The author

Thomas Schwarz is Executive Secretary of the Medicus Mundi International Network and the Geneva Global Health Hub (G2H2) and a member of the G2H2 working group on WHO and global health governance and financing. Thanks to the working group members who kindly provided feedback on an earlier draft. Contact: schwarz@medicusmundi.org. The proposals featured in this blog were also assessed and discussed at the civil society meeting ahead of WHO EB 144, on 23 January 2019.

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Civil society engagement with the World Health Organization: Towards a new era of partnership or defending a shrinking space?

Current trends related to the space of civil society at the World Health Organization are ambivalent: Will there be a momentum towards a stronger voice of civil society, or is the right of civil society to contribute to the political, normative and regulatory work of WHO at risk? We focus this blog on current policy making processes at global level and in particular on the governing bodies of the WHO (Executive Board and World Health Assembly).

By Thomas Schwarz

“We are building a strong civil society space in Geneva for more democratic global health.” This is the claim and ambition of the Geneva Global Health Hub as shown on the G2H2 website and in its publications.

If one looks at the report of an ad-hoc WHO-Civil Society Task Team¹ published in December 2018, one might think that this stronger space for civil society, at least related to WHO, is close to being realized. The Task Team report entitled “Together for Triple Billion” announces “a new era of partnership between the World Health Organization and civil society” and includes, at global level, recommendations such as “to build in explicit, accessible opportunities for Civil Society Organizations and community input into policy and governance at all levels.”

“Thank you for your engagement in WHO”

The Task Team report was well received by the WHO secretariat. In a short preface to the report, WHO DG Tedros Adhanom Ghebreyesus lauded “civil society partners” as “unique and powerful voices of the people that WHO serves.” After the launch event on 7 December, Dr Tedros tweeted: “I am committed to implementing the recommendations of the ‘Together for Triple Billion’ report at WHO and I urge civil society organizations and countries to do the same. We all have a role to play. Thank you for your engagement and trust in WHO.”

These statements by Dr Tedros are encouraging, aren’t they? So you might not be surprised to find, in a document for the 144^th session of the WHO Executive Board in January 2019, a set of recommendations to “stimulate the participation of non-State actors in official relations in governing bodies meetings” (Report of the Executive Board Chairperson on the outcome of the informal consultation on governance reform, document EB 144/34: item E, page 10, and appendix).

However, three out of four recommendations included in this section have the potential to rather hinder, restrict or complicate civil society engagement in WHO governing bodies:

• “(b) Incentives could be created for non-State actors in official relations to speak as clusters or constituencies. A limited number of speaking slots for non-State actors per session of the World Health Assembly and the Executive Board could be considered.
• (c) The Chairperson should exercise his or her discretion to ensure an effective discussion, including with respect to the time allotted for statements. Non-State actors will have timely notice of allocation of time for their interventions.”
• (d) To consider continuing discussions on organizing an informal meeting with non-State actors in official relations. A concept note reflecting informal consultation’s discussions will be circulated before EB144 to facilitate further discussions.”

These recommendations forwarded by the EB chair need to be assessed on the background of the history and practice of the WHO Framework of Engagement with Non-State Actors (FENSA)² adopted in 2016. In addition to dealing with the engagement of WHO with civil society (in particular: NGOs), FENSA “endeavours to strengthen WHO engagement with non-State actors (NGOs, private sector entities, philanthropic foundations, and academic institutions) while protecting its work from potential risks such as conflict of interest, reputational risks, and undue influence.”

Hardly feasible and difficult to accept

From the perspective of an NGO in official relations with WHO that has, over the years, substantially and meaningfully contributed to many debates at the World Health Assembly and the WHO Executive Board, also by integrating in its delegation and statements various critical and vocal civil society actors such as the People’s Health Movement’s WHO Watch team (see its great “WHO Tracker”), these proposals are difficult to accept.

Integrating the great variety of civil society voices in one or two “clusters” or “constituencies” and related statements will be hardly feasible. How to build such constituencies along the various topics on the agenda of a World Health Assembly, most of them covered by strongly varying groups of NGOs particularly engaged in a topic? Any ad-hoc efforts to integrate civil society statements would overstretch the capacities of the NGOs engaged in following policy processes at the WHO. Take the civil society information and strategy sessions organized by G2H2 ahead of the WHO governing body meetings: These sessions show the efforts needed for such an endeavour – and its limitations.

However, “speaking in one voice” at a WHO governing body meeting is quite easy for business sector representatives. The private sector lobbyists have the necessary capacities to align their strategies, positions and statements, as they have been doing over the years. The proposal is therefore an invitation to the business associations – that have not been really vocal in recent World Health Assembly and WHO EB meetings, but have rather left it up to WHO member states such as the USA to represent their interests – to have an even stronger visibility and say.

After the failure of the WHO “civil society initiative” (2001-2004) ³ and after FENSA, the new proposals can be seen as a next step in two parallel processes:

• Limiting or watering down the constitutive (see Art. 71  of the WHO Constitution) and traditional right of NGOs to speak at the World Health Assembly and at WHO EB sessions, for the sake of “more efficiency” of these governing body meetings;
• getting into business with the commercial sector, for the sake of promoting “inclusive global partnership” – a key narrative of both SDGs and the new WHO mid-term strategy (General Programme of Work 13).

For the same reasons, the proposal for an “all-in-one” meeting/forum is highly sensitive. Most NGOs engaged in WHO advocacy, with their limited advocacy budgets, just do not have the capacity to invest more time and travel expenses in such a meeting or forum. Results coming out of such all-in-one meetings will always be lowest common denominators, grey areas and differences between positions will not be visible in favor of supposed stronger aligned positions. And there is the obvious risk, as seen in the “dialogues” organized by the WHO Global Coordinating Mechanism on NCDs, that such all-inclusive meetings contribute to further blurring the distinction between public-interest NGOs and private sector actors of all kind. Earlier proposals for a “Committee C” of the WHA (2008) or a “World Health Forum” (2011) have been dropped.

How to defend the shrinking space of civil society?

There have been various proposals for reform of the WHO governing body meetings in the past (such as EB126/26, “Method of work of the governing bodies”, with follow-up in the 2010 WHA), but the mess has remained the same: There is in fact too much useless and mainly promotional (how important the issue is, how engaged everybody is in addressing it) and repetitive talking, and no structured and really interactive debate. But this regards all statements by all delegates and could be cured with some simple common-sense regulations to be respected by all delegations. With the proposals outlined above, the whole burden is on the weakest partner, civil society.

The proposals forwarded by the EB chair have the potential to substantially change – and deteriorate – the scope of our engagement in WHO’s normative and regulatory work.

So, and this goes particularly to civil society colleagues: Be aware of what’s going on, make up your mind, and get vocal! Here some concrete proposals for further reflection and action:

• Let us consider what “affirmative action” could be proposed for really strengthening the voice of civil society in the political and normative work of the WHO at all levels, beyond the Task Team proposals. We once encouraged WHO “to undertake and properly resource public hearings that must be inclusive, participatory, democratic, accountable and transparent, including through electronic means, in order to inform the development of relevant public health policies, rather than creating new permanent peer structures that do not appear to tackle the heart of the global governance intricacies.” (Delhi statement, 2011).
• Let us consider how to relaunch the conversation with the WHO Secretariat on the transparency and inclusiveness of WHO processes. When a G2H2 delegation met WHO DG Dr Tedros in November 2017, we submitted him a memo on “practical issues regarding transparency, inclusiveness and ‘user friendliness’ of WHO processes and meetings”, such as providing NGOs in official relations with WHO a dedicated, self-governed space in the Palais des Nations respectively at the WHO HQ for civil society meetings during the WHA and the WHO Executive Board. Unfortunately, the “WHO letter on participation of non-State actors at WHO governing body meetings and on other forms of engagement” received in May 2018 as a reply remained vague and, referring to the rules and procedures of the governing body meetings, could not outline any substantial improvements. It looks as if these rules and procedures are not carved in stone any longer…
• Let us consider what civil society mechanisms in other UN institutions could be used as a reference (both for good and bad practices). Just be aware that governance of a “member stated owned” multlilateral institution is different from governance of a global public private partnership. So rather look out to FAO than GAVI…

The concept note on “Participation of non-State actors in governing body meetings” (Appendix to WHO EB document 144/34) ends with a small paragraph on “Nothing about us without us” that reads as follows: „During the informal consultation debates, several Member States have stressed that they are keen to hear the views and proposals of non-State actors themselves (in accordance with the principle of ‘Nothing about us without us’). Conversations with non-State actors in this respect should be transparent, inclusive and efficient.”

Yes, please do so.

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Blog published on 14 January 2019.
Comments are welcome!

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References added on 25 January 2019

• Open letter by Thomas Schwarz to the WHO EB members, 28 January 2019: Good governance starts at home
• MMI statement at 2011 World Health Assembly: “Global Health Governance”. 
• Input by Thomas Schwarz at DGH missions briefing, 2013: WHO: Democratic governance – at global and national level
  …some messages need to repeated

References added on 28 January 2019:

• IOGT International: Statement at EB144, on agenda item 7.1
• Civil society statements at EB144: Temporary documentation