[This year marked the 75th anniversary of the WHO. As the UN
agency approaches its yearly assembly in Geneva, it is struggling to
secure adequate resources for functioning independently of the private
sector and pressures from high income countries.]
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75 YEARS AFTER ITS FOUNDATION, WHO STRUGGLES FOR SOVEREIGNTY  
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Dian Maria Blandina
May 17, 2023
Peoples Dispatch
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_ This year marked the 75th anniversary of the WHO. As the UN agency
approaches its yearly assembly in Geneva, it is struggling to secure
adequate resources for functioning independently of the private sector
and pressures from high income countries. _

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During its existence of nearly seven decades, the World Health
Organization (WHO) has been successful in eradicating smallpox,
launched the ambitious Alma Ata declaration for primary health care
(PHC), and is now leading global efforts to achieve the Sustainable
Development Goals. However, its impact has been diluted by the
influence of transnational corporations and other global institutions,
particularly the World Bank and International Monetary Fund.
Neoliberal economics and attacks on multilateralism have created a
difficult context for WHO’s work, severely impacting its independent
functioning and ability to address dire health needs, especially in
resource-poor settings.

TRACING THE ROOTS OF THE WORLD HEALTH ORGANIZATION AND ITS FOUNDING
PRINCIPLES

The WHO was established in 1948, but its form and work are a
continuation of the League of Nations Health Organization (LNHO).
Since the very beginning, its annual decision-making meeting, the
World Health Assembly, operated under the principle of “one state,
one vote.” This meant that every country was equal regardless of
economic or political influence. The spirit was to resolve issues
through dialogue instead of majority vote, which can be influenced by
factors other than public health needs.

By design, the WHO is not meant to fulfill all the roles in global
health or impose penalties. Instead, its effectiveness and success
rely on the cooperation and solidarity of its members. A prime example
of such collaboration is the successful eradication of smallpox
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where countries set aside their differences to work closely with each
other and WHO.

The WHO Constitution
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preamble comprises nine principles, and while the phrase “Health is
a state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity” is frequently
referenced, the other principles are also noteworthy. They emphasize
the fundamental right to health for all people, the significance of
equal development in health promotion worldwide, the role of child
development and education in achieving a healthy society, the
importance of informed public opinion and cooperation in improving
public health, and the obligation of governments to provide sufficient
health and social measures to safeguard their citizens.

FROM IMPERIAL HYGIENE TO SOCIAL MEDICINE—AND BACK?

Despite the “one state, one vote” principle, WHO’s decisions
have always been influenced by politics inside and outside the
organization. Soon after its creation and the beginning of the Cold
War, the WHO began to align more closely with US foreign policy.
Because of this, between 1949 until the mid-1950s, the Soviet Union
and its allies left WHO, leaving what little counterbalance for social
medicine becoming nonexistent. This resulted in the WHO essentially
reviving an outdated disease-oriented, ‘imperial hygiene’
approach, putting aside social medicine principles. In spite of this,
the then-leaders of the WHO remained hopeful that social medicine
would make a comeback to the agency’s list of priorities.

In the late 1970s, following the success of campaigns such as smallpox
eradication, the WHO was able to revisit its origins. Under the
leadership of Dr. Halfdan Mahler, the agency returned to the ideas of
social medicine through its Primary Health Care strategy. The strategy
aimed to strengthen health infrastructure and support economic and
social development, particularly in rural areas.

The ideas were not unlike those explored by the LNHO in 1937, when the
organization emphasized the link between health and social advancement
during the Intergovernmental Conference of Far-Eastern Countries on
Rural Hygiene. In 1978, the Conference on Primary Health Care in Alma
Ata, Kazakh ASSR—today’s Kazakhstan—saw all the countries in the
world defining a structure for promoting “Health for All”, and
addressing health problems in the Global South. The conference
produced the Declaration of Alma Ata
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which outlines PHC ideals that health movements worldwide still
follow: attaining the highest level of health through community
participation and a multisectoral approach. 

Many governments, organizations, and individuals thought that WHO’s
ambitious vision of PHC was unrealistic and impossible to achieve. As
early as a year after the Alma Ata conference, they began the process
of converting the Declaration’s lofty ideals into practical and
measurable technical interventions at a small conference in Bellagio,
Italy. This conference was heavily influenced by US policymakers and
sponsored by the Rockefeller Foundation, with assistance from the
World Bank. The Bellagio conference resulted in the concept of
Selective Primary Health Care, with a preference for cost-effective,
narrowly focused interventions, which can be easily monitored and
assessed. For most of those dedicated to the Health for All approach,
this was equal to a counter-revolution. 

FINANCIAL FREEZE

At the same time, the WHO’s budget started to dwindle. WHO’s
financing was primarily composed of membership fees paid by member
countries, which are determined by their population and income. This
is the money that is fully flexible for the WHO to use as it deems fit
and gives it independence in operations and setting priorities.
However, in the early 1980s, the WHA put a freeze on WHO’s budget,
i.e. not letting the contribution amount grow in real dollar terms and
only adjusting for inflation and exchange rates, which then limited
the organization’s funds and ability to operate freely. This
happened precisely as the HIV/AIDS pandemic was beginning to emerge.
Another decision followed in 1993 to take out inflation and currency
adjustments out of the equation, which makes the WHO’s budget slowly
fall in real terms and worsens the agency’s already precarious
financial situation. The actual value of each country’s flexible
contribution to the budget has slowly declined in the following years,
forcing the WHO to resort to funding from multilateral agencies or
donor nations. The donors decide which programs they want to support
and have the option to withdraw funding if they are not satisfied with
WHO’s work, heavily compromising its independence. Wealthy donor
nations and multilateral agencies such as the World Bank have
considerable control over how these funds are used, and establish
“disease-oriented” programs, separate from WHO’s programs and
exert strong influence on WHO’s policies and decisions. 

By the early 1990s, 54% of the WHO’s budget came from earmarked
donations or donations from actors other than the organization’s own
members.  This caused a multitude of coordination and decision making
difficulties. Today, this kind of funding makes up more than 80%
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budget, making it almost impossible for the WHO to fulfill its
constitutional duties, let alone fight for its own vision. 

The WHO tried to resist some pressure from powerful governments and
groups, but was rarely successful. The International Code of Marketing
of Breast-Milk Substitutes and the Framework Convention on Tobacco
Control were a couple of notable wins in WHO’s battle against
multinational companies. At the turn of the new millennium, the WHO
started collaborating more closely with the World Bank and has since
taken part in activities which effectively promote commodification of
medicine, privatization of health care, and free trade policies. This
has done a great deal of damage to the health service infrastructures
in developing countries, not to mention diverting them from their path
of social and economic independence. 

BUILDING A STRONGER WHO 

There have been some attempts by the WHO leadership to increase
funding by the governments. But it has not worked. Many members and
multilateral agencies pay only lip-service to the idea of
strengthening the WHO’s position as the central authority in global
health governance. For example, a pandemic treaty is currently being
negotiated at the WHO which could bring about significant changes to
international health practices and global health governance. But
parallel processes are undermining the WHO. The Pandemic Fund
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a G20 and World Bank initiative, has the WHO as only an observer in
its policy-making. Another initiative at the IMF
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aimed at tackling climate crisis and pandemic preparedness, was not
created with health or WHO needs in mind. In February, these two
institutions, with the Rockefeller Foundation’s support, convened
at Bellagio
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plan an alternative global health system without WHO’s
participation.

On its 75th anniversary, let us reflect on the significance of the WHO
and the kind of organization we need to go forward. We should take
this opportunity to evaluate past actions and take steps to ensure
that the WHO can serve its purpose. Otherwise, we risk the WHO falling
further under the control of powerful donors and international
financial institutions, taking us further away from achieving health
for all.

_Lee en español aquí
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_PEOPLE’S HEALTH DISPATCH is a fortnightly bulletin published by
the PEOPLE’S HEALTH MOVEMENT
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and to subscribe to People’s Health Dispatch, click HERE
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