Aid is still not as effective as it ought to be

Dr Margaret Chan
Director-General of the World Health Organization

Opening remarks at a consultation on global health governance
Geneva, Switzerland

11 March 2011

Colleagues in public health, partners in health development, ladies and gentlemen,

I will be brief, as the purpose of this consultation is to hear your views and benefit from your ideas and experiences. I thank you all for coming on such short notice.

Governance became an issue immediately after the financial crisis of 2008, which seemed to come out of the blue. In a matter of days, thinking about the world’s economic outlook moved from prosperity, to austerity, to talk about another Great Depression. How could this happen?

Experts at the World Economic Forum attributed the crisis to a complete failure of corporate governance and risk management at every level of the financial system. The previous thinking that “greed is good” turned out to be reckless, destructive madness.

In other words, talk about governance was talk about mistakes, blame, and changes needed to prevent similar mistakes in the future. In essence, the issue of financial governance was a question about who makes the rules for responsible behaviour and enforces them.

It did not take long for the governance issue to enter debates about international health cooperation.

After all, the past few years have been a time of high ambitions, unprecedented investments, some striking innovations, and some clear and measurable achievements.

If there was greed at work, it was greed for better health outcomes, as fast as possible.

But this has also been a time of truly stunning increases in the number of actors, agencies, and initiatives funding or implementing programmes for health development. The landscape of public health is crowded. Activities in some areas, in some countries, are frankly chaotic.

Commitment to the health-related MDGs has unquestionably brought results. But many wonder if we are getting the best possible results from these increased investments. In other words, aid is still not as effective as it ought to be.

In some instances, there is a sense that the way development assistance is being delivered can do more harm than good.

Ask a developing country about the current situation, and you are likely to get some frank answers. Yes, they need and want development assistance, but on their own terms, in line with their own priorities, and delivered in ways that develop essential health infrastructures and capacities.

They want, for example, help in developing information systems for collecting comprehensive health information, and not a range of separate systems for data on individual diseases.

The same is true for systems for drug procurement and delivery, for financial planning and management, for reporting requirements, for regulatory capacity, and for a host of other essential public health functions.

Developing countries will tell you about the need for changes in donor behaviour and more coherence in activities. They want capacity. They do not want charity.

This ought to be a powerful incentive for donors. Building capacity builds self-reliance. Self-reliance is the best exit strategy for development assistance.

And here we come up against a central dilemma. Donors are impatient. For a variety of reasons, including many very valid ones, they need quick and measurable results. Capacity building takes time and is notoriously hard to measure.

Ladies and gentlemen,

The basic question raised by the financial crisis has come home to public health. Who makes the rules for responsible behaviour and enforces them? Who governs international health cooperation?

Is it donors, philanthropists, funding agencies, and bilateral aid? Does money drive the agenda and, de facto, define the exit strategy when funds run out or priorities shift?

Or is it WHO guided by the expressed needs of Member States and backed by the multiple experts it consults? In short: how much say do WHO and its governing bodies really have?

This is not a question I intend to answer on my own, and I thank you again for coming to this meeting. Your views and experience will be invaluable as guidance as I continue discussions with Member States on the best way forward.

WHO has some assets, of course. It is constitutionally mandated to act as the directing and co-ordinating authority on international health work. It has more than 60 years of experience. It has universal membership, and each member has an equal say, an equal vote.

WHO operates on the assumption that ministers of health are ultimately responsible for the health of their country’s citizens and should thus be in charge of health policies implemented in their countries.

This is the foundation for a government’s accountability to its people.

Let me mention another important practical asset. WHO is trusted as an agency with the reduction of human misery as its one and only agenda.

WHO can bring people together. But when it comes to our own governance, we are, basically, an exclusive club. Our Constitution is a good one, but it limits decision-making powers to Member States.

Our procedures for setting the agenda for international health work and defining policies and strategies do not give a voice to many others who have demonstrated their ability to have a decisive impact on health. I am referring to civil society organizations, global health initiatives, foundations, the private sector, industry, and many more.

The challenge for WHO is to become more inclusive, without compromising its core competencies, its neutrality, its well-established value system, or the trust it has earned during decades of work.

The challenge, especially in the new reality of financial austerity, is for WHO to be more effective and efficient. This means working better with partners. And this, too, is a question of governance.

I look forward to your advice.

Thank you.