Although the announcement is and interesting read, there are few surprises among the proposed reforms. However, there were two things that stood out to me. First, although the contingency fund and other proposals seem reasonable, I question the actual viability of such reforms. These are proposed reforms, suggested by the the Executive Board, but in need of approval by the World Health Assembly (WHA). Even if approved by the WHA, the implementation of these proposals will be determined by the availability of funds. The WHO's budget has been in decline for years. The budget for 2012-2013 was 20% less than the previous budget. The current budget (which was approved in 2013) is $3.97 billion dollars. In it, the funds for responding to health crises was reduced by half of its previous level.
In addition to the decline of the WHO's already small budget --- consider that the budget for Department of State Health Service in Texas in $3.3 billion --- the WHO also maintains very little discretion over its funds. In 2013, 30% of the WHO budget was comprised of core contributions from member states. Core contributions are unearmarked and allocated according to the WHO financing decisions. The remaining 70% of the budget was comprised of voluntary contributions --- two thirds of which came from member states and the remaining third came from donations provided by foundations, like the Bill and Melinda Gates Foundation, philanthropic groups, and other large organizations. Because 70% of the budget comes from voluntary contributions, actual funds available do not always meet proposed program budgets. For example, in 2010, the WHO's proposed budget exceeded total funds by 20%. In addition, voluntary contributions can be and generally are earmarked by donors for specific projects --- like HIV/AIDS. This mean that even if the WHA approves the suggested reforms, and these reforms are incorporated into the next budget, and that budget is approved, the implementation of such programs is highly dependent upon funding decisions by individual donors.
The second aspect of the announcement that stood out to me, was the rhetoric about the necessity of strengthening the International Health Regulations (IHR) and health systems in developing countries. The IHR are binding regulations that structure countries' responses to disease outbreaks. Specifically, the IHR establish states' responsibility in monitoring, reporting, and responding to health emergencies while also limiting those responses to avoid interference with international trade. Specifically, the IHR establish core capacities necessary to detect, assess, report and respond to public health crises at the national and international levels.
Although the IHR are the one of the primary mechanisms through which state cooperate to control infectious disease, state level capacities generally condition the effectiveness of disease control efforts. The WHO's announcement correctly identifies struggling health systems in developing countries and the lack of core capacities as a major obstacle detecting, assessing, reporting, and responding to outbreaks in a rapid and effective manner. Domestic level health systems are the first line of defense in disease control. The IHR require addition capacities, which the WHO strives to help states develop. Yet, the function and disfunction of the health system as a whole is often neglected in favor of focusing on core capacities. When discussing global public health, a weak health system in a developing country cannot and should not be ignored. The Executive Board's statement clearly outlines the necessity of improving core capacities and health systems in general:
"As events since the start of this century have shown, outbreaks rarely have only local or regional
consequences in our highly interconnected and interdependent world.
The International Health Regulations need more teeth. They provide the principal line of collective defence
against the threat from emerging and epidemic-prone diseases. The world will never reach true health security
until more countries, and eventually all countries, have core capacities in place.
We need a far more rigorous methodology for evaluating these capacities than self-assessments in a
questionnaire. And we need to treat the importance of getting these capacities in place like the emergency that
We need to stop thinking about core capacities as something that should be tacked onto a country's health
systems, like an extra arm."
This is the message that has gotten lost in much of the developed world. Not only must we be willing to fund the WHO --- and a wide range of its priorities --- in order to improve global health, but we must also view failing health systems in developing countries as more than unfortunate products of circumstance and poverty. We cannot just add additional capacities specifically for monitoring and reporting. We must view the shortfalls of health systems in developing countries as threats in need and deserving of real attention.
This rhetoric stood out to me because of both its accuracy and its irrelevance. Developing country level capacities for surveillance, reporting, and response, and building more effective health systems are arguably two of the most important challenges in global health. The concurrent influences of poverty and poor health --- where poverty threatens health and health undermines prosperity --- make developing countries fertile ground for outbreaks. In addition to the devastation of these outbreaks to the local population, the inability to control outbreaks increases the likelihood of spread.
Yet the accuracy of this statement does not prevent it from being largely irrelevant. Among development scholars and practicioners, the need to strengthen local systems is an obvious and constant recommendation. Yet, despite decades of development efforts and the coming conclusion of the Millennium Development Goals, improving basic health systems and core capacities has been a slow and difficult journey --- in large measure due to the apparent irrelevance of disease and death in developing countries to those in developing countries. One need only look at the current Ebola crisis to be convinced of both realities.
This part of the announcement stood out to me because it is an acknowledgement of the reality and necessity of strengthening health systems in developing countries, in an announcement of reforms that will likely be disregarded, defunded, and dismissed by those most capable of doing so.