Examination of Witnesses (Questions 588
- 599)
MONDAY 21 APRIL 2008
Dr Gaudenz Silberschmidt
Q588 Chairman:
Good afternoon and thank you very much for attending today. Could
I also offer a general thanks to the Swiss for being so involved
in the health issue and also the World Health Organisation; we
are very grateful for that. We have about an hour, we may or may
not need all of that time. What we would like to do is hear your
views on a number of issues related to the World Health Organisation
and your own Health Foreign Policy. You will get a transcript
of the remarks that you make here sent to you for corrections
of a factual nature. After this session, if there are any things
you feel we have missed out or you would like to bring to our
attention, please do so through the Clerk. Could I, perhaps, start
by asking you to say a little more about your Health Foreign Policy
in Switzerland. The particular interest for us is how that has
changed your approach or your policy, if you like, to international
health issues and intergovernmental organisations, not just the
World Health Organisation but other organisations to which it
is relevant.
Dr Silberschmidt: Thank you very much. Good
afternoon. I have brought you a print-out copy of the Health Foreign
Policy. To go back a little into the history of why and how it
came about, our Secretary of State, my direct boss, Thomas Zeltner,
was a member of the WHO Executive Board from 2000-2002 and realised
the growing importance of international affairs, not only for
Ministries of Development but also for Ministries of Health. He
created a senior management position reporting directly to him
on international affairs. Between Health and Development Ministries
we started to look into how to formalise. We more or less got
stuck on that process but the Government Cabinet decided they
did not want to have only country-wise foreign policy strategy
papers and annual strategies, ,but they also wanted to have sector-wise
strategies, which was a window of opportunity where we managed
to become the pilot of sectoral foreign policy, which is defined
as an agreement on objectives. Now they are working on energy,
environment, trade and culture, so other sectors are following.
This meant we had the Ministry of Foreign Affairs as the neutral
broker between the Ministry of Health and the Swiss Development
Cooperation, which is formerly part of Foreign Affairs but very
independent, as it often is in many countries. This triangle is
quite crucial. I have had exchanges with many colleagues from
other industrialised countries and the tension we most often have
is that the Minister of Health is in the lead in the WHO, whereas
the Ministry of Development has most resources and is paying most
money to WHO. All the time there is the question as to who is
really the decision-maker. With the brokering of the Ministry
of Foreign Affairs this allowed us to come to an agreement of
objectives and, to my knowledge, we are still the only country
that has one which is jointly signed by the Ministers of Foreign
Affairs and Health. This was signed by both and submitted for
information to the Government Cabinet, but they wanted to keep
it as an agreement of objectives between the two Ministries. I
have to specify that we are a system without a Prime Minister,
so it is the whole Cabinet which fulfils the function of Prime
Minister. I know that a few other countries are working on the
same model, Sweden for example, whereas the UK has probably gone
into it much deeper in the thinking but, as far as I know from
the Department of Health, it is still a document of the Department
of Health, it is not a joint document of the three main partners,
Health, Foreign Affairs and Development, independent of Development
and Foreign Affairs being the same ministry or not. What we are
currently doing is trying to deepen strategy topic-by-topic. We
have started with two documents, one on food safety issues where
we are currently negotiating a bilateral agreement with the EU,
and then we have to see what resources we are putting into the
EU, into Codex Alimentarius and other organisations. A second
such paper will be on the migration of health personnel, where
so far the office responsible for migration, the Development Corporation,
and the cantons responsible for the hiring of personnel and other
relevant actors sometimes do not even know each other. We have
tried to take stock of what we are doing. Unlike the UK, we are
not such a big importer of personnel from developing countries,
but we hire in France and Germany and the Germans hire in Poland,
the Polish hire in Belorussia, so there is a domino effect where
we are a main actor in the migration question. Health Foreign
Policy provides us with a decision-making platform where we have
one level which I co-chair with the ambassador responsible for
sectoral policy in foreign affairs and at the ministerial, the
Secretary of State level, we have a once-a-year platform where
we can bring all the issues together and draw attention to them.
Last summer I was invited at the Ambassadors' Conference of all
Swiss ambassadors to present the Health Foreign Policy and it
was useful to put it in the picture of diplomacy where health
has traditionally been absent. This summer for the first time
I will be teaching junior diplomats on health. Whilst trade, environment,
human rights etc. are in the diplomatic training, health has been
missing so far. It gives that visibility but also gives a coordination
mechanism. As next step we will go deeper into the intellectual
property and public health question. There we have established
a specific coordination mechanism. We are currently setting up
an electronic platform where we are in a trial phase, but afterwards
all government actors of the Swiss Health Foreign Policy will
save their key documentation in the same place. That means that
an embassy, wherever it is, can put information into the health
platform and we can put what we do to the WHO or bilateral meeting
when the Swiss and UK ministers meet. We have a joint platform
there and we hope for quite a lot of synergies.
Q589 Chairman:
Thank you very much. That is a very helpful description. Could
I ask you something that, perhaps, I should have clarified at
the beginning. I understand that your title is Head of International
Affairs, but you are also Vice-Director of the Federal Office
of Public Health. Does the Vice-Director mean that you are second-in-command
of the public health system in Switzerland?
Dr Silberschmidt: There is the Director. A Vice-Director
is what is often called in other countries Director-General. That
means I am one of five of the second-in-line. There is one formal
deputy and I am one of the four others. It is a sign that international
affairs has been upgraded. I am in the hierarchical position that
David Harper has in the UK, while I have the function of Sarah
Hendry. I report directly to the top official.
Q590 Chairman:
In other words, the aim of the structure in Switzerland has been
to put the international affairs bit at the second tier of the
Ministry, if you like. Is that a fair understanding?
Dr Silberschmidt: Yes.
Q591 Baroness Whitaker:
This is only a very small clarification. Is that because international
health matters affect the health of Swiss citizens? Or is it because
of a recognition of the importance of international health to
the rest of the world? Are you able to separate those two?
Dr Silberschmidt: That is a key question and
the answer is clearly both. What we have tried to do with the
Health Foreign Policy is to move beyond the domestic/others question.
We had a lot of discussion on how to translate Gesundheitsaussenpolitik,
which was the original title, into English, whether it should
be "Foreign Health Policy" or "Health Foreign Policy".
We wanted to avoid giving the impression of speaking of the foreigners.
It is a continuum of how international policy affects us, the
Framework Convention on Tobacco Control, what the EU is doing,
the obesity work which is directly affecting us. We are probably
not that far, but in ten or 20 years it will start to affect our
healthcare system as well, to what we do on trans-border issues,
planning with France for a pandemic and how is International Geneva
working where we have a project with the WHO to be able to handle
the trans-border issue, to our EU relations, to global health
security issues, to pro-poor health service. It is important to
get out of the division between industrialized and developing
countries into a continuum, especially as most countries are emerging
economies and do not fit into either of them any more.
Q592 Lord Howarth of Newport:
In the document you have just given us, whatever its title should
be, it is mentioned among your medium-term goals, on Page 15 under
"Improve international collaboration on health issues,"
that you seek to "strengthen the normative role of WHO".
I wondered what, more precisely, you had in mind by "normative
role" and in what regard you think it needs strengthening.
Dr Silberschmidt: Especially in the drafting
period about two or three years ago there was some tendency in
WHO to see first and foremost the operative role which means its
development function. It was also linked to the fact that much
more money is involved in the operative role than in the normative
role. I would not question the amount of money that has to be
involved in the operative role, but at that time a large proportion
of senior management brainpower was going into the operative and
not into the normative role. In the operative role, WHO is one
of many players. It can be the World Bank, the WHO, an NGO, there
are many players. While in the normative health function, and
I am speaking of the International Health Regulations, the Framework
Convention of Tobacco Control, the Global Strategy of Diet, Physical
Activity and Health, the currently negotiated Global Strategy
and Plan of Action of Public Health Innovation and Intellectual
Property, the Strategy on Alcohol and so on, be it soft law or
hard law, there was not sufficient attention. We were firmly convinced
that WHO should really work on both legs, on the normative and
the operative.
Q593 Lord Howarth of Newport:
So it is about the development of a global vision, a strategy
and standard setting?
Dr Silberschmidt: Yes. At the global but also
the regional level.
Q594 Lord Howarth of Newport:
Yes. Do you consider that the WHO has improved its performance
in that respect in the period since this document was drafted?
Dr Silberschmidt: I would say on leadership
it looks quite balanced. We can take the example of the Intergovernmental
Working Group on Public Health Innovation, where initially the
D.G. might have underestimated its importance, although now and
it has top leadership attention and the Secretariat has been moved
into her own office. She realised that IHR implementation and
the Global Strategy on Public Health Innovation and Intellectual
Property, are absolute core issues.
Q595 Lord Howarth of Newport:
The international scene has been changing very much in terms of
the arrival of major new players, the Global Fund, the Gates Foundation,
PEPFAR, all sorts of organisations powerfully resourced. Do you
think that the WHO has known how to adapt to these new developments
and turn them to best account?
Dr Silberschmidt: I am in the process of publishing
an article on that question in The Lancet,[2]
where we propose a Committee C for the World Health Assembly.
One of the key challenges is the fact that WHO is not the biggest
player any more and you have intergovernmental players. The Global
Fund is somehow mixed, the current chair is from the private sector,
which is a good thing. The Bill & Melinda Gates Foundation,
has more resources than the WHO; and, while efforts like the Downing
Street meeting last September are very welcome, we think it should
be complemented by more transparent and sustainable action, so
the proposal is to have a committee where engagement with the
other organisations could be annexed to World Health Assembly
resolutions. We have deliberately put it out as an article, an
opinion piece, in The Lancet and not as a formal government
position because we want to stimulate debate. You are absolutely
right, one of the challenges of the coming years is to find a
governance mechanism which keeps the momentum, keeps the independence
of the different organisations, but assures coordination between
all the global health players.
Q596 Lord Desai:
Your medium-term goal Number Ten is to "improve the efficiency
of multilateral players", et cetera, and one can do that
in different ways. You are either looking at players that have
a variety of objectives, like Development and Trade and Education,
trying to coordinate NGOs' ideas on that, or you are thinking
in the Health field between the WHO and all the other coordinating
bodies. Which way do you read your objectives?
Dr Silberschmidt: First of all, as you see in
the lead agency, that are colleagues from the (SDC) Development
Cooporation. One of the strengths is that we have both in the
same document and one of the weaknesses is I cannot fully defend
that, although I will try my best. We need both. We need the global
governance mechanism, where the top key players start to get into
mechanisms of coordinating what they are doing at the global level
and at the same time colleagues from the Swiss Development Corporation
have been co-hosting and co-sponsoring initiatives with the UK
towards the "One UN" approach towards real coordination
in the developing countries where action on the ground is going
on. I think both approaches are fully complementary.
Q597 Baroness Whitaker:
I would like to narrow that down to the IGOs which look into monitoring
human and animal health. I think you give them a fairly good press
in your written evidence, where you say: "the coordination
of WHO, FAO, OIE, the World Bank and the UN System Coordinator
as key actors is working well". I am sure people have learnt
quite a lot from pandemic flu outbreaks, and coordination is probably
much better than it was; but I have to say we have heard from
other people that it could work better, particularly with the
OIE and FAO. I just wondered what your views were, not only on
how it works now—and there are good points and bad points—but
what should be done if it should need to be improved in the future.
Dr Silberschmidt: First of all, my statement
was not an absolute but a relative statement. Overall, to make
intergovernmental organisations work together is extremely difficult.
We are well-advanced in the field of pandemic preparedness and
they co-organise meetings and at the rome meeting you do not know
who is actually in the lead. Often it is easier for a single meeting
than it is in the implementation. It is probably useful if I give
you an example which I have been working on. We have asked for
a review of the Swiss health system done by OECD and WHO jointly.
I can tell you it was a real fight to get them to do it jointly.
From my point of view, politically it was absolutely crucial because
the political right wing would say, "WHO, that is not that
serious" and the political left wing would say, "OECD
is about economics, health is different". This document has
become the standard reference on the Swiss health system for actors
in Switzerland since it was published. Because we managed to get
both organisations to work jointly it was not possible to say
it was biased one way or the other, but it was difficult. On the
migration of healthcare personnel we also had a joint project.
I would say the difficulty within the organisation, within the
Secretariat of the organisation, was more often in the middle
management. It is not too difficult to make desk officers work
together and with top officials you usually manage to get them
at the table, but with middle management there is a tendency to
drive it apart. On the other side, we should also blame ourselves
as governments, and there I think policy coherence is absolutely
crucial because the mandate we governments give to the organisation
often drives them apart. What we are trying, and we are far from
reaching the ideal point, is when we defend something in WTO.
To take an example, we asked for a waiver on tariff and taxes
on essential medicine. That was something within the competence
of WTO because it has to be raised in trade negotiations. But
since trade colleagues have been defending that in WTO we are
defending the same thing in WHO. On the other hand, when it comes
to access to medicine questions from them, they have started to
consult us on what our view is. Yes, we have to blame the secretariats
of the international organisations and continue to put pressure,
but we also have to blame governments because we give different
views, and even from the same government department or ministry
there are different people and the coordination is not sufficient.
So one project comes up at one point and in another organisation
a similar project comes up. It needs consistency within the positions
to say, "Stop, we do not want to work there any more".
I can give another example. We tried to stop the Council of Europe
doing whatever niche they can pick on health, and I have been
fighting for five years to have them focus on the human rights
question because material in the context of foodstuffs is technically
important but I just cannot see the relevance to the human rights
question. The Council of Europe had a committee on materials in
the context of foodstuffs.
Q598 Baroness Whitaker:
What you are describing is surely an inherent tension which is
part of the dynamics of organisations and you can never completely
do away with it. I think what I would like to hear about is things
that we can and should do away with. There are always going to
be different mandates because there are perfectly legitimate interests
that happen to conflict with each other at various points. Particularly
in the animal health organisations, the FAO and the OIE, perhaps
there are structural aspects of coordination which could be improved
so that health is better protected?
Dr Silberschmidt: I think we have achieved improvements
in WHO which is in my responsibility. What I hear from FAO and
less from OIE is less promising. Yes, I think sound governance
is something we can do systematically in whichever organisation
we are in. We can really insist on sound governance, on coordination.
I often ask the question, "Have you spoken to them?"
and there I think we can make a difference. Sound governance of
each of the organisations, policy coherence within governments
and systematically asking on projects, "Have you consulted
the others? Why are those not at the table at this conference?"
the more governments ask, the better the response will be.
Q599 Baroness Whitaker:
Finally, would you see that most room for improvement would be
in the conduct of national governments or through their own representatives
on FAO and OIE?
Dr Silberschmidt: It needs both. The Secretary-General
has to make policy coherence efforts within the UN family but,
on the other hand, we from governments should do our part and
insist on that at the lower level because it is not only a top-down
effort.
Baroness Whitaker: That is a very important
point. Thank you very much.
2 Note by Witness: Creating a committee C of
the World Health Assembly; Gaudenz Silberschmidt, Don Matheson,
Ilona Kickbusch; The Lancet-Vol. 371, Issue 9623, 3 May 2008,
Pages 1483-1486. Back
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