In Bill Gates' speech this past week in front of nearly 60 government ministers and 1,800 delegates at the 64^th Assembly of the World Health Organization (WHO) in Geneva, the Microsoft cofounder urged countries to invest in vaccines and "save ten million lives' by 2020. The timing of the billionaire's appearance was highly symbolic, as the United Nations agency is about to "embark on the most extensive financial accountability reforms in its 63-year history", according to WHO director-general Margaret Chan.

Dr Chan's assessment is dire. She says that, having fought on too many fronts and taken on too many commitments over the last decade, the WHO now finds itself in need of reform. It needs to be more selective and strategic in setting priorities. Chan says that even if the institution has already been living on an austerity budget, it will have to go through deeper structural reform if it is to cope with the health challenges of the 21st century, such as the rise of chronic, non-communicable diseases. She said the recent financial crisis had opened a "new and enduring era of economic austerity."

The WHO's total budget for 2010-2011 is $4.5 billion. Of this, $1.56 billion come from voluntary donations (53% from member states, 21% from the UN and other international institutions, 18% from foundations, 7% from NGOs, and 1% from the private sector). A 10 to 15% drop in these contributions has left the WHO with an estimated 300 million dollar deficit for 2011, which it pledges to reabsorb over the next three years. These financial difficulties will lead to job cuts (the WHO headquarters in Geneva is expected to shed 300 jobs from a total of 2,400), less travelling, fewer publications and new recruits, and the merger of certain services.

It is no wonder then that private-public partnerships are becoming ever more appealing to the WHO. Gates, whose contributions represent almost 10% of the organization's entire budget, is the best example. The American philanthropist was the WHO's second biggest contributor after the US in 2008, when he donated $338.8 million. For the 2010-2011 period, his contributions total $220 million.

The great difficulty facing the cash-strapped institution, of course, is how to make sure that private actors such as Bill Gates do not interfere too much with its health policies. Two years ago, the WHO found itself confronted with a scandal concerning the swine flu epidemic, as it emerged that a certain number of its advisers had close ties with the pharmaceutical industry. Even if the UN agency has tried to protect itself against this kind of conflict of interest, its decision to disclose the names of its so-called flu specialists only after the end of the epidemic caused much criticism.

Another famous example is Paul Herrling, member of a WHO working group for R&D financing. Proposed by Switzerland and appointed by the organization's Executive Council last January, this Novartis research executive will evaluate a 10 billion dollar proposal – of which he is the author.

NGOs have been quick to show their concern about the planned changes, even if they are not opposed to private-public partnerships. One of the projects that attracted most attention is Margaret Chan's desire to establish a Global Health Forum that would include both private and public health actors. "By creating this Forum, the private sector would suddenly be given the same importance as public actors and NGOs. This could potentially lead to a significant increase in the drug industry's influence on the WHO's sanitary policies," says Tido Von Schoen-Angerer, head of the Campaign for Access to Essential Medicines of Doctors without Borders.

He agrees that companies, especially in the pharmaceutical sector, must be among the WHO's discussion partners, but he fears that the proposed Forum could chip away at the World Health Assembly's powers. "Rather than allowing all kinds of private actors to be part of the organization's governing process, it would be better to emphasize the WHO's leadership and improve the private sector's participation in the already existing frame."

Rohit Malpani, political councillor for the NGO Oxfam, thinks the private sector – Bill Gates in particular – already yields a certain amount of influence on the WHO. The negotiations have only just begun, but a pressing question has already started to emerge: will the WHO continue to be in charge of the world's health policy, or will its role be reduced to that of a mere coordinator?

Read the original article in French.

Photo -US Mission Geneva