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The 72th World Health Assembly: Some reflections from a democratic Global Health Governance point of view

By Winne van Woerden
on June 26, 2019

Amongst all those identifying themselves as ‘working in the field of Global Health’, there seems to be at least one agreed-upon-statement.

The world is changing faster than ever”.

Quite objective, very bold, and undeniably true.

However, logically, the follow-up question/statement would be regarding what to do about it.

What to do with this change? How to handle, or use it?”

This is where the objectivity ends. Or to put it in contemporary terms, this is where polarization begins.

Let’s say you aren’t currently reading this blog, let’s say you were, for example, a delegate at the 72th World Health Assembly (WHA) in Geneva (20-28 May) – which I was fortunate to attend.

Odds are high that, concerning the question in the beginning, the answer for many of you would be something like:

We need to explore new ways to deliver and align programs, with new partnerships and new technologies, in order to face these challenges ahead of us”.

As a WHA delegate, chances are you won’t be as critical of the overall WHA process & governance as we (global health and other) students may be (and even are expected to be) during the majority of our academic endeavors, as you have very different aims. Indeed, as a participant in the WHA game, you have a position to fulfill, a role to play and more often than not, an agenda to push for. As many of you have inside knowledge of this game and setting, after several years of participating, perhaps, you have some serious doubts concerning the rules of the game and you would be eager to express some of your critical thoughts about the position of the players or the size of the board; others might not have them at all. The point is: instead of bringing these reflections to the table, you will focus on your strategies on how to be successful in your role. Instead of coming up with some criticism (of the governance/process), you will work on your diplomatic skills and come up with a powerful talk full of innovation and charisma. And instead of being too overly critical, you will probably not go too much against the current ‘mainstream discourse’, as it doesn’t help you in the role you’re supposed to play at the WHA.

Now, go back to being a blog reader. What changed? Well, you are (now) an observer rather than an insider and thus are granted the freedom of being as critical as you want to be. This is, in a way, exactly the position I was fulfilling when in Geneva last month, as I was given the opportunity to join the 72th WHA and thus hear many of its attendees give their versions of the above posed answer statement first-hand.

So after a week of listening to the huge variety of delegates, and on my way back from the Assembly (while watching the beauty of the Swiss Alps through my bus window), my (increasingly critical) mind wandered off freely in a number of directions. It was working overtime, actually, in spite of the stunning backdrop.

Highs & lows of my first WHA

Let’s make up the balance of my first WHA visit.

For sure, there was a part of me feeling highly grateful I was granted this experience so soon in my career and for the many inspiring people I met and the new connections I was able to make. I knew I was just introduced to a world where Global Health decisions are made at the highest level so my future-thinking-networking-part felt very content, definitely. However, there was this other part, and I realized that this part was about mý own position in it all. Till this point, I had considered myself as a proud representative of what has been called the ‘Global Health attitude’, that is our deep commitment to health as a fundamental quality of liberty and equity. As for many of the conversations I held as a student in Global Health over the past months, I had always been eager to defend my belief in a world where health policies are shaped in a democratic, just and transparent manner, centered around the right to health. In essence, I went to Geneva as an advocate for democratic Global Health governance, driven by a deeply rooted optimistic mindset. I’m standing too early in my career to be cynical, perhaps. After my first WHA participation, this essential part of me was feeling all but content, instead it was feeling disheartened and frustrated and confused.

I realized how witnessing the WHA showed me a truth I was very well aware of (as it has been covered in classes for example, and I’ve read about it before), but I had never really seen it happening so clearly in front of me, out in the bold blank open. The WHA slammed me in the face with the undeniable fact that we are indeed living in a world were power imbalances are as present in Global Health governance as they are in every other form of negotiations around the world. The whole experience screamed to me how the world of Global Health is (still) run by powerful voices with both health ánd in many cases –  perhaps even more importantly – non-health interests. Interests that are then getting blurred in the process of speaking  a ‘universal’ UN-language, which – due to the search for ‘consensus’ – more often than not ends up in the lowest common denominator.

Against this general backdrop, ‘Universal Health Coverage’ (UHC) still clearly won the contest of ‘being raised the most’, by all sorts of participants, public & private ones, but there was one other expression that came relatively close,  namely ‘multistakeholderism’. Multistakeholderism is, already for some years, the preferred partnership paradigm amongst international leaders gathering at the WHA and other (UN) events alike. The issue, however, is: who are the actors believed to have a “stake” and thus present at such meetings? As when I’d ask you to look at the ‘We’ and the ‘us’ at the beginning and the end of the answer statement (mentioned in the opening paragraph of this blog), can we say they represent the same people? Can we say they represent the so-called “global community”, gathering together at the WHA? I think we all know the answer to that. While perhaps the amount of WHA attendees has grown significantly over the past years, many important “stakeholders” are still virtually absent. This gap in representativity is silencing counter voices that are of utmost importance for having an equal debate and for advancing the creation of a policy climate that protects against vested interests of powerful “stakeholders”.

In addition, it is well known how during all sorts of meetings,  being present and having a voice does not necessarily mean having a true say as well. Some voices, for example from the young generation, are still more like ‘token voices’ that everybody pays lip service to, and they can even be offered a public forum at plenaries etc, but when real decisions are made, the young aren’t really invited anymore. And although perhaps not to the same extent, the same goes for many civil society voices, in spite of all the rhetoric of ‘meaningful engagement with civil society’. Practice is often different.

In addition, as already mentioned, the “UN way of doing things” doesn’t really help either, often. In many WHA sessions, due to the need of getting to a ‘consensus’ within the current UN negotiation system, you don’t end up with the level of democracy as its creators might have intended originally. Rather, it often leads to conservatism, slowing down the process of the structural change we really need of  getting at least on track when it comes to achieving democratic Global Health governance. The biggest problem, from my point of view, is how this procedure at the WHA inevitably occurs at the expense of the interests – and lives in many cases – of the powerless many, those who, ironically, shouldn’t be ‘left behind’. The “lowest common denominator” is usually not what they need, but rather suits the powerful interests in the room.

So, let’s say again you are a delegate at the WHA. You can, off course, accept this imbalance, even if you might not like it much. You accept this as an unavoidable characteristic of the world we inhabit.  And to be fair, I wouldn’t blame you, as needless to say, even if you are a delegate from a LMIC, most probably YOU aren’t at the have-not side of the spectrum – let alone if you’re from a high-income-country. But please, please, don’t PRETEND then that you are. Please don’t pretend you are truly willing to bring about the structural change that a different world needs – a world scenario where in fact your favorite term ‘UHC’ forms the core center and where no-one is ‘left behind’. As we both know, there is a structural problem here. Achieving the political, economic and social change that UHC requires, will only be possible when a deliberate shift in power is made, leading to a world where those who are currently not at the table are being favored over, yes, you (and me too perhaps). Or if that’s not feasible, at least, a world in which representatives of, say, the Global Fund and Gavi would have just the same ‘voice’ and power as representatives of Copasah and eSwatini, and dr. Tedros (and especially WHO’s – somewhat reluctant – funders) would listen as much to Bill Gates and Michael Bloomberg as to a refugee in Guinée or Greece, or a woman living in the DRC with a daily agenda of life mattering concerns that have emerged on the global agenda not so long ago, only to be kicked off of it when classified as ‘not of international significance’ after a thorough investigation she probably hasn’t noticed at all.

The elephant in the room

Certainly, the identity of the elephant standing in the UN halls is well-known: democratic Global Health governance is (still) not part of  the SDG health script. And in a world where space for civil society is increasingly shrinking, that might not change soon. So even with the imposing amount of high-skilled translators present in Palais des Nations, chances are “the elephant” will never be converted into UN-speech.  But I’m too much of a newbie to the Global Health world to accept that.

Are we going to be able to consider taking a different turn in the current flow of multistakeholderism and “partnerships” where certain ‘partners’ will always outgun others? Will we ever have a constructive conversation on the restoration of progressive taxation (and spending) as a means to redistribute wealth and tackle this current crisis of extreme inequality in power and resources at the World Health Assembly? I don’t know- perhaps, this is something only Lennon-like dreamers should imagine. But what I do know is that I hate pretending. So let’s just be honest then and admit we aren’t all like Lennon, and we don’t all dream of a world where everyone is given fair opportunities, where money and power and resources are divided in an equal manner and where unicorns exist. Let’s just admit to each other next time when we, ‘the Global Health community’, are gathering in Geneva, how at the end of the day, when enjoying one of the receptions in the Intercontinental Hotel, our words about ‘leaving no one behind’ are too often left behind themselves in the Plenary and Committee halls. Let’s admit how at the end of the day, we humans have failed big time in governing the (Global Health) world.

Only if we’re honest about that, perhaps our conversations will lead to real progress on the SDG Health agenda (although perhaps, this again is another version of a book written by ‘all relevant actors having a stake’, and thus, material for another blog…)

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