Research Article: The Global Health System: Lessons for a Stronger Institutional Framework

Date Published: January 26, 2010

Publisher: Public Library of Science

Author(s): Suerie Moon, Nicole A. Szlezák, Catherine M. Michaud, Dean T. Jamison, Gerald T. Keusch, William C. Clark, Barry R. Bloom, Gill Walt

Abstract: In the last in a series of four articles highlighting the changing nature of global health institutions, Suerie Moon and colleagues propose future actions to strengthen these institutions.

Partial Text: The global health system is in a period of rapid transition, with an upsurge of funds and greater political recognition, a broader range of health challenges, many new actors, and the rules, norms and expectations that govern them in flux. The introductory article of this series (Szlezák et al. [1]) laid out some of the many challenges facing the global health system. This system is defined as the constellation of actors (individuals and/or organizations) “whose primary purpose is to promote, restore or maintain health [2]” and “the persistent and connected sets of rules (formal or informal), that prescribe behavioral roles, constrain activity, and shape expectation [3]” among these actors. The second article (Frenk [4]) defined the key attributes of national health systems as a core component of the global system. The third article (Keusch et al. [5]) analyzed the institutional evolution of one of the system’s most important functions—the integration of research, development, and delivery.

Cutting across these five core functions is the question of how changes in the global health system redefine the role of WHO. WHO is facing “an urgent need to define and assert a clear and effective role for itself, as never before” [45]. There are at least three key roles that we believe only WHO can fulfill and therefore must do well. The first is global stewardship, i.e. identifying needs to be met and taking a leadership role in setting global norms. Second is as a provider of operational support to countries: WHO has a unique capacity to engage the best experts worldwide, which should enable it to provide technical assistance to governments through normative guidelines and recommendations reflecting best evidence and practice. To retain the legitimacy to do so, it must maintain the highest technical and ethical standards [46]. The third is its special role in governance: as the major global intergovernmental health organization, WHO has a unique convening power and mandate for decision-making on major health-related issues. Its governing body, the World Health Assembly, with its 193 Ministers of Health, provides WHO its singular legitimacy to carry out these mandated roles of stewardship, country support, and governance, albeit with a high degree of bureaucratization and politicization. Yet WHO’s regular budget resources are remarkably limited. For the 2006–7 biennium, the formal budget assessed on countries was less than $1 billion (with voluntary contributions the total budget was just over $3 billion); the following period, three-fourths of the budget was allocated to the regions [47]. This excessive budgetary decentralization undermines WHO’s capacity to deliver the global public goods demanded of it.

Several general lessons have emerged from our study of institutions in the global health system.