[The WHO] is healthcare’s cartographer, collecting the best information, charting it and communicating the findings effectively for others to use.
This blog post was contributed by Liz Charles, RN, BSN, MBA (Duke ‘13). Liz, funded by SEAD, spent the summer in Geneva, Switzerland participating in Duke's Global Health Fellows Program.
This summer as a Duke Global Health Fellow and recipient of the SEAD Global Governance and Policy Scholarship, I have been interning at the World Health Organization in the Department of Public Health Innovation, and Intellectual Property and Trade, where I have been testing first-hand the analogy of the far-welded sheep.
My first exposure to Global Health Policy in Geneva was at the World Health Assembly (WHA). This WHO annual meeting brings country delegates together to define the organization’s annual agenda. Not just a logistical challenge, the WHA is an amazing exercise in diplomacy, negotiation and networking. Each resolution passed must receive a unanimous vote of approval.
Watching the delegates spend hours debating single phrases, “work vs. mandate” or “transform versus establish” tested my own patience. It also meant a lot of time was spent with very little output. The process certainly seemed to resemble the far welded sheep, legs kicking, but going nowhere. Moreover, I was surprised that the Secretariat (the WHO employees who live these issues everyday) were relegated to the role of onlooker. They uphold the parent-child ultimatum, “Do not speak unless spoken too.” This is part of their mandate as international civil servants. UN employees are “prohibited from any action or influence that would suggest affiliation with a government or organization.” Does that mean they really are the on-looking sheep?
From the outside the far-welted analogy was looking all too accurate.
At the conclusion of the WHA, I became emerged in my work. My project was to collect research priorities and prioritization methods from across the organization. This information would feed into the larger effort (a Consultative Executive Working Group report) of incentivizing research into neglected areas through innovative partnerships and financing methods.
This assignment was an incredible opportunity to see how the WHO directs and coordinates international health.
1. Shaping the Research Agenda: Research Priorities
I attended parts of a 3-day Tuberculosis research priority-setting meeting. As I read through the program, I was impressed by the guest list of star-studded TB experts, including academics, executives from Product Development Partnerships (a type of public–private partnerships that focuses on drug, device, and vaccine development), Non-Governmental Organizations, governments and civil society (activists) representatives. For three days, these experts presented, discussed and developed a list of high priority research needs for the areas of basic science, product development, and health system strengthening, focusing on the most urgent research needed to eradicate TB.
The WHO’s power to convene the best minds to address health challenges is incredible and perhaps, unsurpassable. This meeting was just one of many that convened during my time at the WHO.
One weekend my fellow PHI interns and I went on a chocolate and cheese road trip through the Swiss Alps. At one point we were looking for Gstaad, a town known for its artisanal ice cream (we had gotten a little side tracked from the cheese and chocolate). We kept asking for directions in our broken French or non-existent German. And we kept getting different answers. The towns in Switzerland can be small; the roads narrow, windy and crisscrossing. We tried to follow the signposts, with their yellow directional signs pointing in different directions. At one junction we stopped the car in front of one such signpost. We were excited to see Gstaad posted, until we realized it was posted three times…on three different signs…pointing in three different directions. At this point we gave up our search for the illusive town and mountain ice cream, turning our attention back to cheese and chocolate.
Finding the right healthcare advice can be like our search for the town of Gstaad. Everyone tells you something different. Their opinion influenced by bias - their funders influence, ulterior financial motives, poor data, unchecked assumptions, or differing regional needs. The WHO’s neutrality means it can offer unbiased advice. A function that is valuable to countries with limited resources that can’t afford wrong turns; or countries dealing with emerging crises who don’t have the time to spend “just driving around”; or for those in need a translator to help connect with other countries/organizations.
Things do move slowly within the WHO, but that is because due diligence is given to every guideline or publication to make certain it is well vetted, accurate and THE absolute, best reflection of what is known. This does limit the WHO’s ability to be nimble and take risks, however it adds credibility and accountability as they full-heartedly strive to fulfill the doctor’s credo, “Do no harm.”
During the WHA Margaret Chan, WHO Director General, spoke forcefully on the fight against non-communicable disease such as obesity, tobacco related diseases, and heart disease (globally the largest causes of death). She mentioned the increasing difficulty to protect health from these threats which are intricately linked to powerful private sector players such as consumer packaged goods and tobacco producers.
“Mosquitoes do not have front groups, and mosquitoes do not have lobbies,” she said, “But the industries that contribute to the rise of NCDs do. When public health policies cross purposes with vested economic interests, we will face opposition, well-orchestrated opposition, and very well-funded opposition.”
In an all out effort against the tobacco industry, the WHO has, over the years, been able to garner enough support to successfully fight back. Responding to the tobacco epidemic in 2003, WHO used improved evidence against tobacco to win approval of the first international treaty (legally binding) negotiated under WHO auspices, The WHO Framework Convention on Tobacco Control (FCTC). This treaty has since become one of the most rapidly and widely embraced treaties in United Nations history.
For World Tobacco Day early in early June, the Tobacco Free Initiative encouraged member states to ban advertising, promotion and sponsorship of tobacco products, thereby helping curve the demise of 6 million people who are killed from tobacco every year.
The WHO’s voice on issues that affect health, especially those issues that pit public health against powerful, resourced opponents capable of buying country support, may be the only way to successfully exert the right kind of pressure and represent the interests of the innocent and helpless.
4. Articulating Policy Options: Prequalification
Supplying quality and affordable medications to the people who need them most has proven a difficult task, especially in underserved areas. The reasons are many, and include poor infrastructure, intellectual property disputes, lengthy bureaucratic processes, supply chain mismanagement and corruption. The WHO is trying to address some of these challenges through its prequalification process.
In collaboration with national and international partners, the prequalification program ensures drugs have meet standards of quality, safety and efficacy. The WHO’s prequalification hallmark 1.) Simplifies bulk medicine purchasing decisions 2.) Potentiates facilitated regulatory processes at the country level and 3.) Results in expedited delivery of certified, quality medications and minimized bureaucratic rigmarole.
This is another vital role that only a neutral body such as the World Health Organization can play, and is another example of the WHO’s effort to direct and coordinate healthcare delivery. Additionally, prequalification is a potential revenue source for the cash strapped organization that has felt the effects of economic downturn in its historically biggest donor countries.
Above are just four ways that the WHO adds incredible value to the global health effort. There are others, such as providing technical support, building capacity and monitoring health trends. While I could elaborate on those as well, I hope I have given enough examples to show that the sheep in the background isn’t idle and aloof; rather it is directly engaged. It stands apart so as to maintain perspective of the whole situation. It’s trying to teach the far welted sheep how to save itself, rather than relying on others for aid. And in recording what happened and warning of danger, it is preventing other sheep from meeting similar fates.
As my internship concludes, I reflect on the analogy of the far-welted sheep. And I remember the hard working staff that made do with fewer and fewer resources, yet larger and larger mandates. Staff who used their pooled expertise to carefully address disease, policy and system issues in a thorough and professional manner. And I conclude that the WHO is not far-welted, but, rather far from it. It is healthcare’s cartographer, collecting the best information, charting it and communicating the findings effectively for others to use. I thank Duke and SEAD for the opportunity to expand my business school education to include a deeper understanding of global health policy and the role of far-welted sheep in global health.