World Health Organization : The mandate of a specialized agency of the United Nations

Conclusions

Why write a thesis about the mandate of the World Health Organization? During the last couple of years I developed a strong interest in international relations and in particular in international organisations. Thanks to my professors, both in Milan and in Rotterdam, I started to know and appreciate this area of study. The interest for health, on the contrary, finds its deep roots in my education. Being that my father is a doctor and my mother a biologist, I have always been immersed in an environment where medicine, which I was taught to consider as an art rather than a science, was constantly on the agenda. The WHO bridges these two interests.

Yet, choosing to write specifically on the WHO's mandate was a result also of recent circumstances. An opportunity that allowed me to be in Geneva for three months[1], from September to December 2002, helped influence this choice. In January 2003, the 111th EB was expected to appoint the future Director-General. In the previous period, the Organization was preparing to welcome, either with hope or resignation, the new World Minister of Health.

And, as Horton says, "when a new Director-General is elected, he has to start considering what is WHO's mission"[2]. While observing this particular event, I began to ponder the immense task laying before Dr Lee. In a small way, I wanted my thesis to contribute to the ongoing debate over what the WHO's mandate is in international health.

The fist part of the dissertation is a description of the WHO as an international organisation. This overview of the WHO's history, structure - its organs and organisational levels - and functions is aimed at providing the reader with the required instruments to be able to understand the following chapters.

The second part is actually the illustration of the WHO's mandate itself. In order to define the mission of the WHO, one must first analyse the nature of the WHO and, thus, the reason for the second section of this paper. Primarily, the WHO is a specialised agency of the United Nations. This aspect of its existence provides the Organization with a two-fold mandate. First, the WHO acts within and contributes to the achievement of UN main goals. Among many others, I chose the UN's role in development, through the setting of the Millennium Development Goals (MDGs). Therefore, one side of the WHO's mandate consists of achieving the Millennium Development Goals by 2015. After pointing out the strict link between health and development, as a main reason for the WHO to be involved in such an issue, I detail what the WHO is currently doing in order to meet the goals.

Secondly, the WHO detains certain 'international responsibilities' attributed to it within the UN system. As a result, the WHO is an autonomous specialised agency. With this purpose, I identify three essential documents to understand the degree of independence given to the WHO. First of all, the Constitution which contains the main objective of the Organization "the attainment by all peoples of the highest possible level of health", encapsulated in the slogan 'Health for All by the Year 2000'. Even though many criticised such an aim as ambitious and unreachable, its visionary and inspirational character has led the work of the Organization for fifty years.

Moreover, I take into consideration two further documents, fundamental instruments created by the Organization in order to better reach its aim. They are, the corporate strategy, and the proposed programme budget. Respectively strategic and political in nature, the corporate strategy delineates four main directions of work for the WHO Secretariat, whereas the proposed programme budget translates into dollars the principal policies of the Organization and outlines the current priorities.

When the recently elected Director-General takes up his post, he should always bear in mind such multifaceted interests in order not to misinterpret WHO's mandate. On one side of the coin, the role of the WHO towards the achievement of the United Nations MDGs and, on the other side of the coin, the supreme constitutional Health for All goal. In both cases, the mandate of the WHO is with no doubt to advance health.

The result is an Organization with an extremely broad mission. The third part illustrates, with various examples, how the Organization can carry out totally different activities in pursuing its mandate. Tuberculosis, a disease that mainly affects the poor and the vulnerable in developing countries, is one example used. A Global strategy for diet, physical activity and health: a new process which principally targets risk factors, as unhealthy diet and physical inactivity, which are widely diffuse in Western countries, but also increasing among the poorest populations, is another illustration. And finally, the example of traditional medicine; all at once an old and new perspective of illness, respectively for developing and developed countries, is examined. Three widely different activities, and one Organization. A variety of activities in the unity of the mandate.

Completing the scene, new actors have been increasingly affecting the WHO in the international health arena. International governmental and nongovernmental organisations and members of the private sector have taken up functions which once were exclusively WHO's competence.

Facing such a diversity and complexity within WHO's mandate, the risk is that the WHO may loose its way. Therefore, it would be useful to fix certain limits to such a wide mission, and delineate a specific path that the Organization should follow to fulfil its mandate.

What could be the main criterium to delineate the margins of a continuously growing and changing reality? The fourth and last part of the dissertation proposes a hypothesis of work that consists of emphasising the WHO's comparative advantage. In this sense, the new Director-General will have to reconsider what the WHO's exclusive role is, in order to avoid wasting money and time, and to ameliorate WHO's performance in international health. What is WHO really good at? Once defined what WHO is for, it is necessary to determine how the WHO should meet the UN Millennium Development Goals and its own constitutional goals.

WHO's comparative advantage is "to act as the directing and coordinating authority on international health work"[3]. There is actually a debate[4] concerning the way and the approach the WHO should keep in implementing such a role. Many think that the role of the WHO should be mainly political, meaning that it should be the coordinating and directing authority on international health work pushing health to the top of the international political agenda. In this way, all the world will turn its attention to health issues, and it will provide the needed resources to advance health for any population of the earth (Africa included). Other think that the comparative advantage of the WHO should be realised mainly at a technical level. All the people, as object of the Health for All strategy, will be cured and healed thanks to the scientific and medical help that the Organization will provide. In the first case, advancing health means to make people who count aware of how determinant health is in producing development; in the second case, advancing health means to set norms and standards at a global level, and to help member states to tackle the major burdens of disease and to strengthen their health capacities and infrastructure.

For this reason, the debate often highlights a hypothetical contrast between the achievement of the Millennium Development Goals (at the political level) and the effort towards the implementation of the Health for All strategy (at a technical level), and argues that focusing on Millennium Development Goals has led the WHO to forget about Health for All[5].

For example, Cohen criticises the fact that in recent years the WHO has neglected the Health for All goal, "either due to institutional amnesia or to the NIH syndrome – Not invented here"[6], and advises that, "For the 21st century, WHO would do well to reinstate the fostering of health systems based on the Health for All principles, policy, strategy and managerial concepts outlined above, to review it, and to update in the light of more recent developments in the health, social and economic development and the integration of its targets into those of the Millennium Development Goals"[7]. Horton accuses Dr Brundtland, because "in 2000, she abandoned the Health for All mission without discussion, replacing it with the controversial realpolitik of market solutions to disease and poverty"[8]. He underlines that "MDGs are important. But if they become WHO's exclusive focus, and if the agency's budget remains flat (which it probably will), other programs and projects – such as those aimed at cancer and heart disease, to take just two examples – will be squeezed. Essentially, WHO's broad agenda is being hijacked"[9].

Considering this debate, the WHO cannot afford to forget any of the two levels: political and technical one. Actually, instead of determining a winner of the 'MDGs v. H4A' match, it is rather interesting to accept a vision according to which the Health for All goal is pursued through the Millennium Development Goals. As Dr Mahler recalls, time ahead the conception of the MDGs, Health for All means "that health is to be brought within reach of everyone in a given country. And by health is meant a personal state of well-being, not just the availability of health services – a state of health that enables a person to lead a socially and economically productive life. Health for all implies [as well] the removal of the obstacles to health – that is to say the elimination of malnutrition, ignorance, contaminated drinking water, solution of purely medical logistic problems such as a lack of doctors, hospital beds, drugs and vaccines"[10]. In this respect, the Millennium Development Goals are the preliminary step for the achievement of the Health for All goal, because they concern the social and economic determinant of the constitutional definition of health. The UN development goals constitute the elimination of the obstacles to WHO health.

The WHO must be both the political voice and technical leader in improving the health of the people of the world. There is no separation of intents. As a specialised agency of the UN, the WHO should work both towards the achievement of UN's goals, and in response to its constitutional aims. The two cannot be in contrast.

When Dr Lee takes up the Director-General position, he will have to decide whether to adopt the position which views WHO's role as merely political or technical, or to finally recognise that he will have to take into account both levels in order to maximise WHO' s performance. Dr Lee will have to show both his technical and political skills. After all, the beginning and the destiny of an Organisation strongly relies on choices and decisions of the people who staff it, and dedicate their lives-work to it.

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Edited by Aldo Campana,