The 71st World Health Assembly is starting today. The event, to be held in Geneva, Switzerland, until Friday (26), is considered the highest decision-making body of the World Health Organization (WHO). It is from there that the sanitary guidelines that must be followed throughout the planet come out of votes that involve the 194 member countries of the organism.

As an integral part of the United Nations system, for a long time in its newly completed 70 years of existence, the organization has played a leading role in the design of global health priorities. A few decades ago, however, it is not so.

"WHO is not the most powerful actor in global health governance. If we talk about the financial weight, there are several actors who are more important than the WHO. And depending on the area, depending on the disease, depending on the issue, there are other actors who are very important, "says João Nunes, professor of International Relations at the Department of Politics at York University in England.

Analysts have been considering this a key moment for WHO. After spending ten years under the command of medical doctor Margaret Chan and going through a crisis of credibility regarding her work in the face of epidemics such as ebola and zika, last year the organization underwent a renovation. There is much anticipation about its new director, Ethiopian Tedros Ghebreyesus, who took over last July and makes his debut in the conduct of the assembly. First African at the helm of WHO, Tedros was pleased to indicate a 60% cabinet composed of women.

What is at stake

If WHO celebrated seven decades in April since its creation, there is another important framework to be celebrated in September 2018: the 40th anniversary of the Alma-Ata Conference, which produced consensus that basic care should be the main pillar. of the "national health systems." And established the goal that, until 2000, the world population should have its right to effective health.

Held in Kazakhstan, then republic of the Soviet Union, Alma-Ata was the apex and the beginning of a turn that would place WHO increasingly outside the global governance of health. "During the 1970s, a more political approach to health was growing within the WHO, Alma-Ata declared the goal of achieving health for all by the year 2000 - that is, during the Cold War. for several sectors to be advancing in a socialist agenda because to speak of collective health, for many people of the time but, even today, it is seen as socialism, it is enough to see the debates about health in the United States ", contextualizes João, who completes: "And the WHO suffered for it."

During the 80s, the reaction came. During the period in which Ronald Reagan and Margaret Thatcher implemented a neoliberal agenda in their countries, influencing the rest of the world, financial institutions such as the World Bank and the International Monetary Fund (IMF) also gained prominence in health, encouraging pro-market reforms in the national systems markets. The WHO, says the professor at the University of York, has retreated to a more technical, apolitical agenda focused on approaches known as 'vertical'.

"There is a tension in the history of global health between what were called vertical approaches, which are interventions focused on a single disease, and horizontal approaches, which privilege the determinants of the disease and look at any context in which they arise. And this tension is present in the history of the WHO, which begins by privileging health in its broadest aspect and then turns to projects of control and eradication of unique diseases, forgetting all the economic, social and cultural changes that need to take place. so that in fact, there is health in its broadest sense, "explains João, for whom the vertical approach remains dominant in global health.

The main discussion of the assembly - and the number 1 priority of the Tedros mandate - is around a topic that divides opinions to be presented (deceptively, the critics argue) as a rescue of the Alma-Ata spirit. Universal health coverage is defended as a form of protection for the poorest of catastrophic health expenses, such as payment for surgeries. The idea, which entered the sustainable development agenda in 2015 as a goal to be achieved by all countries by 2030, is for governments to archive these expenses, guaranteeing a minimum role for services, examinations and procedures. This can be guaranteed with public funds and private provision, as in the hiring of health insurance, as in the aforementioned example of Thailand; as with the structuring of a national public system that guarantees universal access, such as the NHS in the United Kingdom.

"The countries of South America defend universal access to health and managed to include that word in the drafting of the resolution on universal health coverage approved at the World Health Assembly in 2014," recalls Luana Bermúdez, relations coordinator of the South American Institute of Government in Health, the Isags, organ of Unasur. "It is not that defending that all are covered is not good, the question is how that coverage will be made, WHO uses many different examples, mixes universal systems with those based on the purchase of services in the market, and that is a strategy to achieve the project. "They are not stupid," he observes.

And it is just universal coverage that is the star of this Assembly. The director general of the WHO left aside the prerogative of opening the assembly and escalated five heads of state for the task. All authorities will defend universal coverage. Among them, it was speculated the weekend, would be the president of Argentina, Mauricio Macri.

Tomorrow (22), the discussion and voting on WHO priorities for the period 2019-2023 is carried out. "The vote on the work plan is a warmer topic on the Assembly's agenda this year." This is what will define the mandate of the Tedros", says Luana.

The plan, which is aligned with the objectives of sustainable development and has an ambitious and marquetero appeal: it wants more than one billion people to have universal health coverage, plus one billion be protected from health emergencies and more than one billion have better health and good being. "It's a vague document, they are political numbers", summarizes.

The plan, which is aligned with the objectives of sustainable development and has an ambitious and marquetero appeal: it wants more than one billion people to have universal health coverage, plus one billion be protected from health emergencies and more than one billion have better health and good being. "It's a vague document, they're political numbers," summarizes the Isags international relations coordinator.

The same, but different

If the centers are under the new director general, the purpose of the World Health Assembly is to give prominence to the countries. Each of the 194 nations has the same weight in the voting. But participation in the Assembly varies. Its alot. "It depends on the ability of the country to have several delegates, since the regulation does not limit the number of representatives, there are countries that carry one delegate, while others participate with 20," explains Luana Bermúdez. As several meetings happen at the same time, a large delegation gives the country the possibility to participate - and influence - all the discussions.

And it's not surprising to anyone that some countries have more power than others. "The position of the countries of the North is always aligned, in times of controversy, they meet in a corner of the room to discuss, it is very clear, they organize themselves very well, and they end up influencing the decision of other countries," says Luana .

During the assembly, many of the negotiations take place behind the scenes, outside the committees. "Countries negotiate in the way they can, with what they have to offer," she says, recalling that in the most controversial resolutions, a drafting group is formed that remains outside the committees. "The jobs sometimes vary at dawn because of the controversy and the countries of the North usually have a lot of influence."

The differences do not stop there. Since 2011 the European Union has gained strength. The UN has guaranteed the EU rights different from any other regional bloc. "The only one who has a vote and is not a country is the European Union, she has a differentiated position from other regional blocs, she can demonstrate, propose resolutions and vote, that is, when the EU countries define a common position, the representative of the block presents the proposal and votes on behalf of its 28 members (27, shortly, if the UK exit is specified).

Crisis in Unasur

Contrary trend follow the countries of South America. Even without the differentiated status of the EU, the bloc created in 2008 was articulating consensus and defending those positions on behalf of the region during the assembly. "Speaking on behalf of 12 countries brings strength and legitimacy to the positions, and small countries that do not have the strength to impose themselves gain expression through this joint action." Caricom [Caribbean Community] does it: there are several small countries that are organized and that resulted in victories, "Luana describes. In 2012, the Caricom managed to choose a Caribbean for the direction of the Pan American Health Organization (PAHO), regional arm of WHO. Carissa Etienne, was reelected last year and stays in the position until 2022.

From 2010 to 2016, Unasur presented common positions in all assemblies, using as spokesperson one of the nations. The access to medicines was the great highlight of the period. The international relations coordinator of Isags explains that this is a problem common to all the countries of the region, regardless of the ideological position of the governments in power, since the rich countries, where the cutting-edge pharmaceutical industry is installed, tend to to defend positions aligned with the interests of these companies. Poor and developing countries are fighting for the opening of drug patents and the transfer of technology, for example.

With the crisis installed since 2017 aggravated by the announcement, made in April this year, that Brazil, Argentina, Chile, Colombia, Paraguay and Peru temporarily suspended their participation in the bloc, Unasur stopped acting in the assembly. "It's a shame that no common position was presented last year, and at this moment, of course, that is no longer possible," laments Luana.

Crisis in WHO

But the turmoil in Unasur are not the only ones that haunt the assembly. The event occurs at a time when all eyes are directed to WHO. The performance of the organization in the so-called health emergencies has been criticized for its slowness. The return occurred with the Ebola epidemic that occurred between 2014 and 2016 and caused 11 thousand deaths. And then, with the Zika epidemic, which hit the world with thousands of cases of babies with microcephaly in Brazil.

With a new outbreak of Ebola taking place right now in the Democratic Republic of the Congo, there is a lot of expectation around the agency's performance. The situation, however, is different since the country - where for the first time in history, in 1976, the disease was recorded - has a history of outbreaks in isolated localities. It is the ninth that faces. In addition, there is a vaccine.

"There is a set of pressures to put WHO in a better position to prepare for health emergencies, but we still do not know the result, but it seems to me that the way WHO positioned itself in relation to this latest outbreak of Ebola already demonstrates some changes of attitude towards the emergency issue. "This is the first time that a general director has gone to the field at the moment of an outbreak", analyzes João Nunes, who believes that WHO has become an easy target, but that little is said about the context in which the action in the 2014-2016 Ebola epidemic took place. "In the previous international emergency, of the flu, the WHO had been attacked for acting too quickly and supposedly creating panic in the population. As they say in Portugal: the organization is criticized for having sometimes calm, sometimes for not ... ".

But there are other pressure factors that show the loss of prominence of WHO. Last Wednesday (05/16), German Prime Minister Angela Merkel and the heads of state of Norway and Ghana sent a letter addressed to Tedros Ghebreyesus and his cabinet. In it, they affirm that "more must be done" to achieve the objectives of sustainable development, known by the acronym ODSs. Among them is the guarantee of healthy lives and well-being for all. As a UN body, it is up to the World Health Organization to take the lead in monitoring its progress.

Well, Merkel and the other leaders seem to believe that this is not the case. In the letter, they invite WHO to participate, along with nine other organizations (such as UNICEF, World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria), in the development of a global plan of action for healthy lives and well-being. for everyone. According to the letter, "all efforts must converge" for the preparation of that plan.

The invitation is a sample of the current stage of fragmentation of efforts in global health - and of the growing discomfort that this generates. It has been read as an indicator that the WHO and, consequently, the assembly have lost space in that arena. The 10th World Health Symposium, which takes place in October in Berlin, and is promoted not by the UN, but by the M8 Alliance, which brings together 25 academic health institutions, all over the world, including the University of São Paulo (USP).

"WHO is not the most powerful actor in global health governance, nor the one with the most financial resources, the Gates Foundation has a larger budget than WHO - and it is not surprising that the organization has to run after the Gates. , of the Wellcome Trust, and of all the other promotion agencies WHO does not have financial autonomy, does not generate its own funds, and therefore depends on its main donors, "says João.

And he gives examples: "In maternal and child health, Unicef ​​is a great actor, in terms of the fight against HIV / AIDS, malaria and tuberculosis, there is the Global Fund, and the Gates Foundation is very strong in the Malaria issue and attention to neglected diseases PEPFAR, which is the responsibility of the presidency of the United States, is also very important in the issue of HIV / AIDS, mainly in the African continent.

Financial institutions continue to play an important role in health. The World Bank today is the main guarantor of the idea of ​​universal coverage. Progress and monitoring reports are made by the entity in partnership with WHO.

The IMF is also a global health actor, to the extent that austerity and structural adjustment initiatives have an impact on health. "There is a whole set of health effects derived from financial policies: a policy of fiscal adjustment with cuts in the SUS has an immense impact on the Brazilian population, which the WHO, with its recommendations, probably does not have", compares João. He adds: "Therefore, many times actors who do not even have direct responsibility for health, end up having an impact on health because things are linked." Health economics is extremely important, in neoliberalism, each more time. "

The article published in April of this year in the blog of the scientific journal The Lancet defends a turn in the geopolitics of global health. According to its authors, Richard Seifman and Ok Pannenborg (former World Bank official), global health can be compared to a house built in the era of industrial capitalism. Over the years, several rooms were added to the original architecture. "It's an invitation to exhaustion," they criticize, naming global health actors, although they only take their acronyms. And some of them: WHO, UNICEF, UNFPA, UNAIDS, IAVI, GAVI, Global Fund, Vaccine Alliance, Stop-TB, Roll-back-Malaria, Malaria-No-More, BMGF, Chan-Zuckerberg Foundation, Usaid, DFID CDC , NIH, GHIF, Wellcome Trust, Norad, CUGH.

"Each disease, each intervention, each financing arrangement, each innovation has its own room that, often, does not even have a door or window that connects it with the rest of the house," they wrote. In good Portuguese, they argue that these puxadinhos are taking the structure to collapse.

But not only because the initiatives - and, therefore, the efforts - multiply and overlap, but also because the inhabitants of the house are twentieth-century creatures, myopic for the growing power and influence that China exerts (and tends to exercise each more). On the contrary, they say, with the election of Donald Trump and his 'American First', it is not an exaggeration to think that the influence of the United States on global health diminishes. Other rich countries, such as the Netherlands, Canada, Denmark, Austria, France and Italy have already followed the same path. (Germany, on the other hand, wants to increase its influence - but has not yet put its hand in the pocket to supplant the United States, according to this article).

In the conclusion, Seifman and Pannemborg defend a kind of "Bretton Woods agreement" or "Marshall Plan" for health, both political frameworks that guided the world towards a pro-market approach. "The West and the East need to find a new way to face the challenges of global health, incorporating a broad range of values, cultural constructs and economic models", they defend, affirming that if the "traditional powers of global health" they do not reposition themselves geopolitically, they will become "obsolete and irrelevant" until the end of the century.

In a comment on the article, the editor of the Impakter site, linked to international philanthropic entities, goes further and argues that a faster solution is to make a "Bellagio agreement", in reference to the Italian city in which the Rockefeller Foundation It has a property where it organizes meetings that mix authorities, academics and businessmen. From there, discussions emerged that dominate the global agenda, including universal health coverage.

Crossroads

Will WHO have enough strength to make changes within that are opposed to that kind of 'solution' coming from outside? "At that moment, the big issues of substance that are posed for the organization are its institutional architecture, its response to health emergencies and its financing - and this for me is a fundamental issue," says João.

The architecture it refers to is on the agenda as a reform of WHO and is one of the five priorities of the Tedros mandate. Everyone waits to see how he will be led by the new CEO. According to Luana Bermúdez, the process of discussion and implementation of the WHO reform has been ongoing for some years.

"The organization was unable to meet the demands of countries and the challenges of global health with the necessary agility to the highest authority in health, in addition to competition with other agencies and philanthropic foundations that began to act in the field of Then the former director, Margaret Chan, proposed a reform in the WHO based on three axes: governance, management and program, but that was seen by some countries as something more 'cosmetic' than a real and profound reform, "he explains. .

According to her, therefore, Unasur defended a more "inclusive and transparent" reform process, based on the assumption that the organization should give greater clarity to the origins and tensions that initiated the reform process, with a special emphasis on the relationship of the relationship between organization and non-state actors. That is, with the big donors. In the evaluation of the block, this dependency represents a risk for the formulation of health policies and for the definition of priorities, which must reflect the needs of the Member States - and not of certain NGOs.

The big announcement by WHO in the week before the 71st Assembly was the result of a partnership with some of these non-state actors. In the second (14/05) a guide was launched with six steps to achieve banning industrial trans fat in all countries until 2023 (same term of the work plan that will be approved by the Assembly). The initiative is stamped by the Gates Foundation and the Bloomberg Philanthropies.

After several years of discussion, the Fensa, framework for the relationship with non-state actors, was approved in 2016. "The creation of the Fensa is an attempt to have some control over the influence of those actors that are not governments. It is recent and is in the implementation phase, "says Luana.

"On the one hand, WHO is a political actor, but it is also a technical-scientific actor and that involves global health issues, such as the resolution of problems through technological mechanisms, governance, etc. But there is also a set of political interests that underlie the organization, "observes Juan, for whom the assembly is, theoretically, the WHO's political organ par excellence because all its members are represented there.

"Theoretically it is a place where disagreements can be expressed, but I think it is more important that the Assembly is the daily life of the WHO expressed in the definition of priorities." The introduction of a topic on the agenda is not done in the assembly ", he observes. The guideline of the event is decided by the Executive Board of WHO, composed of 34 members with technical qualification in the field of health indicated by the countries. The mandates last three years, and expire alternately. The council decides what will be discussed at the Assembly in January and meets a second time in May, immediately after the closing of the assembly.

"It is in the daily operation of the WHO that certain topics, ideas and agendas are introduced, that is where the most profound, or most technical, discussion exists, because there is more time." The Assembly is the place to be discussed and approved afterwards. more generally and more broadly, these priority documents, but the definition of priority is something that happens behind the scenes, in the meetings of the committees and in the daily work of the organization.

An example of a discussion that is drawing attention in this year's agenda is given as an example: the impact of snake bites. "How the snake bite emerged as a topic to be discussed? There was a whole lobbying, negotiation, and research work on its impacts that slowly made that issue an important issue." The Assembly will examine a document that a resolution on the subject has already been prepared and voted on, "João describes. (By the way: the problem was added to the list of tropical diseases in November and the resolution is an initiative of Costa Rica and Colombia. An estimated 90 thousand people they die every year and 400 thousand suffer with side effects of poisoning, such as loss of limbs and vision.)

"The question of who controls, how certain issues get on the agenda and get off the agenda; this, in fact, raises questions about what the interests behind certain subjects are. The WHO responds to many demands - and not all of them are necessarily suspicious or undemocratic. But there are demands from donors, states and international actors who provide the money, "says the professor.

But even in the face of this increasingly complex political scenario - and even because of it - João Nunes believes that the WHO and therefore the assembly are still important and need to be defended. "At the national level, only a public entity with a sense of collective health and solidarity can provide health. And the same applies on a global scale. That is why, despite all the shortcomings and deficiencies of WHO, I continue to defend it. The other actors have their own interests in view. Only the WHO and its democratic bodies can still guarantee this idea of ​​health as a collective good, and the question of solidarity between countries. This is something that is in the genesis of the organization and needs to be maintained. WHO is our best guarantee of a more supportive conception of global health. "