Policy Bite : Making global action effective

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Amanda Howe writes:

I have held a number of leadership positions in my career – including owning a practice from 1984-2001, running a medical course from 2004-2008, being an Officer and Trustee of the Royal College of GPs from 2009–2015, and being President of WONCA 2016-2018. The scale of these positions moves from micro to macro, and the ‘chain of command’ is much looser and more complex as the scale increases. In fact, WONCA is a network of member organisations, all of which are autonomous and choose whether to be part of WONCA or not: so the President is mainly a representational and ‘figurehead’ role, who can encourage a sense of direction and lend expertise but cannot demand any specific change.

The question of how to achieve consensus and ensure that action occurs, if needed, is therefore a complex one for an organisation such as WONCA. This has been mirrored by the challenges we have seen for the UN in taking any effective steps in the crises in Yemen and Syria, and more recently in our shared experience of WHO’s lead into the 40th anniversary of the Alma Ata Declaration. Having agreed to make a major Declaration leading into country level implementation, there has been widespread consultation, development of supporting documentation, and an ‘invitation only’ meeting in Astana – but with an intention to engage multiple stakeholders. The named partners are member states, registered non-State actors (NSAs, including WONCA), civil society organisations, donors, and some ‘nominated’ experts. The third version of the Declaration is now in the process of signoff at country level, and many arrangements remain outstanding - a huge challenge to bring this altogether, and to ensure real ownership of the initiative.

The majority of attendees at the Astana meeting have to be self-funding, so there are significant risks that this might exclude some groups and favour others unless the process is well managed. Some free places are allocated for constituents deemed a priority – for example, representation from low and middle income countries (LMICs), and from ‘youth’ constituents. WONCA sees the need to ensure the voice of family medicine is heard in the debate about how to strengthen primary health care for universal health coverage as an absolute global priority at this stage, but we have been invited! So we have agreed to fund up to five representatives – a substantial budget implication, and one that we shall evaluate afterwards.

Just as WONCA is dependent on all its constituent parts to meet deadlines and prepare for Seoul Council, so WHO has had to align the inputs of multiple players into its final version of the Declaration. WONCA has been able to comment on a number of the documents, but these have often come to us with very short timelines, and of course with no guarantees that our suggested changes will be taken on board. The workload for those at the heart of this has been very challenging, but also been significant for those attempting to engage with the process. The bigger question though is not what is involved at this stage but what will happen after the anniversary, as we move into the next decade.

The stated intention is to have an implementation phase, where member states and others will be asked to make specific commitments to deliver on the Astana ‘promise’. As an NSA, we have to renew our programme of work with WHO on a regular basis, and this may allow WHO a means to call us to account for our involvement – but the member states themselves also have to align. Funding from WHO can of course be used as a lever for change, but the kinds of reforms needed for UHC are not those which commonly attract WHO funding – this is more usual for e.g. the Ebola crisis, and is often dependent on complex pathways (including donor availability and expectations). So the likelihood of action will rest on whether member states actually agree with the overall analysis of what is needed and why; can actually harness the resources to make the changes needed – including training a different workforce and improving investment into the primary care sector: and whether conditions are sufficiently economically and politically stable to allow progressive changes.

My conclusion is therefore that global action can only be effective if the constituent partners agree with the key priorities set, and are in a position to work towards the change they agree. This is true for WHO, and it is true for us. WONCA tries to use the funding it gets from membership fees and other sources to facilitate sharing of knowledge and also effective communications – both internally to members and externally to others. We are reliant on each member organisation – indeed, each member – to continue to put effort into changes that are needed for our patients and peoples to get the health care they deserve. Creating a momentum round a set of ideas, a form of words such as a ‘Declaration’, and a major meeting or conference to explore and launch this, is a common mode of working – see for example the Delhi Declaration which came out of the Rural Working Party’s meeting earlier this year. But any such statement is really judged by what happens afterwards.

So we look forward, both to Seoul and to Astana. We shall make our own WONCA Declaration at Seoul, and carry this forward into the next biennium, and onwards to Astana. I know the new Executive under Dr Donald Li as President will continue to serve WONCA’s mission as best they can. We hope all members will feel part of this effort, and share their views and actions to our common goal – “to improve the quality of life of the peoples of the world … by fostering high standards of care in general practice/family medicine”.

Thank you all.
Amanda Howe.
WONCA President