World Health Organization : The mandate of a specialized agency of the United Nations

ORGANISATIONAL LEVELS : HEADQUARTERS, REGIONAL ORGANIZATIONS AND COUNTRY OFFICES

The previous chapter dealt with the main characteristics of the World Health Organization's structure, as far as it concerned the distinction of a plenary organ, an executive body and a permanent staff. This chapter will consider the three organisational levels of the Organization: headquarters, Regional Organizations and Country Offices.

The reason why it is possible to make a distinction between three layers of organisation is the origin of the WHO. The first chapter showed that, although the WHO was formally created in 1948, it was in many aspects an amalgamation of several organisations dealing with international health, including the Office International d'Hygiene Publique, the Health Organization of the League of Nations and the Pan American Sanitary Organization. The resulting structure of the WHO reflects the beginnings, with responsibilities divided among the headquarters, the Regional Organizations and the Country Offices[1].

The World Health Organization's headquarters is based in Geneva. It hosts the meeting of the governing bodies, but it is mainly the base of WHO permanent staff. About 2000 people are part of the WHO Secretariat in Geneva. The Secretariat of the headquarters in Geneva is composed of the Director-General and of all the technical and administrative staff which can be divided in eight divisions, called Clusters (see figure)[2].

The Director-General (DG) is the chief technical and administrative officer of the World Health Organization. According to article 31, the "Director-General shall be appointed by the Health Assembly on the nomination of the Board"[3],[4] for a five-year term. Hence, the Director-General is elected by the member states and s/he is subject to the authority of the EB.

Nonetheless, the Director-General is very powerful and independent. It has an enormous discretion because s/he appoints all professional staff, even the Executive Directors, who are the heads of the Clusters. Yet, s/he suffers from a structural weaknesses, with respect to the regions[5].

The Director-General is also the ex-officio secretary of the WHA, the EB and of all commissions and committees of WHO and of conferences convened by WHO.

According to article 33, the Director-General is also in charge of maintaining the external relations of the Organization, having direct relations with the governmental departments of the member states, especially to their health administrations, and to national governmental or nongovernmental health organisations, as well as with international organisations and with Regional Offices[6].

Among his/her main functions there is preparing and submitting to the EB the financial statements and budget estimates of the Organization[7].

The Director-General is assisted in his/her duties by the rest of the Secretariat. In particular, the Director-General works closely with two Cabinets. The first one is the Headquarters Cabinet, which is the Director-General's close Senior Management Team, with which s/he normally meets on a weekly basis. This is composed of the Director-General himself/herself, the Chef de Cabinet and the eight Executive Directors[8]. The second one was created by Dr Brundtland on 27 May 1999 with the aim of creating a better unity of purpose throughout WHO. She said in a meeting with all staff: "The purpose of this body is to build a common platform for the way we bring One WHO forward, to ensure that we speak with one voice in the governing bodies, with other partners and in other fora"[9]. She wanted to develop a much closer interaction between regions and headquarters and among the regions themselves, and establishing more efficient and constructive working relations with the Regional Directors, as well. Therefore, the Global Cabinet, which meets 5-6 times a year, is composed of the Director-General and the Regional Directors. Executive Directors or other staff the Director-General considers useful for the discussions may be invited to attend the meetings[10].

Both Cabinets do not take binding decisions for WHO. They are mechanisms to assist the Director-General in his/her decision-making. In that sense they play an important role in the decision-shaping process, and it is possible that the same issue might be considered in both Cabinets. In such cases, this would provide the Director-General with a useful range of perspectives before s/he takes a decision. The work in the Cabinets helps provide a broad and informed background for decisions, as well as for all participants to benefit from discussions and common analysis. A question of hierarchy between the two Cabinets does not even arise, as they are parallel mechanisms reflecting headquarters/Regional Organizations perspective and issues[11].

The current Director-General is Dr Gro Brundtland[12]. However, the WHO had four Director-Generals in the past. It follows a brief biography of Dr Brock Chisholm, Dr Marcolino Gomes Candau, Dr Haldan Mahler and Dr Hiroshi Nakajima.

Brock Chisholm of Canada, the first Director-General of WHO, was born in Oakville, Ontario, on 18 May 1896. In July 1946, he was elected Executive Secretary of the WHO Interim Commission. Dr Chisholm became WHO's first Director-General on 21 July 1948 and, refusing re-election, he left at the end of his mandate in 1953 to settle in British Colombia.

Dr Marcolino Gomes Candau of Brazil was born in Rio de Janeiro, Brazil, in 1911. Dr Candau joined the staff of the World Heath Organization in Geneva in 1950 as Director of the Division of Organization of Health Services. Within a year, he was appointed Assistant Director-General in charge of Advisory Services. In 1952, he moved to Washington as Assistant Director of the Pan American Sanitary Bureau -- the WHO Regional Office for the Americas. In 1953, while occupying that position, he was elected, at the age of 42, WHO's second Director-General. In 1958, 1963 and 1968, Dr Candau was re-elected for his successive terms in that office, which he held until 1973.

Dr Halfdan T. Mahler of Denmark was born on 21 April 1923 at Vivild, Denmark. In 1951, he joined WHO and spent almost ten years in India as Senior WHO Officer attached to the National Tuberculosis Programme. From 1962, he was Chief of the Tuberculosis Unit at the WHO Headquarters in Geneva until 1969, when he was appointed Director, Project Systems Analysis. In 1970, he was made Assistant Director-General of WHO while retaining the direction of Project Systems Analysis. In 1973, while occupying that position, Dr Mahler was elected WHO's third Director-General. He was re-elected for two successive five-year terms in 1978 and 1983 respectively. Under Dr Mahler, in 1979, the Thirty-second World Health Assembly launched the Global Strategy for Health for All by the Year 2000.

Dr Hiroshi Nakajima of Japan, was born at Chiba City, Japan, on 16 May 1928. Dr Nakajima joined WHO in 1974 in the position of Scientist, Drug Evaluation and Monitoring. In 1976, he became Chief of the WHO Drug Policies and Management Unit. It was in this position that he played a key role in developing the concept of essential drugs, as Secretary of the first Expert Committee on the subject. In 1978, the WHO Regional Committee for the Western Pacific nominated and elected Dr Nakajima as Regional Director, an office he held for two consecutive terms until 1988, when he was elected Director-General of WHO. In 1993, Dr Nakajima was re-elected to a second term of office as Director-General. In 1997, Dr Nakajima announced that he was not seeking another re-election and that his term of office would end in July 1998.

Besides the close work of the Headquarters Cabinet and of the Global Cabinet, the Director-General is also assisted by the staff distributed among nine Clusters. A distinction can be made between 'technical' Clusters and 'governing' Clusters. The first five are: Communicable Diseases (CDS), Noncommunicable Diseases and Mental Health (NMH), Sustainable Development and Healthy Environments (SDE), Health Technology and Pharmaceuticals (HTP) and Family and Community Health (FCH). The second four are: Director-General's Office (DGO), Evidence and Information for Policy (EIP), External Relations and Governing Bodies (EGB), General Management (GMG). Each of these Clusters is divided in departments according to different areas of work, as well as in Unit or Working Team. To make an example, I take the case of the NMH, which is divided in Noncommunicable Diseases Prevention and Health Promotion (NPH), Management of Noncommunicable Diseases (MNC), Injuries and Violence Prevention (VIP), Mental Health and Substance Dependence (MSD). Physical Activity is then a Unit of the Department of Noncommunicable Diseases Prevention and Health Promotion.

Each Cluster is headed by an Executive Director, each Department by a Department Director and each Unit by a Unit Coordinator. The Executive Director is directly appointed by the Director-General. S/he is in charge of determining the basic strategies and policies of the Cluster, and of deciding how the Cluster budget should be divided among the activities of the different Departments and Units.

The structure of the headquarters has not always been the one just described. This conformation derives from one of Dr Brundtland's reforms[13]. Looking at the history of the Organization, one can observe that it keeps changing according to the necessity of the Organization. For example, the Secretariat of the headquarters was subdivided just in three divisions in 1957 [14] and in five in 1986[15].

Furthermore, even the role of the Executive Director has changed. Prior to Dr Brundtland, with Dr Nakajima, Executive Directors were called Director–General Assistants. Each of them was in charge of controlling a specific number of programmes, which were not regrouped in Clusters. They were more than anything else political links for the external relations. When Dr Brundtland came, she decided to get rid of the Director-General Assistants, because she had already the adequate external contacts, as the Former Minister of Norway and she did not need other political persons involved[16]. She instituted the more technical figure of the Executive Director.

The principal resource of the WHO is its multinational staff, both technical and administrative. This resource is supplemented by the use of various categories of short-term and temporary staff with special skills, and by various instruments for obtaining the best and most internationally representative advice. They are expert advisory panels, expert committees, study groups, scientific groups and other scientific and technical meetings.

The origin of the expert advisory panels has to be traced back to the Health Organization of the League of Nations. It was the first organisation to appoint small international groups of outstanding experts to meet from time to time to advise on various technical subjects such as cancer, malaria and nutrition[17]. The composition of these 'commissions' was constant, and their members did not represent their governments but acted in an entirely personal capacity. In 1948, the first World Health Assembly adopted regulations for expert committees, which have been modified several times. Nowadays the regulations in force are the Regulations for expert advisory panels and committees[18], adopted by the thirty-fifth World Health Assembly. According to those, the Director-General has the authority to establish expert advisory panels on any subject and to select their members, who are appointed after consultation with the national authorities concerned. Each panel consists of experts in a particular subject and from different parts of the world, who have undertaken to give the Organization technical information and advice on developments in their own fields. The members of the panel are normally appointed for a period of not more than four years and they are not remunerated. Their advice may be given by correspondence or at meetings to which they may be invited.

Expert committees, as well as expert advisory panels, are regulated by Regulations for expert advisory panels and committees[19]. They are groups of expert advisory panel members convened by the Director-General for the purpose of reviewing and making technical recommendations on a subject of interest for the Organization. Members of the committee are selected from one or more expert advisory groups. The criteria taken into consideration are an adequate representation of different trends of thought, approaches and practical experience in various part of the world, as well as interdisciplinary balance. Membership of an expert committee lasts only for the duration of its meeting[20].

Study groups are regulated by the Regulations for study and scientific groups, collaborating institutions and other mechanisms of collaboration[21]. The WHO convenes study groups instead of expert committees, when one or more of the following conditions are met: the subject to be study concerns too limited an aspect of a general problem; the knowledge on the subject to be studied is still to uncertain and makes the opinion of the participating members too diverse for there to be a reasonable expectation of authoritative conclusions; the necessity to have an administrative procedure faster and simpler than that involved in meetings of expert committees; the study may imply the participation of too narrowly specialised participants who may belong to many different disciplines[22].

Scientific groups are as well object of the Regulations for study and scientific groups, collaborating institutions and other mechanisms of collaboration[23]. They can be convened to review given fields of medical, health and health system research, to assess the current state of knowledge in those fields, and to determine how knowledge may be best extended.

In order to obtain expert advice, the WHO also makes use of collaborating centres[24]. A collaborating centre is a national institution designated by the Director-General of the WHO to form part of an international collaborative network carrying out activities in support of WHO's mandate for international health work and its programme priorities. It could be an entire institution, or a department or laboratory within an institution[25].

The origin of the collaborating centres, as the one of the expert advisory panels, has to be traced back to the Health Organization of the League of Nations. At that time national laboratories were first designated as reference centres for the standardisation of biological products. As early as 1949, the Second World Health Assembly laid down the policy that the Organization should not consider "the establishment, under its own auspices, of international research institutions", and that "research in the field of health is best advanced by assisting, coordinating and making use of the activities of existing institutions"[26].

Regarding to the mandate of the collaborating centres, they play a strategic role in helping the Organization meet two main needs: first, they contribute to implementing WHO's programme priorities, in coordination with the headquarters and the Regional Offices; secondly, they strengthen institutional capacity in countries and regions. In order to fulfil this role, collaborating centres have various functions, as collection and dissemination of information, standardisation of terminology and nomenclature, of methods and procedures, education and training, provision of information and advice on scientific, technical and policy issues, and participation in collaborative research[27].

The Regional Offices, or, as the Constitution names them, the Regional Organizations constitute the second layer of the World Health Organization's organisational structure.

In pursuance of the Constitution, the 1st WHA divided the world into six geographical areas and authorised the EB to set up a Regional Organization for each of them as soon as the necessary majority of consents was obtained. Article 44, in the XI Chapter of the Constitution, entitled Regional Arrangements, states that the WHA "shall from time to time define the geographical areas in which it is desirable to establish a regional organization […] to meet the special needs of such area"[28]. Once the Regional Organization has been constituted, it is "an integral part of the Organization in accordance with this Constitution"[29].

There were two main reasons for the creation of Regional Organizations. The first was early recognition that effective international health cooperation requires both global and local action. The second one was the prior existence of well-established regional health organisation, as the Pan American Health Organization, at the time of WHO's creation. These organisations were highly successful organisations and the process of negotiation was, for this reason, a highly sensitive and political one. Many problems arose relatively to the distribution of authority, membership and financing[30].

To have a general idea of the dimension of these Organizations, it is interesting to have a look at Table 2[37].

It would be interesting to describe each of these Regional Organizations one by one. However, this would deviate us from the main aim of this contribution. In particular, this part wants to be just an introductory part to provide the reader with the right instruments in order to be able to understand the next parts. For this reason, a detailed description of each single Regional Organization will not follow. However, I will report some of the main characteristics.

As long as it concerns the distribution of the 192 member states across the regions, the membership of the Regional Organizations is mainly, but not necessarily, geographically determined, since each member state is free to select the region to which it wishes to belong. For example, Ethiopia and Pakistan belong to the Eastern Mediterranean Region, while Algeria and Morocco to the European Region. As a WHO Representative, Dr Harttman, said at the Induction Course for New Staff, which I had the opportunity to take part to, the six Regional Organizations are determined "more according to a political division than to geographical distribution"[39].

Before coming to the composition of the Regional Organizations, it is important to highlight an aspect, in order to make clearer the reader's understanding. It is frequent to encounter the Pan American Health Organization (PAHO), while reading about WHO's Regional Offices. The reason is that the Pan American Health Organization serves as the WHO Regional Office for the Americas.

This confusion derives from the historical steps which led towards the constitution of the World Health Organization[40]. The International Sanitary Bureau of the Americas was formed by the governments of America in 1902. It was renamed the Pan American Sanitary Bureau (PASB) in 1923 and finally Pan American Health Organization in 1958. When the WHO was formally created, the Pan American Health Organization did not want to be amalgamated with the other international health organisations to create a new universal one. It always wanted to remain a separate institution, diverse from WHO. Finally, it was considered as a Regional Office of the WHO[41].

As a consequence, article 54 of the Constitution states that the Pan American Health Organization "shall in due course be integrated with the Organization"[42], as well as the Regional Organizations. Technical results follow. The Regional Committee for the Americas is known as the Pan American Sanitary Conference, Regional Committee of the World Health Organization", and the Regional Office as the Pan American Sanitary Bureau, Regional Office of the World Health Organization". These titles are always to be used when referring to the Regional Committee or to the Regional Office for the Americas in official documents or publications[43].

As the organs which compose the structure of a Regional Organization, they are the Regional Committee and the Regional Office.

The Regional Committee is a plenary body of representatives (usually Ministers of Health) of the member states and associate members of the region. According to article 48[44], Regional Committees shall meet as often as necessary and shall determine the place of each meeting. Article 50 is a list of the Regional Committee functions, which can be summarised in two: to formulate policies on matters of an exclusively regional character and to supervise the activity of the Regional Office[45].

The Regional Office is the administrative organ of the Regional Committee. In addition, it is required to carry out the decisions of the WHA and of the EB within the region. According to article 52, "the head of the Regional Office shall be the Regional Director"[46]. The Regional Director is formally appointed by the EB but is nominated by members of their respective Regional Committees. It is interesting to notice that the election procedure for the Regional Director is the same as the one for the Director-General. They are both chosen by member states, and this means that the legitimacy source is the same. Contrasts easily arise[47]. Besides the Regional Director, the rest of the regional staff is appointed in a manner to be determined by agreement between the Director-General and the Regional Director. Its main functions are to coordinate regional planning, management, monitoring and evaluation; to ensure technical cooperation; to ensure technical guidance and coordinated support to member states formal organisational levels; to support the work of the regional committee, its subcommittees, WHO Representatives and field staff; to facilitate intercountry cooperation; to prepare regional programme budget proposals[48].

The World Health Organization has also country level representation through Country Offices located in selected member states. The purpose of a Country Office is to work with the government, through the national Ministry of Health, in order to implement WHO policies and programmes, and more generally, to support the development of the country's health system.

Even if Country Offices widely differ in dimension, they are usually headed by a WHO Representative (WR). The WR is selected and appointed by the Regional Director to a specific member state or a group of member states, on request. According to Dr Hartmann[49], with respect to WR's background, they may be doctors or public health specialists. They must be very experienced persons, since they represent the Director-General and the Regional Director at country level. Their main functions are to support Health Ministers through technical cooperation, to promote health issues among other sectors and, above all, to give response to emergencies.

The activities at country level are an indispensable element of WHO work. Dr Brundtland refers to the country operation of the WHO as "a vital aspect of our work. They are critical to the success of all efforts to bring about equitable improvements in people's health"[50]. Dr Namita Pradhan[51], Senior Policy Analyst, currently working for the Director-General office, talked about how the WHO may be more effective at country level. "It can provide technical help to the countries when they need it; it can make the WR talk to the other health actors to get all them together; it can help countries in resource mobilization, to assess situation and to analyse problems and it can also work on manpower development"[52]. An article of The Lancet refers to a 1997 study of the Organization's performance at country level, which "proposes that WHO and member states adopt a new concept-'the essential presence'- as a logical framework for the shaping of WHO's relation with each country. By 'essential' the investigators mean that the mechanism should be necessary and sufficient to achieve the desired goals. The 'presence' would vary according to the country's need, its capacity, and on the performance of other external agencies […] it would diminish over time as the country acquired increasing capability, and as its specific needs change"[53]. At the same time, it should also be stressed that "the type of role that WHO plays at country level depends not only on the capacity of the WR and of WHO systems to respond to country's need, but also on the interest of the Health Ministry and other partners to use WHO as an ally in health development"[54].

With the purpose of making WHO's country operations more effective, Liaison Offices were established at different time in WHO's history. They have the purpose to increase and facilitate the cooperation with some of WHO's partners. They are the WHO Office for the Organization of African Unity and the Economic commission for Africa (WAC), in Addis Ababa, the WHO Liaison Office(WDC), in Washington, WHO Office at the European Union (WEU), in Brussels, WHO's Office at the United Nations (WUN), in New York.

The WHO organisational structure is distributed, as we analysed, over three levels: the headquarters, the Regional Organizations and the Country Offices. How to consequently balance the work of the three levels has been, however, subject of ongoing debate. The discussion over the decentralisation issue has seen many different opinions arise[55].

Some believe that the establishment of the Regional Organizations was due to an objective necessity. Siddiqi recalls that decentralisation "became an aim of the Organization and its founders because of the existence of regional health organizations when the WHO was established" and that it was clear that those "organizations should be replaced by a single organization"[56]. At the same time, it was agreed that "the disparity of health conditions in different parts of the world was one of the several reasons requiring a decentralized organization"[57]. Such a decentralised organisation would be more able to remain in touch with reality and with people it served.

The criticisms, which decentralisation mainly receives, concern the excessive autonomy and independence maintained by Regional Organizations from headquarters. As previously said, the Regional Director is elected by the Regional Committee, which is composed of member states. As a consequence, Regional Director and Director-General enjoy the same kind of power, deriving from the exact same source. For this reason, it is extremely difficult to control Regional Organizations from Geneva.

In order to strengthen such a link between headquarters and Regional Offices, Dr Brundtland has tried to tie the Regional Organization's budget to the one of the headquarters: 'One budget for One WHO', seven different budgets in one integrated budget.

Even though having a unified budget should lead to a higher level of coordination and less conflicts, there are still numerous contrasts and it results difficult to coordinate an activity where all six regions are implied[58].

[1] Ministry for Foreign Affairs, Tomorrow’s global health organization: ideas and options, Norstedts Tryckeri Ab, Stockholm, 1996 , p.73

[2] See www.who.int

[3] Constitution, art. 31

[4] For further information about the Director-General elections, see Part IV

[5] Ministry for Foreign Affairs, Tomorrow’s global health organization: ideas and options, Norstedts Tryckeri Ab, Stockholm, 1996, p. 73. Regional Directors are, in fact, elected by members states, as well as the Director-General. Even if Director-General and Regional Directors are at different position in the hierarchical scale of the organisation, they end up having many contrasts because they are both elected directly from the member states.

[6] Constitution, art. 33

[7] Constitution, art. 34

[8] Cabinet, intranet.who.int/homes/dgo/cabinet/index.shtml

[9] Dr Gro Harlem Brundtland Director-General Elect The World Health Organization, Speech to the Fifty-first World Health Assembly, Geneva, 13 May 1998, Document A51/DIV/6

[10] Global Cabinet, intranet.who.int/homes/DGO/global_cabinet/

[11] About the Global Cabinet, intranet.who.int/homes/dgo/global_cabinet/members/index.shtml

[12] For complete information about Dr Brundtland, see Part II, Ch. 3, p. 131 and Part IV, Ch. 2, p. 224

[13] See II Part, Ch. 3, p. 135

[14]] OMS, Los diez primeros años de la Organization Mundial de la Salud, Ginebra, 1958, p. 103

[15] Bettegazzi, N., I programmi “Salute per tutti da oggi al 2000” elaborati dall’Organizzazione mondiale della sanità: motivazioni, prospettive e limiti, Dissertation for the University of Medicine of Pavia, Academic year 1986-7, p.99

[16] See in Part II, Ch. 2, p. 93 and Ch. 3, p. 139, the role that Dr Brundtland has in creating contacts with influential personalities in the political and economic arena.

[17] WHO Manual, available at policy.who.int

[18] Regulations for expert advisory panels and committees, in WHO, Basic Documents, 43^rd Edition, Geneva, 2001, p. 101

[19] Regulations for expert advisory panels and committees, in WHO, Basic Documents, 43^rd Edition, Geneva, 2001, p. 101

[20] Commonwealth Department of Community Services and Health, World Health Organization, A brief summary of its work, Australian Government Publishing Service, Canberra, 1988, p. 22

[21] Regulations for study and scientific groups, collaborating institutions and other mechanisms of collaboration, in WHO, Basic Documents, 43^rd Edition, Geneva, 2001, p. 110

[22] During my stay at the WHO, with the Traditional Medicine Team, I had the opportunity to follow one of this study group, concerning the Good Sourcing Practice (GSP) guidelines. Ms Yukiko Maruyama, Assistant Acting Coordinator, revealed to me that "the expert panel for the Traditional Medicine Team has not been convened since the 1960s. It is too expensive to do so". This other kind of working group is supposed to be as much informal as possible. They are at the first steps of the formulation of the guidelines concerning GSP, and they want the persons invited to be free to say what they agree and what they do not agree on relatively to the proposals. The first draft was made by a specialised institute of Chicago. The TRM Team revised it and made the new draft circulate among a group of expert. The experts sent back their comments over it. The meeting was held to give the experts a chance of reviewing the documents together, exchanging their diverse experiences. By the end of it, they had to insert in the draft their comments. This draft is currently being circulated and experts are still making comments on it. The working group will be convened once again to finalise the document, before the consultation during which the member states will have to agree on that. These are the general steps which a guideline document goes through, taking into account a margin of diversity which depends strictly on the subject.

[23] Regulations for study and scientific groups, collaborating institutions and other mechanisms of collaboration, in WHO, Basic Documents, 43^rd Edition, Geneva, 2001, p. 110

[24] Extensive information can be found in Department of research policy and cooperation, WHO collaborating centres, WHO, Geneva, May 2000

[25] WHO collaborating centres, whqlily.who.int/general_infos.asp

[26] Coordination of research, WHA resolutions, Document WHA2.19 and International research laboratories, WHA resolution, Document WHA2.32 (1949), in Department of research policy and cooperation, WHO collaborating centres, WHO, Geneva, May 2000

[27] WHO collaborating centres, whqlily.who.int/general_infos.asp

[28] Constitution, art. 44

[29] Constitution, art. 45

[30] Lee, K., Historical Dictionary of the World Health Organization, The Scarecrow Press. Inc. Lanham, Md., & London, 1998, p.8

[31] See www.whoafr.org

[32] See whqlibdoc.who.int/amro

[33] See Intranet.who.sci.eg

[34] See www.euro.who.int

[35] See w3.whosea.org/index.htm

[36] See www.wpro.who.int/rd.asp

[37] Any further information can be read at www.who.int/archives/who50/enregion_home.htm

[38] See www.who.int/archives/who50/enregion_home.htm

[39] Induction Course for New Staff – II Module, attended at the WHO during my internship.

[40] See Part I, Ch 1, p. 2

[41] See complete discussion about the difficulties with integrating the PAHO in Siddiqi, J., World health and world politics, Hurst & Company, London, 1995, p. 69

[42] Constitution, art. 54

[43] WHO Manual, available at policy.who.int

[44] Constitution, art. 48

[45] Berkov, R., The World Health Organization: a study in decentralized international administration, Libraire E. Droz, Geneve, 1957, p. 29

[46] Constitution, art. 52

[47] "In any event it is clear that the Regional Director owes its appointment to the Board and the Committee, and not to the Director-General, to whom he is, hierarchically speaking, subordinate". Berkov, R., The World Health Organization: a study in decentralized international administration, Libraire E. Droz, Geneve, 1957, p. 30

[48] Commonwealth Department of Community Services and Health, World Health Organization: a brief summary of its work, Australian Government Publishing Service, Canberra, 1988, p. 20

[49] Induction Course for New Staff – II Module, attended at the WHO during my internship.

[50] Speech of Dr Gro Harlem Brundtland at the Global Meeting of WHO Representatives and Liaison Officers, on 26 March 2001, www.who.int/director-general/speech It is interesting to notice whether the country level is effectively taken into consideration in WHO's action or not. See evaluation about Dr Brundtland's term in Part IV, Ch. 2, p. 224

[51] Induction course for new staff – II Module. attended at the WHO during my internship.

[52] ibid.

[53] Lucas, A., World Health: WHO at country level, in The Lancet, vol. 351, no 9104, 7 March 1998, pp. 743-747

[54]Cooperation for health development: WHO's support to programmes at country level, Royal Ministry of Foreign Affairs, Oslo, 1997, p.12

[55] See complete discussion in Berkov, R., The World Health Organization: a study in decentralized international administration, Libraire E. Droz, Geneve, 1957

[56] Siddiqi, J., World health and world politics, Hurst & Company, London, 1995, p. 62

[57] ibid.

[58] These issues will be considered also in the II Part, Ch. 3, p. 166