The History, Functions and Structures of the World Health Organization
In order to understand how WHO functions when dealing with the area of maternal health it is first necessary to understand something of the history, functions and structures of WHO. These three areas are closely interrelated. It is important to examine all three in order to paint a complete picture of WHO’s functioning in relation to maternal Health.
The constitution of the World Health Organization entered into force on the 7th April 1948; however the idea of an international (or at least transnational) approach to dealing with matters of health had existed since the middle of the 19th century with efforts centred on combating infectious disease[1]. As the 20th century progressed, the focus of international health policy broadened[2].
The constitution of WHO indicates that, by the middle of the 20th century nations were willing to cooperate in a broad range of health-related policy matters. Chapter II, Article 2 of WHO’s constitution lists the twenty-two functions of WHO[3]. In addition to a continuing focus on infectious disease there are also functions that specifically deal with areas including research, assistance to government and addressing non-infectious disease that had previously been given little attention on the international health policy stage.
The constitution of the World Health Organization also addresses its structures. These structures are complex, with three levels of organization at an international level, the World Health Assembly (WHA), comprising representatives of every WHO member state[4], The Executive board, which comprises members elected by the WHA[5] and The Secretariat[6] comprised of WHO’s Director-General and technical and administrative staff[7]. The constitution also specifies provisions to create regional organizations[8] and “committees considered desirable to serve any purpose within the competence of the organization[9]”.
The focus of WHO’s work has shifted over time. This is not surprising, considering the broad scope of WHO’s mandate that the organization tends to focus its work around only some of its functions at any given time. The organization’s Eleventh General Programme of Work 2006-2015 details the six core functions it is focusing on between 2006 and 2015[10]. These functions are:
- Providing leadership on matters critical to health and engaging in partnerships where joint action is needed;
- Shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge;
- setting norms and standards and promoting and monitoring their implementation;
- Articulating ethical and evidence-based policy options;
- Providing technical support, catalysing change, and building sustainable institutional capacity;
- Monitoring the health situation and addressing health trends[11].
This set of functions, according to WHO are based on an analysis of WHO’s comparative advantage as an actor in the international system
[12]. This advantage WHO believes, lies in the organization’s “neutral status and near universal membership, its impartiality and its strong convening power
[13].” This set of functions and WHO’s claims about its comparative advantage will be examined in greater detail later in this paper.
Two points become apparent from reading WHO’s
Eleventh General Programme of Work 2006-2015, the first is that WHO is acutely aware of the challenges it faces if it is to remain a relevant actor in international health
[14] (a topic that will be returned to later in this paper) and second, the direction of WHO’s work for this period is geared towards meeting the health related Millennium Development Goals. Both these points indicate that WHO is aware of the fact that it cannot function as an independent actor in the international system. Any action WHO takes must be informed by the actions of other actors in the international system and likewise WHO’s actions impact upon the actions of other actors in the international system.
The Millennium Development Goals
Before examining WHO’s role in maternal health it is important to understand how the Millennium Development Goals (MDGs) have come to play such a prominent role in shaping WHO’s work. The MDGs came out of the United Nations Millennium Declaration which was endorsed by 189 countries in September 2000
[15] and resolves to work towards combating poverty, ill health, discrimination and inequality, lack of education and environmental degradation
[16].
The MDGs are eight specific goals that the 191 United Nations (UN) states have committed themselves to achieving by 2015. The MDGs are:
1. to eradicate extreme poverty and hunger;
2. to achieve universal primary education;
3. to promote gender equality and empower women;
4. to reduce child mortality;
5. to improve maternal health;
6. to combat HIV/AIDS, malaria and other diseases;
7. to ensure environmental sustainability; and
8. to develop a global partnership for development
[17].
These goals are interdependent
[18], progress or lack thereof in achieving one goal will have effects on progress towards achieving the others. Likewise it is acknowledged that in order to achieve the MDGs all sections of the UN system will be required to work together and, more importantly, that the UN alone cannot achieve the MDGs. Achieving the MDGs will require the cooperation and action of UN member states and of other international, regional and local governmental and non-governmental organizations. WHO in particular accepts this to be the case; WHO’s need to work closely with other UN bodies, states and other actors in the international system is a major theme of WHO’s
Eleventh General Programme of Work 2006-2015.
The MDGs are unique in that they have broad support across the international system. The constituent bodies of the UN and all 191 UN member states are committed to achieving the MDGs. Regional organizations including the European Union
[19] and the Association of Southeast Asian Nations
[20] (ASEAN) frame, to varying extents, their policies in a variety of areas around the achievement of the MDGs. Many major international charities such as the Red Cross
[21] and OXFAM
[22] are focusing their work, again to varying degrees, on achieving the MDGs. There are also many civil society organizations, operating at local, national, regional and international levels that are engaged with the MDGs
[23]. Considering this broad support it is little wonder that WHO have chosen to focus so heavily on the achievement of the MDGs in the
Eleventh General Programme of Work 2006-2015.
WHO and Maternal Health
Following the preceding discussion of WHO’s functions and Millennium Development Goals it is now possible to examine how WHO functions in the area of maternal health. This discussion will be framed around WHO’s contribution to achieving MDG 5 which concerns improving maternal health. It will first examine exactly what maternal health is, before looking at how WHO functions in relation to maternal health at the international, regional and national levels.
Defining Maternal Health
The World Health Organization defines maternal health as referring to “the health of women during pregnancy, childbirth and the postpartum period
[24].” Maternal health is complex. There are a broad range of conditions, complications and circumstances that can negatively impact upon maternal health. Some of these are specific to pregnancy, childbirth and the postpartum period
[25] (the period immediately following pregnancy or childbirth, defined as being 42 days in length by the International Statistical Classification of Diseases and Related Health Problems (ICD)
[26]). Others are either pre-existing conditions or conditions that are contracted during pregnancy, childbirth and the postpartum period that are exacerbated or complicated by pregnancy, childbirth or the postpartum period
[27]. Some conditions and complications are acute in nature and others chronic
[28]. Conditions and complications can affect physical health, mental health or both
[29]. Many conditions and complications are universal, affecting women worldwide
[30]. Others are common in the developing world and almost unheard of in the developed world
[31]. Certain conditions and complications of pregnancy are strongly associated with cultural practices
[32]. The one fact that links all these conditions, complications and circumstances is that they are, almost without exception, preventable and/or treatable
[33].
WHO and Maternal Health: The International Picture
The goal of MDG 5 is to improve maternal health. This goal was translated into two targets to be achieved by 2015
[34]. These two targets are:
1. to reduce by three quarters, between 1990 and 2015, the maternal mortality ratio; and
2. to achieve by 2010, universal access to reproductive health
[35].
The second of these targets is the major goal of the International Conference on Population and Development and was incorporated into the MDGs in 2005
[36]. The first is one of the original MDG targets. Progress towards these goals is measured by a number of indicators. The indicators related to the first target are:
a) the maternal mortality ratio; and
b) the proportion of births attended by skilled health personnel
[37].
The indicators related to the second target are:
a) the contraceptive prevalence rate;
b) the adolescent birth rate;
c) antenatal care coverage; and
d) the unmet need for family planning
[38].
It is clear from examining these goals that WHO must address a number of challenges if it is to succeed in meeting these goals by 2015. These challenges are multifaceted. They relate not only to health but to culture
[39], economics
[40] and gender
[41] amongst other factors.
At an international level WHO coordinates much of its policy related to maternal health through the Department of Making Pregnancy Safer (MPS). MPS was formed in 2005
[42] and works “to strengthen WHO’s role in providing technical, intellectual, and political leadership in the field of health and human rights
[43].” The department aims to “strengthen WHO’s capacity to support countries in their endeavour to improve maternal and newborn health
[44].” MPS evolved out of WHO’s Safe Motherhood Initiative
[45] and focuses its work on 75 priority countries. These countries, located mostly in sub-Saharan Africa and south and central Asia
[46] account for 97% of maternal mortality
[47].
MPS primarily focuses on four key working areas:
1. strengthening national capacity by assessing the technical capacity of health systems and health policy within countries;
2. building partnerships with governments and other actors in order to build upon existing strategies for poverty reduction and cost-effective interventions;
3. monitoring progress towards achievement of the MDGs through global surveys and data analysis; and
4. advocacy, particularly mobilizing resources at national, regional and international levels in order to increase investment in maternal health, advocate continuum of care approaches in the area of maternal and newborn health and work towards achieving universal maternal health coverage and skilled care at all births
[48].
The most recent MPS annual report published in 2008 continues with these themes detailing achievements such as the development and enhancement of partnerships with other UN organizations, academic and professional organizations
[49], capacity building workshops
[50] and the development of major advocacy projects
[51].
MPS also publishes recommendations for preventing, managing and treating a variety of common conditions and complications of pregnancy
[52] and on what care should be provided as standard to all women before, during and after pregnancy, childbirth and the postpartum period
[53].
Regional Strategies
With the exception of the Pan-American Health Organization (PAHO) (which serves as WHO’s regional office for the Americas (AMRO)
[54]) which includes maternal health in its general report on health in the region
[55], each WHO regional office, the Regional Office for The Eastern Mediterranean (EMRO), the Regional Office for Africa (AFRO), the Regional Office for Europe (EURO), the Regional Office for South-East Asia (SEARO) and the Regional Office for the Western Pacific (WPRO) publishes reports dealing specifically with maternal health
[56][57][58][59][60].
These reports all take on a similar form. All are focused on one or more of the MDG targets and all follow roughly the same structure. This structure looks at the current situation in each region, strategic directions for the region, and implementation frameworks. What becomes apparent from reading these reports is that all WHO regions face a number of similar difficulties in making progress in the area of maternal health. These difficulties mostly stem from deep and in many cases deepening inequalities within regions. Economic capacity of states and individuals, pre-exisiting health problems including infection and malnutrition, cultural values including gender discrimination and religion and political instability are some of the root causes of inequalities in the area of maternal health
[61][62][63][64][65][66].
In addition to the common problems that all WHO regions face there are a number of issues that are specific to particular regions. These problems, like those which all WHO regions face are rooted in a complicated web of economic capacity, health, culture and politics. One well-known example of a maternal health issue that exists almost entirely at a regional level is obstetric fistula in Africa
[67].
Each WHO regional office believes that if the maternal health situation is to improve they must work to overcome these difficulties at a regional level. For example EURO states that “a regional strategy for Making Pregnancy Safer (MPS) provides the opportunity to call attention to the maternal and perinatal ill-health situation in the region and creates a means to unite efforts to accelerate actions needed to improve maternal and perinatal health in the European region. This strategy was developed in response to requests from some of the 53 European Members States based on their needs
[68].” Similarly AFRO states that its regional roadmap for improving maternal health “provides a framework for building strategic partnerships for increased investment in maternal and newborn health at institutional and programme levels. Consensus amongst the major stakeholders at African regional level to support countries over the next eleven years using this Road Map is a breakthrough in maternal and newborn mortality reduction efforts
[69].”
It is clear to see that the regional level of WHO plays a significant role in improving maternal health and in achieving MDG 5 not only because WHO regional offices are equipped to deal with problems that are specific to particular regions but also because they play an important role in coordinating international policy. WHO regional offices are not merely concerned with issues that affect their own regions, they are also deeply involved with attempting to tailor regional solutions to global problems in the area of maternal health.
WHO and National Policy
WHO’s major contribution to the health policy of individual nations is normative in nature. One of WHO’s major functions, as discussed above, in the area of maternal health at an international level is to publish recommendations on how to care for women before during and after pregnancy, childbirth and the postpartum period and how to prevent, manage and treat many of the complications that can arise during this period.
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