembly -- a co-sponsor with the assistant secretary for Global Health Affairs, Nils Daulaire; and David Holman (sp) is here, who's been very important in moving this forward at Johns Hopkins, the World Medical Association and the NGO IntraHealth -- in which we will discuss what opportunities exist for WHO leadership.

Now, there are other initiatives going on.  There's going to be action this summer at the Security Council with respect to the Resolution on Children in Armed Conflict.  And there's going to be a campaign in the fall by the ICRC.  So there's a lot of other happening -- things happening.

But this is one unique function, we think, that WHO can play on evidence development and data-collection methodology.  Those of you who are interested, I have a flyer about it.

HUANG:  Okay.  You can share that if you want.

QUESTIONER:  Thank you.

HUANG:  Larry, do you --

QUESTIONER:  Thank you, Larry and Andrew.

HUANG:  Is this a comment or --

GOSTIN:  I think it's a comment, yeah.

HUANG:  It's a comment, okay.

Okay, we'll go to Kate.

QUESTIONER:  My name is Kate Schecter.  I'm from the American International Health Alliance.  And I wanted to delve a little bit further into your -- one of your recommendations on the issue of predictable and sustainable financing.

In my own personal experience, I've worked primarily in the Eurasia, Eastern European region with WHO Euro.  The lack of funding in the areas where there's often a lot of rhetoric about something being very important has really weakened the ability of WHO to really enforce many of the other recommendations that you're -- that you're listing here.  And your last line, you know, that the overhead charges might drive donors towards other multilateral organizations seems to me to be the key problem here, is that the funds have been so diverted from so many different important multilateral organizations that WHO often is the loser when it comes to the member states really standing by their pledges.

So I'm curious, beyond what you have here, what are you recommending as a way to create a sustainable flow?

GOSTIN:  Well, the overhead charge was the secondary recommendation.  The primary one was for member states to give a -- an assured, predictable, scalable amount that would be bound by -- and actually, Margaret Chan, particularly since she was -- she's heading into an election, was remarkably blunt against states, saying that they -- and it really struck me; I think she's right -- (chuckles) -- that states really aren't stakeholders in the organization.  They're not member states.  They don't share -- they don't share a -- an accountability.  It is their organizations.  Member states own it.  And unless they step up and do the right thing, I don't believe that it will be sustainable.

I think -- it's -- I mean, basically there are only three ideas on the table.  And in reverse order of lousiness or -- no, in order of lousiness -- (laughter) -- is -- one is Margaret Chan's idea, which is basically to get -- they're not lousy; they're good, but they're just -- they're good ideas, but they're not enough -- is -- you know, she's going to try to get developing -- really kind of transitional states to give more:  China, Brazil, India.

I -- when I -- I just got back two days ago from Delhi.  And, you know, we were floating the idea there that the Indian government shouldn't always be a recipient of global funding; they should also give.  And so if you think about the --

HUANG:  The same dynamic as in China, right?

GOSTIN:  And with China.  No, China may give in order to get Margaret Chan elected, but that's not what we're -- that's not the way it ought to work.  It's too political.

HUANG:  Do you think she's going to get reelected for sure?

GOSTIN:  Not for sure, but I think she has a good shot.  Others may have --

HUANG:  It's an honest answer.  (Chuckles.)

GOSTIN:  Others -- yeah, not for sure.  But I think she has a shot.  I mean, she's -- clearly, she's well-liked and well-respected.  And if -- and China's going to back her very, very strongly, and that's always an important thing.

So that's the first idea.  The second one is the overhead.  And -- but the third one is the one about sustainable, non-tied budgetary contributions.  That would be by far the ideal one.

HUANG:  Thank you, Larry.  The -- Mariel (sp)?

QUESTIONER:  Thank you.  I asked for the floor after you.  I think that the comment on the -- well, I am PAHO, PAHO staff, PAHO WHO staff.  And I thank you very much for your reflections and sharing with us your very, very interesting insight.  I think that putting the emphasis on the issue of funding and sustainability is really absolutely key.  I think this is one of the issues with which we have been struggling along the last, at least five years.

The problem that this brings -- and you have pointed this out very well -- is the issue of other donors really governing.  So they -- the true governance of the institution as a multilateral organization with a real concept of multilateralism is maybe distorted or even threatened by this parallel budget that is established through donors, who are very well intentioned, but they have their own priorities.  And there are so many different sets of priorities, as you were mentioning, and not necessarily they are the most sound technically or they don't make a lot of sense.

But I think that the -- our nature as a multilateral organization and the representativeness -- the issue of representivity -- I don't know if I'm saying it well in English -- is absolutely key.  And I think there is not an exact comparison with the other perceived-as multilateral organizations.  Like Global Fund is not truly -- it's not truly multilateral.  It's true that they have brought the voice very strongly of the civil society and NGOs, and this is very important, I think, for the -- in the whole -- in WHO reform process.  But they -- we will have to balance this with the one member state, one vote; and the responsibility to fund -- to fund in a sustainable way and to agree on a given set of priorities.

And regarding the issue of overhead, I think the overhead -- we have to be very sincere with the cost of executed resources because it -- we end up cross-subsidizing.

GOSTIN:  We do.

QUESTIONER:  And we do this too frequently.  In the end, this is also a way to change priorities, because apparently we have a set of priorities, and then we have the parallel projects, the other projects that we have to -- we really are cross-subsidizing if we don't charge the right amount of overhead.

And lastly, about the oversight of the regional offices, I think it's very crucial -- we in PAHO have very close oversight.  We have what is called the Regional Committee or Directing Council every September.  And member states are extremely participatory; they don't leave us alone.  They will -- they will be extremely -- provide a lot of feedback on regional discussions.  And I think this is also a way to exert the -- to assert and (serve them ?) the rights of a multilaterally-funded organization with membership -- with member states to present their voices and views.

GOSTIN:  Yeah, I mean, I agree with, I think, everything you said.  I mean, I think you were right on all of it.

You know, currently the kind of multilateral aspect of WHO is thought to be a problem, because member states don't kind of act as they own it.  But it's also it's greatest strength, because it's the most democratic and it's the way the U.N. agencies were intended to work.  

There is a lot of cross-subsidization.  One of the things that WHO complained about -- complains about is that -- we're talking about the WHA, every WHA, they're given dozens of new mandates, unfunded mandates.  And so one idea that's been put out there is, is that if a country supports a mandate, fund it.  But that's been -- the developing world has been very upset by that, because it puts them at a disadvantage.  So I do agree with what you said.

The last thing, of course, is that PAHO is very different and very special than any of the other regional offices.  It's the only regional office that predated WHO.  It functions robustly, in many ways much better than Geneva headquarters.  So -- and I love Mirta.  Mirta Roses is a -- is a terrific director.

QUESTIONER:  (Laughs.)  (Inaudible.)  Thank you.

HUANG:  Well, thank you.

Steve.

QUESTIONER:  Thank you very much, Larry.  On the NCD piece, I think everybody came away from Moscow aware that there were problems of definition and there were -- there's not going to be big new money, and the formation of this social movement is in its very early stages.  And there's -- you know, there was a lot of admission among the different groups that they weren't hanging together, and there was some recognition that as the balance of leadership shifts back to New York, it's not clear who's in charge.  

GOSTIN:  Yeah.

QUESTIONER:  It's not clear that anybody really is in charge, and that the dialogue with business -- while business remains so fundamental to the solutions, the dialogues -- (off mic) -- kind of difficult.

GOSTIN:  Yeah.

QUESTIONER:  But I also think there was some -- there was some really important things that sort of came out of it.  I mean, people can agree that the core is four diseases and four risk factors, so you can sort of -- the universe of what you're talking about.  You can debate around inclusion of this or that.  But trying to convey to people -- I think it's possible to convey to people what those are and that these are lifestyle and behavioral phenomenon with a heavy prevention, but also a care and treatment piece.

But Chan's leadership was pretty impressive.  You know, I mean, she really showed the value of mobilizing WHO to prepare that, and then her own opening and closing statements were quite powerful and really demonstrated that she could accomplish something like that.  And there was a close alignment in her messaging.  And the realism and exhortation to get business in the mix and to be realistic and focused, you know, was very closely aligned with what Secretary Sebelius had to say.  

And while Putin was four hours later or however long -- late he was, he was the lone really head of state of any significance that was there, and he showed that this government really was changing.  And so there's -- the absence of political leadership has been one of the huge gaps here.  And you had a little bit of a sign that, in fact, something along those lines might be possible.

Having 90 health ministers, having 300 different -- you know, 300 different civil representatives together there, that was not a bad outcome, I don't think, in terms of just how late this -- they were to get themselves started to get organized, how little time there was.  There were some pretty -- there were some pretty positive things that came out of that.  And that -- WHO came out looking pretty good, I thought, in terms of using its good offices and Margaret Chan's leadership to get some very focused messages across to people.

HUANG:  At least there's some silver lining in the cloud, don't you think?  (Laughter.)

GOSTIN:  Yeah.  And you know, those are -- that's very insightful.  The -- I particularly like the idea that -- maybe not even the four diseases, but the four risk factors, people can get their heads round.  I mean, it's -- I think there's a, you know, global recognition that those four risk factors could make a huge difference in health burdens.

And I do think Margaret Chan has exhibited great leadership.  She's in an awfully difficult position, you know, because the civil society groups were against -- they think that, in Moscow and in other venues, that she was cozying up too much to industry; whereas I think you and I believe that you need to involve industry.  So she is in a very, very difficult position.

But I can't disagree with anything that you said.  You know, the -- I guess it depends on what your expectations were -- are -- for the summit.  Certainly going to have a huge impact, but whether it has the impact, the game-changing impact that AIDS has, or whether it will get the political and economic support that it really, really needs to succeed in the long term, I think may be an open question.

QUESTIONER:  Don't you think -- don't you think also that sort of the outcome the -- it's so -- this meeting is so much different than the UNGASS meeting.  I mean, the -- it's not going to -- they may be able to agree to some target goals between now and then.  And those negotiations are continuing, and that's a key thing to watch on how they do that.

GOSTIN:  Yeah.  Mm-hmm.

QUESTIONER:  But it's not going to be driven by external money.  It's not going to be driven by donor activism.  It's not going to have a large international organization driving the process.  It's not going to be driven by a social movement the way the HIV/AIDS piece was.

GOSTIN:  That's the --

QUESTIONER:  It's going to be driven by governments -- the emerging powers that wake up and realize that they can't live with this.

GOSTIN:  Yeah.

QUESTIONER:  It's going to be the Putins of this world who wake up and say:  We can't field an army, we can't sustain economic growth, we can't be a global power if we don't fix this problem.

And it's also going to be aided by businesses who figure out that they can make a -- they can make a future on this, too, I think, and look good.

GOSTIN:  Yeah.  Yeah.

QUESTIONER:  I mean, I think the leadership is going to come from another way.  The summiteering is going to help set the frame and raise the consciousness, but I don't think the -- I think the drivers for it are going to be different than what happened 10 years ago.

GOSTIN:  Well, that's very interesting, I mean, and, you know, there are signs, you know, that emerging economies are doing it.  It will be interesting to see.  I mean, right now, the trajectory of NCDs in Russia, India, China are very poor.  And whether you do have visionary -- I mean, if a Putin steps up, or other leaders in other countries do step up, then it would make a huge, huge difference.  I agree.

And you think it will -- you think it may happen?

QUESTIONER:  Well, if you believe that these leaders are concerned about their strategic stability and their performance in the world --

GOSTIN:  Yes.  Yeah.

QUESTIONER:  And that data begins --

GOSTIN:  The data's there.

QUESTIONER:  I mean, I think that's what led Putin to make this conversion, you know, over the last several years.

GOSTIN:  Yeah.  Mm-hmm.  Yeah.

QUESTIONER:  And some of it -- and some of it's expensive, and some of it's just a matter of political will, and to change, you know, the choices people make in their living and to change their national conversations that they have around drinking and tobacco and bad diet and inactivity.

GOSTIN:  Absolutely.  Mm-hmm.  Absolutely.

HUANG:  Thank you.  I think -- well, we have only like a couple of minutes, so I'm going to ask Steve and -- I mean, I'm sorry, Chris and Professor Weiss, maybe you -- why don't we collect the two questions, and then ask Larry to answer both of them?

QUESTIONER:  Chris Decker, the National Intelligence Council.

I want to ask:  You, Jack Chow and others have raised that WHO recognizes it needs to change the power balance between Geneva and the regional offices.  Have the regional offices recognized the need to change the power balance, and is it in the same direction as Geneva thinks?

GOSTIN:  No.  I mean --

HUANG:  Well, let's --

QUESTIONER:  Oh, right.

Professor Weiss?

QUESTIONER:  Thank you.  A comment and a question.  And the comment is on your five things that you proposed, which I think are very helpful.  I want to focus a second on transparency, performance and accountability, perhaps not surprisingly.  And I would be interested in your thinking about how to deal with the corruption issue, which occurs at many levels, and accountability from the bottom up, which is to say what really happens; when things happen in the field, how do they get there; and the potential role for nongovernmental organizations and communities there, not only in the multiple stakeholder forum, but really in terms of having some awareness of what's happening and understanding.

And two very quick things.  One, have you considered the CGIAR, the old Consultative Group on International Agricultural Research, as a model for any of the activities in the WHO?  Because it was very successful for a while.  And it let WHO -- or the CGIAR take control of setting the priorities and then the donors came in.

And a final comment here on the proposal to deal with the protection of health workers, which is the experience that the peacekeepers had when the U.N. went to have a new agreement on protection of peacekeeping operations, peacekeepers.

GOSTIN:  OK.  Well, both good points.  I mean, on the regional -- on the region side, I mean, it's not in the interest of the regions to change because at the moment they -- the regions have autonomy; they have autonomy over their funding, their staffs, their -- things like that.  

But it does -- it's still a problem from a global perspective, because so much of the budget, so much of the activity, so much of the policy-norm making takes place in the regions.  And if -- and often you've got mixed messages.  I've seen it.  I've seen, you know, the Middle East taking a very, very different position than, say, Latin America or other places.  And it's so -- it -- and it does make -- it doesn't put WHO in good (light ?).  

And -- but that's, you know, political dynamics.  So it will have to be the member states that make this choice.  I think they're the only ones with the power.  The secretariat has -- doesn't have the authority to make any change.

And then, Edie, I mean, there's many, many questions that you asked, all good ones.  On accountability and particularly corruption, I was -- this paper was referring to WHO.  I don't think there's a great deal of corruption at WHO, at least certainly not nationally -- at the global headquarters in Geneva.  But they do have performance and accountability and transparency problems.

And -- but in this larger paper, we spent a lot of time talking about accountability and honesty and stewardship at the national level where it is a very significant problem.  And it's been very, very -- there are a lot of ideas out there on how to try to make it better.  But it's hard, because you don't want to withhold donor funding if there's corruption, because then the people get hurt.  And so you have to -- so it's -- it becomes a really, really difficult idea.  I think CGIAR is a good model.  I don't think it has been thought about as much as a model going forward for WHO, but it's actually very helpful.

HUANG:  Thank you, Larry, for that very important and insightful update.  And, well, I guess we can do -- thank you.  (Applause.)

GOSTIN:  (It's my pleasure ?).

HUANG:  And that will -- concludes our sixth session of the Global Health Governance Roundtable Series, but that is not going to be the end.  We are going to continue, I think, to do the roundtable on global health governance next year.  So if you have any ideas, please feel free to share with us.  And also -- and, well, thank you so much for coming and for making such a stimulating discussion possible.  And stay tuned, and we'll keep you posted.  Thank you.