E1 | World Health Organization
The strategic importance of the WHO as the UN’s specialist health agency, its many influential programmes and policies at global, regional and national and community levels, and perhaps above all, its humanitarian mission, earn it worldwide authority and guarantee it a central place in this report. While it may be seen as the leading global health organization, it does not have the greatest impact on health. As many sections of this report illustrate, transnational corporations and other global institutions – particularly the World Bank and International Monetary Fund – have a growing influence on population health that outweighs WHO’s. Furthermore, some of these institu- tions, the Bank in particular, now operate in direct competition with WHO as the leading influence on health sector policy. The rise of neoliberal economics and the accompanying attacks on multilateralism led by the US have created a new, difficult context for WHO’s work to which the organization, starved of resources and sometimes poorly led and managed, is failing to find an effec- tive response. The purpose of this chapter is to explore this decline in WHO’s fortunes from the perspective of a critical friend, and suggest how it might begin to be reversed. The problems of global health and global health governance are be- yond the reach of any entity working in isolation, requiring WHO leaders and staff, governments, health professionals and civil society to work together in new alliances. A new shared vision of WHO for the 21st century must draw on its strengths, but be reshaped for the modern world, as part of a broader vision of global governance. And then we have to make it reality. The Health for All movement partly succeeded in moving from vision to action: this time round, as inequalities widen and the health of many of the world’s poorest people worsens, we have to do even better, because failure will be catastrophic.
A complex organization Entering the Geneva headquarters of WHO is an awe-inspiring, even in- timidating experience. Having made your way there past a series of imposing buildings occupied by a range of famous organizations, including the United Nations and the International Red Cross, and admiring the distant views of the Swiss Alps, you finally reach a huge 1960s block set in a grassy campus. Its interior, gleaming with glass and marble, seems designed to impress rather
269 Holding to account | E1 final part of the chapter therefore focuses on three major drivers of WHO per WHO ofdrivers majorthree thereforechapter onfocuses the of partfinal The solutions. on short but description on long are critics the that noted is it reforms, and criticisms major recent reviewing In institution. an as WHO on card report brief a present will it Rather, report. this in elsewhere cussed dis are policy health global of Issues proposals. reform and criticisms many despair.and angerfrustration, to inspirationand optimism from Inevitably,too, suchlarge a anddiffuse organization provokes strong feelings, dangerous.and difficult both it generalizationsabout make it, with and it for gionaldifferences itsinstructures, andtheinfinite variety peopleof whowork re and complexity the it, does it where and does WHO what of range im mense The body. health leading world’s the and health for agency specialized UN’s the organization, same the of part are settings these all Yetdanger. cal member states – and how they need to change. to need they how and – states member ofattitudes the and WHO, environmentofinternal resources,the – formance office in a country in conflict where staff operate under conditions of physi of conditions under operate staff where conflict WHO in country the a from office in way long a is It bottle. a than rather breast the from babies their feed mothers new help to midwives encouraging are consultants WHO world. the over all fromprofessionals health of hundreds house cubicles small of corridors smart less rather Upstairs, match. to menu exotic enormousrestauranttheanoffers andglobe, the ofcornerevery visitorsfrom befriend.thanBesuitedbureaucrats secretariessmart shouldersand rub with hs hpe cno d jsie o h fl rne f H atvt ad the and activity WHO of range full the to justice do cannot chapter This The calm, hushed atmosphere is a far cry from the simple bush hut where hut bush simple the from cry far a is atmospherehushed calm, The 20 HealthministersgatherattheWorld HealthAssembly. 270 - - - - - World Health Organization ------271 WHO WHO came into formal existence in 1948 as the UN specialist agency for The sources consulted worldwide in making this assessment include litera include assessment this making in worldwide consulted sources The The The importance of health to the global political agenda of the day was re The The Secretariat is the administrative and technical organ responsible for health, health, incorporating several existing organizations that represented a long history of international health cooperation. WHO’s objective is the attain Some background tal tal human right and that governments are responsible for the health of their peoples – bold statements treated warily by governments who equated social equity and socialized medicine with ‘the Communist threat’ (Lee 1998). Thus politics and health were inseparable even at WHO’s birth. ture written by academics, development agencies, policy analysts, present and and present analysts, policy agencies, development academics, by written ture former WHO staff The and members views official health of journalists. some countries individual from literature in selectively reviewed were states member and major donor networks. Interviews were conducted with past and present WHO and staff members, consultants and advisers, other The observers. staff members included people working at global, regional and country levels in a range of specialties and fields, at different levels of seniority and from dif semblies of delegations from all member states is unique in the UN system, and and system, UN the in unique is states member all from delegations of semblies to influence. exert opportunities unparalleled countries developing offers flected flected in the decision to give WHO its own funding system and a governing body of all member states that is still unique among UN specialist agencies. Its basic and have structure composition overall changed organizational little body governing its agencies specialist non-subsidiary UN other Like 1948. since states member UN All UN. the to annually reports but decisions, own its makes and others may join it. Through the World Health Assembly, its 192 member states the approve of programme work and A budget and decide major policy. on selected board the with executive membership, rotating basis 32–strong of geographical a (although representation country than rather expertise personal (WHO decisions assembly of implementation oversees maintained), is balance global website, 2005). Its accountability to its annual global and regional as ferent ferent national backgrounds, some newly arrived in the organization, others Many long-serving. WHO informants felt anxious about speaking openly, and views The identifiable. be not would they that basis the on interviewed were all described here represent an aggregate rather than those of any individual. ment ment by all peoples of the highest possible level of health, defined as a state absence the merely not and well-being social and mental physical, complete of of Its also constitution asserts disease or that health infirmity. is a fundamen Holding to account | E1 initiated or endorsed such key initiatives as the expanded programme on im on programmeexpanded the as initiativeskey such endorsed or initiated He industries. food and pharmaceutical the in corporationstransnational of practices commercial the challenging conscience’, ‘health global a as WHO establishedHe general. in healthglobal of perhaps and WHO of age golden a Halfdan Mahler, DG Dr from 1973–1988, is whose remembered term of office Best is often change. spoken significantof as over presided least at or Each led has years. 60 nearly in (DG) directors-general six only with leadership, its of longevity the shows also It successes. its of some and operates, it which in illustrateschallenges,magnitudeitsthecomplexityenvironmentof thethe of particular needs, with an infinite variety of funding and governance arrange governance and funding of variety infinite an with needs, particular meet to WHO with partnership in evolved have institutions different Many people worldwide work on projects or in centres funded or supported by WHO. required. skills/experienceis of setspecialized very a whenespecially candidate, favoured a recruit to ignored often is practice in but regions, all represented. A quota system is meant to ensure a fair distribution of staff from over disproportionatelywomen with services, support and administrative in working ie staff, ‘general’ are thirds two other The levels. senior at creasing de women of proportion the with men, are thirds two and doctors medical 1948. sincedisagreement and debate of matter a been has levelserational challenges of achieving good overall governance.overall good achieving of challenges many the highlights that fact a family, WHO the of complexity and range the secondments from member states. No organogram could successfully capture and funds with supported strongly sometimes work, of programmes agreed jointly conduct Centres Collaborating WHO designated of Hundreds ments. not only to lack those qualities but also to take office at a time when neoliberal Hiroshifollow.successorNakajimamisfortunehisDrto the actof hardwas It 1). chapter B, part in detail in cussed declaration(dis Ata Alma the – crown the in jewel the – substitutes,andmilk munization,the model list of essential drugs, the international code on breast Milestones op main three these betweenresources and power of balance 140 The countries. around in offices WHO in or centres, specialist and outposts their and offices regional six the in headquarters, at either working secondments, and contracts short-term on more thousand several and appointments, service career- or fixed-term on staff 3500 around has It activities. the implementing s el s hs drcl apitd tf, hg vrey n nme of number and variety huge a staff, appointed directly these as well As are majority vast the whom among ‘professional’, are staff the of third A alrs iinr ad nprtoa laesi ws las on t b a be to going always was leadership inspirational and visionary Mahler’s A look at some of WHO’s major historical milestones (Lee 1998) (Lee milestones historical major WHO’s of some at look A 272 ------World Health Organization - - World World World health situation situation health World published. 273 on health systems. health on Box E1.1 in WHO history Milestones World health report report health World : most data drawn from Lee 1998) Lee from drawn data most : Health Report Health Control. Tobacco on Convention Framework when its constitution approved, becomes World Health Day. First First Day. Health World becomes approved, constitution its when Mass states. member 53 by attended (WHA) Assembly Health World syphilis. for begun programmes treatment the are they Regulations, Health International the renamed (later health). international governing rules binding only First 1967). till started not programme means report. heid. South Africa leaves WHO. leaves Africa South heid. identified. smallpox of case natural Last drugs. essential of tries. substitutes. Source 2003 2003 WHO initiative. 5 by 3 Launches DG. sixth is Jong-wook Lee Dr 2005 established. Health of Determinants Social on Commission 1998–2003 1998–2003 DG. fifth is Brundtland Harlem Gro Dr 2000 established; Health and Macroeconomics on Commission 1965 1965 model. services health basic the forward puts WHO 1973–88 director-general. third is Mahler Halfdan Dr 1974 created. immunization on programme Expanded 1977 list model Publishes 2000. Year the by All for Health proposes WHA 1978 coun 134 by signed care health primary on declaration Ata Alma 1981 1981 breast-milk of marketing the on code international adopts WHA 1982 Geneva. in AIDS on meeting Consultative 1986 signed. promotion health for charter Ottawa 1988–98 DG. fourth is Nakajima Hiroshi Dr 1995 WHO First ( 1948 1948 7, April health. for agency specialist UN’s the as established WHO 1951 Regulations Sanitary International the adopt states member WHO 1955 launched. programme eradication malaria Intensified 1959 funds of (lack smallpox of eradication global to commits WHA 1964 apart against protest in rights voting Africa’s South withdraws WHA health policies were beginning to supersede the social justice model model of the justice to health social supersede were beginning policies health by accompanied right, the to shift ideological global a was backdrop The all. for oil recession, crises and economic rising debt. WHO’s core remained funding Holding to account | E1 programmes,susceptiblewasthatheand influence. US to Hopes werefurther vertical in rooted strongly too was experience his that concerned were others internal matters more sensitively – he has worked in WHO since 1983 – though handle would insider an that felt who staff many by enthusiastically greeted (Yamey2002).countriesdeveloped from men white by dominated still top-heavy, and centralized remained WHO term five-year her of end the At uncomfortable. was climate organizational the and reasons, right the for necessarily not favour in were who people promoting of sake the for or sake, change’s for change just was it that felt staff Many 2001). Matzopoulos and (Lererappointment her by generatedoptimism internal the erodedgradually appointedandlarge numbers staffof redeployed majorain restructuring that were managers top New results-oriented. and businesslike more WHO make partnership initiativespartnership with the World Bank which during tenure, her about views mixed are There 4). chapter E, part (see treaty health public first world’s the Control, Tobacco on Convention Framework p and agreed, were Goals Development Millennium UN the where summit the at agenda the on growth and health. Macroeconomics on and Health that Commission explored the relationship inter the between economic like the initiatives up through higher agenda, development health national pushing about set She welcomed. widely experience, was political international and national with background medical departure. his lamentedFew ures. i mngmn sye hg-rfie iareet ad omncto fail communication and disagreements high-profile style, management his responses to these challenges, also alienating WHO staff and partners through convincing with up come to failed ultimately and struggled Nakajima 2002). dis- social integration,andfrom demographic andsocial shifts (Lee 1998, andBuse andWalt disasters natural or human with conflict armed combining emergencies complex from diseases, emerging newly other and AIDS from reforms. sector market-orientedhealthimplementing on tional route to better health nevertheless felt obliged to accept its large loans condi loans large its accept to obligedneverthelessfelt health better to route the about said Bank World the what like much not did who those Even role. leadership its challenged and field health the entered actors new while static The appointment of her successor Dr Lee Jong-wook was likewise initially likewise was Jong-wook Lee Dr successor her of appointment The to aiming reforms internal sweeping introduced Brundtland Meanwhile h eeto i 19 o D Go alm rntad wo obnd a combined who Brundtland, Harlem Gro Dr of 1998 in election The At the same time, new healththreatstime,newsamedemandedthe urgent responsesarisingAt – WHO also strengthened its organizationalideologicalstrengthenedrelationshipitsalsoand WHO Her most acclaimed achievements included putting health rudn al ebr tts o nos te 03 WHO 2003 the endorse to states member all ersuading and encouraged and pursued controversial public-private (Buse and Walt and (Buse 274 2002). - - - World Health Organization - - - 275 Even the harshest critics admit that WHO can claim many important In many countries it remains the best trusted source of objective, evid- After After 18 months in post (at the time of writing) it is too early to pass defin- Many Many of these shifts in WHO policy and management over the decades achievements achievements since 1948. Many are highlighted elsewhere in this report. In disease prevention and control WHO led the global eradication of smallpox. It is making good progress towards eradication of poliomyelitis, leprosy and dracunculiasis, and ongoing efforts to tackle malaria, cholera, tuberculosis and HIV/AIDS (albeit inadequately funded and unlikely to reach the desired targets). Its leadership role in collecting, analyzing and disseminating health evidence is unrivalled. It is the leading global authority preparing guidelines and standards on numerous issues, and the foremost source of scientific and technical knowledge in health. ence-based, ethically sound guidance and support on health. Since Lee’s ap ence from a distant regional centre that sometimes has only limited knowledge knowledge limited only has sometimes that centre regional distant a from ence of what is going on in the field. Seen by many as the most important focus of WHO activity, and promised a stronger role in the Lee reforms, most of the country offices remain attached to low-prestige ministries of health, and are offices country-based the with comparison in resourced inadequately and weak of other international organizations and government development agencies. Current context: recent successes itive judgement. Lee’s flagship initiative to treat three million people with AIDS AIDS with people million three treat to initiative flagship Lee’s judgement. itive with antiretroviral therapy by the year 2005 (known as 3 by 5) demonstrates a passionate, high-risk approach that has divided staff and partners, arousing Gates) (e.g. foundations private of influence The opposition. and support both and the to grow continues GAVI) GFATM, (e.g. partnerships and public-private question of WHO’s place in this emerging configuration is still unresolved. of the on Meanwhile new Health could rep Commission Social Determinants raised raised by his attempts to revitalize WHO’s commitment to Health for All, in contrast to Brundtland’s more neoliberal focus. were were reflected in the six WHO regional offices, though their locally regional directors elected (RDs) exercise considerable autonomy from headquarters. The changes gradually filter down through the regional offices to independ much enjoy may too the these although WHO administer, they offices country resent resent an important advance. pointment pointment as DG it has regained some of its reputation as the world’s health and of conscience, facilitation an global effective to response the severe acute health public critical its underlined has outbreak (SARS) syndrome respiratory Holding to account | E1 performingimportant globalcommunicable diseasesurveillance conand • advocacymarginalizedfor population poor,groupsthepeoplesuchas • 2004,Murrayal.interviewset personal and communications). Theseinclude: Walt2002, DFID 2002, Minelli 2003, Selbervik and Jerve 2003, Kickbusch 2004, andTangcharoensathienWibulpolprasert BuseMatzopoulosand2001, 2001, and Lerer 1998, Lee 1997, Godlee example (for strengths traditional its tion • the gradual therenaissance primaryofhealth healthcareand promotion, in • goodpractical analyticalandviolenceareas keysuchas workon and • returninginternationalhealththeto development agenda; • work: of areas new into WHO taking is which of some and strengths,tional cornerstone of international relations’ (Lee 1998). (Leerelations’ international of cornerstone a as WHO for need the recognises world the that work (this) all for is ‘It role. provisioneffectiveof technical supportsomecountries,in withintightre • excellentstaffwhosetechnical expertise internationaland healthexperi- • innovativeintersectoral programmes HealthysuchasCities. • promotionagendasofvalue-based,thatare knowledge-based supportand • productionauthoritativeof guidelines standardsand thatsupportexcel • activegreatersupportainvestmentfor relevant inapplied and health sys • interagencyalliancesPartnershipthe suchas SafeMotherhoodfor and • moreactivetransparentand engagementreform WHOprocessesin with • emerginginnovative approaches knowledgeto management usingnew • global,regionalnational and health reports cross-countryand studiespro • with AIDS and peoplewithAIDSandwithmental illness; healthcomplexandemergencies; ay oml n ifra eautos n cmetre o WO men WHO on commentaries and evaluations informal and formal Many ence unsurpassed;are vidingevidenceanpolicy, basefor practice advocacy; and There is also praise for recent work, some of which builds on these tradi these on builds which of some work, recent for praise also is There health,ratherthanideologically drivenpoliticallyor motivated; sourceconstraints; trolfunctions, withSARS;as NewbornHealth; cludingchallenges commercialto interests thatdamagehealth; PerformanceAssessment Networkeightleadingof donor countries; someinfluential memberstates,Multilateralthe suchas Organizations technology; temsresearch; lentpractice; 276 ------World Health Organization - - - - 277 The often contradictory accusations and criticisms of WHO reflect the exist the reflect WHO of criticisms and accusations contradictory often The A A controversial review of its partnership with WHO by the UK Department continued domination of biomedical thinking, are said to or lack impact thinking, of biomedical domination continued approaches. intersectoral and to systemic, hinder sustainability is said to be with countries wrong. cooperation technical states. member viser, monitor and evaluator limits its ability to discharge functions such functions to discharge its ability limits and evaluator monitor viser, reporting. global as independent by are Fund for TB dogged turf wars. AIDS, and Malaria, it activities whose interests business with partnerships into public-private than courting. rather be should condemning and nepotism. corruption ence ence of a wide range of critics, with different agendas. A number of criticisms emanate from interests that want to weaken WHO’s mandate and capacity to tackle urgent global health problems, especially poverty, or to challenge the hazard merchants (commercial enterprises profiting from products that damage health). Other reflect criticisms over frustration WHO’s lack of politi Current context: major criticisms Current context: for International Development pronounced it ‘an improving organization’ (DFID 2002), while others note how WHO has begun to and ‘refashion reposi • • and results; management on focus performance internal stronger • on rights; of human for example WHO staff, training better • to and medicines. access control tobacco for global advocacy effective • • the reflecting programmes, control disease single-focus ‘vertical’, WHO’s • and activities standard-setting global normative, between The balance • from pressure political by skewed intense are constantly Its priorities • ad technical as roles advocate, conflicting and sometimes Its multiple cal cal will and strength to tackle the drivers of poverty and health inequity, and its inefficiencies. Of the latter group, the following bullet points represent a selection of the more common criticisms: tion tion itself as the coordinator, strategic planner, and leader of “global health” initiatives’ (Brown et al. 2004). Much of this praise, however, has a ritual air, run through rapidly as an appetiser to the main dish – strong criticism. • • society. with civil partnerships It has not effective built • such as the Global agencies, international major with other Its relations • by entering principles It on and moral values is said to be compromising • and of is by beset rumours of is ineffective being accused Its leadership Holding to account | E1 yond its control. It is tempting to underestimate the complexity of the challeng that undermine or manipulate the organization, and fail to support the progres waysin actfora,differently voteWHOthen record, in whothe states,off often memberfrom quick-fixsolutions.critiquescome Strongfor desire a and goat health evidence and knowledge. and evidencehealth publicbest the on basedaction take torefuse they humanityifagainst crimes international all health actors’, of even taking countries requested to an international is court for that system reporting of kind new a through governance mandate, including ensuring ‘transparency and accountability in global health stronger and new a it giving and WHO strengthening means this says (2004) of good global governance without losing their energy and creativity. Kickbusch systemtowardsa movecan partnershipshealthalliances andpatchworkin of present the how ask They organizations. society civil and local for-profit private, and global and states; nation organizations; international – together work partners which in governance health for arrangements novel requires globalization (2002), Walt and Buse to According governance. health global stronger for call commentaries of group powerful most The inequality. and whatneeds tobe done beyond indisputable statements about tackling poverty about consensus little is There solutions. practical on short and accusation, 2003). Jerve and (Selbervikinformants its by similar broadly be to perceived Bank World the and UNICEF WHO, of performance in part E). A recent survey commissioned by leading donor countries found the with the UN system and weak international governance (see the other chapters widespreaddiscontentofprevailing mood internationalthe other agenciesin at levelledbeing arecriticisms similarMoreover, one. globalcollective a than ratherorganization individual an of failures the as problem the view to or es, theirexperienceas perhapspositives.makesthe themmoreawareof externalthoseoftoughacademicas leastas observers, roundedmorealso but consultantsusuallyandstaffatare WHOcriticisms within. sivesbyThe made • Its management Its top-heavy,is hierarchical, overpaidcentralized, and rul • Some are diametrically opposed. Some reveal a tendency to use WHOnews. asgood thana ratherscape news bad on focus to tendencythe of becausesimply speeches and their range and scope is enormous. They may appear unbalanced • Its staffdominated Itsareprofessionals by fromdeveloped countries within • ial, n pras rcal, h ciius r ln o dsrpin and description on long are critiques the crucially, perhaps and Finally, be way often are but many, just not are door WHO’s at laid problems The hs ciiim ad tes per n udes f ok, rils and articles books, of hundreds in appear others and criticisms These sufficientexperience poorcountries.of ing autocraticallying entrenched,overan bureaucratic subculture. 278 ------World Health Organization 279 21 WHO – up in the clouds? Standing Standing in the marble halls of WHO headquarters in Geneva, or seeing Reactions Reactions have been mixed to this idea of WHO as a ‘world policeman’ and practice and culture in shifts internal enormous the make WHO can Yet a a WHO official check in to fly business class to a distant location, it is to hard imagine that the organization is in a long-running funding crisis. But but but director-general Lee at least agrees that ‘business as usual’ will not do. He promises a return to the aims and ethical commitments of Health for All – scale-up of health systems, guided by the principles and practice of primary health care, adapted to a rapidly changing health landscape and through delivered synergizing swift responses to health emergencies with long-term strengthening of health infrastructure. Asserting that a world torn partners its and WHO by whether asks he trouble, gross serious in is inequalities health are up to the challenge, and gives his answer: ‘We have to be’ (Lee 2003). develop the leadership capacity essential at all levels to turn Dr Lee’s rhetoric into reality – to drive good global health governance, resources secure and deliver effective programmes? And the can the other necessary global health leaders sink their differences to support WHO and each other in a new spirit be now will reform WHO for prospects The commitment? and of co-operation with to and considered reference environment political its internal resources, context. Inadequate resources Holding to account | E1 paymasters. WHO has felt obliged to sideline the primary health care approach politicaltheir and them to results quickdemonstrate to requirement the and donors of desires the with conform to neglected even and distorted are ties exert greater control over their money by giving WHO extrabudgetary funds ear public-privatepartnershipscountriesWaltrichprefertoand (Buse2002).The tries,otheragencies andcharitable foundations increasinglyandis turning to and waste of human resources.human of waste and inefficiencyin resultingfunds, scarce organizations,for other with and itself, donorshelpsustainto incentivean system whichby WHOmust compete with the Thus fundraising. themselves find reluctantly knowledge technical their for hired staff while externally, and internally funds, for other each against Programmeswasted.competeis effortand time much so WHO inlacking are as intensive input from professionals whose sole function is fundraising. Both wellexcellentrequirescoordination,internal cut-throatasand is money such forCompetition funding. core more than ratherprojects, specific for marked coun to bowl begging its take to has itself WHO function, to order in fact, In on destigmatizing mental illness, people often say, ‘Let’s ask WHO for money.’ campaign advocacy an or say, nurses, for programme training new a start to extrabudgetaryfunds. in more much gives it though – 2004 in budget service health national England’s of 0.02% just – 2002) (DFID budget For example, the UK contributes only US$ 22 million a year to the WHO regular tionwithWHO(andother agencies). UN Theamounts anycaseareinmodest. indolence or policy. The US only pays 80% of its levy because of its dissatisfacits ofbecause levy its of 80% pays onlypolicy. US indolenceor The through whether time, on dues their pay to fail countriesdramatically. Some diminished has terms real in value whose budget, regular its in growth zero had has agencies, UN other with along WHO, 1980s early the Since US). the always paid) ranges from 0.001% to 25% of WHO’s core funding (the latter from not is it (though contributed be to percentage the so account, into economy its of size the takes that formula complex a by determined is budget regular the to contribution state’s member Each 1 : 2.6. approximately therefore sources) is all from donations (voluntary funds extrabudgetary to funds core 2004). Health of (Departmenttime same the at service healthnational England’s on spent budget approximate the of 0.5% over just to example, for high-incomeanyequivalent,state:memberspending healthof the fraction of tiny a is It purpose. its forinadequate woefully was 2003 and 2002 for million 2,223 US$ of budgetbiennial WHO global Thedeceptive. be canappearances The most important negative consequence, however, is that health priori health that is however, consequence, negative important most The hopingagency. Whendonor a is WHO that assumedmistakenly often is It WHO’s core budget was US$ 843 million for those two years. The ratio of ratio The years. two those for million 843 US$ was budget core WHO’s 280 - - - - World Health Organization ------281 Most Most WHO programmes and departments have to spend their budget al All this has a strong impact on the organizational climate and staff de Other Other problems arise from the trend towards public-private partnerships: in in favour of so-called ‘vertical’ programmes that focus on controlling specific diseases to specific targets – ‘a case of the tail wagging the dog so vigorously as to make it almost dysfunctional and disoriented’ (Banerji 2004). This epi tive options. Too many are stuck in a honey trap – they cannot afford to leave as as leave to afford cannot they – trap honey a in stuck are many Too options. tive similar employment back home may not pay so well, especially in developing countries. WHO staff members in professional grades in headquarters and regional offices have tax-free salaries, an excellent pension scheme and many other benefits, although they often also pay for two residences, one at home and one in their duty station, and other expenses such as school fees. tially tially compromised by greater interaction with the commercial sector. Pro grammes jointly funded and implemented by a consortium private of partners may, if public care is and not taken, inappropriately benefit the private partners rather than the target populations. Yet safeguards against conflicts of interest are underdeveloped in WHO. Second, there has been sideration little of con whether it would be better to find alternatives to partnerships with caused given by the business, adding fragmentation further institutional partners to the international health aid mix (Richter 2004). has This activities. programme than rather and overheads on salaries location far-reaching negative implications in the absence of adequate programme funding, or good coordination between or even within departments, or prop erly resourced central functions (for example, translation, interpretation and publishing). In one important and fairly typical HQ department, the biennial cost of employing over 30 staff runs into several millions of dollars while the regular programme budget is only US$ 500,000, supplemented by very extrabudgetary few funds. Thus staff run essentially separate programmes that are barely funded from the regular budget, and in some cases barely funded at all. first, first, the way in which WHO’s ability to the safeguard public interest is poten demic demic of programmes donor-driven is not not cost-effective, and sustainable, may damage health system WHO infrastructures. cannot fairly be blamed for it, since it is so often undermined by big global health initiatives, the focus of major donors on NGOs, and the policies of government donors and huge like foundations Gates; but it does stand accused of not fighting hard enough against the trend. velopment. velopment. While some motivated staff move elsewhere, many of those who remain for many years, often described as ‘dead wood’, have few other attrac Holding to account | E1 grammes. changes so little over the years that when long-termwhenWHO-watchersthatworkyears andthe atmosphereoverlittle changes so the new: it is Neither concern. huge for cause a is WHO inside moodfrantic pervasivelybutdepressed the and orderdifferent a of is this but middle.Peoplethecomplainingmajoritylike oftenbosses,vastin theirabout the from not but newcomers, idealistic the from or top the at people cessful suc the from comes mostly talk positive The emerged. despair and cynicism point. starting good a therefore is and faces, it challengesother the of many unlikegrasp, WHO’s withindirectly is within from reformThird, criticism. the repeating beyond attention little it pay WHO on commentators published of group biggest the are who specialists health public and demics to wag furiously.wag to sage, a call for a comprehensive HIV/AIDS strategy, but its title caused tongues that few will ever read, still less act on. People feel unsupported and unable and unsupported feel People on. act less still read, ever will few that paper a of draft 20th or 10th or the producing computer travel a of front duty in away hide pointless endless, into escape few a though impossible, the achieve to hard extremely work still staff Most goals. ambitious their achieve to needed resources financial and human the lack to continue programmes warp. time a in are they feel they absence an after return ers The internalenvironment: JurassicParkorChangingHistory? worker, while undermining the effectiveness and sustainability of many pro many of sustainability and effectiveness the undermining while worker, individual the of productiveness often and security the damages it but fire, and hire to power greater it gives and moneyorganization the saves This fits. bene- few have and paid poorlycontrast by arecontractsshort-term rolling of its latest world health report (WHO 2004). No-one disagreed with its main mes without better leadership and management. Second, the policy analysts, aca analysts, policy the Second,management. and leadership better without improve to able be not will WHO environment, external its in occur changes above. It receives special attention here for three main reasons. First, whatever able array of hindering forces that compound the funding problems described itself.change evenapparently cannot it when history change can WHO that believinggrandeur: of delusionsleaders’ WHO the of example pandemic. the anotherjust them to against seemedway. thatIt it see not didhowever, people, battle Many the in efforts their redouble to partners and n h itriw cnutd o ti catr a atr o aah, anger, apathy, of pattern a chapter, this for conducted interviews the In t s o ol lw oae ht otiue t te ie ap eln. Most feeling. warp time the to contributes that morale low only not is It Thehundreds staffof whowork forlong periods inWHOoffices seriesaon New posters appeared all over WHO headquarters early in 2004 promoting2004 in headquartersearlyWHO over allappeared posters New Thislack of capacity in management and leadership is just one of aformid- Changing HistoryChanging was doubtless chosen to inspire WHO staff WHOinspire to chosendoubtless was 282 - - - - - World Health Organization - - 283 What happens to turn people motivated by altruism, full of ideas and expert- and ideas of full altruism, by motivated people turn to happens What The The open letter changed little, and Asvall was re-elected in 1995. When he An internally commissioned programme review from the same period The The WHO regional offices have been scrutinized to a varying degree, de ise, ise, and determined to make a difference, into tyrannical, cynical or fearful bureaucrats? The obvious answers are lack of leadership and poor manage to to speak openly, while bullying and sexual harassment are swept under too are there the members, staff individual dedicated of efforts the Despite carpet. to mechanisms give few functioning staff effective a voice or collective handle lead to department personnel independent a robust, alone let well, grievances much-needed improvements. retired retired in 2000 hopes were high that his successor Dr Marc Danzon, who did provide would messages, its to sympathetic seemed had but letter the sign not care health WHO of evaluation external an to reaction his Yet approach. fresh a reform programmes in 2002 highlighted how such expectations had largely been dashed. Although pressure from member states ensured the report was presented to the next regional committee, there was no sense that it was ever taken seriously. pending pending on the of openness the They directors. regional tend to be elected on effects corrosive the environment, charged politically the yet platforms, reform gradually can re-elected are they ensure to desire their and status, and power of European with dissatisfaction growing 1994 in example, For zeal. their dampen Dr director Jo regional Eirik led Asvall open to from letter a an unprecedented number of significant asking managers, member states programme for active help with reform. Their pessimism contrasted with the upbeat earlier years under Asvall and his predecessor Dr Leo Kaprio (RD from 1967–1985), when Health for All guided and inspired the values, structure and programmes of the regional office. ment. ment. Few staff have the necessary management skills when they start work in WHO, and little is done to develop them. Most senior from so promoted within, they know their own well but system extremely may WHO leaders are Moreover, things. doing of ways better and different to exposure little had have extraordin- an – doctors are staff professional the of majority overwhelming an arily archaic feature given that teamwork, collaboration and interdisciplinary approaches intersectoral, are such frequent WHO buzzwords. Where are doctors The researchers? action and psychologists scientists, social nurses, the may have important medical knowledge but their training and professional socialization on the lone hero model rarely teaches them how to be effective managers or interdependent team members (Davies 1995). Holding to account | E1 h oerdn cnen n h cue rn o goa pltc. hs h Japa the Thus politics. global of arena crude the in concern overriding the is – role the for suitability of regardless – elected national own your countries.Getting weaker from votes secure or appointment particular a ensure to exerted be may pressure Improper decisive. be may country own candidate’s goals. healthsupersede easily can games power which helpsRDs,intenselycreateelectingandaninDG the political environment in role their with combined agreements, country collaborative and committees regional Assembly, Health World the through organization the on influence Their states. member of attitude the above: describedproblems capacity and the role of international and bilateral agencies and international NGOs to de to internationalNGOs andagencies bilateral international and of role the coordinatehelping and together bringing in role stewardshipstronger a play round. way other the than rathersecond,politicians and firsttechnocrats as regardedstill are staff WHOseniorthat surprise electoralisproblemsperhapsthe withpolitics,and familiar are These needs. health or prioritiesorganizational agreed with line promisestocountries toattract their vote, promises that are not necessarily in pre-election making into tempted are candidates incumbent Furthermore, waning. was him for support and progress no showed term first his though nese government manoeuvred strongly for the re-election of Dr Nakajima even Africanregional office in particular has been strongly criticized in recent years The offices. regional six the of performer worst the means no by considered werereportedstaffthemselves by theirfrustrationandsenseof palpable.was shortcomingstheseAll noted. alsomanagement capacitywas of lack ancy. Its as incoherent, inward-looking, and reluctant to relinquish its historical ascend describeddevelopmentwas systems health in of support its and states presence member peripheral a considered was office regional The programmes. multiagencyenceof working,pervasiveacommunication andlackof between tegrated in- working’ (Panch 2002). to It noted programme barrier managers’ fundamental limited experi a as stands that protectionism and insecurity of climateprevailing a creating and competitionaffecting ‘scarcity by acterized charges of inefficiency, nepotism and corruption.and nepotisminefficiency, of charges Member states The politicalcontext:powergames ( foundthatthe organizational culture ofthe European regional office was char The Lancet The In the race for top positions,appointed,topelectedbothandfor racesupportthe from the In Many member states, particularly developing countries, would like WHO to These problems are not peculiar to the European regional office, which is which office, regional European the to peculiar not are problems These 04, ln wt ms o te fia cuty fcs including offices, country African the of most with along 2004), A third set of forces interacts with and compounds the funding 284 - - - - - World Health Organization - - - 285 , , the higher profile of CSOs in securing access from pressure One member way inappropriate of circumventing World World Health Report Strengthening Strengthening WHO’s presence in countries technically, financially and Perhaps Perhaps mindful of her battles with member states during the row over The The countries that are most in need of WHO support are usually, however, Civil Civil society politically could be a means of helping countries to develop a policy framework framework policy a develop to countries helping of means a be could politically for them they that to health want enables better what decide donor assistance and to The control senior it WHO effectively. post in a country should be held by a highly qualified senior expert with director status, supported by an able team of national staff and rotated staff from elsewhere in country focus, as WHO. promised by A Dr Lee (and greater his predecessors, without very vis velop a unified, purposeful health strategy and activities to implement it. They They it. implement to activities and strategy health purposeful a unified, velop see WHO as leader here, the a and natural international independent trusted, honest broker with strong humanitarian values that advocates adherence to key principles and international agreements. the the 2000 ing ing bodies (the Assembly and the executive board) where they have a right to make a statement – although not a vote. Another 500 organizations have no contacts through mostly WHO, with relationships ‘informal’ but rights formal NGOs nonprofit private and for-profit private Both programmes. work on made are included in the WHO definition of civil society, raising controversy about distinguish to policy-makers for need the highlighting and interest of conflicts between public-benefit and private-benefit organizations. states states and other global institutions is to promote transparency and greater accountability to civil society. However, civil society’s role in WHO is restricted. quite Around 200 civil society organizations govern the of those are including meetings, WHO in in participate can they meaning ‘formal’ relations, those those with the least power and influence. The US and other OECD countries exert tight control over WHO, not least because of their control of funding. Recent public discussions have shown how the US in particular continually pressurizes WHO to steer clear of and ‘macroeconomics’ ‘trade issues’ that it health’. to right ‘the as terminology such avoid to and scope, its outside are says naturally mandate WHO’s about states member among consensus of lack The reflects the conflicts within the international order. ible results), could counterbalance the centralized bureaucracy in HQ regional and offices – while recognizing that good intercountry work, including setting global and regional norms and standards, grows from and synergizes the bottom-up, intersectoral, collaborative approach to planning and imple mentation in countries. Holding to account | E1 talking about poverty – here, as we pay $2 for a cup of coffee, while mil while coffee, of cup a for $2 pay we as here, – poverty about talking be to Geneva in here people WHO for hypocritical almost seems It know. really who those of expressions and feelings, views, the bring movements ‘These2003.meetingrepresentativesin PHMatold Leeat Drfield,’health Lee. Dr director-generalincoming of interest the by boostedstronger, grown have WHO andMovement thebetween links theitself. then,WHOSince of and wasreflected– theorganizationalin structure manyofministries healthof top-down and vertical driven, medically – approach technical dominant The neglected. been had care health primary comprehensive implement priorities.these achieve to strategy the as care health primary comprehensive with policy-making, international and national local, in priorities top as development equitable and health healthprofessionals, academics andresearchers re-establishItsgoaltois. activists, social NGOs, organizations, society civil organizations, people’s of coalitiongrowing a now is whichMovement, HealthPeople’s nascent a of manifesto the Health, for CharterPeople’s consensus a to led dialogue The All. forHealth of goals theinternational governmentsofagenciesand by sidelining the was concern common A countries. 75 from activists and semblyBangladeshin 2000inattracted 1500people health– professionals ain t WO smaie i te hre ad vial a
The diminished power of WHO 287 Woefully Woefully inadequate resources, poor management and leadership prac There There have recently been signs of a change, with WHO making statements in in relation to the World Bank has been noted elsewhere in this report. controversial The nature of the Bank’s policy advice to developing countries has barely been challenged in public by WHO, and for a period in the 1990s they often sang from the same hymn sheet. At other times WHO has been forced to take a weakened position: for example, its guide to the health implica lenge lenge to the ability of member states and corporate interests to bully WHO. It would also increase the political challenges of the environment in which WHO works, while CSOs would have to be accountable and differentiated on a basis. public-interest Some ways forward Relations Relations with other international agencies to to medicines, and the mobilizing role of the first People’s Health Assembly in 2000, Brundtland tried to raise the civil society profile, the notably establishment through of the Civil Society Initiative. These attempts have hampered by member states and no been new policy on the issue has been agreed, although meetings between Dr Lee and the People’s Health Movement have been positive (Box E1.2). Greater openness to CSO involvement would bring an and policy of scrutiny closer including benefits, many equate equate and leads to weak or skewed solutions. velopment which should be responsible for these efforts has been reorganized reorganized been has efforts these for responsible be should which velopment twice in three years. Yet WHO’s understanding of health and health systems must be rooted in a strong analytical framework in techno- present which The social, account. into economic, taken are determinants political and cultural managerial analysis, predominantly biomedical rather than social, is inad tices, and the power games of international politics are just some of the forces forces the of some just are politics international of games power the and tices, about about restrictions on health spending imposed special- policy by social in lacking the woefully is it Bank However, Fund. Monetary and national the Inter- ists, economists, and trade and intellectual property lawyers who could help create an alternative agenda. The headquarters department of health and de tions of multilateral trade agreements was watered down under pressure from from pressure under down watered was agreements trade multilateral of tions the World Trade Organization (Jawara and Kwa 2003). At country level WHO officials often find themselves in competition with the Bank: while the World Bank has a mandate that also includes influencing and interacting with the more powerful trade and financial ministries, WHO’s mandate tends to be restricted to the health sector. Holding to account | E1 pleadingdonorordemands. SomemajorrolesthatWHOhave forbeen reiter special of because made exceptions no with advantage’,‘comparative unique and strengths its on based agenda action focused more and new a develop to WHO with work and this recognize must states Memberunsustainable. ingly increas is resources few too with things many too do to tendency its people; all to things all be to authority the nor resources the neither has WHO made. be to have will choices difficult but WHO, in happen cannot this why reason All. the for Health in of philosophy embodied are process, change successful every in present and ence peoples of the highest possible level of health’. of level possiblehighest the of peoples all by attainment ‘the – constitution its in out set as objective, noble WHO’s to closer us move will That heard. be and listen minds, their speak meet, can gather becomes an open, democratic, global decision-making forum where all strengthenedmustbe tablethattoptheroundsowhich richpowerful theand societycivil with Links wars. turf in resourcesand time wastingwithout do to everyone for enough than more is There problems. health world’s the tackle destabilizingtoefforts are competitivethatrivalry ofbarriers theovercome to found be must Ways governance. and improvement health global to bution discussion. for point starting a recommendationsas the in ated in the interviews and literature consulted in writing this chapter are noted n laesi. rncly tee rcie, rw fo rsace experi researched from drawn practices, these Ironically, leadership. and of understanding little practices management so effective of ingredients have the and staff management change own its as long as initiatives support such serious to provide cannot WHO others. develop or empower cannot externally.or internally change support or lead to shape no in is and credibility as well as expertise lacks working, of ways actual its and preaches, and displays such a striking dissonance between it its espoused values what practise not does that organization An principles. those advocate to placed poorly is partners external with co-operate to how know not does and conformity rewards candour, punishes staff, own its to listen not does that organization an But internally. many by supported and Lee Dr by advocated systems. care healthreforming successfully in or orderinternational the in changelasting achieving ofdifficulties the to similar are ways many in and powerful are change to obstacles The WHO. in changesustainable hindering Many organizations have successfully reinvented themselves and there is no Dialogue with key actors can clarify and re-energize WHO’s specific contrispecificre-energizeWHO’s and clarify can actors key withDialogue People who are not themselves empowered and constantly developing developing constantly and empowered themselves not are who People is 1) chapter B, (part Approach Care Health Primary the of revival The 288 - - - - World Health Organization ------289 Below are proposals for WHO’s core roles derived from cies and international NGOs cies to and a international develop multisectoral purposeful unified, health strategy and activities to implement it. ety ety organizations need support to have a more direct voice. Public-interest organizations must be differentiated from those representing commercial interests, including front organizations funded by transnational corpora tor tor of health information and experience. research, including research on the health impact of economic activities. transnational goods such as research and development capacity, and con chise, chise, perhaps with an electoral college of international public health ex perts to complement the member states' votes, including representatives from civil society Candidates organizations. should be required to publish with them, about debate widespread facilitate should WHO and manifesto a trol trol of transnational externalities such as spread of pathogens. threats to health. agen bilateral and international together bringing and coordinating in role tions. directors needs to be tempered. Possible solutions include a wider fran of governments. This involves representation of broader groups of interests interests of groups broader of representation involves This governments. of including civil society, and processes that ensure a wide range of voices is heard and heeded. health health and development policy, and asserting the human right to health. health and health care. • • Conducting, commissioning and synthesizing health and health systems • Promoting and protecting the global commons, including the creation of • • Providing a mechanism for coordinating transnational/cross-boundary • in to WHO’s presence countries play a Strengthening stewardship stronger • The politicized nature of the elections of the and director-general regional Democratization/ governance Democratization/ • as of as well the people WHO as an to organization position measures Take • civil soci Southern at WHO. and Initiative the Support expand Civil Society WHO’s WHO’s core purpose Recommendations • • Promoting the principles of the Alma Ata declaration on Health for All. • and maintaining Establishing, global monitoring norms and standards on • dissemina and repository trusted and informed an as role its Strengthening our our literature review and interviews, which can be debated and fleshed out in the future: • Acting as the world’s health promoting conscience, a moral framework for Holding to account | E1 Leadership and management and Leadership pro extrabudgetary of funding their of proportion a shift should Donors • agreed an towardsdonationsoverall their increase to striveshould Donors • programmingand Funding There should be a strategic assessment of where WHO should be influential • WHO should develop strong safeguards against conflicts of interest in fund • Thebenefits, risksandcosts globalof public-private partnerships healthin • encourage to developed be should formulae allocation resource Explicit • donors – priorities overall agreed follow should donations Extrabudgetary • Programmes (and the organization's structure) should be organized around • re their match to donors ask and priorities fewer on work should WHO • Recruit more diverse staff from different backgrounds and cultures, includ • Revisit WHO’s mission with all staff to renew their collective ownership and • leadership: and managementtheir improve and culture the target. ing more women, more people from the South, more people who are not are who people more South, the from people more women, more ing financial institutions.financial existing liaison mechanisms between WHO and the international trade and the and bodies, multilateral other to relation in health of interests the in requirements. management and leadership roles' the reflect that criteria selection open should be openly debated and compared to alternatives.to compared and debated openly be should staff/programmecosts.core/extrabudgetaryandbetween balances better outputs. and programmesspecific to tightly too them tying avoid should divisions. and unitstems-oriented sys of strengthening the in resulting Approach, Care Health Primary the states. member withagreements laborative col in through followed be should priorities‘project-chasing’; these avoid andactivities and costs staffbetween balance the shift to them, to sources budget. total any the in declinecorresponding without budget, the of arms two the between funding of portioning ap equal roughly a be should aim The budget. regular the into grammes ing, priority-setting and partnerships.priority-settingand ing, funding for core infrastructurefunctions. core for funding sufficient including it, to stick and funds allocate strategy, a develop that from and advantages, comparative agree priorities, clarify commitment: Actions that WHO leaders can take to change to take can leaders WHO that Actions 290 ------World Health Organization ------291 The World The Health World Organization and the Transition Contribution to WHO Bulletin roundtable on donor funding and na Gender and the professional predicament in nursing. Milton Keynes, stracts/WG1/FeeBrownCuetoPAPER.pdf, accessed 29 March 2005). stracts/WG1/FeeBrownCuetoPAPER.pdf, health partnerships: in search of ‘good’ global health governance. In: Reich M, ed. Public-private partnerships for public health, Harvard series on population and in tional allocations on health. Unpublished paper. ing ing countries, intersectoral action and project management. terion for staff recruitment, especially at senior levels. ments. rapid for mechanisms with policies personnel robust introduce/enforce and and nepotism corruption, of tolerance zero and support, staff and response abuse of staff. sociation organized on trade union principles with collective bargaining powers and a properly resourced secretariat. ous improvement, through giving all staff excellent continuing professional professional continuing excellent staff all giving through improvement, ous development opportunities; high-level management training for all senior staff; learning from good practice and sharing ideas, approaches and in and individual collective non-blaming meaningful, and regular, formation; performance review. at global, regional and country levels. employed for long periods on a series of short-term contracts. little benefit for the individual, WHO or countries. academics, policy-makers and researchers, including short-term second from ‘International’ to ‘Global’ Public Health. Joint Learning Initiative Paper 1–1. Harvard, MA., Global Health Trust (http://www.globalhealthtrust.org/doc/ab doctors, and more people with experience in a variety of settings in develop in settings of variety a in experience with people more and doctors, ternational health. Cambridge, Ma, Harvard University Press. Open University Press. Brown T, Cueto Brown M, Fee E T, (2004). • • Require proof of effective leadership and management experience as a cri • Make WHO a learning organization with a culture committed to continu • • Review and streamline administrative processes and procedures. • departments, personnel WHO of independence and capacity the Strengthen • Strengthen mechanisms to represent staff interests, including a staff as • • Introduce regular rotation of staff to avoid stagnation and gain experience • End casualization of the workforce, including reducing number of staff • Stop unstructured consultancies, internships and secondments that have • Make better use of the expertise of senior WHO-friendly practitioners, Buse K, G Walt (2002). The Health World Organization and global public-private References Banerji D (2004). Davies C (1995). Holding to account | E1 Selbervik H, Jerve A (2003). A Jerve H, Selbervik Lee JW (2003). 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