The World Health Organization between North and South

Nitsan Chorev

• Publisher: Cornell University Press
• Year: 2012
• Print ISBN: 9780801450655
• eBook ISBN: 9780801464393
• Topic: Politics & International Relations
• Subtopic: Peace & Global Development
• Index: Politics & International Relations

Since 1948, the World Health Organization (WHO) has launched numerous programs aimed at improving health conditions around the globe, ranging from efforts to eradicate smallpox to education programs about the health risks of smoking. In setting global health priorities and carrying out initiatives, the WHO bureaucracy has faced the challenge of reconciling the preferences of a small minority of wealthy nations, who fund the organization, with the demands of poorer member countries, who hold the majority of votes. In The World Health Organization between North and South, Nitsan Chorev shows how the WHO bureaucracy has succeeded not only in avoiding having its agenda co-opted by either coalition of member states but also in reaching a consensus that fit the bureaucracy's own principles and interests.

Chorev assesses the response of the WHO bureaucracy to member-state pressure in two particularly contentious moments: when during the 1970s and early 1980s developing countries forcefully called for a more equal international economic order, and when in the 1990s the United States and other wealthy countries demanded international organizations adopt neoliberal economic reforms. In analyzing these two periods, Chorev demonstrates how strategic maneuvering made it possible for a vulnerable bureaucracy to preserve a relatively autonomous agenda, promote a consistent set of values, and protect its interests in the face of challenges from developing and developed countries alike.

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THE WORLD HEALTH ORGANIZATION

In his address before state delegates at the World Health Assembly, on May 15, 1975, the director-general of the World Health Organization (WHO), Dr. Halfdan T. Mahler, spoke of the “changes that are rapidly taking place in the political and economic relationships between Member States.” He boldly predicted that “1974 will be remembered by many of us, and possibly by future historians, as a turning point in our thinking about the future social and economic development of mankind.”1 In 1974, the United Nations (UN) General Assembly had passed a resolution calling for a New International Economic Order (NIEO), which was indeed a turning point in the relations between developing and developed countries. It was also a decisive moment for the WHO, which saw in the following years a radical transformation in its priorities, policies, and programs. In a later speech, Mahler insisted that in making these changes, the WHO was “merely respond[ing] to the imperatives of contemporary history.”2

Mahler’s statements echo a familiar sentiment in the scholarly literature—that international organizations are nothing more than carriers for the wishes of their member states. But Mahler’s remarks were disingenuous, for he knew well that the WHO was not simply mirroring external imperatives. Rather, the WHO leadership and staff were able to advocate a global health agenda that, while acceptable to developing countries, also reflected the WHO’s own principles and interests. In this book I argue that international bureaucracies, including at the WHO, have the capacity to restructure global ideational regimes that member states impose on them, and that they restructure these regimes to fit their own institutional cultures.

Through coercion or learning, some elements of external regimes such as the NIEO are successfully transmitted, but others are transformed, with the result that the policies of international organizations are only selectively aligned with member states’ demands. Policies and priorities at the WHO during the 1970s only partly corresponded to the call for a New International Economic Order. Similarly, in the 1990s, the WHO’s policies did not fully reflect the dominant neoliberal logic. The experience of the WHO was hardly unique: policies and programs in other international organizations, such as the International Labor Organization and the UN Children’s Fund, have also often significantly deviated from the principles defining the dominant logic in accordance with the organizations’ own agenda. My purpose is to identify and explain the capacity of such international bureaucracies to protect their interests in the face of external demands.

The WHO in Comparative-Historical Perspective

The WHO was established in 1948 as a specialized agency of the United Nations responsible for directing and coordinating authority for international public health. As the designated agency on worldwide health matters, the WHO was tasked with setting norms and standards, articulating policy options, providing technical support to countries, monitoring and assessing health trends, and shaping the global health research agenda.3 The overall objective of the organization, as defined in the founding constitution, was particularly ambitious: “The attainment by all peoples of the highest possible level of health” (WHO 1958: annex 1). This wording established two commitments at the heart of the organization’s mission: the notion that universal access to health services is its principal objective, but that it is simultaneously concerned with the quality of those health services. The constitution, which was adopted by the fifty-one member states participating in the International Health Conference in July 1946 (WHO 1958: 38–45), also offered a progressive definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity,” which committed the WHO to the viewing of health beyond its biomedical focus. The constitution declared that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” and further committed the WHO and its member states to the pursuit of equality by declaring that “unequal development in different countries in the promotion of health…is a common danger.” The last preamble of the constitution announced, “Governments have a responsibility for the health of their peoples, which can be fulfilled only by the provision of adequate health and social measures” (WHO 1958: annex 1).

Given the desperate health conditions of the poor and other vulnerable populations across the globe, the objective of universal access of quality health care has been, and remains, a daunting task.4 In 1946, when the WHO constitution was signed, and still today, challenging physical environments, inadequate social and economic conditions, and limited health care infrastructure have provided fertile ground for poor health. In 1950, life expectancy in low-income countries was forty years, and twenty-eight of every hundred children in those countries died before the age of five.5 Infectious diseases were prevalent. Malaria, for example, affected some 300 million persons yearly and caused about 3 million annual deaths, and smallpox affected almost 200,000 people per year. Over the last half-century some conditions have improved in the poorest countries, but avoidable diseases and excess mortality have persisted. By 1990, life expectancy in developing countries had increased to sixty-three years, and child mortality improved but remained high, with ten deaths for every hundred children. Treatable infectious diseases have remained a major cause of death. According to the most recent estimates, in 2008, malaria caused about 250 million clinical episodes and about 850,000 deaths. Over 9 million people become sick with tuberculosis (TB) each year, and there are almost 2 million TB-related deaths worldwide. The devastating HIV/AIDS epidemic over the past twenty-five years has further complicated efforts at improving global health and eradicating health disparities. In 2009, around 33 million people were living with HIV and 2.6 million people were newly infected; 1.8 million AIDS-related deaths occurred that year. It is estimated that 25 million people have died of AIDS-related deaths so far. Lack of available resources—the annual expenditure on health in developing countries in 1990 was $41 per capita, compared to $1,860 per capita in Western economies—means that the toll of ill health has fallen mostly on the Global South.

In the face of such suffering on the one hand and limited state capacity on the other, how was the World Health Organization to fulfill its mandate? As in other international organizations, the inevitable tension between technical possibilities and political and economic constraints was reflected in the institutional arrangements in place.6 Like its mission and objectives, the organizational structure and working procedures of the WHO were also defined by the member states participating in the International Health Conference. The result was a three-layered organizational structure made of the World Health Assembly, the Executive Board, and a secretariat headed by a director-general.7

The World Health Assembly (WHA) is where member states enjoy direct representation, and it is therefore the more overtly political layer. Delegates to the assembly are representatives of their designated states, usually elected from the national health administrations and competent in the field of health. However, governments with large delegations often send, in addition, delegates familiar with issues of foreign affairs. The assembly meets annually, usually at the WHO’s headquarters in Geneva, Switzerland. At the meetings, the assembly decides on the organization’s policies, approves a general program of work, reviews and approves the budget, and gives directives to the Executive Board and to the director-general (WHO 1958: 84). Decisions are made through votes. Like the UN General Assembly and most specialized agencies (but unlike the Security Council, the World Bank, and the International Monetary Fund [IMF]), the assembly follows the principle of one-country/one-vote.

The Executive Board (EB), which meets twice a year, considers the program and budget estimates prepared by the director-general and submits them to the assembly with its comments and recommendations. The board also submits proposals and prepares general programs of work for approval by the assembly (WHO 1958: 92–95). Board members are elected by the assembly for three-year terms. Originally, the board was to consist of between twelve to eighteen persons (WHO 1958: 41), but that number has increased to improve representation of new members and today the board is composed of thirty-four individuals. The rules of rotation do not allow member states to be elected consecutively, so that even the largest contributors to the organization can be part of the board only every other term. Unlike delegates to the assembly, members of the Executive Board are expected to act as experts on behalf of the whole conference and not as representatives of their respective governments (WHO 1958: 41).

Finally, the WHO has a secretariat, the bureaucratic body of the organization, which comprises the technical and administrative personnel of the organization and is responsible for carrying out the WHO’s programs and campaigns. Since the 1950s, the WHO staff has grown from around a thousand to more than eight thousand personnel in professional and general service positions. Professional positions are most often held by medical doctors, public health specialists, scientists, epidemiologists, and more recently, by experts in the fields of health statistics and economics. Member states have no authority over the appointment of staff. The function of the staff is to implement the organization’s activities, conduct studies and author reports commissioned by the assembly, and otherwise assure the functioning of the organization. The director-general, who heads the secretariat, is nominated by the Executive Board and elected by the World Health Assembly to a five-year term and can be reelected. Among the many significant responsibilities of the director-general, one of the most important is the authority to suggest the annual budget, which identifies the organization’s priorities and commits member states to provide the funds to pursue them (WHO 1958: 106, Lee 2009).

The prominent role of the World Health Assembly, and therefore of member states, in the process of decision making has secured the dominance of geopolitical logic in the global health agenda. Especially in the first few decades of the WHO’s history, the Cold War division between East and West directly shaped international health priorities (Litsios 1997, Manela 2010). Following decolonization, the World Health Organization, along with the rest of the UN system, was greatly affected by the demands of the newly independent countries of the Global South for a New International Economic Order. In the mid-1980s, in turn, the NIEO logic was replaced with a U.S.-led neoliberal agenda, best expressed in what has become known as the “Washington Consensus” (Williamson 1990). For UN specialized agencies, including the WHO, each period was characterized by the emergence of a distinct global ideational regime and by exogenous pressures to follow that regime. An overview of the policies formulated by the WHO staff and leadership and adopted by the executive and the assembly illustrates, however, that these policies did not faithfully echo the call for a New International Order in the 1970s nor the neoliberal principles of the 1990s.

The WHO Responds to the New International Economic Order

In the 1960s, with the undoing of colonialism, the large number of newly independent nations that were now recognized by the United Nations radically changed the conversations, debates, and declarations in the entire UN system, where developing countries had become the majority. Encouraged by the ability of oil-producing countries to raise the price of oil, which suggested to other poor countries that the power of their majority vote could be backed by the dependence of industrial countries on their raw materials, they called for economic and political change. Following a successful political mobilization of the Group of 77 (G-77), a coalition of Third World countries unified in their determination for an improved position in the capitalist world system, in 1974 the UN General Assembly adopted a number of resolutions that articulated the call by developing countries for a New International Economic Order. The NIEO contained a number of principles regarding the obligations of developed countries and the rights of developing countries that would reduce the inequities among states by allowing poor countries to achieve economic and social development, mostly through industrialization and improved terms of trade for primary commodities. Thus the G-77 advocated the principle of states’ economic sovereignty over their natural resources and economic activities in their territories, including the right to restrict the activities of multinational corporations. The G-77 also called for a stronger regulatory capacity of those international organizations that followed a one-country/one-vote rule and a limiting of the influence of the international financial institutions that rich countries dominated through weighted votes. Developed states were asked to help shift industrial production to the South, transfer Western technology, and provide aid and debt relief. In an attempt to reduce both exploitation and dependence, the NIEO also contained a commitment to collective self-reliance.

In response to the call for a New International Economic Order, the WHO—which in the 1950s and 1960s focused on biomedical determinants and technological solutions—adopted a new agenda, with an unprecedented commitment to address the political, social and economic causes of poor health. This shift came with a novel focus on the question of equity—a concern with the systematic disparities in health between more and less advantaged social groups. Most centrally, the WHO leadership and staff mobilized member states around the unprecedented goal of “Health for All by the Year 2000” and advocated the novel approach that a focus on primary health care was the most adequate means to achieve that goal. The primary health care approach rejected the costly high-technology, urban-based, and curative care that led to skewed resource allocation in the national health systems in many developing countries. Instead, it prioritized universal access to essential health services. These essential services were to be provided at the community level, by nonprofessional workers trained for that activity. The rejection of costly or otherwise inappropriate technologies applied also to drugs, and the WHO staff prepared a model list of “essential” drugs, which aimed to help governments to rationalize their imports of expensive medicines. Directly challenging multinational corporations, the WHO criticized the unethical marketing of infant formula and of inappropriate drugs.

These new programs corresponded, but not quite fully, with the principles underlying the call for a New International Economic Order. The main objective of the NIEO was the attainment of economic development in poor countries, mostly through industrialization and improved terms of trade. Social development, namely, improvements in living conditions and quality of life, was a secondary concern. At the World Health Organization, this order was reversed: the WHO’s main concern was the contribution of health to social development. Provocatively, the pursuit of social development was claimed to be attainable even under conditions of scarce resources—that is, independently of the need for economic development. The WHO’s concern with equity also deviated from the original principle. The G-77, identifying long-lasting relations of exploitation between industrial capitalist countries and the Third World, called for a more equitable distribution of world resources. Developing countries did not intend UN agencies to influence how additional resources gained by poor countries would be internally distributed. The WHO programs concerned with addressing the issue of equity, however, focused not on equity among states but on equity within states. Health for All by the Year 2000 offered the promise of greater equity in access to health care, and the primary health care approach, including the call for “appropriate” technologies, required the spending of scarce resources on poor populations, thereby identifying practical steps toward equitable distribution at the national level. The WHO also deviated from the call in the UN General Assembly and other venues for increased financial aid. Instead, the primary health care approach was framed around the notion of self-reliance, which required health services to be at a cost that the country could afford to maintain. Finally, while many of the WHO’s core initiatives, including the rejection of inappropriate technology, the list of essential drugs, and statements against unethical marketing, reflected support for economic sovereignty and followed developing countries’ desire to confront multinational corporations, the WHO secretariat opposed a code of conduct regulating the marketing of pharmaceutical products.

The WHO Responds to Neoliberalism

The G-77 mobilization, which American critics called “Third World Radicalism,” was doomed to failure as soon as the economic leverage that developing countries believed they had held all but disappeared with the debt crisis, which started in Mexico in 1982 and affected the entire Global South. The New International Economic Order was soon dead. It was replaced with articulations of the interests of the North, which were effectively encapsulated in the so-called Washington Consensus that was comprised of a number of basic market-liberalizing prescriptions (Williamson 1990). This new, U.S.-led logic, which was based on neoliberal ec...

Table of contents

• Preface
• 1. The World Health Organization
• 2. The Strategic Response of International Organizations
• 3. A New International Order in Health
• 4. Appropriate Technology, Inappropriate Marketing
• 5. The WHO in Crisis
• 6. Health in Economic Terms
• 7. How to Win Friends and Influence Enemies
• Conclusion: Structural Transformations of the Global Health Regime
• References