The World Health Organisation and The World Bank: A Shift in Leadership?Introduction

The political and economic pressures on the leadership in global health haveundergone significant change over the last generation. National sovereignty over local economic policy has been weakened by external pressures accompanying thesteady evolution from centrally planned national economies to internationallyinfluenced market economies.

An increasingly complex arrangement has developed between the significant playersin global health. Specialist United Nations (UN) agencies such as the World HealthOrganisation (WHO), traditionally tasked with the job of global leadership in health programming, have been challenged in their leadership throughout the last twodecades. This challenge has come primarily from the World Bank, and increasingly,numerous civil society organisations (CSOs), and other international donors.This discussion will briefly look at how the players in global health have changedover the last twenty years and how their roles have changed within the evolvingglobal political and economic environment during that time.

Post World War II

Health and poverty immediately following World War II were considered, on thewhole, as relatively distinct global concerns. This view was reflected in the mandatesof the international agencies set up following World War II. The World Bank andInternational Monetary Fund (IMF) ostensibly taking charge global economicstability and the redevelopment of Europe, and the remaining specialist UN agenciestaking charge of political and health security.

The World Health Organisation

Following World War II, global health was primarily seen to be the responsibility of the WHO and its fellow UN agencies, the United Nations Children's Fund (UNICEF),the United Nations Population Fund (UNFPA) and the and Agriculture Organisation(FAO).The WHO, set up as a UN agency in 1948, often played the lead role in developmentof health programming. Its constitutional aims were

"...the attainment by all peoples of the highest possible level of health. Health ...as a state of complete physical, mental and social well-being and not merely the absenceof disease or infirmity. '

Strengths of the WHO

Its strengths in the few decades following its inception were in areas such ascommunicable disease control, leading to real and significant advances in life-expectancy and child mortality in many areas of the world.The global health gains made from interventions in communicable diseases werelimited however, and during the 70's and 80's emphasis was to be placed on thereformation of health systems, embodied by the declaration of Alma Ata in 1978 andthe ideals of primary health care.

Challenges for the WHO

Significantly, some of the challenges to the "Health For All" Alma Ata declaration,supported by the WHO, were largely lack of progress in a push towards a "newinternational economic order"

, and an increasing gap between the rich and the poor

.Poverty reduction was one critical aspect of improving global health largely out theWHO's sphere of control.

Resource constraints have also acted to place significant pressure on the World HealthOrganisation in effectively discharge its mandates. The last decade has seen a twenty percent reduction in the real purchasing power of the WHO's allocated budget, andthis reflects, to a degree, progressively diminishing support form The United States.

It has also been suggested that in the changing political and economic climate over thelast few decades of the 20

century, the WHO was slow to restructure and adapt itsrole in global health. Some may say this was manifested in its sub-optimal response tothe global HIV/AIDS pandemic.

Whilst WHO increasingly lacks necessary funding, it remains an important andlegitimate contributor to international health programming.

"An agency like the World Health Organisation has a unique mix of technical expertise, legitimacy in all corners of the world, and especially anoperational presence on the ground in dozens of the world's poorest and neediest countries.

"Sachs

WHO Public-Private Partnerships

In an attempt to expand its effectiveness, the WHO commenced a strategy of engineering health programming partnerships with private companies in the early1990's. These public-private partnerships were partly a consequence of the pressuresof resource constraints.The WHO states that the aims of these cooperative endeavours are to

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encourage industry to abide by the health-for-all principles;

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facilitate universal access to essential drugs and health services;

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accelerate R&D in the fields of vaccines, diagnostics, and drugs for neglecteddiseases;

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prevent premature mortality, morbidity, and disability by givingspecialattention to policies and behavioural change;