American Mock World Health Organization: An Innovative Model for Student Engagement in Global Health Policy

The American Mock World Health Organization (AMWHO) provides a platform for students to apply their knowledge of global health policy through simulations of the World Health Assembly (WHA). This model engages and empowers future global leaders in health policy while sharpening their skills in diplomacy, public speaking, and conflict resolution. The major theme for the AMWHO 2015 was Universal Health Coverage, reflecting what the WHA had discussed in preceding months.

I n January 2014, founder and author Neha Acharya created the American Mock World Health Organization (AMWHO) at the University of North Carolina at Chapel Hill, based on the Ontario Model World Health Organization (OMWHO) in Toronto, Canada, an organization holding conferences that simulate the annual World Health Assembly (WHA) held in Geneva, Switzerland. Its sister structure, Model United Nations, replicates the United Nations General Assembly, and is widely popular in both high schools and universities throughout the world. Within the United States, few students have similar opportunities to sharpen skills and explore a future in health policy. Mock World Health Organization conferences fill that gap by engaging students in health diplomacy by replicating the WHA debating a particular, complex global health issue.
While attending OMWHO, author Neha Acharya observed that diplomacy was key to realizing the goals of global health, a concept and skill not prevalent in global health policy curricula. As Ilona Kickbusch and coauthors note, it is necessary for public health professionals to have training in diplomacy and for diplomats to have training in public health to build necessary capacity in health diplomacy. 1 Yet while Lee and Smith agree that "negotiation of health-related agreements can benefit from the skills and experience of diplomats," they argue that "in the past, the 'toolbox' of the health policy maker has not included expertise in international negotiation." 2 With an increasingly integrated and globalizing world, future global health leaders are faced with multifaceted issues that require a skill set in negotiating and forming policies with other global health actors. WHO's significant challenges in effectively cooperating with key stakeholders make diplomacy training a practical tool that can better prepare aspiring public health professionals to listen, negotiate, and develop solutions. 3 Since the founding 2014 AMWHO conference, 2 international AMWHO conferences have been held. In this article, we describe the structure and procedures of the AMWHO conference and roles that students play while illustrating the content of the debate with a case study from the Americas region during the AMWHO 2015 conference. We also present findings from online surveys of AMWHO 2014 and 2015 participants to inform successes and opportunities for growth.

Conference Roles
During each 3-day mock WHO conference, delegates assume the role of either a WHO Member State Ambassador, an NGO representative, or a media correspondent. Most delegates represent WHO member states as they debate, strategize, and form resolutions. A handful of delegates represent NGOs and the media. Reflective of the role of NGOs in global health governance, resolutions proposed by WHO Member State delegates can only pass with approval from a majority of the NGO delegates. Representing the role of the media in global health governance, media correspondents move between committees to report on the proceedings of debate, often influencing the direction of discussion.
Dais members are students from the host university who are trained in parliamentary procedures to ensure a realistic WHA simulation. Three key actors sit on the dais of each committee and facilitate debate during committee sessions: Chair: facilitates debate and ensures that procedural matters follow Robert's Rules of Order Vice Chair: assists delegates with the processes of drafting and approving resolutions Rapporteur: keeps committee order by maintaining the speakers' list, calling roll, tracking all resolutions and votes, and facilitating communiques between delegates

Conference Schedule
Participants spend the first 2 days of the conference in committee sessions, where they debate how to best address the chosen theme, negotiate draft working resolutions, and gather support for their proposed plan of action. They spend the third day in plenary, where all regional committees convene to amend and finalize draft resolutions (Table 1). Subject matter experts provide insight into the theme at scheduled presentations throughout the conference. The conference ends with closing ceremonies, where awards are announced for Best Delegate and Best Position Paper from each region.

Committee Sessions
Set Up and Training Committee sessions comprise the majority of the first 2 days. During committee sessions, WHO Ambassador delegates convene in regional blocs The students convene in regional blocs at committee sessions during the first 2 days of the conference.
based on the WHO regions: Africa (AFRO), the Americas (AMRO), Europe (EURO), Eastern Mediterranean (EMRO), South-East Asia (SEARO), and Western Pacific (WPRO). SEARO and WPRO are combined into 1 region for the conference to allow for a substantive amount of delegate representation in the region. On Day 1, AMWHO conferences begin with a delegate training session to familiarize the students with parliamentary procedure and the overall conference. The first committee session follows shortly thereafter. Within this session, delegates present ideas on setting the resolution agenda to a narrower, region-specific subtheme of the main conference theme. All subsequent resolutions are written on the agenda topic, which is set by majority vote.

Subject Matter Experts
After delegate training on Day 1, an opening ceremony features a subject matter expert who introduces the delegates to the conference theme. This speaker provides a framework and context for delegates to better understand and write their position paper on the topic of debate. Throughout the remaining days of the conference, 2 to 3 subject matter experts speak to provide insight from their fieldwork, research, and other experiences. See Table 2 for a list of speakers from the AMWHO 2014 and 2015 conferences.

Debate Procedures
On Day 2, committee sessions continue, and delegates engage in discourse on the best solutions to the committee subtheme. Delegates address the entire committee in moderated caucuses and obtain consensus on their proposed plan of action. Delegates later enter into an unmoderated caucus for informal discussions that move toward drafting resolutions.

Resolutions
Each region can form up to 2 resolutions. Between 1 and 3 Sponsors write the resolution and are responsible for seeing its passage. Signatories support the spirit of the resolution but may not fully agree with the entirety of the clauses. By the last committee session of Day 2, fully formed draft resolutions are submitted to the dais. At this time, delegates may amend each other's resolutions by adding or removing clauses, altering language, or adding specificity through sub-clauses. At the end of the day, each regional committee votes on all amended draft resolutions. If passed, the draft resolution goes to plenary on the last day for consideration by all member state representatives.

Plenary
Delegates from all regional blocs convene in plenary on the final day of the conference. Sponsors present an overview of each resolution, and the conference as a whole amends and votes on the regional resolutions. Those that pass plenary are sent to the World Health Organization in Geneva for review.

PUBLICITY AND OUTREACH
AMWHO recruited both undergraduate and graduate students through social media marketing, through the American Public Health Association, and emails to individual professors and to university listservs. Table 3 outlines the universities represented at both international conferences, as well as universities hosting regional or local conferences. AMWHO also received sponsorship from local and global health organizations.

CONTENT OF DEBATE
The AMWHO 2015 conference selected the theme of "Universal Health Coverage" in alignment with a topic discussed by the WHA in the months preceding the conference. Table 4 describes the content of discussions and debates that occurred in each region during this conference, and the Box provides more details about the debate that emerged specifically from the AMRO region. The experience concluded at plenary, where AMRO's resolution was passed with the addition of a few amendments. See the Appendix for the AMRO resolution that resulted from the plenary.

SURVEY FINDINGS AND DISCUSSION
In total, 124 and 113 attendees from around the world registered for the AMWHO 2014 and 2015 conferences, respectively. At the conclusion of each conference, we conducted an anonymous   The theme of AMWHO 2015 was Universal Health Coverage. Over the 3-day conference, most participants were grouped into regional committees, based on the WHO regional offices. Some participants assumed the roles of NGO representatives or media correspondents. This case study of the Americas Region (AMRO) committee highlights illustrative examples of the experience of participants.

Day 1 Committee Session: Setting the Resolution Agenda
Upon arrival, each delegate had identified the issues relevant to his/her particular country in the form of position papers. The first committee session began in a disjointed fashion when delegates were given their initial opportunity to speak as a wide variety of concerns were presented.
Under the theme of universal health coverage, the dominant topics in AMRO were primary care accessibility, definitions of essential medicine, health outcomes measurement, health financing, and health workforce and resources. Delegates formed a consensus on the following established agenda: "Ensuring universal health coverage as defined by equitable access to health services for all, with an emphasis on access to care for vulnerable populations."

Day 2 Committee Sessions: Negotiating Draft Resolutions
Delegates aimed to clarify their agenda by agreeing upon key definitions. A comprehensive definition of vulnerable populations ultimately served as a pre-ambulatory clause to the resolution, which set the tone to recognize that each country has distinctive marginalized groups. Further discussion was also needed to define the intent of the phrase "equitable access to all" in the agenda; the delegates ultimately settled upon calling for child health care, primary care, and preventative care. Several countries advocated the inclusion of mental health in this definition, but it was not included.
Once these goals were more clearly defined, debate turned to topics that structurally supported the chosen agenda subtheme. Many of the dominant topics not chosen as the subtheme were later addressed as subtopics in the agenda. The committee discussed the importance of health information systems, accounting for financial hardships, and expansion of health services into underserved regions. Health information systems were proposed to monitor outcomes and thus assess the success of various universal health coverage systems. Finances were tackled with a call for collaboration between countries on international issues as well as better coordination of existing funds within countries.
Throughout debate, the delegates worked within the WHO's scope of power and avoided infringing upon any country's sovereignty. As delegates moved to unmoderated caucus to write resolution clauses, NGOs requested to modify clauses to maintain their influence but rejected any clause that would impose excessive responsibility upon them.
Resolution sponsorsthen presented the draft resolutions for amendments and approval. Among various amendmentsthatdealtwithslightwordingchanges,AMROvoted to include the aforementioned clause concerning mental health, which was pivotal for some delegates whose votes were unsecured. Due to the dichotomy of wealth in the region, the committee did not pass a contentious amendment that acknowledged responsibility to donor countries.

Successes
The vast majority (98%) of respondents from the AMWHO 2014 conference indicated the conference as being "good" or "better," and 90% of respondents indicated they would recommend the conference to a friend. Similarly, the majority (90%) of respondents from the AMWHO 2015 conference rated the experience as "good" or "better," and 97% indicated they would recommend AMWHO to a friend. Survey respondents were also asked to summarize their AMWHO experiences. Table 5 presents some of the open-ended feedback received from respondents according to the objectives that AMWHO seeks to realize. For example, respondents indicated AMWHO provided opportunities to gain practical experience in formulating global health policy that is not possible in a classroom environment. Other respondents pointed to AMWHO's ability to allow participants to think from the perspective of policy makers and other stakeholders.
In addition, the International Federation of Medical Students' Associations (IFMSA) contact at WHO headquarters indicated that the AMWHO 2014 resolutions were succinct and practical and that only a few amendments exceeded the limitations of the WHO; as a whole, the IFMSA contact indicated the resolutions were similar in style, content, and urgency as those created in the WHA. AMWHO will receive feedback on the 2015 conference by March 2017.

Obstacles
Two major challenges identified in the AMWHO 2014 conference were the plenary structure and the desire for professional development opportunities. The AMWHO 2015 conference provided an opportunity to grow and address these challenges to improve participants' experience.

Plenary
Many participants found the AMWHO 2014 plenary session to be less engaging and productive than the regional bloc sessions. In response, the dais of AMWHO 2015 received additional training to enable them to better facilitate debate, and we imposed time limits for the plenary debate of each resolution. We also placed limits on the number of resolutions each regional bloc could submit to plenary. The 2015 feedback showed that while plenary improved, there is still room for improvement in delegate engagement during plenary debate.

Professional Development Opportunities
Based on 2014 feedback, AMWHO 2015 expanded its professional development and networking opportunities. As a direct result, we hosted the "Lunch and Learn" event on Day 2, during which professionals from a variety of fields and sectors, e.g., business, education, and academia, were invited to eat with students and discuss their careers, paths, and interests. Another purpose of the "Lunch and Learn" event was to expose students to the various fields necessary to realize global health equity. Based on survey responses, the "Lunch and Learn" event was Day 3 Plenary: Convening All Regional Committees to Amend and Finalize Resolutions In his keynote, U.S. Ambassador Kolker illuminated that it was out of character for a number of countries in the AMRO region to vote in favor of LGBTQ recognition and advised the delegates to be careful to accurately represent their country's official positions in this simulation of international debate.
Similar to the resolutions of most regions, amendments proposed by countries of other regions during plenary were friendly and passed with little contention. The most substantive changes made included an amendment that removed a line requesting NGO collaboration in the WHO audit, which was recommended prior to implementing a universal health coverage system and an amendment to focus on evidence-based outcomes to determine universal health coverage success. Finally, a clause that provisioned for data protection throughout universal health coverage was added.

BOX. Continued
The vast majority of conference survey respondents rated the conference "good" or "better" and said they would recommend it to a friend.

CONCLUSION
AMWHO fills a gap in global health policy education by providing students with exposure to the mechanics and political dynamics of the World Health Assembly, and an experiential opportunity to develop skills essential to careers in global health governance. After 3 international conferences, AMWHO has developed an effective structure, with post-conference survey results indicating that AMWHO fulfills its objectives.
Since the creation of the conferences, AMWHO has sought to sustain its experiential education efforts by creating university chapters that engage in mock debate and that host regional conferences throughout the year (Table 3). This has filled an unmet need on campuses with growth from 5 to 12 chapters in 2016 alone.
AMWHO is working toward a future as a registered nonprofit that is in all high school and collegiate institutions in the United States, similar to Model United Nations. As AMWHO grows in scope, its purpose remains to develop, improve, and expand our capacity to create a generation of students who understand the complexities of diplomacy and policymaking. With continued growth, the organization has potential to contribute to developing a cadre of learned, well-trained, and capable global health practitioners for years to come.  Delegates noted that "AMWHO 2014 was a truly unique event; tackling international issues in healthcare by engaging in constructive debates and drafting resolutions allowed us to think critically about . . . solutions to promote health worldwide" and was "an ingenious way to engage students from various disciplines through interactive and self-guided learning." Guidance to future directions One delegate reflected, "Coming with very little experience in the global public health arena, AMWHO has allowed me to figure out where my purpose is: at the intersection of public policy and public health. I truly give AMWHO significant credit for giving me clarity regarding my future plans." Another attendee said, "[AMWHO] revived my passion for diplomacy and advocacy. This was the first time I saw that my dream could actually be realized and that my potential and the possibilities are endless." Putting theory and knowledge into practice Several students commented on the practical nature of the conference. For example, 1 participant observed, "I learned that the intricacies and difficulties of forming global health policy are not something you can really learn in a lecture. The kinds of experiences provided at AMWHO allowed a paradigm shift not possible in class."

Understanding other perspectives
One student remarked, "AMWHO is a unique opportunity because we learn to think in the perspectives of policymakers, which helps us understand the difficulties involved with it. As future public health leaders, it's important to understand why nations or parties support or deny certain policies. If we can understand someone's perspectives, only then can we begin to cooperate with him/her to create more comprehensive solutions to our world's greatest problems." Introducing diplomacy and global health skills One student noted, "As a scientist, it is important for me to understand how health policy is made since it both influences and is influenced by scientific research. Because of AMWHO I feel much better prepared to be an active participant in bridging the gap between research and global health." The American Mock World Health Organization fills a gap in global health policy education by providing students with the opportunity to develop skills essential to careers in global health governance.

2.
Urges the provision of a basic set of services to be available to all, prioritizing promotion of primary and preventative care, emphasizing maternal and child care a. Strongly suggests that the basic scope of services in a given nation be expanded beyond the three broad areas stipulated above to encompass specific health needs of each country i. Strongly urges that the issue of mental health be made a priority when deciding to expand the scope of basic services provided ii. Recommends results-based implementation of services in accord with the data generated by health information systems and encourage innovative determinations of success in areas (such as mental health) for which data-base metrics of success do not completely address the situation 3. Endorses the development by member states of systems for Universal Health Care (UHC) in which all populations with a focus on aiding vulnerable ones, have access to needed health services without incurring financial hardships a. Encourages the creation of partnerships and collaborations between countries, which may be necessary to make the development of such a system feasible in some developing nations b. Encourages better targeting and coordination of existing funds to address international issues, including but not limited to migrant populations, disease epidemics, international information databases, and assistance to countries in need with regards to individual universal healthcare coverage systems. c. Supports the exploration of various financing schemes for individual contributions on a country-bycountry basis d. Affirms countries' responsibility to develop cost-effective health coverage systems i. Emphasizes strengthening prevention-based programs as a way to potentially lessen financial burdens from preventable diseases, especially among vulnerable populations 4. Urges the expansion of health services into underserved regions to provide primary and preventive health services a. Suggests the development of health facilities in both rural and urban regions to help lessen the geographical barriers and opportunity cost to health care access for vulnerable populations b. Encourages the development of an able and plentiful health workforce to ensure that people of all regions have access to quality health care i. Suggests that the aforementioned workforce also serve to educate the local populous with regards to personal healthcare ii. Calls upon both individual nation as well as the international community to begin a selfsustainable training program, focusing on developing community health worker programs iii. Calls to be accomplished via the building of human capital of local individuals from communities and local indigenous groups. This will ensure sustainability, cultural relevancy, and trust from locals of health workers.
1. Encourages the formation of Community Health Workers (CHW) programs that are integrated with existing or developing health systems, including supervision and remuneration c. Suggests utilizing existing and local infrastructure as well as creating and improving new health care infrastructure to maximize efficient resource allocation and ensure cultural sensitivity 5. Expresses its appreciation for Non-Governmental Organizations (NGO) participation, and encourages focused exit strategies for countries to remain self-reliant and sustainable