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

PART II : What is WHO's mandate?

Chapter 2

AN AUTONOMOUS SPECIALISED AGENCY: THE BROADER MANDATE OF THE WHO

The nature of specialised agency of the United Nations determines the mandate of the World Health Organization. In the previous chapter, I described the role of the WHO in the international development agenda, as it is defined by UN main goals. The present chapter will take into consideration the other side of WHO's mandate, the one influenced by the goals that the Organization itself sets.

The WHO states its main aims and purposes in three documents, different in their characteristics, but equally fundamental. They are: the Constitution, the corporate strategy and the budget; respectively viewed as representing the constitutive, strategic and political aspects. The analysis of these documents supports the idea that the mandate of the WHO goes far beyond the Millennium Development Goals of the UN and, generally, far beyond the role of the Organization in the economic development context.

This chapter will first describe the main aim of the Organization, as it is stated by the Constitution; secondly, it will deal with the tools to reach this aim: the corporate strategy, which outlines the strategic directions of the Organization to fulfil its aim, and the budget, which will be described as a political document essential to determine the Organization's policy. The question, which needs to be considered, is in what terms each one of these documents determines or contributes to influence WHO's mandate.

3.1. The Constitution

The Constitution is one of the determinants of WHO's mandate because it gives a precise definition of health, and because it defines the objective of the Organization. Being that the Constitution clarifies the concept of health and states the main aim of the Organization, it is actually the most important instrument to define WHO's mandate.

In order to look at the Constitution of an international organisation and to give it an interpretation[1], it is extremely important to individuate its original mandate. Archer notes that "most international organisations, be they IGOs or NGOs, usually have their aim stated in the basic document by which they have been established […] The proclaimed aim is the most apparent statement of the intentions behind the existence of an organization"[2]. Obviously, to state objectives or goals for an organisation does not guarantee anything about their fulfilment. However, as Bennet observes, "the coming together of fifty nations to form an international organisation indicates a desire to accomplish certain common purposes, and the agreement on a statement of these purposes, usually incorporated into the opening passages of the basic final document of such a conference, specifies the range and limits of the areas of mutual concern"[3].

Therefore, the reason of the establishment of an organisation and, thus, its main purpose can be usually read through the lines of its Constitution, sometimes also called Charter or Statute[4].

As far as it concerns WHO's Constitution, it was prepared by the Technical Preparatory Committee, which met in Paris from 18 March to 16 April 1946. This Committee drew up proposals for the Constitution which were presented to the International Health Conference which met in New York from 19 June to 22 July 1946. On the basis of this proposals, the Conference worked out, drafted and adopted the Constitution of the WHO, which was signed on 22 July 1946 by the representatives of 51 members of the UN and of 10 other nations. The Constitution came into force on 7 April 1948[5].

This paragraph will therefore, look at the WHO Constitution as a precious text which encapsulates the potential of the WHO. Also relevant is the question of how the Constitution determines WHO's mandate. This document helps defining WHO's mission because it provides the definition of the concept of health and specifies the Organization's objective.

3.1.1. What does WHO mean with 'health'?

The concept of health is defined by the Preamble of the Constitution, which contains some of "the most advanced and visionary expressions underlying the establishment of WHO and defining its mission"[6].

3.1.1.1. A unique definition of health

The founding fathers of the WHO defined health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity"[7].

Among the various definition of health which can been formulated[8], the one given by the WHO results absolutely unique and innovative. One of the interesting elements is that WHO's definition of health is a positive concept. While previously health was usually defined as the absence of disease[9], the WHO founding fathers defined it as a state of complete well-being. Yet, before the Second World War, Sigerist, a well known public health professional, affirmed that "health is not simply the absence of disease; it is something positive, a joyful attitude to life, and a cheerful acceptance of the responsibilities that life puts upon the individual […] A healthy individual is a man who is well balanced bodily and mentally, and well adjusted to his physical and social environment"[10].

Therefore, the WHO definition introduces the idea of a complete status of well-being, which takes into account all the determinants of health: not just the physical ones, but also the mental and social ones. Being that the determinants of health are also social and economic in nature, a consequence is that the WHO has a role in achieving the MDGs. Reaching the UN goals by 2015, therefore, indirectly means to eliminate the obstacles to such a definition of health.

However, achieving the MDGs cannot become exhaustive[11]. The WHO definition of health does not refer just to HIV/AIDS, tuberculosis and malaria, which mainly characterise developing countries, but also to other kinds of ill health. One could think that nowadays and, above all, in the proximate future, the greatest challenges to human's health are and will be communicable diseases; this position, however, does not consider some basic data, which have been presented, as follows, in the document 'Trends and challenges in world health'[12].

Table 1: Ten leading causes of DALYs, 1998

Rank Cause % of global DALYs
1 Lower respiratory infections 6.0
2 Perinatal conditions 5.8
3 Diarrhoeal diseases 5.3
4 HIV/AIDS 5.1
5 Unipolar major depression 4.2
6 Ischaemic heart disease 3.8
7 Cerebrovascular disease 3.0
8 Malaria 2.8
9 Road traffic accidents 2.8
10 Tuberculosis 2.0

Source: Trends and challenges in world health, p.13

Table 2: Ten leading causes of DALYs, 2020

Rank Cause % of global DALYs
1 Ischaemic heart disease 5.9
2 Unipolar major depression 5.7
3 Road traffic accidents 5.1
4 Cerebrovascular disease 4.4
5 Chronic obstructive pulmonary disease 4.1
6 Lower respiratory infections 3.1
7 Tuberculosis 3.1
8 War 3.0
9 Diarrhoeal diseases 2.7
10 HIV/AIDS 2.6

Source: Trends and challenges in world health, p.16

As it is shown in the two tables above, the percentage of disability-adjusted life years (DALYs) shows that the leading causes of the global burden of disease are expected to change from a pattern dominated by communicable diseases to a pattern dominated by noncommunicable diseases and injuries. Therefore, once more, health cannot be considered as the mere absence of diseases and infirmities generally caused by poor living conditions, but as a complete status of well-being affected by different kinds of determinants. The role of the WHO cannot be shrunk to its role in development.

Evidence of this broad interpretation of the concept of health is, as I will afterwards show, that the 'right to health' is intrinsically linked to many other human rights, whether categorised as civil and political, economic, social and cultural. The 'right to health' in many occasions includes the right to adequate food, water, clothing, housing, health care, education, security in case of unemployment, sickness, disability, old age or lack of livelihood in circumstances beyond individual's control.

Furthermore, the concept of health implies the notions of social responsibility for health and the duty of individuals for the care of their health, which will then become fundamental in the definition of the 'right to health' by the International Covenant on Economic, Social and Cultural Rights. This aspect of health derives from the antiquity, when health was considered a beneficial advantage and one that required action by the individual to preserve it. For example, in the Hippocratic writings it is said that "a wise man ought to realize that health is his most valuable possession and learn to treat his illness by his own judgement"[13]. During classical times and through all the Middle Ages, the struggle for survival limited people's ability to provide physical health and shifted the attention towards mental, social and spiritual dimensions of health. By the end of the eighteen century, the belief that long life was a consequence of societal actions, as well as of individual actions, started to gain further importance. The individual's behaviour and approach to all aspects of life, therefore, became a crucial element for achieving health. The 'right to health', which will be then carefully discussed, should take into account also this perspective, and health should not be meant exclusively as something due to the individual.

For its particularity, the WHO definition of health has been many times criticised. For example, it has been said that "WHO's definition of health seems to work against its effective functioning […] As one commentator puts it, this definition is a fine and inspiring concept and its pursuit guarantees health professionals unlimited opportunities for work in the future, but it is not of much practical use"[14]. The main criticism that Saracci moves to the described concept of health is that "a state of complete physical, mental and social well-being corresponds much more closely to happiness than to health"[15]. Nevertheless, health greatly contributes to individuals' happiness.

Again Prof. Cesana refers to such a definition as not original, and rather mythical. According to the author, WHO concept of health would introduce the concept of a new 'global medicine' which claims to be involved not just with the ill person, but also with the healthy one. The result would be an Organization, and an entire understanding of medicine, characterised by ubris against freedom of individuals[16].

I think that the definition given by the WHO is surely very ambitious, but it is also very comprehensive, and it essentially looks at the human being in a holistic way. The human being cannot be considered just in his physical and strictly technical terms, but when one thinks of a man, one should think of his body, his mind and his hearth according to the meaning attributed to it by the Bible. As Prof. Minelli says, "health urges the daily individual responsibility. Health consists in creating, maintaining and recovering a delicate equilibrium at two levels: within the person, between spirit, mind and body; in respect to the outside, with the natural and cosmic forces within which every human being lives"[17]. The WHO's definition is fundamental as unique, and it constitutes a 'comparative advantage' with respect to any other kind of organisation or institution.

After all, as Gruskin and Tarantola say, "the WHO definition projects a vision of the ideal state of health as an eternal and universal goal to strive constantly towards and has its main purpose defining directions for the work of the Organization and its member states"[18].

3.1.1.2 The 'right to health'

The part of the Preamble which affirms that "the enjoyment of the highest attainable standards of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social conditions" is essential to fully understand WHO's concept of health. The frequently used term 'right to health'[19] is an abbreviated expression which refers to this part of the Constitution. It basically means that health can be considered as a human right.

The concept of human right itself would require a vast and deep research and explanation[20]. I limit to give a general definition which will provide the reader with a broad understanding of the context. The UN Charter recognised that "all people are born free and equal in dignity and rights" in 1945. Three years later, in 1948, the Universal Declaration of Human Rights was adopted as a common standard of achievement for all people and all nations. The basic characteristics of human rights is that "they are the rights of individuals because they are human, that they apply to people everywhere in the world, and that they are principally concerned with the relationship between the individual and the state. In practical terms, international human rights law is about defining what governments can do to us, cannot do to us, and should do to us"[21].

A new language for health and human rights

Health has been object of diverse documents concerning human rights. However, the link between health and human rights start to be recognised approximately a decade ago. In particular, in the last few years, the development of a health and human rights language has allowed the connection between health and human rights to be explicitly named and to be object of work.

One of the highest result of the process has been the establishment of a UN special rapporteur on the 'right to health'. The request came from Brazil at the beginning of 2002, and the Brazilian resolution was passed in April 2002. The role of such a rapporteur is "vast and vague: to gather right-to-health information from all sources, to identify areas of cooperation, to report on the status of the right to health throughout the world, and to make policy and legislative recommendations"[22].

It will follow a description of the various steps through which the 'right to health' evolved and moved from the margins to the mainstream both in the UN and WHO context[23].

As I mentioned, the 'right to health' was enshrined by the WHO Constitution over 50 years ago. Actually, before of that time, the Technical Preparatory Committee for the Constitution had proposed that health should be the object of a human right declaring that "the right to health is one of the fundamental rights to which every human being is entitled"[24]. This proposal was not adopted at that time, nevertheless the linkage between health and human rights started to gain attention.

The Universal Declaration of Human Rights[25] of 1948 does not refer specifically to the 'right to health', but by a careful analysis of the text, it is possible to find indirect references to it. First of all, the 'right to health', at least intended as the effort to reduce infant mortality and increase life expectancy, is implicit in the wider concept of 'right to life' which is considered one of the fundamental rights of the human person[26]. In the same documents, there are also some related provisions, as the prohibition of torture or cruel, inhuman or degrading treatment, and the subjection of persons to medical or scientific experimentation without their free consent. In particular, article 25 provides that "everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including […] medical care", and article 24 provides that "everyone has the right to rest and leisure, including reasonable limitations on working hours and periodic holiday with pay".

The first most important recognition of the 'right to health' in an international convention appears in the International Covenant on Economic, Social and Cultural Rights[27] in 1966. Article 12 states that "the states parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health". Furthermore, the text individuates the measures that the states parties should take to guarantee the full realisation of such a right. They are: "(a) the provision of the reduction of the stillbirth-rate and of infant mortality for the healthy development of the child; (b) the improvement of all aspects of environmental and industrial hygiene; (c) the prevention, treatment and control of epidemic, endemic, occupational and other diseases; (d) the creation of conditions which would assure to all medical service and medical attention in the event of sickness".

A few years later, the WHO collects the suggestions given within the UN context, and the WHA proclaims that 'health [without qualification] is a human right', in two different occasions in 1970 and 1977 [28].

A little time after these resolutions, the same assertion was made by the International Conference on Primary Health Care, held in Alma-Ata, URSS, from 6 to 12 September 1978. Article I of the Declaration of Alma Ata[29] declares that "health, which is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector". The conceptual framework of Health for All, which was started by this conference, will be treated in the following paragraph.

Furthermore, in the World Health Declaration[30] of 1998, the WHO member states reaffirm their "commitment to the principle enunciated in its Constitution that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being. In doing so, we affirm the dignity and worth of every person, and the equal rights, equal duties and shared responsibilities of all for health".

The meaning of the 'right to health'

After an overview of the various references to the linkage between health and human rights both in the UN and WHO context, it is important to define the actual meaning of the 'right to health'.

Many times the expression 'right to health care' is used instead of 'right to health' because what is meant by 'right to health' is actually intended as a right to the provision of health. For example, Marmor suggests that "almost all of the twentieth century debate over the 'right to health' in fact has addressed issues concerning not health per se but the distribution of access to medical care"[31].

However, one of the participants at a Workshop on the Right to Health as a Human Right, held in The Hague in 1978, Professor W.P. Von Wartburg, commented as follows: "Since health, unlike a commodity, is not available on demand, it follows that any attempt to interpret the basic rights of the citizen in a modern society as giving him an active claim to the enjoyment of good health must be regards as mistaken from the very outset. The State cannot be held liable to the citizen in respect of any claims for the maintenance or restoration of health or for the alleviation of health"[32].

Therefore, the interpretation of 'right to health' as the mere provision of health services seems restrictive and reductive in comparison with the provision of the Constitution, of the Declaration of Alma-Ata and of the World Health Declaration.

On the other side, the vision of a 'right to health' as the right to be healthy does not appear more convincing, because it directly invests questions as "does it mean that everyone has the right not to be ill?", which the WHO has no competence in answering.

The interpretation which I accept is, therefore, the one recently formulated by the Committee on Economic, Social and Cultural Rights in its 22nd session, held in Geneva, from 25 April to 12 May 2000, and stated in the General Comment No. 14 in article 12 of the International Covenant on Economic, Social and Cultural rights[33]. The definition of the 'right to health' provided by this document is extremely interesting, because it presents a two-fold aspect of the 'right to health'. As Mary Robinson, the UN High Commissioner for Human Rights, says, "the right to health does not mean the right to be healthy, nor does it mean that poor governments must put in place expensive health services for which they have no resource"[34]. The 'right to health' implies both an individual and a governmental aspect. The 'right to health' is to be understood neither as the right to be healthy nor as the right to the provision of health care. The General Comments states that "the right to health contains both freedoms and entitlements. The freedom includes the right to control one's health and body, including sexual and reproductive freedom, and the right to be free from interference, such as the right to be free from torture, non-consensual medical treatment and experimentation. By contrast, the entitlements include the right to a system of health protection which provides equality of opportunity for people to enjoy the highest attainable of health"[35]. Therefore, the notion of the highest attainable standard of health takes into account both the individual's biological and socio-economic preconditions and State's available resources. For example, reference is made to the 'possibility' to encounter a number of aspects that cannot be addressed "solely within the relationship between states and individuals; in particular good health cannot be ensured by a State, nor can States provide protection against every possible cause of human ill health. Thus, genetic factors, individual susceptibility to ill health and the adoption  of unhealthy or risky lifestyle may play an important role with respect to individual's health"[36].

Thanks to the General Comment of the Committee, a risk individuated by Scruton can actually be avoided. The author thinks that phrasing the Health for All goal in human rights terms would authorise unlimited political intervention in the pursuit of it. As a consequence, this position could mean to "ignore all the concerns of those who wish to distinguish the sphere of individual freedom and responsibility from that one of state control"[37].

Furthermore, the interpretation given by the Committee is interesting because the 'right to health' is considered as an inclusive right, extending not only to timely and appropriate health care, but also to the underlying determinants of health, such as access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health related education and information. Therefore, the 'right to health' cannot be considered as separated from the other human rights, but indispensable for the exercise of several of them[38].

The General Comment also sets out four criteria by which to evaluate the 'right to health'[39]:

a)  Availability. Functioning public health and health-care facilities, goods and services, as well as programmes, have to be available in sufficient capacity.

b)  Accessibility. Health facilities, goods and services have to be accessible to everyone without discrimination, within the jurisdiction of the state party. Accessibility has four overlapping dimensions:

  • Non-discrimination;
  • Physical accessibility;
  • Economic accessibility;
  • Information accessibility.

c) Acceptability. All health facilities, goods and services must be respectful of medical ethics and culturally appropriate, sensitive to gender and life-cycle requirements, as well as being designed to respect confidentiality and improve the health status.

d)  Quality. Health facilities, goods and services must be scientifically and medically appropriate of a good quality.

WHO's involvement with the 'right to health'

After having defined the concept of 'right to health', I will move to the current involvement of the WHO with this issue. Although the linkage between health and human rights seems to be so evident and fundamental, it is not until the late 1990s that WHO began to consider systematically in its work how the 'right to health' affects health policies and programmes[40].

While the WHA has not decided yet to adopt a general WHO's human rights policy, the Secretariat has been working to introduce human rights consideration into its programmes and strategies, especially with Dr Brundtland. In particular, the corporate strategy mentions as one of the new emphases for the Organization "the adoption of a broader approach to health within the context of human development, humanitarian action and human right"[41]. Furthermore, in a written submission by the WHO to the 58th session of the Commission on Human Rights, the WHO Secretariat as identified six areas of work for the biennium 2002-2003, in order to strengthen its focus on human rights:

  • Development of a WHO health and human rights strategy;
  • Enhancement of the knowledge base of rights-based approach to development and their application to health;
  • Development of tools to integrate human rights in health development policies and programmes;
  • Strengthening WHO's capacity to identify and to address the human rights implications of its work;
  • Providing technical support to member states to integrate human rights in health development policies and programmes;
  • Supporting the UN human rights system and other partners in advancing health as a human right and other health-related rights[42].

The Strategy Unit within the Director-General's Office is the focal point within the Organization for human rights, and technical departments work on the intersection between human rights and specific health topics. It is noticeable a parallelism with the Millennium Development Goals issue. Health and human rights, as well as health and development, can be considered as cross-cutting issues through the work of the Organization as a whole.

Furthermore, the 'right to health' can also be seen as another advocacy tool. The author of the WHO publication health and human rights, Ms Helena Nygren-Krug, affirms that "linking health and human rights could act as a force for mobilizing and empowering the most vulnerable and disadvantaged. Advancing health as a human right means making people conscious of both their oppression and possibility of change"[43].

According to my research, the WHO attributes to health a very broad meaning: a complete status of well-being including physical, mental and social determinants as well as a human right. In taking up its role, the WHO should never forget this concept which stands at the origin of its mandate.

3.1.2. The objective of WHO: Health for All

Article 1 of the Constitution states that "the objective of the World Health Organization shall be the attainment by all peoples of the highest possible level of health"[44]. The objective of the Organization is translated into the 'Strategy for Health for All by the year 2000'[45] (HFA)[46].

3.1.2.1. The origin of the Health for All Strategy

The HFA is the consequence of a dissatisfaction concerning the work of the WHO, and the role of the Organization itself, both in the developed and developing countries, in the 1970s[47]. Within the industrialised ones, many health systems became top-heavy. This meant that health-promoting and clinical services were overcome by sophisticated hospital care and that people were becoming more and more dependent on the 'medical miracle' to cure the effects of a lifetime of unhealthy living. Within the poor countries, bigger shares of the budget were diverted towards expensive city hospitals, whereas smaller health posts and clinics, both urban and rural, did not have enough resources. At the same time, important health needs were not considered. It was not given care to the basic causes of the people's ill health, such as malnutrition[48].

In the same period, the WHO started to study and recognise the positive outcomes of innovative and successful approaches that had been tried in some developing countries. These new methods were different, although some common elements could be delineated. For example, one was an evident commitment to universal coverage: essential care should be brought to the entire population, especially to the ones in greatest need. Another element was the active participation of individuals, families and communities: health workers should enter and keep in contact with the population, in order to determine which needs are to be considered more urgent. The greatest discover coming from these innovations was a new way of perceiving promoting and protecting health. This new way was based on "an approach to health not only based on sound technology but entered on people and inspired by the values of universality and equity"[49].

As a consequence, the WHO started to recognise that it would be important to redefine its basic role. In his annual report for 1975, Director-General Mahler[50] stated that: "separate programmes, each designed for the control of a specific disease, are not likely to solve the overall problem […] We must also remind ourselves that the urgent health problems of developing countries relate to poverty, to infection, to malnutrition and undernutrition, to lack of accessible potable water, and to multiple environmental hazards. Such basic threats to health are unlikely to be countered by conventional health services techniques […] The main lesson learnt is that, in the fight against disease, too much emphasis must not be placed on  health technologies alone. What we can achieve in this field depends directly on the level of economic development of the countries concerned"[51].

Given the context, the conceptual framework of the Health for All Strategy itself was defined by the WHA in resolution WHA30.43 in 1977. This document states that the main social target of governments and WHO in the coming decades should be "the attainment by all citizens of the world by the year 2000 of a level of health that would permit them to lead socially and economically productive lives"[52]. The meaning of the Strategy was clearly illustrated by Dr Mahler, who affirmed that 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"[53].

3.1.2.2. The Health for All Strategy

In pursuance of this change of strategy, the Declaration of Alma-Ata[54] was adopted in 1978, at the International Conference on Primary Health Care, jointly sponsored and organised by WHO and UNICEF. The Declaration together with a number of implementing recommendations, sets a new vision for global health.

  1. HFA is based on five principles defined in the Declaration:
  2. Resources for health should be evenly distributed and essential care should be accessible to everyone;
  3. People have the right and duty to participate individually and collectively in the planning and implementation of health care;
  4. Promotive, preventive, curative and rehabilitative services for the main health problems in the community should be provided;
  5. Technology should be appropriate for each country concerned and maintainable with resources the country can afford;
  6. The realisation of the highest level of health requires the action of many other social and economic sectors in addition to the health sector.

The Declaration stated that Primary Health Care (PHC) was the key to attaining Health for All. PHC was to be considered "essential health care which is to be made universally accessible to individuals and families in the community in ways accessible to them, through their full participation and at a cost that the community can afford"[55]. PHC should include at least the following eight elements: (1) health education related to prevailing health problems and the methods of prevailing and controlling them; (2) promotion of food supply and proper nutrition; (3) provision of an adequate supply of safe water and basic sanitation; (4) maternal and child health care, including family planning; (5) immunization programmes against the major infectious diseases; (6) prevention and control of locally endemic diseases; (7) appropriate treatment of common ailments and injuries; and (8) provision of essential drugs[56]. PHC was to be equally applicable to all member states, although the way would be different accordingly to individual governments depending on the social and financial resources.

The WHA decided to sustain the HFA and, in 1979, it decided that WHO' s programmes and the allocation of resources should be functional to its commitment to achieve HFA by the year 2000. In particular, in 1981, the WHA adopted the Global Strategy for Health for All by the year 2000[57] for the implementation of the HFA. The WHA requested the EB to monitor and evaluate periodically the Strategy and to formulate future general programmes of work in that direction.

Under the Global Strategy, countries were provided with ten different targets to measure their progress towards the achievement of the goal by 2000, and additionally they had to create their own targets. Furthermore, a set of indicators was proposed in order to proceed with the progress evaluation. There was also a reporting procedure set up to make the member states report on their improvement at three year intervals. The national reports were then sent to the Regional Organizations where they were reviewed by respective Regional Committee[58].

The HFA basically started a radical revolution, which was also a 'social revolution' in public health. The revolution was given by the fact that "its objective was to change the mentality of the population concerning its own health care, to change health services structures and the distribution of resources thereto, and to reorient the role of professional health personnel […] The emphasis of public health shifted from the medical approach to the determinants of health, which touched deeply the social, political and cultural structure of the societies concerned"[59], fully applying the constitutional definition of health.

After a few years, the world started to realise that the decided goal was actually too high to be reachable. For example, PHC required that medical doctors be redistributed more equitably between urban and rural areas, which was only possible in the public sector. Medical association of Western countries did not agree with the assignment of medical functions to second category health personnel and with the use of traditional non scientific medicines. The large pharmaceutical companies were hostile to the 'essential medicines' programme. The different reasons for this failure were summarised by the Director-General as: (1) insufficient political commitment to the implementation of HFA; (2) failure to achieve equity; (3) the continuing low status of women; (4) slow socio-economic development; (5) difficulty in achieving intersectoral action for health; (6) unbalanced distribution of, and weak support for, human resources; (7) widespread inadequacy of health promotion activities; (8) weak health information; (9) pollution, poor food safety, and lack of safe water supply and sanitation; (10) rapid demographic and epidemiological changes; (11) inappropriate use of, and allocation of resources for, high-cost technology; (12) natural and man-made disasters[60]. The main reason was, though, of economic character. The critic economic situation of many countries was perhaps the major constrain to the achievement of the HFA.

Even if there were evident problems in the actual implementation of the HFA, it remained the cornerstone of WHO's institutional vision through all the 1990s. Yet it was clear that this conceptual framework should be revised and updated for the coming of the new millennium. In 1995, the 48th WHA stressed the continue validity of the Strategy as a 'timeless aspirational goal' and agreed that a new global health policy should be elaborated. The WHA requested the Director-General in resolution WHA48.16 to take the necessary steps for renewing the Health for All Strategy, together with its indicators, by developing a new holistic health policy based on the concept of equity and solidarity, emphasizing the individual's, the family's and the community's responsibility for health[61].

As a consequence, in 1998, the new global health policy 'Health for All in the 21st Century'[62], contained in a synthetic 'World Health Declaration'[63], was adopted by the WHA with resolution WHA51.7. The renewal of the Health for All, concurrent with the 50th anniversary of the WHO and the appointment of a new Director-General, offered to the Organization a unique opportunity to restate its purpose.

The new Declaration developed the main principles and approaches that are currently guiding WHO's action. Following the basic guidelines of the previous HFA, the Declaration focuses on the place of health in social and economic development and as collective commitment to the ethical concepts of equity, solidarity and social justice.

Again, the WHO formulated ten targets for the measurement of the progress towards the new stated goal. The aims of such a provision are to develop a share division of the ten most important health issues, to give a new impetus to the development of health policies for the following period of time and to motivate all members to take action and to set priorities for the allocation of resources[64].

The Health for All Strategy has often been criticised and often defined ambitious, pretentious and, as someone would say, utopian. A "slogan utopique sans substance, la 'santé pour tous en l'an 2000' était jugée comme un objectif irréalisable dans le délais fixés"[65].

If this position can be considered, on a certain point of view, appropriate because it takes into consideration the mere fact of an implementation failure, it also results sceptical and with no consideration for the 'aspirational element' which many times play a fundamental role.

The perspective radically changes, if one starts thinking that this goal was never actually thought as practically achievable. It was more than anything else a means to encourage the countries to commit themselves and to act towards that direction. Therefore, "Health for All was meant to motivate, not necessarily to be attainable"[66].

As a consequence, it has to be born in mind that the HFA represents the first time that a global target for health is formulated inter alia to encourage the setting of health targets by countries. The principles stated were the same for all countries, because international policies are useful when they can be adapted at the national level to national and local needs. Cohen, former Adviser on Health Policy in the Director-General's office, affirms that what they wanted was to issue "guidelines for the formulation of Health for All strategies as well as a model for the adaptation to local circumstances that reflected national and regional strategies as seen from a global perspective"[67].

The extreme importance of the Health for All goal, as main objective of the WHO, should not be neglected or forgotten when studying WHO's mandate[68]. As Cohen advises, the "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 it in the light of more recent developments in the health, social and economic sectors, including the contribution of health to sustainable social and economic development and the integration of its targets into those of the Millennium Development Goals"[69].

Starting from the concept of health, I have analysed WHO's objective, as stated by the Constitution and implemented by the Health for All Strategy. A status of complete well-being should be a global status, meaning that it should be for all. Taking into account these different and complex elements, one can realise that WHO's mandate is vast and broad. Actually, much wider than the role that the Organization plays in the economic development arena.

3.2. The corporate strategy

The corporate strategy for the WHO Secretariat is the second determinant of WHO's mandate that I consider with the purpose of this contribution. In particular, if the Constitution states the objective of the Organization, the corporate strategy indicates, through the main strategic directions of work, the means for the achievement of that objective.

The corporate strategy was issued by Dr Brundtland a few years after she took over as fifth Director-General of the WHO, in 1998. This document can be understood in its meaning only by looking at the general context of reform which characterised Dr Brundtland's five-year term. One should not think that the renewal within the WHO was to be completely attributed to the innovative spirit of Dr Brundtland. Profound changes – political, economic and social - were, in fact, and still are, affecting the world. International organisations, as the United Nations and their specialised agencies, should constantly be able to respond to this transformation, in order to remain effective in international work. At the end of the twenty-first century, the UN, as a system itself, was going through a wider process of reform[70]. Therefore, it is likely that a strong pressure from the outside led the WHO to be invested by the same regenerating wind of transformation.

In this paragraph, I will first present the context of reform in which the corporate strategy was formulated, and second, I will describe and analyse the strategy itself, in order to understand how it affects WHO's mandate.

3.2.1. A context of reform within the WHO

Dr Grø Harlem Brundtland's[71] candidacy to the Director-General post was confirmed by the EB during its 111th meeting, in January 1998, and her mandate started on 21 July 1998. The term lasts till the 21 July 2003, date in which the appointment shall terminate[72].

During the six months, from January to July 1998, she nominated a Transition Team, which was expected to review the Organization and to advocate changes to its previous structure. The members of the Team were people who obviously knew the Organization very well, although they were mostly external experts with no history in the Organization. For example, the leader of the Team was Ambassador Jonas Gahr Støre, who had previously served Dr Brundtland as a Special Advisor, Director-General of International Affairs, and finally as Ambassador in the Norwegian mission to the United Nations, when Dr Brundtland was Prime Minister of Norway.

The Transition Team's meetings took place in an ecumenical centre about 500 meters from the headquarters, in order to show their independence from the WHO. The work focused on 'satellites'[73]. Each of them produced its own timetable of work, which consisted of relevant information and interviews with everyone, from the director level up, and with other people selected within the Organization. In her address to WHO staff, on her first day of work, Dr Brundtland referred to these interviews affirming that, "from your [the staff] interactions with the Transition Team you know the broad guidelines of our initial thinking. You have already shaped a significant part of it by your active involvement and creative contributions. We have carefully listened to your advice and your input"[74], [75].

The Transition Team then defined objectives and competencies for new job positions within the Organization, and senior staff was invited to apply. The senior managers were assured that their contract would be honoured, although they might be reassigned to other duties. Dr Brundtland argued, "the initial structural changes have been carried out with full employment security. We have not asked people to leave. Some have been reassigned and some have seen their job descriptions change. But that is the reality at any workplace"[76].

The rotation of the staff was traumatic, with approximately 750 employees changing office, but the management's view was that the process had to be quick. Dr Brundtland opted for "determined and fast change. […] Fast, but steady. It needed to be fast. To respond to member states who had legitimate demands to see real change in real time. But also to get staff quickly on new tracks"[77]. From conversations with WHO staff members, who personally assisted to the transformation, the impression which one could gain is a top-down abrupt change, as if Dr Brundtland had come to get rid of what WHO had been so far, to erase everything, with complete disregard to the past of the Organization. As others recall, "the message to observers was that the WHO had changed. The Transition's Team policy was that the past was irrelevant and that the Organization had turned over a new leaf. According to one of Dr Brundtland's Policy Advisers, 'it's as if a new government from a different party had come into power. The message had to be that anything that came before was bad'"[78].

In order to support and enhance this project of transformation, Dr Brundtland started a Renewal Fund. The reason was reportedly "the tightness of our budget. There was no room in our regular budget to carry out critical task to foster rapid change […] The Renewal Fund is making [the rapid change] possible – and I am very grateful to the countries who responded to my call and made an extra and extremely valuable contribution. Our target was and still remains to raise 10 million dollars to be spent over three years. As of today we are close to 7 million dollars"[79]. The Norwegian government had agreed to pay for the cost of the Transition Team and also United Kingdom, together with Belgium, Canada, China, Croatia, Denmark, Finland, Japan, Netherlands, Sweden, Switzerland and Tunisia decided to support the reform process.

Although one is aware of the context of reform which characterised the UN system as a whole, the commitment by Dr Brundtland herself to the necessity of a change appears evident and very strong [80]. The question arises, however, why she was so committed to change. Her reasoning was partly due to timing, "the transition from one century to another sees changes which will be faster and more dramatic from an economic , social and health perspective […] The world is in transition. So accordingly WHO must be in transition"[81]. Therefore, on her first day of work, she announced: "yes there will be a change. A change in focus. A change in the way we organize our work. A change in the way we do things. A change in the way we work as a team"[82]. Starting from this point of view, she took up a great responsibility[83].

The previous WHO seemed to be characterised, internally, by a structure with a weak top management, and, externally, by its decreasing importance on the international development scene and in the field of health itself. The result was an Organization still technically strong, where the staff continued to provide important advice and assistance to member states, but which nobody was proud to work for[84]. Many attributed this situation to the two five-year mandates of the previous Director-General, Dr Hiroshi Nakajima[85], under which the WHO seemed to have lost its direction. As to the internal organisation, "the number of directors at the WHO had almost doubled and three-quarters of its budget went on salaries and overheads". In a 1995 editorial, Richard Smith, British Medical Journal editor, argued that WHO was "overcentralised at headquarters and regions, top heavy, poorly managed, bureaucratic and smells of corruption"[86]. Tollison and Wagner accused the WHO desiring "to promote is own well-being […] the majority of WHO's regular budget is allocated to a bloated bureaucracy that is out of step with the evolving health problems of the developing world"[87]. Externally, the WHO seemed to have lost its international esteem and its position of global leadership. In a sentence, the WHO could be defined as "corrupt, bureaucratic, inefficient, unresponsive, unaccountable, overly medical and far to male"[88], a place where good ideas go to die.

Dr Brundtland's election was therefore seen by many as an opportunity for WHO to reclaim its confidence and influence after "a decade of decline, weak leadership, allegation of corruption at all levels, and paranoid defensiveness when any kind of external scrutiny was conducted"[89].

According to a Senior Brundtland Adviser, "the challenge was to take WHO off the sidelines […] It's a balancing act between high-profile projects – we need to get back into the mainstream, but need to get the headquarters into shape first"[90].

To be responsive to such a challenge, the reform of the Organization required both the internal and external front: internally, Dr Brundtland had to reform a failing UN agency; externally, she had to restore the Organization's place on the international stage[91].

3.2.1.1. Internal reforms

Internally, Dr Brundtland aimed at constituting 'One WHO' through structural and administrative reforms. In this respect, it is interesting to read how Dr Brundtland described the faults of the Organization when she took over: "First, the unity of the Organization was weakened. People spoke of more than 50 WHOs, meaning that more than 50 individual programmes at headquarters. They spoke of 7 WHOs, meaning Geneva and the six Regional Offices. They spoke about 2 WHOs, meaning the one financed by the regular budget and the one financed by extrabudgetary contributions. Second, the Organization was gradually developing into what I would call a 'non-aligned Organization – meaning that the different parts of it moved in different directions. The Regional Offices operated each in their regional sphere. At headquarters, the programme directors did the best they could in a vacuum of priority setting"[92]. The reforms were intended to creating one WHO, speaking with one voice. Dr Brundtland said: "WHO is one. WHO must be one: setting its priorities as one, raising additional financial resources as one, speaking out as one"[93].

According to Dr Brundtland's speeches, the main internal reforms would concern the headquarters' structure, the Regional Offices and the budget. The first two have already been covered during the discussion of the structure of the Organization[94], and the third one will be object of the next paragraph. Therefore, only a brief mention is necessary in order to leave more space to the external reforms.

The establishment of a new Cabinet[95], which gathers the Director-General and the Executive Directors, was one of the instruments to make the Organization speak as One. The aim of this 'governmental' style organ is to link different activities and share diverse experiences. It is composed of 10 members. Six of the members are women and four men. Dr Brundtland "did not go for a majority of either men or women but for a balance of experiences"[96]. And she got it. Of the nine Cluster heads, two were recruited from inside and seven from the outside. Of the seven, four had extensive experience of working for or within WHO. The reason of this choice was the necessity of a change in perspective: "we needed an influx of new eyes, fresh experience from the realities in government, national health systems and the private sector"[97]. There was an even split between the north and the south and all of the six Regions were represented. Furthermore, "the average age of the Cabinet has dropped by almost a decade, from 59.2 to 49.9 years. […] The new cabinet provides a welcome infusion of energy, skills and diversity, which seems to be reviving a latent innovative spirit throughout the Organization"[98].

As second element of structural reform, I consider the redefinition of WHO programmes: 19 major and 52 specific programmes were reduced to 35 departments, corresponding to 35 areas of work, and allocated within nine Clusters[99]. As a consequence, Dr Brundtland observed: "what we are after is a better unity of purpose – a purpose which is more than the sum of vertical approaches. WHO must be one, and not 50 programmes working separately"[100].

As heads of the Clusters nine Executive Directors were selected. The Executive Directors are appointed by the Director-General, who can hire and fire them, although they have financial independence. They are, in fact, supposed to have a better understanding of what it is needed by the Cluster and by the projects within it. Thus, they have the power of allocating resources in their Cluster as they prefer, and they have direct contact with the donors. Dr Brundtland wanted the Clusters to offer "a more unified approach to resource mobilization […] we should not artificially centralize our fundraising efforts. Donors expect to see first class expertise and hands-on experience before they allocate extra resources"[101].

The criteria for the appointment are scientific and technical in character so as to reinforce the technical basis of the Organization. While previously the Director-General Assistants were politically important in order to provide the needed political contacts, Dr Brundtland, thanks to her high position in the political arena, has taken up this role. The Executive Directors maintain a technical function. To offer a better idea about the meaning of the shift towards 'technical' rather than 'political' senior appointments, Lerer and Matzopoulos affirm that "they were not there to play a geopolitical game. They owe their allegiance to Dr Brundtland and you now have the right kind of politics in the Organization"[102]. The just presented structural transformation is one example of the decentralised system that Dr Brundtland was trying to promote as a replacement to the previous over-centralised structure.

On the same line, Dr Brundtland also created the Management Support Unit (MSU), which basically means management closer to the programme implementation. As Brundtland says: "we have moved management support near to managers […] The role of administration and management is truly to support, facilitate and back up all our technical work"[103]. This new element has brought an increase in numbers and diversity of personnel for the Organization's administration (staff at the Geneva headquarters keep augmenting) and dilution of responsibility for the supreme head of the Secretariat, the Director-General.

With respect to the Regional Offices, the Regional Directors still maintain a vast degree of autonomy, since they are elected by the Regional Committee, which is the representative organ of the members states. The situation constitutes a risk: the fact that the Regional Offices actually act on their own without any kind of connection with the headquarters. For this reason, Dr Brundtland wanted the Regional Offices to be characterised by financial dependence on the WHO central office, through unifying the budget of the regions with that one of the headquarters[104].

Furthermore, Geneva should "work closely with the Regional Directors seeking to assure consistency throughout WHO. We are One WHO, not seven, one in Geneva and the six Regional Offices. We are seeking more unity of purpose and each Regional Office has undertaken studies on its own structure and direction to better pursue our new priorities and strategic directions"[105].

Relatively to the budget, the main changes consist in the method for its formulation, in the unification of the headquarters budget with that one of the six Regional Offices and in the shift from a resource-based budget to a result-based budget[106].

3.2.1.2. External reforms

On the external side, Dr Brundtland recognised the importance of replacing health on the international political agenda, and the value of international cooperation for health.

Replacing health on the development agenda

The previous chapter was an illustration of such a concept. Dr Brundtland was aware that health issues were not of great interest at international level, whereas developmental issues were moving under the international spotlight[107]. Therefore, the WHO had to focus on poverty and economic development matters in order to have the attention back to health. Dr Brundtland has been one of the major actors in this change of perspective, through the institution of the Commission on Macroeconomic and Health and its main findings. Health has recently started to be recognised as one of the main determinants of economic development, and the WHO has committed itself to the achievement of the Millennium Development Goals. Thus, one could say that one of Dr Brundtland's greatest achievement has been "to make health a serious and credible political issue"[108]. On her first speech in front of the 51st World Health Assembly, she expressed her wish "to focus the technical support and normative work of the WHO and at the same time to bring the Organization more firmly into the political arena"[109].

The method for bringing about difference consists of reaching "the levels of political decision-making where the broader agenda for development is set. We must speak out for health in development, bringing health to the core of the development agenda"[110]. Therefore, her commitment, since the beginning of her term, has been "to move health up the political agenda and, at the same time, redefine what 'politics' means. For me, political responsibility is the key – political responsibility that every country has in relation to its people. As for WHO, whatever we can do that is productive, gives lasting, sustainable results, and makes an impact on people's conditions around the world: that's what making a difference is all about"[111].

Going back to the politicisation issue previously mentioned[112], it is interesting to note the positive approach to the presence of politics in international organisations[113]. Horton also recalls that "Jared Siddiqi[114] argued that politicisation was the cause of WHO's 'great dishonour'. […] Exactly the opposite has turned out to be true. The politicisation of health by Dr Brundtland has injected fresh life into an agency suffering diminishing influence"[115].

Reaching out the others

The first way to bring the Organization's back to the international agenda is reaching out other international actors and seeking new partnerships, especially with other UN agencies, with international organisations, with civil society and with the private sector.

Since the beginning, Dr Brundtland underlined the importance of 'reaching out the others'. In her first statement to the 51st WHA, she observed that "the global health field has seen a steady increase in the number of actors and stakeholders. This we should not fear. I wish to invite those who have real contributions to make to join us"[116]. When she says so, she refers to "UN agencies, […] to international financial institutions, as the World Bank, the International Monetary Fund and the regional development banks, […] to the NGO community […] and to the private sector"[117]. On her first day of work, Dr Brundtland, delineating the external feature of the reform, affirmed: "we must reach out to the rest of the UN family […] we must reach out the many stakeholders – in civil society, in the private sector and in the broad health and research community"[118].

The global health agenda has, in fact, become so broad and vast that it is practically impossible that a single Organization would be able to manage being responsive and effective. Therefore, WHO needs several, varied partners to face new and increasing challenges. This is what is commonly called global health cooperation[119]. The partners of such a cooperation can be other international and regional[120] organisations, particularly UN agencies, as well as actors of the civil society and of the private sector[121].

This contribution does not analytically describe the relation of the WHO with other international and regional organisations and with the UN agencies[122]. Such an explanation  would stray too far from the scope of the analysis. However, I cannot avoid to refer to the totally refreshing and tremendously increasing cooperation of the WHO with actors of the civil society and with the private sector. One should not think that this kind of partnerships did not exist before Dr Brundtland came, but, under her five-year term, it has impressively improved and it has incredibly affected WHO's role in the international scene[123]. Public and private sector have increasingly started to cooperate[124].

When I refer to partnerships within the scope of this contribution, I adopt the definition of global public-private partnership (GPPPs) given by Buse and Walt, that is a "collaborative relationship which trascends national boundaries. Each partnership brings together at least three parties, among them a corporation (and/or industry association) and an intergovernmental organization, to achieve a shared health-creating goal on the basis of mutually agreed division of labour"[125].

First, I will analyse the case of the civil society. The term civil society (CS) has not a single agreed definition. For the purpose of this contribution, I adopt the one provided by the WHO, according to which civil society is seen as a social sphere separate both from state and market. It would be, therefore, according to the 'triadic' theory, one of the three sections of society: state, civil society and market. In the past years, the state and the market have seen rising new actors in the international and national scene[126]. As Steele poetically affirms, "the Prince and the Merchant have been the two powers of the past, the Prince representing the State and the Merchant the business class or groups; now there is a growing third force called Civil Society that is a new and most welcome player on the world scene"[127].

Civil society organisations (CSOs) refers to non-state, not-for-profit, voluntary organisations formed by people within the social sphere of civil society. Therefore, this term also includes the nongovernmental organisations (NGOs). While the term CSOs covers a variety of organisational interests and forms, which can include also informal social movements coming together around a common case, the NGOs usually have a formal structure and, in most cases, they are registered with national authorities[128].

In 1948, the Constitution of the Organization itself recognised the importance of collaborating with NGOs. Article 18 lists among the functions of the WHA, instructing the EB and the Director-General "to bring to the attention of members and of international organizations, governmental or non-governmental, any matter with regard to health which the WHA may consider appropriate"[129], and article 71 provides the possibility for the WHO, "on matters within its competence, [to] make suitable arrangements for consultation and co-operation with non-governmental […] organizations"[130].

In 1987, the 40th WHA adopted a resolution called 'Principles governing relations between the WHO and nongovernmental organizations'[131]. Those principles emphasised "the harmonising of intersectoral interests among the various sectoral bodies concerned in a country, regional or global setting"[132]. However, the interpretation and application of these principles were less flexible and tended to reflect a WHO perspective which limited health to the formal health sector.[133]

In 2001, Dr Brundtland, facing the increasing importance of civil society also in its informal side[134], launched the Civil Society Initiative (CSI), with the task of reviewing informal, as well as official[135], working relations between WHO and CSOs and to guide the policy discussion on how to improve mutually beneficial relationships[136].

One of the major activities of the CSI was to conduct a review of WHO's current policy and practice regarding CSOs, during the period July 2001- July 2002. The results of this review have been published in a report called 'WHO's interaction with civil society and nongovernmental organizations'[137] which shows the growing importance of such actors in the global health arena, and it brings the evidence for a necessary change in the WHO's policy concerning NGOs.

This new challenge encouraged to develop new principles of partnership between WHO and CSOs. The new approach is contained in a document recently discussed at the 111th session of the EB and entitled 'Policy for relations with nongovernmental organizations'[138]. Its aim is "to make WHO more friendly to NGOs", says Ms Nadia Younes, Executive Directors of the External Relations and Governing Bodies Cluster[139].

In order to facilitate the contacts between WHO and NGOs, the new approach proposes that the traditional distinction between formal/official and informal/unofficial relations be substituted by a two-fold policy of accreditation and collaboration. The first policy regards to "the principles whereby nongovernmental organizations may attend and participate in meetings of WHO governing bodies and committees and conferences convened under their authority "; the second policy is aimed "to encourage and facilitate new cooperative activities with nongovernmental organizations and to establish coherent methods of work between WHO and nongovernmental organizations". These policies should also be supplemented by guidelines, as listed in the document, and not reported here[140].

Once analysed the WHO' efforts to reach out CSOs, I can now deal with another frequent actor in WHO's partnerships: the private sector. The private sector includes non-public entities and in general all entities whose existence and activities are ruled by private law. Yet, when WHO uses the term 'private sector', it mainly refers to commercial enterprises, which are defined as "businesses that are intended to make profit for their owners"[141].

As for the CSOs, WHO's interactions with the private sector have been recently increasing. In September 2001 a compendium was carried out to analyse the rising presence of this kind of partnerships. The results showed that there where 59 on-going collaborations[142] and that they accounted for 17% of WHO's 1.2 billion extrabudgetary contributions during the biennium 2000-2001.

The WHO has different objectives when it collaborates with the private sector. Basically they are: to increase resources for health in case of necessity; to enrol as many actors as possible to improve health conditions; to increase WHO fund itself in order for the Organization to comply to its role of international leader in health; to diversify funds in order for the Organization to be less dependent on a single source; to mobilise partners and to influence them so that their internal practices conform to WHO's policies[143].

Given the objectives, there are different kind of interactions between the WHO and the private sector. A categorisation of the interactions can be carried out according to their finality. They can be aimed at influencing the private sector in order to make it change policies or marketing strategies; at influencing the private sector to make it apply WHO standards; at using the private sector for health advocacy; at using the private actor's network to achieve a specific effect for health; to use the private sector as a financing source[144].

The kind of relationship that the WHO should maintain with the private sector has become object of an interesting debate. On one side, many think that cooperation with the private sector is extremely useful as it provides the resources needed to start important initiatives; while others argue that such a behaviour will compromise WHO's independence. For example, Ellen't Hoen, of Médicins sans Frontiéres, argues that historically the pharmaceutical industry has "systematically undermined WHO's attempt to implement rational drug policy"[145]. The WHO is likely to loose its independence if it invites industry to be part of its partnerships. However, Harvey Bale, Director General of the International Federation of Pharmaceuticals Manufacturers (Geneva) encourages WHO' partnerships with the private sector, because "industry's know how is essential to the success of programmes like GAVI (Global Alliance for Vaccines and Immunization) and IAVI (International AIDS Vaccine Initiative)"[146].

In a note to the 109th session of the EB, Dr Brundtland demonstrated her awareness. She recalled that, in the UN Millennium Declaration, the heads of State and Government resolved to develop "strong partnerships with the private sector"[147]. However, Dr Brundtland recognised the risks of such involvement and the need for clear standards in dealing with industries. For example, she stated that "there can be risks of focusing on the production of inappropriate medicines, equipment of commodities. There is a need to ensure that health systems are not distorted by donations; that costs remain under control; and that advice is independent. There is potential for real or perceived conflicts of interest. Staff need to be trained to avoid these and a system of checks and balances needs to be in place"[148].

In order to respond to this requirement, the Government and Private Sector Relations Department (GPR) and in particular the Private Sector Team[149] is in charge of establishing the policies and framework for working with the private sector as well as exploring new ideas for reaching out potential partners[150].

On the legal front, the WHO's principles for the interaction with the private sector are stated in the document 'Guidelines on working with the private sector to achieve health outcomes'[151].

On the technical and ethical front, the basic principles of collaboration are[152]:

  • Global appreciation of the collaboration, which refers to a general understanding of the objective of the collaboration, of the mechanisms involved, of the feasibility of the project and of its added value to public health;
  • Independence, which refers to the possibility of a conflict of interest;
  • Image, which concerns any kind of collaboration with a partner whose mage could in any way adversely affect WHO's image;
  • Material and financial equilibrium, which concerns an analysis of the respective benefits to be derived respectively by WHO and its partners.

This paragraph wanted to be just a description of the many changes Dr Brundtland has brought to the WHO during her five-year term. The last part of this contribution will try to give an evaluation of the outcomes of her mandate, individuating her failures and her successes[153].

3.2.2. Analysis of the corporate strategy for the WHO Secretariat

Once the context of reform which characterised Dr Brundtland's term has been outlined, a description and analysis of the corporate strategy for WHO staff will follow, underlining in particular in what aspects this document affects WHO's mandate.

As means of introduction, I want to provide the reader with a definition of the term 'corporate strategy' which originally belongs to the management field in the private sector[154]. First of all, 'strategy' means "the plan of action that prescribes resources allocation and other activities for dealing with the environment and helping the organization attain its goals"[155]. More specifically 'corporate-level strategy' is that "level of the strategy concerned with the question 'what business we are in?' and it pertains to the organization as a whole and the combination of business units and product lines that make it up"[156].

The corporate strategy for WHO staff is, therefore, a strategy adopted by the WHO to redefine its main role and reorganise its activities towards specific directions of work, in order to improve the world health. From this perspective, this document consistently contributes to defining WHO' s mandate.

The process of developing such a strategy was started by Dr Brundtland in early 1999 in the wider context of WHO' s reforms.

During her statement to the EB in its 103rd session, Dr Brundtland used the term for the first time: besides the structural changes that had characterised the past few months since the election, "we need more clearly to identify what I would call a corporate strategy"[157]. The definition of corporate strategy provided by the Director-General was "a joint understanding of WHO's role in making a difference[158] in development"[159]. As a consequence, in the same occasion, Dr Brundtland committed herself to create a corporate strategy: "my aim is to present a full outline to the WHA of a corporate strategy with a clear message of what we will do and how we will do it"[160].

A few months later, in a document called 'Looking ahead for WHO after a year of change'[161], the Director-General outlined what WHO should be referring to in its daily work, and she described the main challenges to be addressed to improve world's health. This document lists four main issues: first, the need to greatly reduce the burden of excess mortality and morbidity suffered by the poor; second, the need to counter potential threats to health resulting from economic crises, unhealthy environments or risky behaviour; third, the need to develop more effective health systems; fourth, the need to invest in expanding the knowledge base that made the 20th century revolution in health possible, and that will provide the tools for continued gains in the 21st century[162].

With respect to how the WHO should act, the same document made two points: first, to be more impact-oriented in the work with countries, and second to be more creative in creating influential partnerships[163]. As to the first one, that meant working for, in and with countries. "In all our activities we always work for countries", said Dr Brundtland, "We do so through two main modalities. The first one implies working in countries by establishing a direct presence to respond to the developmental needs of one particular country or a group of them. The second modality is to work with the entire community of countries, helping them to mobilize their collective wisdom, knowledge and action for producing international public goods"[164]. As to the necessity of establishing partnership[165], Dr Brundtland is convinced that "we have to make a shift. We need to move from our traditional approach, which too often has favoured our own small-scale projects, to one which gives more emphasis to strategic alliances in which we influence both the thinking and spending of other international actors – and where what we do fits into a broader picture"[166].

The text presenting the corporate strategy for the WHO Secretariat[167] was introduced by the Director-General at the 105th session of the EB[168].

The centre-piece of the corporate strategy is determining WHO' s particular role in world health. For this reason, in her report to the EB, Dr Brundtland defined the strategy as a guiding document for the Secretariat in defining WHO' s role in front of a changing global environment: its "aim is to enable WHO to make the greatest possible contribution to world health through increasing its technical, intellectual and political leadership"[169].

The report from the Director-General, firstly, places the corporate strategy in a broader context, in order to give a description of the effective change in international health to which the WHO is called to respond to; secondly, it outlines the main components of the policy framework; and, thirdly, it focuses on the products of the strategy, which are the general programme of work and the budget 2002-2003.

The global health context has been changing from several points of view. As first, the understanding of causes and consequences of ill-health is now different. It is increasingly evident that achieving better health depends on many social, economic, political and cultural factors, in addition to health services. Moreover, there is a growing recognition of the role that better health can play in reducing poverty. Second, health systems themselves are becoming more complex. In many countries, aside the State, whose role is changing rapidly, many other actors – as private sector and civil society's actors - start to have a place in the health sector. Third, safeguarding health is gaining prominence as a component of humanitarian action. The importance of protecting health in emergencies is increasing. Fourth, the world is increasingly looking for greater coordination among development organisations. The reforms of the UN system as a whole are aimed to make organisations more responsive to the needs of member states and to guarantee a common point for reaching the International Development Goals. To address this challenge will require more emphasis on effectiveness through collective action and partnerships, as well as a dynamic approach to management[170].

In such a broad and constantly changing context, WHO has to define its particular role in world health. Moreover, it is specifically advised that WHO take up those tasks where it can demonstrate its comparative advantage in comparison to other actors at international and national levels.

Following these requests, the corporate strategy defines what is the mission of the WHO, and, particularly - this is the reason why we have declared this document fundamental in the definition of WHO's mandate - it lists four main strategic directions of work for the Organization.

As far as it is concerns the mission, WHO' s main goal remains, according to the Constitution, the attainment by all people of the highest level of health. Further in the document, it is reaffirmed that WHO's goals are to build healthy populations and communities and to combat ill-health.

The means set by the corporate strategy for the achievement of those goals is given by the four strategic directions. These four points summon up those listed by the abovementioned document 'Looking ahead for WHO after a year of change', and they provide a broad framework for focusing the technical work of the Secretariat. It has to be noted in principle that even if the directions are divided and set out in four different sentences, they are actually interrelated. This means that real progress in improving people's health cannot be achieved through one direction alone. Anyhow, they are:

  • Strategic direction 1: reducing excess mortality, morbidity and disability, especially in poor and marginalized populations.
  • Strategic direction 2: promoting healthy lifestyles and reducing factors of risk to human health that arise from environmental, economic, social and behavioural causes.
  • Strategic direction 3: developing health systems that equitably improve health outcomes, respond to people's legitimate demands, and are financially fair.
  • Strategic direction 4: developing and enabling policy and institutional environment in the health sector, and promoting an effective health dimension to social, economic, environmental and development policy[171].

After having individuated the role of the Organization and its main strategic directions, more specific areas of action for the Organization have to be defined in the broad global health context. These definite areas of emphasis are defined as priorities. In her statement to the 105th EB, the Director-General refers to priorities as "areas of work where we will strengthen our focus, increase our efforts and provide additional resources. These are areas which hold a potential for significant changes in the burden of disease with the use of cost-effective interventions, health problems with major socio-economic implications, or which have a disproportionate impact on the lives of the poor, and areas where we see a real opportunity to act"[172]. As one could think, priority setting is a very hard task within an Organization as the WHO. Some principles have, therefore, been set in order to facilitate the choice. The criteria are described by the Director-General as follows:

  • "Values – because we seek to deliver on our mandate, to build healthy communities and fight ill-health with a special emphasis on the situation of the disadvantaged.
  • Evidence – because we depend on solid analysis of the challenge and the likely impact of our contribution.
  • Strategy – because we need to map the road towards the goals we are fixing.
  • Specificity – because we need to work plans that translate into budget allocations and expected results.
  • Continuity – because priorities cannot change at every crossroads"[173].

On a more practical and technical basis, the criteria are:

  • Potential for significant change in burden of disease with existing cost-effectiveness technologies;
  • Urgent needs for new information;
  • Health problems with major impact on socio-economic development and a disproportionate impact on the lives of the poor;
  • WHO's advantages, in relation to provision of public goods, building of consensus around policies, strategies and standards, initiation and management of partnership;
  • Major demands for WHO support from member states[174].

On the basis of the abovementioned criteria, nine priorities have been chosen to focus WHO's efforts to:

  • Health systems
  • Malaria, HIV/AIDS and tuberculosis
  • Tobacco
  • Maternal Health
  • Safe blood
  • Mental health
  • Cancer, cardiovascular disease, diabetes and chronic respiratory diseases
  • Food safety
  • Change in WHO

Analysing the broad mission attributed to the WHO by the corporate strategy, through the comprehensive strategic directions and the variety of priorities, the risk individuated by Horton[175] seems to be overcome. How could the WHO, in fact, reduce its global mandate to just one of the strategic directions, specifically the fourth one? How could the WHO be involved exclusively with one of the nine priorities concerning the worst infectious diseases as malaria, HIV/AIDS and tuberculosis. As Burci and Vignes underlined, WHO' s mandate rather seems to go far beyond the poverty reduction issue and the development agenda[176].

3.2.2.1.The general programme of work 2002-2005

In her statement to the 105th EB, the Director-General added that "the corporate strategy is not a product itself. It is a process of organizational development and institutional change which will lead to products and informed decisions"[177]. The two main products of the corporate strategy are the general programme of work 2002-2005 and the budget 2002-2003.

While the budget will be object of the next paragraph, it will follow a brief description of the general programme of work.

The formulation of a general programme of work is a constitutional obligation. Article 28 of the Constitution lists among the EB's function also that one "to submit to the WHA for consideration and approval a general programme of work covering a specific period of approximately six years"[178].

The general programme of work 2002-2005[179], elaborated by the WHO Secretariat in 2000, was submitted by the EB to the WHA in January 2001[180] and approved by the WHA in May 2001. From the very beginning till Dr Brundtland's term[181], nine general programmes of work have been approved. However, the current programme presents different characteristics.

The previous programmes[182] generally covered a period of six-years, and they were usually very long documents. The aim of these documents was to outline the main policies of the Organization for a given period of time. They were constituted through an assessment of global and regional health policies, the needs of member states and an evaluation of the previous general programmes of work. They were made up of a number of individual programmes, each consisting of organised activities directed towards the achievement of specific objectives. The classified list comprised four interconnected categories: direction, coordination and management; health system infrastructure; health science and technology, and programme support[183].

The current general programme of work 2002-2005, "in contrast with some earlier programmes of work, is shorter, concentrating on policy, and covers four, rather than six, years"[184]. This approach actually moves from the idea that "the purpose of translating policy into practice is best served through the programme budget and operational plans prepared closer to the time of the implementation"[185].

After this initial statement, the general programme of work, six page long, is nothing more than a copy of the corporate strategy. For this reason, I have decided to give just a short mention of it. The text goes exactly through the same steps: the changing context of international health, the strategic directions, the core functions and the organisation-wide priorities. One is therefore led to think that Dr Brundtland was not very much convinced of the utility of such a document, and that she prepared it just because it still represented a constitutional obligation.

The general programme of work, therefore, does not seem to maintain the fundamental role that it had in the past, as long as it concerns the definition of the strategic policies of the Organization. Under Dr Brundtland, its function has been taken up by the corporate strategy.

However, from various conversations with WHO staff members, I was surprised by hearing that not many among the civil servants actually have read or have notion of the strategy which is intended to shape their work. The corporate strategy has been yet defined as "a very general framework, as a point of reference. As everyone knew it was there, but nobody really thought of its implementation"[186].

If the Constitution is still the fundamental source to define WHO's objective, there is confusion when one tries to determine the key documents in defining the means to achieve that aim. For this reason, aside the corporate strategy and the general programme of work, I have to introduce a third element: the budget.

3.3. The budget

The budget[187] is the third determinant of WHO's mandate that I consider with the purpose of this contribution. Thanks to conversations I had with members of the WHO Secretariat, and for what I have mentioned above, the budget turns out to be the main political document, as long as it defines the policies of the Organization and the financial means to implement them. For this reason, the budget is an extremely important document and it strongly affects WHO's mandate[188].

The budget of an organisation is generally a document which is fundamental for the functioning of the organisation itself[189], being specifically a financial plan for executing a programme of activities in a specified period.

The budget is actually the translation in dollars of the programme of activities of the Organization for a period of two years. As it is said, "programme budgeting identifies the objectives to be aimed at and translates them into the costs required for their achievement"[190]. A member of the WHO Secretariat told us that "the budget is like a 'catalogue of wishes' which describes intentions and priorities of the Organization from a financial perspective"[191].

Therefore, corporate strategy and budget have basically the same function: they are means towards the realisation of WHO's mission. However, if the corporate strategy defines the basic principles of action, the budget translates the theory into practice.

In this paragraph, I will first deal with the general financing of the WHO, and secondly I will analyse the current budget 2002-2003, highlighting its particular characteristics and showing how it influences WHO's mandate.

3.3.1. Financing the WHO

The financing of the WHO is set out in three main documents: the Constitution, the financial regulations and the financial rules.

The constitutional provisions are of prime importance in defining the budget process. Within the specialised agencies, the budget estimates are usually prepared by the head of the administration and then presented to the main plenary organ which must approve them according to an appropriate procedure[192]. Articles 55 and 56 of the WHO Constitution are no exception to the rule[193]. Article 55 states that "the Director-General shall prepare and submit to the EB the budget estimates of the Organization. The EB shall consider and submit to the WHA such budget estimates"[194]. The following step is described by article 56 that states that "the WHA shall review and approve the budget estimates and shall apportion the expenses among the member states in accordance with a scale to be fixed by the WHA"[195].

As the Constitution does not regulate financial matters in detail, additional documents are to be considered to have a general overview of the financing issue. These are, in fact, the financial regulations and financial rules[196]. These documents, together with the Constitution, represent the legal sources of this paragraph.

Since the 1980-1981 biennium, the programme budget has covered a two-year period beginning in an even-numbered year instead of a one-year period. This change was aimed at simplifying and lightening the preparation procedure, the approval and the implementation. Furthermore, it was also expected to guarantee a better coordination at the UN system level[197].

As far as it concerns finding resources to meet expenditures, there are different methods. The WHO provides two main financing sources:

  • regular budget;
  • extrabudgetary resources.

The regular budget refers to the obligatory annual contributions levied from the member states, and it finances the ordinary program of the Organization.

The assessed contributions of the member states, according to the abovementioned article 56, are apportioned in accordance with a scale fixed by the WHA. This scale should follow as closely as possible the scale of assessment of the United Nations[198], according to which a certain percentage of the Organization's expenditures are assessed to each member state on a scale.

The main criterion used by the UN in order to apportion its expenses has been the 'capacity to pay' of the countries. However, there are different conditions to be taken into account to measure the 'capacity to pay' of a member. The UN has determined along the course of the history different elements. The first element to be considered, even tough not sufficient, is the national income. In 1946, the General Assembly introduced three other factors: per capita income, temporary dislocation of national economies arising out of the II World War, ability of members to secure foreign currency. In 1965, the General Assembly added, especially for the case of developing countries, the factor of possible economic and financial difficulties. Finally, in 1981, the General Assembly listed seven criteria, besides the national and per capita income, needed in order to measure the capacity to pay: particular consideration to least developed countries, economic disparities between developed and developing countries, conditions adversely affecting capacity to pay, heavy dependence on one or a few products, ability to secure foreign currency, accumulated national wealth and different methods of national accounting[199].

Following the UN scale of assessment, the WHO should also take into account the difference in membership and the establishment of minima and maxima[200].

In order to avoid the UN become too dependent on one or a small group of its members, the General Assembly established a maximum limit of contribution. The General Assembly fixed it at 25% of the total expenditure in 1972. The minimum contribution was to be 0.04% in 1946, but it was reduced till 0.001% in 1980.

The WHO decided to maintain the same rate, and therefore, the maximum contribution of a member state shall not exceed the 25% and the minimum assessment should be the 0.001%[201].

To make an example, it is sufficient to have a look at the WHO scale of assessment for the biennium 2002-2003[202]. The highest contribution is the 22% of the total expenditure from the United States, corresponding to US$92 691 940. There are then many countries, like Bhutan, Chad, Congo, Gambia, Mauritania, Nigeria whose contribution is the 0.001% of the total expenditure, corresponding to US$ 4 213.

It is important to note that such a divergence does not have a correspondent in the right to vote. The obligatory contributions constitute a heavy burden just for a very small number of states, which do not get any advantage when the moment to vote comes. This inconvenient, which is a characteristic of the UN system as a whole, has been object of many criticisms and of requests for reforms, especially from the United States[203]. Although the principle 'one country, one vote' resists, the fact that the regular budget expenses are mainly paid by few countries brings a series of political consequences, as the inevitable influence of those countries on the programme of the Organization[204].

The extrabudgetary resources are defined as all resources other than those of the regular budget. The main sources of extrabudgetary contributions are the following[205]:

  • Official development agencies (ODA) of governments of member states, including in particular those which are members of the Development Assistance Committee (DAC) of the Organization for Economic Cooperation and Development (OECD), i.e. Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Ireland, Italy, Japan, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, United Kingdom of Great Britain and Northern Ireland, United States. The member states are the WHO's core source of extrabudgetary resources: ODA currently represents about 60% of voluntary contributions.
  • United Nations organisations, as (a) the principal funding sources for grant assistance – the United Nations Development Programme (UNDP), the United Nations Children's Fund (UNICEF), the World Food Programme (WFP), and the International Fund for Agricultural Development (IFAD); and (b) the Bretton Woods organisations, including the World Bank and the International Monetary Fund. In the past decade the financial support from UN organisation has declined significantly, however strategic working relationships have increased. An example is the joint fundraising effort with UNAIDS on prevention and control of HIV/AIDS.
  • Intergovernmental organisations outside the UN system, such as the European Union and the regional development banks.
  • Foundations and trusts, such as the Bill and Melinda Foundation, the Rock Feller Foundation and the Rotary Foundation.
  • Local authorities. Approximately 200 local governments, cities and authorities have to date contribute financially to WHO' work. The strategy is to encourage WHO representatives to promote this involvement.
  • Nongovernmental organisations.
  • Private sector.
  • Individual donors, societies, etc.

3.3.2. Budget 2002-2003: a new style

After having outlined the basis of WHO financing, this paragraph will analyse the current programme budget for the biennium 2002-2003[206]. The reason for dealing with this particular programme budget is, besides the fact that it is the current one, that it presents many differences from the past ones. The changes it has gone through under Dr Brundtland's administration, have made it a stronger strategic instrument, essential to determine WHO's mandate.

Dr Brundtland's reforms had direct influence on the preparation of the programme budget 2002-2003[207]. In her opinion, this document was going to be "a key instrument for advancing the process of change and reform in WHO" and therefore, "both in its content and in the way it has been prepared, it marks a significant departure from previous biennium"[208].

One of Dr Brundtland's changes concerning the budget has been to make this document as clear and transparent as possible. Addressing the Geneva Group, Dr Brundtland said that the new budget is "shorter and […] sharper. It is strategic"[209]. Member states were often complaining of the incomprehensible character of the document described as "lacking detail, being unspecific, and having no mechanism for control"[210]. The budget should instead be a clear indicator of the direction of work the Organization wants to keep: "our budget reflects the work and priorities of this Organization"[211]. For this reason, the programme budget 2002-2003 was strongly affected by the corporate strategy and by the general programme of work 2002-2005.

In the programme budget 2002-2003, the work of the WHO is divided in 35 areas denominated 'strategic orientations by area of work' and in 11 priorities. These areas of work do not correspond to any organisational structure either at headquarters or in the Regional Offices. They are chosen among many because they better represent the focus of the Organization. For each area of work, the budget will present the following sections: issues and challenges, goal, WHO objectives, expected results and performance indicators[212].

  • Issues and challenges: a concise analysis of problems, issues and trends in relation to each area of work.
  • Goal: higher development objective to which the work of the Organization will contribute. A goal in this terms refers to broader changes – often, but not always expresses in terms of health status – which are beyond the capacity of any organisation to bring about. Certain goals have been formulated by the international community (MDGs), others are based on the global Health for All target, others have to be formulated specifically for the area of work concerned.
  • WHO objective(s): this is what WHO is committed to and which can be used as a yardstick to measure performance.
  • Expected results: this expresses what WHO expects to achieve as a consequence of its actions. Its achievement represents the direct responsibility of the WHO.
  • Performance indicators: these will be developed for WHO objective and each expected result, once the agreement on goal, objective and expected results is reached.

Most reforms of Dr Brundtland's administration have been directed towards the achievement of 'One WHO'. One of the new method introduced has been the adoption of 'One budget for One WHO'. There used to be seven different and separated budgets: one for the headquarters and one for each one of the six Regional Offices[213]. The Regional Offices were used to prepare a document which was subsequently consolidated at global level without explicit discussion of objectives, strategies, approaches or resource allocation. On the contrary, the proposed programme budget 2002-2003 has been developed through an Organization-wide process. Each area of work has been worked out jointly between headquarters and regions. They have been worked closely together in a global context developing mutually supportive programme activities. An example is the fact that the draft of the proposed programme budget is reviewed by all the regional committees before it is presented to the EB. The 2002-2003 programme budget, therefore, expresses more fully "the interdependence of the different parts of the WHO within agreed global objectives, strategies and expected results"[214].

A further characteristic of the proposed programme budget 2002-2003 is that it concentrates on results rather than on resources. The principle of result-based budgeting is applied in substitution of the resource-based management. The latter approach starts with the available resources and then decides what to deliver and how. The result-based approach starts defining what should be delivered and how, fixing goal, objective and expected results, and then it decides the resource required. Defining in advance the aims to which the resources are directed, this approach should reduce the waste.

 Last but not least, Dr Brundtland has maintained the trend of the past decades during which the regular budget of the WHO has remained fairly static, whilst the extrabudgetary resources have been considerably increasing.

Until the 1970s, the WHO regular budget kept increasing thanks to the assessed contributions from the member states. However, since the early 1980s, the regular budget has been limited by the UN policy of zero real growth and more recently zero nominal growth. As a solution to complement the missing but still needed resources, the voluntary contributions have incredibly augmented.

The tables below (Table 3 and 4) show the increase of extrabudgetary contributions from the biennium 1980-1981 to the biennium 2000-2001[215].

Table 3: Breakdown of extrabudgetary contributions to WHO (US$ millions) 1980-1999

  ODA UN System Other TOTAL
1980-1981 138 86 20 244
1982-1983 130 90 21 241
1984-1985 118 90 26 219
1986-1987 182 89 34 320
1988-1989 237 90 39 366
1990-1991 261 144 33 438
1992-1993 295 127 70 492
1994-1995 333 106 81 520
1996-1997 360 98 141 599
1998-1999 460 78 250 788
2000-2001 765 66 406 1237

Source: WHO[216]

Table 4: Extrabudgetray contributions per biennium and change in extrabudgetary contributions from one biennium to another

Source of funds Biennium 98-99 % Change
00-01 v 98-99
Biennium 00-01
US$ % US$ %
Member states 444,974,600 59.94 70.34 757,977,658 62.04
Local government and cities authorities 16,905,734 2.28 18.30 19,999,198 1.64
UN and IGOs 54,415,085 8.00 3.55 61,524,129 5.04
Foundations 124,543,880 16.78 36.82 170,402,757 13.95
Private sector and NGOs 96,522,227 13.00 119.46 211,824,608 17.34
Total contributions 742,361,526 100.00 64.57 1,221,728,350 100.00

Source: WHO[217]

There has been an increase of 31.5% over the biennium 1996-1997, an increase of 57% over the biennium 1998-1999 and an increase of 65% over the biennium 2000-2001.

As far as it concerns WHO programme budget 2002-2003, WHO total budget for the biennium 2002-2003 is US$ 2,223 million, of which US$ 843 are raised through assessed contributions and US$ 1,380 million are voluntary contributions (Table 5).

Table 5: All sources of funds

Source of funds 2000-2001 2002-2003
Total regular budget
Total other sources
842 654
1 097 000
842 654
1 380 000
Total all sources 1 939 654 2 222 654

Source: Proposed programme budget 2002-2003

As Beigbeder recalls, this situation has inevitably positive, but also negative consequences. The positive aspects are that, without an extrabudgetary fund, it would not have been possible to finance programmes that have actually produced very good results. The financing through voluntary contributions has, for example, allowed the expansion of the Expanded Programme on Immunization (EPI), the Special Programme on Research and Training in Tropical Diseases (TDR) and the Programme for Control of Diarrhoeal Diseases (CDD). Furthermore, these programmes mostly gain a certain financial and administrative autonomy that allows them to more easily adapt to the changes avoiding the slow WHO bureaucracy[218].

As far as it concerns the negative aspects, one problem is that voluntary contributions are for nature 'imprévisibles et changeantes'[219]. As a consequence, it becomes extremely difficult to plan and to allocate resources in terms of personnel, equipment and furniture on a programme in a long-term[220]. Furthermore, the most frequent criticism to this kind of funding is to make the Organization 'donor driven'. The extrabudgetray funds currently account for more than a half of the Organization's total expenditure and more than 80% of these funds come from a small group of ten industrialised donor countries. One of the negative aspects would, therefore, be that the management and the programmes of the Organization be strongly affected by those powerful countries.

On this issue, I agree with the thesis of an international policy study on the effects of donors and their voluntary contributions upon the WHO[221]. One point made by the authors is that voluntary contributions are totally consistent with the WHO's constitution and priorities, as far as it concerns the objectives, the activities, the focus and the method of work. Thus, they do not seem to have unduly distorted the initial setting of WHO priorities. At the same time, the governing bodies of the Organization involved in the budgeting process have constitutionally the power to exercise their control over the procedure and to avoid donor's overwhelming power.

The overall conclusion of the study is that, "there is evidence that the donors, particularly a few donor countries have exerted considerable influence on the Organization, […] however, it is by no means clear that this has resulted in the Organization being donor driven and neither does it appear that the negative effects on the Organization have greatly outweighed the positive ones. Donors have encouraged many positive developments in the WHO"[222]. The authors suggest that donor's contributions are extremely positive and WHO should try to have them increasing. However, a reform would be needed in order to have a stronger control from the governing bodies of the Organization also on the extrabudgetary funds, and not to have donors interfere with WHO's mandate. Apparently both the requests have been fulfilled by Dr Brundtland's reforms. I have already mentioned the importance she attributed to the development of partnerships with donors, being them from other international organisations, UN agencies, as well as from the civil society and the private sector. Among her reforms, it is also important to recall the unification of the process of approval for the regular budget and the extrabudgetary funds. The governing bodies involved with this procedure have now to deal with both kinds of sources.

The proposed programme budget 2002-2003 has been, more than any previous one, a fundamental document in defining WHO's mandate. Defining 35 areas of work and 11 priorities, it has fixed the margins of WHO's work.

Looking at the resources assessed to each one of the activities, one can understand where WHO is going and what are its main interests[223].

I will present two tables that show the allocated resources for every single priority in the current budget and in the next one (proposed programme budget 2004-2005). It will be sufficient to look at these data in order to understand that WHO's mandate is definitely very broad, and to perceive where WHO is directed.

Table 6: Planned resources by priority areas (2002-2003)

Priorities Planned resources
(US$ thousand)
HIV/AIDS 129 812
Malaria 118 212
Tuberculosis 104 650
Health systems 57 923
Evidence for health policy 43 225
Making pregnancy safer 37 157
Mental health 28 147
Tobacco 25 208
Safe blood 25 727
Surveillance, prevention and management of noncommunicable diseases 20 029
Food safety 10 399

Source: Proposed programme budget 2002-2003

Table 7: Planned resources by priority areas (2004-2005)

Priorities Planned resources
(US$ thousand)
Tuberculosis 173 980
HIV/AIDS 160 430
Malaria 148 676
Evidence for health policy 81 976
Child and adolescent health 79 307
Health and environment 77 552
Essential medicines 52 506
Surveillance, prevention and management of noncommunicable diseases 45 258
Making pregnancy safer 38 507
Tobacco 37 036
Mental health 33 007
Safe blood 21 490
Food safety 20 846

Source: Proposed programme budget 2004-2005


 

[1] For further information concerning the interpretation of international organization constitutions, see Amerasinghe, C. F., Principles of institutional law of international organisations, Cambridge University Press, Cambridge, 1996, pp. 23-59

[2] Archer, C., International organisations, G. Allen & Unwin, London, 1983, p.51

[3] Bennet, A., International organisations: principles and issues, Englewood Cliffs, N. J.: Prentice Hall, Inc., 1984, p. 53

[4] For further information about the general characteristics of the Constitution of international organizations, see Conforti, B., Le Nazioni Unite, CEDAM, Padova, 2000 and Draetta, U., Principi di diritto delle organizzazioni internazionali, Giuffrè Editore, Milano, 1997

[5] WHO Manual, available at policy.who.int

[6] Burci, G., Vignes C., The World Health Organization, Manuscript to be published, 2002, Ch. 5

[7] Preamble of the Constitution

[8] Various definition of health have been considered in the course of history. The three main recurrent perceptions are: the one which sees health as a subjective or objective phenomenon, and in term of whether it extends beyond the physical domain; the one which includes the means of improving and maintaining health; and the one which considers value and aim of health. See Yach, D., Health and illness: the definition of the World Health Organization (1998), available at www.medizin-ethik.ch/publik/health_illness.htm

[9] "[…] as well as you might define life as the absence of death". See Khayat, M.H., Spirituality in the definition of health: the World Health Organization's point of view (1998),

available at www.medizin-ethik.ch/publik/spirituality_definition_health.htm

[10] Sigerist, H.R., Medicine and human welfare, Yale University Press, New Haven, 1941

[11] Here I refer to the risk outlined by Horton when he refers to the DFDI paper Working in partnership with the World Health Organization. See Part II, Ch. 2, p. 48

[12] Trends and challenges in world health, Document EB105/4

[13] Mentioned in Yach, D., Health and illness: the definition of the World Health Organization (1998), available at www.medizin-ethik.ch/publik/health_illness.htm

[14] Saracci, R., The World Health Organization needs to reconsider its definition of health, in British Medical Journal, vol. 314, no. 7091, 10 May 1997, pp. 1409-1410

[15] ibid.

[16] Cesana, G., Il "Ministero" della Salute, Studio Editoriale Fiorentino, Firenze, 2000, p. 35

[17] Minelli, E., with Degiacomo, E. and Schiantarelli, C., Agopuntura clinica: tradizionale e moderna, Edizioni RED, Milano, 2002, p. 23

[18] Gruskin, S., Tarantola, D., Health and human rights, handed during a WHO Workshop: Health and Human Rights training, available at cfserver.hsph.harvard.edu/cfdocs/worldmap/view_faculty.cfm?ID=905

[19] Health as a human right, www.who.int/archives/who50/en/human.htm and Health & Human Rights, www.who.int/hhr/en

[20] For further information, see Mahoney, K.E., Mahoney, P., Human rights in the 21st century: a global challenge, Martin Nijhoff Publishers, Dordrecht, 1993

[21] Gruskin, S., Tarantola, D., Health and human rights, handed during a WHO Workshop: Health and Human Rights training, available at cfserver.hsph.harvard.edu/cfdocs/worldmap/view_faculty.cfm?ID=905

[22] These are words of the rapporteur, Paul Hunt in an article entitled The right to health: from the margins to the mainstream, in The Lancet, vol. 360, no. 9348, 7 December 2002, p. 1878

[23] For further examples to show the linkage between health and human rights within the UN system, see Smith, L., The right to health, in Mahoney, K.E., Mahoney, P., Human rights in the 21st century: a global challenge, Martin Nijhoff Publishers, Dordrecht, 1993, pp. 486-490 and in The right to the highest attainable standard of health, CESCR General Comment No. 14, E7C.12/2000/4 (11/8/2000). For example, article 5 of the International Convention on the Elimination of all Forms of Racial Discrimination, articles 11 and 12 of the Convention on the elimination of all forms of discrimination against women and article 24 of the Convention on the Rights of Child.

[24] Quote in Burci, G., Vignes C., The World Health Organization, Manuscript to be published, 2002, Ch. 5

[25] Universal Declaration of Human Rights (1948), available at www.un.org/Overview/rights.html

[26] Smith, L., The right to health, in Mahoney, K.E., Mahoney, P., Human rights in the 21st century: a global challenge, Martin Nijhoff Publishers, Dordrecht, 1993, pp. 479-493

[27] International Covenant on Economic, Social and Cultural Rights (1966), available at www.unhchr.ch/html/menu3/b/a_cescr.htm

[28] See Selection of the countries in which the twenty-fifth WHA will be held, WHA resolution, Document WHA23.41 and Technical cooperation, WHA resolution, Document WHA30.43 mentioned in Burci, G., Vignes C., The World Health Organization, Manuscript to be published, 2002, Ch. 5 and in Smith, L., The right to health, in Mahoney, K.E., Mahoney, P., Human rights in the 21st century: a global challenge, Martin Nijhoff Publishers, Dordrecht, 1993, pp. 479-493

[29] Declaration of Alma-Ata (1978), available at www.who.int/hpr/archive/docs/almaata.html

[30] World Health Declaration (1998), Annex to WHA resolution, Document WHA51.7

[31] Marmor, T., The right to health care, in Ed. Bole, T.J., III & W.B. Bondeson, Rights to Health Care, Kluwer, Dordrecht, 1991, p. 23

[32] Report of the International Conference on Primary Health Care, WHO, Geneva, 1978, p. 2

[33] The right to the highest attainable standard of health, CESCR General Comment No. 14, E7C.12/2000/4 (11/8/2000)

[34] 25 questions and answers on health & human rights, Health & Human Rights Publication Series, Issue No. 1,  WHO, Geneva, July 2002, p. 9

[35] The right to the highest attainable standard of health, CESCR General Comment No. 14, E7C.12/2000/4 (11/8/2000), p.2

[36] ibid., p.3

[37] The author's position results of great interest because it highlights an interesting issue which has been already mentioned in the text: shall health be considered a right, meaning that it is due by the state to the individual, or a responsibility for the individual? Scruton, R., WHO, What and Why?: Transnational government, legitimacy and the World Health Organization, The Institution of Economic Affairs, London, 2001, p. 20. I think that the General Comment of the Committee properly composes the two elements: the individual freedom and the entitlement. Furthermore, even if I enter a field which is not of my direct competence, I should always take into account a factor X: health itself is more than anything else a 'gift'.

[38] 25 questions and answers on health & human rights, Health & Human Rights Publication Series, Issue No. 1,  WHO, Geneva, July 2002, p. 10

[39] For a more detailed description of the four elements, see The right to the highest attainable standard of health, CESCR General Comment No. 14, E7C.12/2000/4 (11/8/2000), pp.3-4

[40] Complete information regarding to the health and human rights link within the WHO, available at www.who.int/hhr and see Rajagopalan-Vorburger, D., World Health Organization and the right to health: a legal analysis of its interaction with other institutions, Dissertation for the Institut Universitaire de Hautes Etudes Internationales, Genève, September 2002

[41] A Corporate Strategy for the WHO Secretariat, Document EB105/3

[42] Burci, G., Vignes C., The World Health Organization, Manuscript to be published, 2002, Ch. 5

[43] Health and human rights, www.who.int/hhr/news/en

[44] Constitution, art. 1

[45]For further information, see Bettegazzi, N., I programmi “Salute per tutti da oggi al 2000” elaborati dall’Organizzazione mondiale della sanità: motivazioni, prospettive e limiti, Dissertation for the University of Medicine of Pavia, Pavia, academic year 1986-7

[46] Health for all: origins and mandate, www.who.int/archives/who50/en/health4all.htm

[47] Starrels, J.M., The World Health Organization: resisting third world ideological pressure, The Heritage Foundation, Washington, D.C., 1985, pp. 7-14

[48] Burci, G., Vignes C., The World Health Organization, Manuscript to be published, 2002, Ch. 3

[49] ibid.

[50] Dr Mahler "is described as a visionary, a charismatic leader – 'almost like a priest', said Dr Miroslaw Wysocki, head of the health information system at the WHO's South East Asia Regional Office. "Health for All was an impossible concept, but he said it and everyone believed him". See Godlee, F., WHO in retreat: is it losing its influence?, in British Medical Journal, vol. 309, no. 6967, 3 december 1994, pp. 1491-1495

[51] Director-General report, OR 229, pp. 7-9

[52] Technical cooperation, WHA resolution, Document WHA30.43

[53] Mahler, H., World Health Forum, mentioned in Müller, J., Reforming the UN: new initiatives and past efforts, vol. 1., Kluwer Law International, The Hague, 1997, III.11/33

[54] Declaration of Alma-Ata (1978), available at www.who.int/hpr/archive/docs/almaata.html

[55] ibid.

[56] Declaration of Alma-Ata (1978), available at www.who.int/hpr/archive/docs/almaata.html.

[57] Formulating strategies for health for all by the year 2000, WHA resolution, Document WHA32.30

[58] Five of these indicators were: (a) the existence of a political commitment; (b) whether there have been resources allocated to such commitment; (c) the degree of equity; (d) the attainment of the committee in attaining health for all; (e)the organizational framework and managerial process. See Rajagopalan-Vorburger, D., World Health  Organization and the right to health: a legal analysis of its interaction with other institutions, Dissertation for the Institut Universitaire de Hautes Etudes Internationales, Genève, September 2002, p. 35

[59] Burci, G., Vignes C., The World Health Organization, Manuscript to be published, 2002, Ch. 3

[60] Health for all in the 21st century, www.who.int/archives/hfa/

[61] WHO response to global change: renewing the health-for-all strategy, WHA resolution, WHA48.16

[62] Health for all policy in the twenty-first century, WHA resolution, WHA51.7

[63] World Health Declaration, Annex to Health for all policy in the twenty-first century, WHA resolution, WHA51.7

[64] Van de Water, Van Herten, Never change a winning team? Review of WHO's new global policy: health for all in the 21st century, TNO Prevention and Health, Leiden, 1999

[65] Beigbeder, Y., L’Organisation Mondial de la Santé, PUF, Paris, 1997, p. 22

[66] Ministry for Foreign Affairs, Tomorrow’s global health organization: ideas and options, Norstedts Tryckeri Ab, Stockholm, 1996 , p. 70

[67] Cohen, J., Global health for the 21st century, in The Lancet, vol. 360, no. 9346, 23 November 2002 , p. 5997

[68] The reference is to the debate appeared on The Lancet in November 2002 and started by Horton's article, (Horton, R., WHO’s mandate: a damaging reinterpretation taking place, in The Lancet, vol. 360, no. 9338, 28 September 2002, p. 960) previously mentioned. The position adopted by Cohen is that the Health for All goals should not be overcome by the recently adopted Millennium Development Goals. The narrow vertical disease control policy should be reinforced by the HFA approach. ibid.

[69] Cohen, J., Global health for the 21st century, in The Lancet, vol. 360, no. 9346, 23 November 2002 , p. 5997

[70] See Part II, Ch. 2, p. 62

[71] Grø Harlem Brundtland was educated as a physician in Norway and graduated from the Harvard School of Public Health with a master degree in public health. For more than 20 years she was in public office in her country, first as Minister of Environment and then as Prime Minister (1981-1985, 1986-1989, 1990-1996). In the 1980s she chaired the World Commission of Environment and Development and she gained international recognition, championing the principle of sustainable development. Dr Brundtland finally stepped down as Prime Minister in October 1996, and she was appointed Director-General of the WHO in 1998. See www.who.int/dg/bruntland/en/

[72] Draft contract of the Director-General to be presented to the 51st WHA, Document A51/4. The contract also states that "subject to the authority of the Executive Board, the Director-General shall exercise the functions of chief technical and administrative officer of the Organization and shall perform such duties as may be specified in the Constitution and in the rules of the Organization and/or as may be assigned to him or her by the Health Assembly or the Board". As a curiosity the annual salary of the Director-General was fixed at $175,344.

[73] The satellites were "budget 2000-2001, in-house and external relations, communications, health and development, health sector development, Roll Back Malaria, tobacco, health and the environment, mental health emergencies, capacity building, collaborating centres and regional members". See Lerer, L., Matzopoulos, R., "The worst of the both worlds": the management reform of the World Health Organization, in International Journal of Health Services, 2001, vol.31, no. 2, p. 429. Note that Lerer and Matzopoulos are consultants of the French firm of consultants, Health Care Management Initiative. They were commissioned by Dr Brundtland herself to review the management practices through which the Organization planned and monitors its performance.

[74] Brundtland, G., Address to WHO staff, Geneva, 21 July 1998, available at

www.who.int/director-general/speeches 

[75] However, if these were Brundtland's intentions, "many employees were shocked by the appointment of Transition Team members to senior positions. The team had been viewed as an impartial external body, and many of the employees it had interviewed had been uncompromising in their criticism of the organization and one another. As one employee described, 'They really emptied their hearts and their knives on each other. It was suicidal'". See Lerer, L., Matzopoulos, R., "The worst of the both worlds": the management reform of the World Health Organization, in International Journal of Health Services, 2001, vol.31, no. 2, p. 430

[76] Brundtland, G., Address to the Geneva Group – Un Directors: Change at WHO, Geneva, 2 March 1999, available at www.who.int/director-general/speeches

[77] ibid.

[78] See Lerer, L., Matzopoulos, R., "The worst of the both worlds": the management reform of the World Health Organization, in International Journal of Health Services, 2001, vol.31, no. 2, p. 430

[79] Brundtland, G., WHO – the way ahead, Statement by the Director-General to the Executive Board at its 103rd session, Geneva, 25 January 1999, Document EB103/2

[80] In this part I used many of Dr Brundtland's speeches in order to document myself. The reason is that, as many members of the Secretariat told me, the Director-General's speeches are precious sources where one can find the main guidelines of the policy of the Organization. In particular, as Lerer and Matzopoulos note, "the transition process was viewed as largely 'guided' by Brundtland's speeches. Her speeches were content-heavy and based on discussions with  her Cabinet and senior policy advisers. See Lerer, L., Matzopoulos, R., "The worst of the both worlds": the management reform of the World Health Organization, in International Journal of Health Services, 2001vol.31, no. 2, p. 421

[81] Dr Gro Harlem Brundtland Director-General Elect The World Health Organization, Speech to the Fifty-first World Health Assembly, Geneva, 13 May 1998, Document A51/DIV/6

[82] Brundtland, G., Address to WHO staff, Geneva, 21 July 1998, available at

www.who.int/director-general/speeches

[83] In front of the Fifty-first World Health Assembly, Dr Brundtland commits herself to the important task she has been entrusted with: "This is a special moment of responsibility. You have given me confidence and I feel responsible towards all of you and to the peoples that you represent". See Dr Gro Harlem Brundtland Director-General Elect The World Health Organization, Speech to the Fifty-first World Health Assembly, Geneva, 13 May 1998, Document A51/DIV/6

[84] From a conversation with Dr Prost, Director of the Government and Private Sector Relations Department.

[85] The Nakajima's administration and in particular the Director-General himself have been attacked from many fronts and have been object of many different kinds of criticism. For example, it is said: "After 15 years under the charismatic visionary Dr Halfden Mahler, WHO staff and donors were unimpressed by Dr Hiroshi Nakajima, who they saw as reserved and poor communicator. […] his severe difficulties in communicating are a major handicap for a UN leader. His spoken English and French are poor, and even Japanese delegates and staff find him difficult to understand. When he speaks privately his passion for the work of WHO is evident, as well as his grasp of the problems it faces; but under stress- at press conferences, for example – he becomes defensive and incoherent". For further information on the critical situation of WHO under Dr Nakajima, see Godlee, F., The World Health Organization: WHO in crisis, in British Medical Journal, vol. 309, no. 6966, 26 November 1994, pp. 1420-1428. However, there are still many current WHO employees, we had the chance to talk to, who would rather still  work under the previous administration than under Dr Brundtland. A case is that one mentioned by Horton, about the letter of resignation signed by Daphne Fresle. She shows her disappointment because "the high hopes" of Brundtland's election "have not been realised". See Horton, R., WHO: the casualties and compromises of renewal, in The Lancet, vol. 359, no. 9317, 4 May 2002, pp. 1605-1611

[86] Yamey G., WHO's management: struggling to transform a "fossilised bureaucracy", In British Medical Journal, vol. 325, no. 7373, 16 November 2002, pp. 1170-1173

[87] Tollison R.D. and Wagner R.E., Who benefits from WHO? The decline of the World Health Organization, The Social Affairs Unit, St Edmundsbury Press, Ltd, Great Britain, 1993, pp. 18-19

[88] Horton, R., WHO: the casualties and compromises of renewal, in The Lancet, vol. 359, no. 9317, 4 May 2002, pp. 1605-1611

[89] Editorial, The Brundtland era begins, in The Lancet, vol. 351, no. 9100, 7 February 1998, p. 381

[90] Lerer, L., Matzopoulos, R., "The worst of the both worlds": the management reform of the World Health Organization, in International Journal of Health Services, 2001, vol.31, no. 2, p. 420

[91] For further description of the elements of transition, see Bilan de dix mois de changement, OMS, 1999 and Robbins, A., Brundtland's revolution at World Health Organization, in Public Health, vol. 114, no. 1, January/February 1999, pp. 30-39

[92] Brundtland, G., Address to the Geneva Group – Un Directors: Change at WHO, Geneva, 2 March 1999, available at www.who.int/director-general/speeches

[93] Dr Gro Harlem Brundtland Director-General Elect The World Health Organization, Speech to the Fifty-first World Health Assembly, Geneva, 13 May 1998, Document A51/DIV/6

[94] See Part I, Ch. 3, p. 28

[95] See Part II, Ch. 3, p. 154

[96] Brundtland, G., Address to WHO staff, Geneva, 21 July 1998, available at

www.who.int/director-general/speeches

[97] Brundtland, G., Address to the Geneva Group – Un Directors: Change at WHO, Geneva, 2 March 1999, available at www.who.int/director-general/speeches

[98] The new WHO cabinet looks refreshingly different, News in British Medical Journal, vol. 317, no. 7157, 1998, p. 492

[99] See Part I, Ch 3, p. 33

[100] Brundtland, G., Address to WHO staff, Geneva, 21 July 1998, available at

www.who.int/director-general/speeches

[101] ibid.

[102] See Lerer, L., Matzopoulos, R., "The worst of the both worlds": the management reform of the World Health Organization, in International Journal of Health Services, 2001, vol.31, no. 2, p. 416

[103] Looking ahead for WHO after a year of change, Statement by the Director-General to the Fifty-second World Health Assembly, Geneva, 18 May 1999, Document A52/3

[104] See Part I, Ch. 3, p. 41

[105] Looking ahead for WHO after a year of change, Statement by the Director-General to the Fifty-second World Health Assembly, Geneva, 18 May 1999, Document A52/3.

[106] See Part II, Ch. 3, p. 162

[107] See Part. II, Ch. 2, p. 89

[108] Horton, R., WHO: the casualties and compromises of renewal, in The Lancet, vol. 359, no. 9317, 4 May 2002, pp. 1605-1611

[109] Dr Gro Harlem Brundtland Director-General Elect The World Health Organization, Speech to the Fifty-first World Health Assembly, Geneva, 13 May 1998, Document A51/DIV/6

[110] ibid.

[111] Dr Brundtland's speech mentioned in The 'new WHO' commits to making a difference, News in British Medical Journal, vol. 317, no. 7154, 1 August 1998, pp. 302-303

[112] See Part. II, Ch. 1, p. 58

[113] Thanks to conversation with members of the WHO staff, I understood that the debate which wants the WHO to be either a totally pure technical agency or an agency involved in the political arena is futile because it does not take into account that the two elements are equally necessary to the survival of the Organization. See Part IV, Ch. 2, p. 229

[114] The reference by Horton is to Siddiqi, J., World health and world politics, Hurst & Company, London, 1995

[115] Horton, R., WHO: the casualties and compromises of renewal, in The Lancet, vol. 359, no. 9317, 4 May 2002, pp. 1605-1611

[116] Dr Gro Harlem Brundtland Director-General Elect The World Health Organization, Speech to the Fifty-first World Health Assembly, Geneva, 13 May 1998, Document A51/DIV/6

[117] ibid.

[118] Brundtland, G., Address to WHO staff, Geneva, 21 July 1998,

available at www.who.int/director-general/speeches

[119]The argument is treated by several articles. For example, see Lee, K., World health: shaping the future of global health cooperation: where can we go from here?, in The Lancet, 1998, vol. 351, pp. 899-902; Walt, G., World health: globalisation of international health, in The Lancet, vol. 351, no. 9100, 7 February 1998p. 434; Lee, K., Collinson, S., Walt, G., Gilson, L., Who should be doing what in international health: a confusion of mandates in the United Nations?, in British Medical Journal, vol. 312, no. 7026, 3 February 1996, p. 302

[120] For example, see the relationship between WHO and the European Union at www.who.int/m/topics/weu/en/index.html and Frid, R., The relations between the EC and international organizations: legal theory and practice, Kluwer Law International, The Hague, 1995

[121] See the website of the Department of External Cooperation and Partnership (ECP), which is in charge of coordinating WHO' relationships and links outside the Organization, ensuring that WHO speaks with one voice and presents a unified and integrated picture to external partners. See www.who.int/ina/about.html

[122] For further information see Beigbeder, Y., L’Organisation Mondial de la Santé, PUF, Paris, 1997, pp. 87-99; OMS, Los diez primeros años de la Organization Mundial de la Salud, Ginebra, 1958, pp. 129-145

[123] Further information about global public-private partnerships, see Buse, K., Walt, G., Global public-private partnerships: part I – a new development in health, in Bulletin of the World Health Organization, 2000, vol. 78, no. 4, pp. 549-561; Buse, K., Walt, G., Global public-private partnerships: part II – what are the health issues for global governance, in Bulletin of the World Health Organization, 2000, vol. 78, no. 5, pp. 699-709; Widdus, R., Public-private partnerships for health: their main targets, their diversity, and their future directions, in Bulletin of the World Health Organization, 2001, vol. 79, no. 8, pp. 713-720; Buse, W., Waxman, A., Public-private health partnerships: a strategy for WHO, in Bulletin of the World Health Organization, 2001, vol. 79, pp. 748-754; Buse, K., Walt, G., The WHO and global public-private health partnerships: in search of 'good' global health governance, available at www.hsph.harvard.edu/hcpds/partnerbook/chap7.pdf; Nelson, J., Building partnerships: cooperation between the United Nations system and the private sector, United Nations, Department of Public Information, New York, 2002

[124] The reasons for this increase are several. I just want to mention the growing disillusion with the UN and its agencies which has brought the donors to impose a policy of zero real growth in UN budget, and a shift towards supplementary, and the fact that the health agenda is so large that no single sector or organization can tackle it alone. For the complete reasoning on the causes of the increasing partnerships, see Buse, K., Walt, G., The WHO and global public-private health partnerships: in search of 'good' global health governance, available at www.hsph.harvard.edu/hcpds/partnerbook/chap7.pdf

[125] Buse, K., Walt, G., Global public-private partnerships: part I – a new development in health, in Bulletin of the World Health Organization, 2000, vol. 78, no. 4, pp. 549-561, p. 550

[126] CSI, What is civil society? Issues and concepts for WHO work with civil society organizations, WHO, Geneva, 2002, p.4

[127] Steele, D., United Nations reform, civil and sometimes uncivil society, in Transnational Association, November/December 2000, vol. 52, no. 6, pp. 282-290

[128] CSI, WHO's interaction with civil society and nongovernmental organizations, WHO, Geneva, 2002, pp. 4-5

[129] Constitution, art. 18

[130] Constitution, art. 71

[131] Principles governing relations between the WHO and non governmental organizations, WHA resolution, Document WHA40.25

[132] ibid.

[133] CSI, WHO’s interaction with CSOs: short historical background, WHO, Geneva, 2002, p. 3

[134] As of February 2002, there were a total of 473 relationships between WHO departments and CSOs: 45% of those were with CSOs in official relations, while 55% of those were not. See CSI, Inventory of WHO/HQ relations with CSOs, WHO, Geneva, 2002

[135] Distinction between formal or official relations and informal or working relations. Only international NGOs can apply for the first kind of relations and they are conferred privileges such as participation in WHO meetings, committees and conferences and the right to make statements in these occasions. Part of the requirement to enter in official relations is the establishment of a joint programme of work  and a three-year plan with a technical department of the WHO. The admittance is authorised by a formal decision of the EB. All other kinds of relations with NGOs and CSOs are considered informal. CSI, WHO's interaction with civil society and nongovernmental organizations, WHO, Geneva, 2002, p. 10

[136] The civil society initiative, www.who.int/governance/civilsociety/en/

[137] CSI, WHO's interaction with civil society and nongovernmental organizations, WHO, Geneva, 2002

[138] Policy for relations with nongovernmental organizations, Report by the Secretariat, Document EB111/22

[139] During the briefing for NGOs before the opening of the 111th EB meeting, 19 January 2003, from 17.30 to 19, at the Geneva HQ, in Room C, 5th floor

[140] Policy for relations with nongovernmental organizations, Report by the Secretariat, Document EB111/22

[141]Guidelines on working with the private sector to achieve health outcomes, Report by the Secretariat, Document EB107/20.

[142] I want to mention here some of these collaborations: Alliance for Microbicide development, Clean Air Initiative, Geneva International Academic Network, International AIDS Vaccine Initiative, International Partnership for AIDS in Africa, Vitamin A Global Initiative. For the complete list, see intranet.who.int/homes/GPR/private_sector/ongoing/index.shtml

[143] From a conversation with Ms Randolph, a member of the Private Sector Team.

[144] ibid.

[145]McCArthy, M., What's going on at the World Health Organization?, in The Lancet, vol. 360, no. 9340, 12 October 2002, pp. 1108-1110

[146] The author also says: "If some people want to throw stones at that and say WHO is prostituting itself by working with the private sector, I would say, well OK, what are you going to do?". ibid.

[147] Public-private partnership for health: WHO's involvement, Note by the Director General, Document EB109/4

[148] ibid.

[149] See www.who.int/gb and intranet.who.int/homes/GPR

[150] With the aim of reaching out new partners in the private sector and of maintaining relations with the old ones, every year, in October, the headquarters of the WHO hosts the Meeting of Interested Parties (MIP). In this occasion, the Organization presents and reviews its work in front of it collaborators. See www.who.int/mip/en/

[151] Guidelines on working with the private sector to achieve health outcomes, Report by the Secretariat, Document EB107/20

[152] From a conversation with Ms Randolph, a member of the Private Sector Team.

[153] See Part IV, Ch. 2, p. 224

[154] See hypothesis previously mentioned from Lerer, L., Matzopoulos, R., "The worst of the both worlds": the management reform of the World Health Organization, in International Journal of Health Services, 2001, vol.31, no. 2

[155] Daft, R.L., Management, Vanderbily University, USA, 2003, p. 133

[156] Daft, R.L., Management, Vanderbily University, USA, 2003, p. 133

[157] WHO – the way ahead, Statement by the Director-General to the Executive Board at its 103rd session, Geneva, 25 January 1999, Document EB103/2

[158] It would therefore be one of the tools to realise what she said to the WHO staff on her first day of work: "Serving WHO is a privilege. We can make a difference". See Brundtland, G., Address to WHO staff, Geneva, 21 July 1998, available at www.who.int/director-general/speeches

[159] WHO – the way ahead, Statement by the Director-General to the Executive Board at its 103rd session, Geneva, 25 January 1999, Document EB103/2

[160] ibid.

[161] Looking ahead for WHO after a year of change - Summary of The World Health Report 1999 by the Director General, Document A52/4

[162] Looking ahead for WHO after a year of change - Summary of The World Health Report 1999 by the Director General, Document A52/4

[163] ibid.

[164] WHO – the way ahead, Statement by the Director-General to the Executive Board at its 103rd session, Geneva, 25 January 1999, Document EB103/2

[165] See Part II, Ch. 3, p. 140

[166] WHO – the way ahead, Statement by the Director-General to the Executive Board at its 103rd session, Geneva, 25 January 1999, Document EB103/2

[167] See Annex 5: a corporate strategy for the WHO Secretariat.

[168] A corporate strategy for the WHO Secretariat, Report by the Director-General, Document EB105/3.

Further information about the corporate strategy are also available at intranet.who.int/homes/POL/brochure/english/WHOgoal.htm and in the CD-ROM 'Responding to health challenges –WHO Corporate Strategy'.

[169] A corporate strategy for the WHO Secretariat, Report by the Director-General, Document EB105/3

[170] A corporate strategy for the WHO Secretariat, Report by the Director-General, Document EB105/3

 

[171] A corporate strategy for the WHO Secretariat, Report by the Director-General, Document EB105/3

[172] Towards a strategic agenda for the WHO Secretariat, Statement by the Director-General to the Executive Board at its 105th session, Geneva, 24 January, 2000, Document EB105/2

[173] Towards a strategic agenda for the WHO Secretariat, Statement by the Director-General to the Executive Board at its 105th session, Geneva, 24 January, 2000, Document EB105/2

[174] General programme of work 2002-2005, Report by the Director-General, Document EB107/34

[175] In Horton's opinion the DFID paper defined WHO's mandate mainly related to the Millennium Development Goals. See Part II, Ch. 2, p. 109

[176] See Part II, Ch. 2, p. 110

[177] Towards a strategic agenda for the WHO Secretariat, Statement by the Director-General to the Executive Board at its 105th session, Geneva, 24 January, 2000, Document EB105/2

[178] Constitution, art.28

[179] See Annex 6: general programme of work 2002-2005

[180] General programme of work, Resolution of the EB, Document EB107.R1

[181] They covered the periods: 1952-1956, 1957-1961, 1962-1966, 1967-1972, 1973-1977, 1978-1983, 1984-1989, 1990-1995, 1996-2001.

[182] For further information about the preparation of general programmes of work in the past, see OMS, Los diez primeros años de la Organization Mundial de la Salud, Ginebra, 1958, pp. 112-128

[183] Commonwealth Department of Community Services and Health, World Health Organization: a brief summary of its work, Australian Government Publishing Service, Canberra, 1988, pp. 29-32

[184] General programme of work 2002-2005, Report by the Director-General, Document EB107/34

[185] ibid.

[186] From conversations with WHO staff members

[187] Budget and finance, available at www.who.int/bfi

[188] The words of Aaron Wildavsky describes the importance of the budget: "Serving diverse purposes, a budget can be many things, a political act, a plan of work, a prediction, a source of enlightment, a means of obfuscation, a mechanism of control, an escape from restrictions, a means of action, a brake on progress, even a prayer that the powers that be will deal gently with the best aspirations of fallible men". Mentioned in Hoole, F.W., Politics and budgeting in the WHO, Indiana University Press, Bloomington and London, 1976, p. 49

[189] In 1976, Hoole already recognised that "since most activities require money, the budget represents the overall concern of an organization", Hoole, F.W., Politics and budgeting in the WHO, Indiana University Press, Bloomington and London, 1976, p. 41. Also Amerasinghe affirmed that "financing is at the hearth of the functioning of international organizations" and that "without adequate funds they could not achieve their purpose and functions". Amerasinghe, C. F., Principles of institutional law of international organizations, Cambridge University Press, Cambridge, 1996, p. 291

[190] Commonwealth Department of Community Services and Health, World Health Organization: a  brief summary of its work, Australian Government Publishing Service, Canberra, 1988, p. 33

[191] Dr Prost, Director of the Government and Private Sector Relations Department, also added that a comparison between the programme budget and the financial report is extremely useful in order to understand whether or not the expressed wishes have been realized or not.

[192] Amerasinghe, C. F., Principles of institutional law of international organizations, Cambridge University Press, Cambridge, 1996, p. 295

[193] There are several articles in the Constitution indirectly referring to financial matters. For example, art. 7, art. 18 (f), art. 28 (i), art. 34 and art. 50

[194] Constitution, art. 55

[195] Constitution, art. 56

[196] Financial regulations of the WHO and Financial rules of the WHO, available at policy.who.int and in WHO, Basic Documents, 43rd Edition, Geneva, 2001, p. 83

[197] Beigbeder, Y., L’Organisation Mondial de la Santé, PUF, Paris, 1997, p. 110

[198] "[…] in establishing the scale of assessment to be used […] the WHA shall further adjust the WHO scale to take into account the latest available UN scale of assessment", Scales of assessment, WHA resolution, Document WHA8.5

[199] Amerasinghe, C. F., Principles of institutional law of international organizations, Cambridge University Press, Cambridge, 1996, p. 299

[200] Review of method of establishing scale of assessment, WHA resolution, Document WHA24.12

[201] Review of method of establishing scale of assessment, WHA resolution, Document WHA26.21

[202] Scale of assessment for the financial period 2002-2003, Report by the Director General, Document A54/27. See Annex 7: scale of assessment for the financial period 2002-2003.

[203] For complete discussion on the American pressure, Beigbeder, Y., L’Organisation Mondial de la Santé, PUF, Paris, 1997, p. 111-114

[204] Strada, A., L'Organizzazione Mondiale della Sanità, Dissertation for the Law Faculty of the Cattolica University of Milan, 1998-9, p.246

[205] WHO Manual, available at policy.who.int and Implementation of budget resolutions, Report by the Secretariat, Document EB105/17 Add. 1

[206] Proposed programme budget 2002-2003, available at

policy.who.int/cgi-bin/om_isapi.dll?infobase=pb02-e&softpage=Browse_Frame_Pg42

[207] The preparation of the proposed programme budget usually starts two years in advance. The budget for the biennium 2002-2003 started to be prepared in 1999 by the Secretariat. The priorities were discussed at the 105th EB in January 2000. The document was presented to the 107th EB in January 2001 and approved by the WHA in May 2001. The proposed programme 2004-2005 budget has been recently presented and discussed at the 111th EB in January 2003.

[208] Implementing the Corporate strategy: work on Programme Budget 2002-2003, Report by the Secretariat, Document EB106/2

[209] Bundtland, G., Address to the Geneva Group – UN directors, Geneva, 2 March 1999, available at www.who.int/director-general/speeches

[210] Lerer, L., Matzopoulos, R., "The worst of the both worlds": the management reform of the World Health Organization, in International Journal of Health Services, 2001, vol.31, no. 2, p. 430

[211] Brundtland, G., WHO – the way ahead, Statement by the Director-General to the Executive Board at its 103rd session, Geneva, 25 January 1999, Document EB103/2

[212] For this explanation, see attachment 4 to the memorandum from the Director-General to Regional and Executive Directors, on 11 February 2000, available at intranet.who.int/homes/MSU/budgetfinance/index.shtml

For an example, see Annex 8 which represent one of the pages of the proposed programme budget 2002-2003.

[213] For a complete explanation of the previous procedure of preparation of the budget, see Commonwealth Department of Community Services and Health, World Health Organization: a  brief summary of its work, Australian Government Publishing Service, Canberra, 1988, pp. 34-35

[214] Implementing the Corporate strategy: work on Programme Budget 2002-2003, Report by the Secretariat, Document EB106/2

[215] As confirmation of the trend, the budget for the biennium 2004-2005 has been recently presented to the 111th session of the EB. The regular budget is US$ 885 million and other sources are US$ 1,896 million, for a total of US$ 2,752 million. The increase is 23% over the biennium 2002-2003. Proposed programme budget 2004-2005, available at policy.who.int/cgi-bin/om_isapi.dll?infobase=PPB04e&softpage=Browse_Frame_Pg42

[216] See intranet.who.int/homes/GPR/general_info/tracking/index.shtml

[217] See intranet.who.int/homes/GPR/general_info/tracking/index.shtml

[218] Beigbeder, Y., L’Organisation Mondial de la Santé, PUF, Paris, 1997, pp. 114-115

[219] ibid, p. 114

[220] ibid.

[221] Vaughan, J.P., Mogedal, S., Walt, G., Kruse, S.E., Lee, K., De Wilde, K., WHO and the effects of extrabudgetary funds: is the Organization donor driven?, in Health and Policy Planning, 1996, vol. 11, no. 3, pp. 254-264

[222] ibid., p. 262

[223] Planned resources by area of work in Proposed programme budget 2002-2003. See Annex 9: Planned resources by area of work.

 

 

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Edited by Aldo Campana,