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Dr. Julio Frenk's answers to PHM's questions

PHM Global Secretariat

11 October 2006
Dr. Julio Frenk's answers to the inquiries from the People’s Health Movement to the Candidates for the position of WHO’s Director General.

1.What will be your top priorities for WHO over the next five years?
In my platform for WHO (available at, I propose a plan of action and will launch a number of initiatives related to three guiding principles:
• Health is a foundation for equitable and sustainable development.
• Health is a source of global security.
• Health cooperation is a model for reform of the multilateral system.
Regarding the first principle, which links the work of WHO to the development agenda, I will implement a major cross-cutting initiative to strengthen health systems, which will interact closely with each of the major disease-specific programmes in WHO and its partners. The idea is to bridge the traditional divide between the “vertical” approach, focusing on specific disease priorities, and the “horizontal” approach, aimed at strengthening the overall structure and functions of the health system but without a clear sense of priorities. Instead, I will promote a “diagonal” strategy whereby explicit intervention priorities are used to drive improvements into the health system.
This initiative will tackle both components of the double burden of disease. On the one hand, it will intensify cooperation with those countries that are lagging in the attainment of the health-related Millennium Development Goals (i.e., improved nutrition, reduction of maternal, newborn and child mortality, and prevention and treatment of HIV/AIDS, tuberculosis and malaria). The objective will be to catalyze an extraordinary solidarity effort from the international community to help these countries get on track toward the 2015 deadline. On the other hand, the “diagonal initiative” will seek to enhance the MDGs by defining clear targets around the growing burden of non-communicable diseases and injury.
Regarding the second guiding principle, at the beginning of my term in office I will launch a global health security initiative. It will implement a series of highly-focused actions to strengthen the disease surveillance network, improve the rapid response capabilities of WHO to health-related crises, and enhance global preparedness against a potential pandemic of human influenza. In addition, a number of other illnesses know no borders, from hepatitis and malaria to HIV/AIDS and new forms of multi-drug resistant tuberculosis. WHO has a critical role to play in enhancing early detection, providing best advice on treatment and containment of infections across the globe, and ensuring that diseases which have eradicated or eliminated do not remerge. In this way, health cooperation will contribute to security and stability within and beyond national borders.
Finally, the third guiding principle calls for a series of internal reforms that will make WHO a model of efficiency, transparency, accountability, and service to Member States. To give operational content to such an ambitious goal, I will immediately convene a high-level task force that will propose to the Governing Bodies of WHO the necessary governance and management changes, along with a strict time frame for implementation. A central component will be an ambitious investment in staff development at all levels and the articulation of networks of expertise across the Organization. Starting with the work of the Transition Team, I will also institute a structured forum where the Director-General meets on a regular basis with the regional directors in order to craft unified policies, coordinate actions, encourage inter-regional dialogue, and facilitate the adoption of best management practices through shared learning among country offices. In the effort to improve the responsiveness of WHO to the needs of the populations it serves, I will seek the active involvement of civil society organizations, just as I have done during my six-year tenure as Minister of Health of Mexico.
2.Will the development of a global strategy to strength Primary Health Care be a priority for you? If so what will you propose to strengthen CPHC?
I will implement initiatives to strengthen health systems in accordance with the basic principles of primary health care, and through the emphasis on health promotion, protection against risk factors, disease prevention, treatment and care. A fundamental tenet of primary care is the need for an intersectoral approach that will tackle the social determinants of ill health. In this respect, I firmly believe that health cannot be seen simply as a specific sector of public administration, but must be understood as a social objective. Therefore, it is not enough to develop health policies in the strict sectoral sense; we also need healthy policies that mobilize interventions from other sectors, to pursue the social objective of better health.
Based on such a broad perspective, WHO must collaborate with countries to develop health systems that assure universal access to high-quality services with adequate social protection for all. Human resources are the key to quality, and WHO must never lose slight of the immense challenges that health personnel face, working under often dire conditions. WHO must act as the leader that brings together key partners to develop, collect and disseminate the evidence, managerial instruments and guidelines that create effective public health policy, building on its direct technical cooperation with individual countries by generating a process of shared learning among countries through the dissemination of best practice models.
3.Where do you stand on the need to repair the damage to public health care systems caused by the inefficiencies and inequities brought about by the privatisation of such systems?
I believe that WHO must cooperate with all nations, especially with developing countries and transition economies, to facilitate universal access to high-quality services with adequate social protection for all. This means bridging the gaps in access to comprehensive care through health systems that are equitable, effective, efficient and financed in a fair manner. International evidence shows that in order to achieve these goals, ministries of health must be able to perform the essential function of stewardship, which implies a public responsibility to provide strategic direction to the entire health system and assure that no one is excluded from its benefits. Evidence also shows that the best-performing health systems are those that are predominantly financed with public resources based on highly progressive financing strategies that protect and prevent, particularly the poor, from having to pay for care out of pocket. While there is no uniform solution, health systems must assure equitable access of all the population to comprehensive health care, especially among the poor. This, in fact, has been the road taken in Mexico recently with the creation of the Seguro Popular de Salud (Popular Health Insurance), which provides publicly financed health insurance to the population that had hitherto been excluded from social security– most of whom are poor.
4.There has been a rapid proliferation of Global Health Initiatives and disease-specific initiatives. How will you seek WHO oversight and control of this situation?
Growing pluralism in the global health scene makes WHO more relevant than ever before. To understand why, it is necessary to focus on the specific functions that WHO is positioned to perform best or, indeed, that only WHO can carry out because of its legitimate mandate.
There are three key functions that every health system—whether national or global—must perform: service delivery, financing, and stewardship. Direct service delivery to populations and individuals is mostly the responsibility of each national government, although WHO has a crucial role to play in cooperating with countries in order to strengthen the capacity and performance of their respective health systems. In addition, WHO is part of the international response to assist populations in distress as a result of emergencies, disasters, and humanitarian crises.
Like service delivery, financing is mostly a responsibility of national governments, complemented by bilateral and multilateral development assistance and, more recently, by new foundations that have been able to mobilize unprecedented—although still insufficient—funds. In the case of the financing function, the main roles for WHO are to advocate for increased allocations to health from both national and international sources, to assist developing countries in gaining access to financial resources (for example, from the Global Fund and new initiatives such as IFF or UNITAID) and in making those resources coherent with national priorities, to use its comparatively small budget as a catalyst for innovation, and to set the example for efficient use of funds in its own internal management.
In this context, stewardship is the essential function of WHO, which no other actor on the global scene can carry out with the necessary legitimacy. Stewardship includes several key activities, among them: providing strategic guidance to the overall global health endeavour; defining priorities on the basis of sound evidence and open ethical deliberation; mobilizing the power of knowledge to set standards that national and international actors can adopt in order to carry out their own work; recruiting other agencies into a broad multisectoral approach that will utilize all tools of public policy to promote health; engaging nongovernmental organisations, academic centres, and the private sector in constructive synergies for health; acting as a neutral and inclusive convener to resolve disputes around sensitive policy issues; assessing through an independent mechanism the impact of programs, whether they are carried out by WHO itself, by its partners or by other international institutions; creating a credible framework for accountability and transparency by all actors; protecting the global health commons through shared reporting and regulatory procedures in order to develop effective surveillance mechanisms and reduce the international transfer of health risks; coordinating large-scale campaigns that require the participation of all nations in order to eradicate or control diseases; mobilizing the global talent pool and facilitating networks of expertise that national and international entities can tap into; systematizing and disseminating the experience of countries so as to facilitate a process of shared learning; therefore, creating knowledge-related global public goods that will benefit all the inhabitants of our global village. In the final analysis, effective stewardship gets translated into forceful leadership to position health as a central domain in the global development and security agenda.
Only WHO can lead the world in fulfilling the essential function of stewardship because it possesses the indispensable legitimacy that stems from its constitution by its Member States. We must never loose sight of the fact that WHO is not only the secretariat, but also—and fundamentally—the organization of nations to pursue the shared objective of better health. Multilateral agencies like WHO constitute the mechanism through which the countries of the world mobilize their collective action in order to achieve goals that none can fulfill on its own and to express their solidarity with each another. But stewardship is not carried out only at the global level. Through its regional and country offices, WHO also translates its expertise into technical cooperation with individual nations, according to their specific development needs, and facilitates country-to-country collaboration.
The roles of WHO in service delivery, financing, and stewardship make it, more than ever before, an indispensable institution in our globalised world.
5.How will you ensure that WHO plays a more assertive role in protecting public health interests in the face of trade agreements (e.g. TRIPS) that would appear to be harmful?
Along with its benefits, globalisation has also brought a growing international transfer of health risks. Some of these include the movement of people, which facilitates the spread of infectious diseases, and trade in harmful products. Controlling these processes is often beyond the authority of any single government. WHO can be the locus for international collective action in the face of this new generation of global or regional health threats. An essential building block to support this effort is a strong capacity to detect, quantify and track new health threats, as well as to monitor the health impacts associated with trade agreements. In this last respect, whenever there are major disagreements on an issue among Member States, the role of the Secretariat of WHO must be to convene the dissenting parties and to bring the best evidence to bear in the search for common ground.
6.Given the pressures from various corporate interests and their allies for WHO to endorse health promoting practices what steps would you take to ensure that WHO is able to resist these pressures?
Credibility and moral authority are the foundations for the essential stewardship role of WHO. In order to guarantee them, it is necessary to strengthen control mechanisms that are common in the scientific community. Some of these mechanisms have already been introduced into the work of the secretariat and of expert advisory groups. In fact, these matters were under my purview when I was in charge of the cluster on Evidence and Information for Policy at WHO headquarters. As Director-General, I will emphasize specific means of assuring objectivity and independence, such as disclosure of potential conflicts of interest, rigorous peer review, and reliance on external networks of expertise formed by leading academic institutions from different countries. I will also ensure, through a Cabinet that is truly representative of the international nature of the agency, and by working with leaders from different parts of the world, that no entity has the possibility to unduly influence the WHO agenda.
7.How will you counter balance the disproportionate influence of the rich country governments, particularly the United States, on policy development within WHO?
While every country faces its own specific circumstances, we all share common risks and opportunities. Health is a universal aspiration that can unite nations for the benefit of all, or divide societies in which it is available only to some. Health offers a concrete opportunity to reconcile national self-concern with international mutual interest. Today, we have a greater opportunity than ever before to close the gaps among countries and overcome the barriers to global health equity.
As mentioned in my response to the previous question I will emphasize specific means of assuring objectivity and independence, such as disclosure of potential conflicts of interest, rigorous peer review, and reliance on external networks of expertise formed by leading academic institutions from different countries. I will also ensure, through a Cabinet that is truly representative of the international nature of the agency, with leaders from different parts of the world, that no entity has the possibility to unduly influence the WHO agenda.
8.What do you propose to increase the voice and influence of civil society groups in WHO?
Accountability to the citizens of countries is enhanced by involving international civil society in a process of inclusive dialogue. I will therefore seek greater engagement of nongovernmental organizations, which often express people’s aspirations and needs, as well of professional associations, which represent the multiple constituencies of health workers. By always acting with the moral authority that derives from rigorous scientific standards, WHO assures the neutrality and therefore the acceptability of its expert technical work. Dissemination of this work fosters transparency and accountability to citizens. In addition, the secretariat can legitimize its involvement in sensitive areas of work by engaging the Governing Bodies in constructive discussion and consensus building. Finally, WHO serves people directly as part of the multilateral response to emergencies, disasters, and humanitarian crises. More generally, WHO must always act as an agent for the dispossessed by advocating for greater attention to their health needs, which are often articulated by non-governmental organizations.
9.WHO has been criticized for many years for being dominated by doctors, and lacking professionals from the social sciences, legal, economic and non-medical disciplines. What is your view on this and what will you do to rectify the imbalance in disciplines and expertise within WHO?
Human resources are the key to quality, and WHO must never lose sight of that. WHO personnel must reflect the diversity of Member States and guarantee an appropriate gender, cultural, and disciplinary balance. Not only is this essential to promoting a the international and plural nature of WHO as an institution, it is also the key to guaranteeing the relevance and excellence of its technical work. A balance of disciplines and expertise must be reflected in all aspects of the work of WHO and will be one of the issues to be taken up by the high-level task force that will propose to the Governing Bodies of WHO the necessary governance and management changes to strengthen efficiency and service to Member States.
10. The phrase "Staff are our most important resource" is commonly stated by leaders when they take office. How will you maximise this most important resource in terms of WHO's work and in relation to staff representation in dealing with management?
The Organization must invest to ensure its staff develops the skills, tools, and competency to make WHO as effective as it can be. We must develop expertise networks to fully mobilize the talent of every WHO staff member for the benefit of the people we serve. As Director-General I will adhere to a policy of open and constructive dialogue with the Staff Association. My experience as Minister of Health will be useful in this regard, since I was able to manage a workforce of close to 200,000 persons without any labour conflict. Again, this will be one of the issues to be reviewed by the task force on governance and management in order to propose and implement specific strategies from the outset.
11.Many argue that there is a particular need to build the capacity of the WHO Regional Office in Africa? Do you agree and, if so, how would you go about this?
I believe that the regional structure is key to an effective WHO. WHO’s presence in countries and its supporting regional offices are one its greatest assets. The Regional Offices provide the real potential to adapt global knowledge and public goods to regional circumstances. In Africa, this knowledge and experience is particularly relevant to address adequately the health issues that this region faces. If we are to strive for global equity, Africa clearly deserves special attention from WHO. This is so because of the huge burden of disease affecting Africa, but also because many countries in this region are the source of valuable innovations that WHO must support. If elected Director-General, I will continue the work to establish common policies and goals across the Organization, and use our budgetary resources where they matter most: at the country level.
12.How will you support and promote the work of the Commission on the Social Determinants of Health from now until it reports in May 2008 and then ensure its recommendations are implemented?
During my period of work at WHO, I supported the establishment of the Commission on Macroeconomics and Health, which proved to be very influential in making the case for investing more money in health. As Minister of Health of Mexico, I have been able to use many of these recommendations to strengthen the health system and expand the health budget at the country level. I am convinced that there is great utility in having an external group of experts to provide recommendations on WHO policy and have met with the Commission on the Social Determinants of Health and have great appreciation for its work and the scope of the influence that it will have. As indicated in the answer to question 2, I strongly believe in adopting a comprehensive approach to health that includes interventions to deal with its social determinants. Therefore, I am committed to supporting the Commission with the tools they need to carry out their work in an independent way. Furthermore, WHO, as a provider of global public goods in health (and knowledge is one of the most important), should develop a platform for dissemination of the Commission’s recommendations to Member States and international organizations in order to be even more effective in influencing health and other social systems.
(PHM thanks The Lancet for the picture.)

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