This report focuses on the World Health Organization’s Regional Office for Europe. It examines its dimensions, history, relationships and the knowledge that it draws on and creates in its work. As a specific focal point for this exploration we examine knowledge in relation to the development of a Ministerial Conference which took place in Helsinki in January 2005 which launched WHO Europe’s Mental Health Declaration and Action Plan for Europe.
The research is part of the European Commission funded KnowandPol project which investigates knowledge in relation to health and education policies within eight European countries. The part of the research that this report focuses on reflects on the way a supranational actor – in this case WHO Europe – uses and produces knowledge. This report is designed to be understood in relation to a series of national case studies from each of the six KnowandPol health teams which investigate the way the knowledge produced by the supranational actor was both contributed to and received by national governments.
Our analysis is based on empirical material of various kinds, both primary and secondary. It includes:
• a review of the secondary social scientific literature on WHO;
• a review of WHO publications, including reports, papers and other secondary documents;
• a close textual analysis of primary documents produced by WHO, including the Mental Health Declaration and Action Plan for Europe, drafts which led to its final development and the documents by which they were informed;
• interviews with key actors involved in the production and use of the instrument including WHO staff, EC officials, project staff, representatives of other international organizations and national officials with particular experience of working at an international level.
A new typology of knowledge:
Our report introduces a new typology of knowledge based on our reflection on the data gathered through the study. We delineate two forms of knowledge – embodied and encoded – and highlight the important role of enactment.
Embodied knowledge. This is knowledge held by human actors, and mobilized and enacted by them as they go about their work. Such knowledge is fundamental to our existence in the world; it structures our experience, our thoughts, and our actions and interaction. Embodied knowledge also includes know-how - knowledge of how to act in or upon the natural or social world for particular ends.
Encoded knowledge. This is knowledge that is embodied or inscribed, not in actors, but in artifacts. These include texts and other symbolic and informational systems - maps, for instance, or databases - but also other kinds of objects. Encoded knowledge, like embodied knowledge, can include elements both of factual knowledge and of know-how.
Enactment. This is less a type of knowledge but a way of putting to use – of enacting – knowledge within particular regulatory environments. Embodied and encoded knowledge must be enacted for it to be used and it can be enacted within forms such as meetings and conferences. These will then themselves produce new forms of encoded and embodied knowledge.
We find that WHO is a knowledge based organisation which produces and distributes knowledge according to an evolving set of standard instruments: technical meetings, consultative visits, surveys, disease surveillance mechanisms, the development of norms and standards, conferences, commissions and reports, among others, as well as (in developing contexts) a limited provision of personnel, medical supplies and other materials. WHO Europe’s work on mental health has mainly involved the generation of consensus on specific problems and issues to identify and promote best practice, and exercises to survey mental health services and policies in member countries.
The development of the Helsinki Ministerial Conference was decided on in 2000 when Marc Danzon took up his post of Regional Director of WHO Europe. A series of meetings to organise the conference and develop documents preceded the conference. The Declaration and Action Plan themselves were finalised before the conference took place and it was adopted unchanged at the conference. A ‘baseline’ survey was developed after the Helsinki meeting in order to assess the extent to which the different European member states had progressed towards the fulfilment of the goals of the Declaration and Action Plan.
We make a number of points about knowledge in this process:
WHO and knowledge:
We make several key points about WHO and knowledge in relation to this process:
• WHO is identified as an active agent of change which has responsibility for making statements about the way mental health policy currently functions in Europe and the direction in which these policies should head.
• Much of WHO’s work involves bringing together (formatting and re-encoding) the work of others and making authoritative guiding statements whose authority is underpinned by WHO’s institutional position.
• The authority of academic knowledge is taken as given.
• The extent to which service user and carer knowledge has authority is still being negotiated.
• The good practice presented by NGOs and different government programmes serves to validate WHO’s plans for mental health by showing that the actions that they propose can work in practice.
There is a focus on the development of appropriate instruments in the discussions preceding the conference. We make the following points about this:
• A wide range of different knowledge-based instruments are identified as needing to be developed in order to fully understand and change mental health policy and systems across the WHO European Region, including indicators, cost-effectiveness studies, and evaluations.
• There is a focus in the documents on WHO European Region as a site of comparison. Indicators and other forms of encoded knowledge are identified as necessary if this function is to be carried out effectively.
• Indicators are validated as necessary for the production of evidence, but the ends to which the data deriving from these indicators will be put is not fully articulated.
We note a process of interinstrumentality in which any form of knowledge exists within a chain of other types of encoded, embodied and enacted knowledge. Specifically we make the following points:
• Official WHO policy instruments, such as resolutions, Declarations, conclusions, conventions, agreements, Action Plans, frameworks and recommendations are key interinstrumental forms created as a result of the enactment and encoding of embodied and previously encoded knowledge at meetings, conferences and other events.
• Interinstrumental references serve the purpose of linking and situating the documents, which then validates their use.
• Instruments such as Declarations and Resolutions are key to the flow of knowledge and the progress of WHO Europe’s vision for mental health.
Knowledge is only relevant in terms of its enactment in relation to other forms of knowledge.
The international order is an interaction order: international relations are also human relations. What is called the ‘international’ is a place and moment in which actors enter the presence of others, a moment at which some relationship between them is posited, in prospect, in some form or another. Those actors chosen to represent their countries at Helsinki were concerned that others should respect the approach taken on mental health policy in their home countries. Actors therefore sought to control the perception others formed of them through the way they performed at the meeting. They did this through controlling the information others were able to gather about them. For example, the teams from those countries who had already made progress in relation to WHO’s agenda set about presenting themselves and their work in a highly visible fashion. Other teams from countries whose mental health systems were lagging behind this agenda performed in a way which aimed to save face.
Much of WHO’s effectiveness lies in the way that it brings things together. WHO assembles different configurations of actors and knowledge within different settings and in so doing draws together and produces knowledge which leads to further action. We draw on the example of WHO working groups and the Helsinki Conference to demonstrate how WHO assembles this knowledge within projects, platforms and alliances. The Helsinki meeting brought together different actors and educated them 4 about WHO’s mental health framework. These actors then took this knowledge forward through new national and international projects.
FREEMAN Richard, SMITH-MERRY Jennifer & STURDY Steve (2009), WHO, mental health, Europe, KNOWandPOL Report.