Conceptual and institutional gaps: understanding how the WHO can become a more effective cross-sectoral collaborator

Globalization and Health

John-Arne Røttingen⁵  Steven J. Hoffman¹  Arthur Cheung⁴  Alex Lefebvre²  Daniel Hougendobler⁶  Nicholas Watts³  Unni Gopinathan⁷ 

[1] Department of Clinical Epidemiology & Biostatistics and McMaster Health Forum, McMaster University, Hamilton, Canada;Faculty of Medicine, University of British Columbia, Vancouver, Canada;Institute of Global Health, University College London, London, UK;School of Medicine, The University of Queensland, Brisbane, Australia;Division of Environmental Health and Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway;O’Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA;Institute of Health and Society, University of Oslo, Oslo, Norway

关键词: Cross-sectoral collaboration;    WHO reform;    Health in all policies;    Social determinants of health;    Global governance for health;    Global health governance;    Global governance;    United Nations;    World Health Organization;   

Others  :  1234181
DOI  :  10.1186/s12992-015-0128-6

 received in 2015-05-01, accepted in 2015-10-29,  发布年份 2015

【 摘 要 】

Background

Two themes consistently emerge from the broad range of academics, policymakers and opinion leaders who have proposed changes to the World Health Organization (WHO): that reform efforts are too slow, and that they do too little to strengthen WHO’s capacity to facilitate cross-sectoral collaboration. This study seeks to identify possible explanations for the challenges WHO faces in addressing the broader determinants of health, and the potential opportunities for working across sectors.

Methods

This qualitative study used a mixed methods approach of semi-structured interviews and document review. Five interviewees were selected by stratified purposive sampling within a sampling frame of approximately 45 potential interviewees, and a targeted document review was conducted. All interviewees were senior WHO staff at the department director level or above. Thematic analysis was used to analyze data from interview transcripts, field notes, and the document review, and data coded during the analysis was analyzed against three central research questions. First, how does WHO conceptualize its mandate in global health? Second, what are the barriers and enablers to enhancing cross-sectoral collaboration between WHO and other intergovernmental organizations? Third, how do the dominant conceptual frames and the identified barriers and enablers to cross-sectoral collaboration interact?

Results

Analysis of the interviews and documents revealed three main themes: 1) WHO’s role must evolve to meet the global challenges and societal changes of the 21st century; 2) WHO’s cross-sectoral engagement is hampered internally by a dominant biomedical view of health, and the prevailing institutions and incentives that entrench this view; and 3) WHO’s cross-sectoral engagement is hampered externally by siloed areas of focus for each intergovernmental organization, and the lack of adequate conceptual frameworks and institutional mechanisms to facilitate engagement across siloes.

Conclusion

There are a number of external and internal pressures on WHO which have created an organizational culture and operational structure that focuses on a narrow, technical approach to global health, prioritizing disease-based, siloed interventions over more complex approaches that span sectors. The broader approach to promoting human health and wellbeing, which is conceptualized in WHO’s constitution, requires cultural and institutional changes for it to be fully implemented.

【 授权许可】

   
2015 Gopinathan et al.

【 参考文献 】

• [1]Thakur R, Weiss T. The UN and global governance: an idea and its prospects. Indiana University Press; 2006
• [2]Friel S, Gleeson D, Thow AM, Labonte R, Stuckler D, Kay A, Snowdon W. A new generation of trade policy: potential risks to diet-related health from the trans pacific partnership agreement. Global Health. 2013; 9:46. BioMed Central Full Text
• [3]Watts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health and climate change: policy responses to protect public health. Lancet. Jun. 2015.
• [4]Gushulak B, Weekers J, Macpherson D. Migrants and emerging public health issues in a globalized world: threats, risks and challenges, an evidence-based framework. Emerg Health Threats J. 2009; 2: Article ID e10
• [5]Closing the gap in a generation: health equity through action on the social determinants of health: Commission on Social Determinants of Health final report. World Health Organization, Geneva, Switzerland; 2008.
• [6]Kickbusch I, Silberschmidt G, Buss P. Global health diplomacy: the need for new perspectives, strategic approaches and skills in global health. Bull World Health Organ. 2007; 85(3):230-232.
• [7]Ottersen OP, Frenk J, Horton R. The Lancet-University of Oslo Commission on Global Governance for Health, in collaboration with the Harvard Global Health Institute. Lancet. 2011; 378(9803):1612-1613.
• [8]Kickbusch I, Szabo MMC. A new governance space for health. Glob Health Action. 2014; 7:23507.
• [9]Frenk J, Moon S. Governance challenges in global health. N Engl J Med. 2013; 368(10):936-942.
• [10]Lee K, Kamradt-Scott A. The multiple meanings of global health governance: a call for conceptual clarity. Global Health. 2014; 10:28. BioMed Central Full Text
• [11]Constitution of the World Health Organization. World Health Organization, Geneva; 1946.
• [12]Cassels A, Kickbusch I, Told M, Ghiga I. “How should the WHO reform? An analysis and review of the literature,” Graduate Institute of International and Development Studies, Global Health Programme Working Paper No. 11. 2014.
• [13]Progress report on reform implementation. Report by the Director-General. World Health Organization, Geneva; 2014.
• [14]Clift C. What’s the World Health Organization for?: Final report from the Centre on Global Health Security Working Group on Health Governance. 2014.
• [15]Hoffman SJ, Røttingen JA. Split WHO in two: strengthening political decision-making and securing independent scientific advice. Public Health. 2014; 128(2):188-194.
• [16]Sridhar D, Gostin LO. Reforming the World Health Organization. JAMA. 2011; 305(15):1585-1586.
• [17]Labonté R. Global health in public policy: finding the right frame? Crit Publ Health. 2008; 18(4):467-482.
• [18]Stuckler D, McKee M. Five metaphors about global-health policy. Lancet. 2008; 372(9633):95-97.
• [19]Shiffman J. A social explanation for the rise and fall of global health issues. Bull World Health Organ. 2009; 87(8):608-613.
• [20]Labonté R, Gagnon ML. Framing health and foreign policy: lessons for global health diplomacy. Global Health. 2010; 6:14. BioMed Central Full Text
• [21]Gagnon ML, Labonté R. Human rights in global health diplomacy: a critical assessment. J Hum Right. 2011; 10(2):189-213.
• [22]Vaughan R. “Competing visions of global health governance,” Center on Global Health Security, Chatham House. 2011.
• [23]McInnes C, Kamradt-Scott A, Lee K, Reubi D, Roemer-Mahler A, Rushton S, Williams OD, Woodling M. Framing global health: the governance challenge. Glob Public Health. 2012; 7 Suppl 2:S83-S94.
• [24]McInnes C, Lee K. Framing and global health governance: key findings. Glob Public Health. 2012; 7 Suppl 2:S191-S198.
• [25]Kamradt-Scott A, McInnes C. The securitisation of pandemic influenza: framing, security and public policy. Glob Public Health. 2012; 7 Suppl 2:S95-S110.
• [26]Yin RK. Qualitative research from start to finish. Guilford Press, New York, NY; 2011.
• [27]Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006; 3(2):77-101.
• [28]Barnett-Page E, Thomas J. Methods for the synthesis of qualitative research: a critical review. BMC Med Res Methodol. 2009; 9:59. BioMed Central Full Text
• [29]Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008; 8:45. BioMed Central Full Text
• [30]Human resources: annual report. Report by the Secretariat. 2013.
• [31]WHO. Engaging for health. 11th general programme of work, 2006–2015. A global health agenda. Geneva, Switzerland; 2006.
• [32]WHO. Medium-term strategic plan 2008–2013. Geneva, Switzerland; 2007.
• [33]Twelfth general programme of work 2014–2019. Not merely the absence of disease. World Health Organization, Geneva, Switzerland; 2014.
• [34]Promoting access to medical technologies and innovation: intersections between public health, intellectual property, and trade. World Health Organization : World Intellectual Property Organization : World Trade Organization, Geneva, Switzerland; 2013.
• [35]WHO and WHO establish joint office for climate and health. Press release no. 996. 2014.
• [36]Collaboration on the prevention and control of non-communicable diseases. Memorandum between UNDP, WHO and the World Bank. 2014.
• [37]WHO. Terms of reference for the UN interagency task force on the prevention and control of noncommunicable diseases. Geneva, Switzerland; 2015.
• [38]Sachs J. Macroeconomics and health investing in health for economic development: report of the Commission on Macroeconomics and Health. World Health Organization, Geneva; 2001.
• [39]World Health Organization. Public health, innovation and intellectual property rights: report of the Commission on Intellectual Property Rights, Innovation and Public Health. World Health Organization, Geneva; 2006.
• [40]Commission on ending childhood obesity. 2015.
• [41]Lee K, Pang T. WHO: retirement or reinvention? Public Health. 2014; 128(2):119-123.
• [42]Lidén J. The World Health Organization and Global Health Governance: post-1990. Public Health. 2014; 128(2):141-147.
• [43]Stuckler D, King L, Robinson H, McKee M. WHO’s budgetary allocations and burden of disease: a comparative analysis. Lancet. 2008; 372(9649):1563-1569.
• [44]Vaughan JP, Mogedal S, Kruse S, Lee K, Walt G, de Wilde K. Financing the World Health Organisation: global importance of extrabudgetary funds. Health Policy. 1996; 35(3):229-245.
• [45]Proposed programme budget 2014–2015. World Health Organization, Geneva, Switzerland; 2013.
• [46]WHO. Report of the workshop on differential pricing and financing of essential drugs. Geneva, Switzerland; 2001.
• [47]Bettcher D, Subramaniam C, Guindon E, Perucic AM, Soll L, Grabman G, Jossens L, Taylor A. Confronting the tobacco epidemic in an era of trade liberalization. World Health Organization, Geneva; 2001.
• [48]WTO, WHO. WTO agreements and public health–a joint study by the WHO and the WTO Secretariat. Geneva, Switzerland; 2002.
• [49]WHO, FAO. Diet, nutrition and the prevention of chronic diseases. Geneva, Switzerland; 2003.
• [50]FRESH–a comprehensive school health approach to achieve EFA. 2002.
• [51]UNCTAD, WHO. International trade in health services–a development perspective. Geneva; 1998.