change in order

The WHO has a new chief. Will India now find its voice at the global health organisation?

India has so far been reticent at the World Health Organisation but is seen as a natural leader for the cause of the global South.

The former Ethiopian Minister of Health Tedros Ghebreyesus was elected as the new Director General of the Word Health Organisation, defeating David Nabarro of the United Kingdom by a massive margin. Tedros is the first person from Africa to be elected to the post in the organisation’s 70-year history. India has never bid for the post, possibly reflecting a lukewarm engagement by India with the premier intergovernmental health organisation. But India now has an opportunity to be one of the leaders in pushing forward the health agenda of developing countries.

The election this year was the first occasion when the entire Assembly voted through a secret ballot, as opposed to previous elections when only the executive board would select the new director general. The massive margin for Tedros indicates that, in all probability, the entire South voted for him – a virtual tri-continental alliance of developing nations. The margin of victory had not been anticipated and possibly marks a silent vote against big power machinations in the WHO.

The WHO faces possibly its biggest crisis since it was set up in 1948. Its finances are in shambles and it faces a $456 million deficit this year. This means many work programs may not go forward and staff might be laid off. For years now the WHO has been dependant on donor funds – mainly from rich countries and foundations like the Bill and Melinda Gates Foundation – rather than through secured funding from countries. As a result, currently 80% of WHO’s funding is tied to programs that donors cherry pick. Work programs that are vital to WHO’s mandate as a norm-setting organisation remain under funded as they clash with the interests of big donors, especially of rich and developed countries otherwise known as the global North. Consequently WHO’s role as a leader in global health has been supplanted by other intergovernmental bodies such as the World Bank, and increasingly by big foundations. The organisation’s efficacy has come under question, especially after its inadequate performance in containing West Africa’s ebola epidemic of 2014.

These are the challenges that Tedros faces after his election. While it appears that the South has voted against the domination of big powers, it is yet to be seen if this unity will be maintained when the WHO debates different issues where the North and the South are often arrayed against each other.

Will India step up?

Tedros’ election is both an opportunity and a challenge for India. India is seen in the WHO as one of the natural leaders of the South and is usually heard with attention. India can possibly provide leadership to the South in pressing for decisions at the WHO that promote the interests of the South. Such interests range from promoting WHO’s role in access to medicines by addressing trade and intellectual property barriers, pressing for technology transfer and capacity building in areas where the South remains deficient, and measures that curb the interests of mainly multinational corporations from the North in industries related to medicines, food and beverages, alcohol and tobacco.

Traditionally, India has not invested significantly in trying to make an impact at the WHO. Countries such as Thailand and Brazil regularly send much larger delegations to the annual World Health Assembly in Geneva. India is often not very prominent in many of the discussions that take place at the Assembly.

In recent years there has been a growing dissonance between some of the positions that India has advocated in the past at international fora like the Assembly and the paradigm shift in economic policies in India. For example, while India has been one of the strongest critics of the impact on access to medicines with strong intellectual property protections, domestic policies are starting to veer towards support stronger intellectual property protection. India advocates for use of flexibilities in the Trade-Related Aspects of Intellectual Property Rights or TRIPS agreement to safeguard public health. But it has issued only one compulsory license that allows domestic companies to produce patented medicines at much cheaper rates. Another significant limitation to India’s leadership at the WHO is its relatively poor track record in providing healthcare services. Our public spending on healthcare is among the lowest in the world. We also have relatively high maternal mortality ratios and lower child survival rates than a majority of low and middle income countries. Consequently India’s advocacy on different healthcare problems is often not rooted in concrete experiences in the country.

Money and more

A key requirement for the revival of WHO’s leadership role in global health is the need to progressively increase untied flexible contributions by member countries. Countries such as India have the opportunity to take the lead in funding the organisation so that the global public organisation can be largely public funded. Unfortunately India and a number of other middle income countries with fiscal capacities continue to lament on the erosion of WHO’s integrity caused by its dependence on donor funds but refuse to increase their contributions to the WHO.

Moreover, India has been reluctant to be seen opposing the United States and other countries of the North. Increasingly, Indian negotiators seem to have their hands tied by signals from Delhi not to push beyond a point in challenging the agenda of the North.

The coming days will may provide an indication of whether India will work to build the solidarity of the South or continue to play an ambiguous role. India will need to align its domestic policies to the overall progressive tenor of its pro-public health advocacy at the WHO. Whether India can play a leadership role in global health is largely predicated on India’s willingness to do so.

The writer is the associate global coordinator of the People’s Health Movement.

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