Global Policy Forum

By Lisa Hayes

Protection of the public's health is part of the social contract between citizens and their governments. The World Health Organization (WHO) has been mandated by member governments to ensure equity in health care. It also sets standards in many health-related areas. These include internationally agreed standards on promotional practices as set out in the International Code of Marketing of Breast Milk Substitutes and the Ethical Criteria for Medicinal Drug Promotion.

In response to the serious shortfall in regular budget funding from member states, WHO now actively seeks funds from commercial enterprises in order to fully implement its work programme. By doing this, WHO sends a message of encouragement and inevitability about involving commercial enterprises in its work. This course of action needs to be more carefully considered as it risks diverting WHO from its mandate and role as the highest, global health policy setting body. It discourages the exploration of other sources of support possibly more in line with WHO's primary health care goals. WHO's action could also negatively influence the funding policies of many other traditional partners.

In the past few years, a number of examples of corporate partnership with WHO have raised serious questions for members of civil society including HAI. For example:

In 1999, HAI found out that the pharmaceutical company Merck, Sharp and Dohme (MSD) had seconded an employee to the staff of WHO's Tobacco Free Initiative. An internal MSD announcement portrayed the employee as an "effective ambassador." Later HAI learned that when the WHO Expert Committee on the Use of Essential Drugs met in November to review additions to WHO's Essential Drugs List one of the proposals made was to add nicotine replacement therapy to the list.

The WHO European Partnership on Tobacco Dependence has been promoted as a model of working that opens the door to future partnerships with the private sector in other important health areas. The project produced a booklet which includes a description of the partnership with Glaxo Wellcome, Novartis Consumer Health and Pharmacia & Upjohn, which manufacture treatment products for tobacco dependence. It gave ample space for company logos and a quote from the CEOs of these three companies.

On World Tobacco Day, May 1999, WHO's Director General stated "Nicotine replacement medicines such as nicotine gums, patches, nasal sprays and inhalers as well as non-nicotine medicines such as bupropion (made by Glaxo Wellcome) can double people's chances of succeeding. They need to be more widely available, but the cost needs to be reduced to bring them within the reach of smokers everywhere."

Other public interest health NGOs have criticized the process by which controversial guidelines on hypertension were developed by WHO and an international working group that was reported to have based its recommendations on two industry-funded studies. The recommendations conflict with current evidence-based guidelines on treating hypertension and inappropriately expanded the potential market for antihypertensive drugs.

Papers written by invited experts for a WHO/UNICEF technical meeting on infant and child feeding were censored by WHO staff when they rejected the food industry's active involvement in shaping national and international infant feeding policies. In another case, criticism from the International Baby Food Action Network (IBFAN) for the Executive Board meeting was also censored. IBFAN's intervention included a comment exposing a report by a baby food company that claimed it followed the breastfeeding marketing code. WHO pressured representatives of the network to remove the comment even though UNICEF supported it. In the end, the comment was made in the statement, but it was deleted from the provisional summary record of the meeting.

Recently, some companies or industry-supported charities have increased their philanthropic work involving WHO. The Global Alliance on Vaccines and Immunization (GAVI) initially supported by a US$750 grant from the Bill and Melinda Gates Foundation and last year's Accelerating Access to HIV/AIDS Care and Treatment initiative spearheaded by five pharmaceutical companies, as well as a number of UN organizations are two new examples of public/private partnerships that call for closer scrutiny. As researchers have already argued, one could certainly believe that giving money to WHO programmes or working with the organization could be seen as a way to deflect criticism about corporate strategy or drug prices for essential medicines. It seems no coincidence that support for such health issues increases when an industry is threatened with tighter regulation or criticized for acting in a socially unacceptable way.

However clear WHO may be about its public health mission, it must recognize that corporate donors will always have a duty to their shareholders to maximise profit. It is essential that funding from the private sector be evaluated according to public health criteria. This applies to all corporations, not just the tobacco and arms industries.

During the past few years, WHO has drafted guidelines on working with the private sector to achieve health outcomes (EB107/20). An original draft was circulated to member states in July 1999 and later that year a limited consultation was held with some members of civil society. As far as we know, the draft guidelines were only circulated in English. HAI called for a second, wider round of consultation, but, to the best of our knowledge, this did not take place. A finalised version of the guidelines was released in late 2000, however, this text raised the same original concerns set out by HAI and other networks and NGOs about the first draft.

The current guidelines propose a framework for assessing these interactions with industry, but fall short in key areas. First and foremost, they fail to give a clear definition of conflict of interest. One consequence of this is that secondment of staff from the private sector, including pharmaceutical companies, is not perceived as a conflict of interest. Another is the guidelines' failure to emphasise the risks related to involving the commercial sector in research. The guidelines answer to conflict of interest seems to be to involve more companies. This is simply inadequate.

The cardinal principle of the guidelines should be complete accountability and transparency. The guidelines make no provision for independent evaluation of potential donors and their compliance with WHO agreed standards and international agreements on human rights, the environment, marketing and labour practices. HAI believes WHO's contractual agreements with all private sector donors should be made public. The process of assessing and approving agreements, as provided in the guidelines, is totally internal. In principle, in-house assessments are inherently flawed because of potential conflicts of interest. Therefore, independent review should be mandatory. External monitoring and evaluation of work involving commercial enterprises must be carried out to see if equitable and sustainable health outcomes are achieved.

These guidelines were on the agenda of the WHO Executive Board meeting held in January simply as a report to be noted. However, instead of merely accepting the guidelines, 14 countries spoke on the issue: (Venezuela, Italy, Congo, France, Belgium, Sweden, United States, Brazil, Cote D'Ivoire, India, China, Guatemala, Bangladesh and Chad.) Most of the speakers raised serious concerns about WHO's independence in light of so much interaction with industry.

As a consequence, the Executive Board decided to create a "virtual" e-mail/internet working group comprised of member states and their advisors to discuss the guidelines in greater detail and to look for ways to improve them. The Executive Board has asked the WHO secretariat to report back in one year's time on the input gained from the virtual discussion and on the ways it plans to improve the guidelines.

It is not only NGOs and member states that are expressing concerns about industry's relationship with WHO. It is also parts of WHO itself. The report of a recent seminar on PPIs co-sponsored by WHO and held in Rome, clearly stated that 'it is timely for WHO to step back from the current situation and reflect on the appropriate role of (Global Public Private Partnerships) GPPPs in order to meet public health and equity needs'. Seminar participants further called for an open discussion on these WHO guidelines. They said that such discussion should involve member governments, civil society and other interested parties taking into account evidence and analysis at the global and national level. Not surprisingly, this report is not being circulated widely by WHO.

One needs to keep asking serious questions about corporate influence at WHO, such as:

Do such public-private interactions contribute to equity in health care?

Do they encourage vertical programmes focused on diseases calling for hi-tech, expensive solutions rather than those identified as national public health priorities?

Are they a quick fix or do they contribute to sustainable health benefits?

And, are these well-publicised collaborations actually about donor image-building, product development and marketing?

Thank you.