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

PART IV: The election of the new Director-General: what is the future of the WHO?

Chapter 2

WHAT IS THE FUTURE OF THE WHO?

Now that a new Director-General has been elected, what will be the future of the World Health Organization? What will a change in WHO's leadership imply for WHO's mandate?

In the next paragraph, I will first reason about the legacy left by Dr Brundtland in order to define what kind of actions the new Director-General should take to better fulfil WHO's mandate.

2.1. What is Dr Brundtland's legacy? Positive and negative aspects of her work.

Since Dr Brundtland decided to stand down, it is legitimate to carry out an evaluation of her five-year term outcomes, highlighting the aspects where she seems to have succeeded and where she does not seem so. From a general point of view, one could positively estimate Dr Brundtland's external reforms, whereas one could find many negative elements in her internal changes[1]. It is commonly thought that Dr Brundtland seems to have been "more successful at raising WHO's profile internationally than at transforming the Organization internally"[2].

The bad news is that the Organization seems to be more centralised now than under previous administrations, and it remains top-heavy.

This means basically two things. On one side, Dr Brundtland focused on the headquarters forsaking Regional Offices and countries; on the other side, with the institution of the Cabinet[3], she wanted to exercise an extreme control over the theoretically independent Cluster's programmes.

With respect to the first element, Horton affirms that "the WHO leadership has neglected the Regional Directors and the Regional Offices and it has completely failed to have an effective response in individual countries"[4]. WHO's work at the country level is "desperately uneven. There is no culture of long-terminism in many Country Offices. Success at the country level requires the construction of primary health care services and systems. Such a long term strategy has been all but abandoned by WHO"[5].

Overall, the WHO is accused to have failed in the African country, which is now in collapse like no other region in the world. The situation is so worrying that, as the results of an analysis carried out by the World Bank shows, "if current trends persist, no African country will achieve any of the mid-decade millennium goals in health, and in fact, will be in a worse position than now"[6]. Horton accuses WHO, and in particular its leadership, not to have a "sense of urgency, no sense that it is the only global agency to advocate on behalf of the world's poorest people"[7]. According to the editor in chief of The Lancet, the WHO is basically failing in its advocacy role for the poor countries in the world[8].

At the same time, one should also take into consideration another element, which is the part that countries, besides international organisations and donors, should play in their own development. Countries often do not have the capability to implement WHO's programmes, although well financed, because of a lack of education[9]. Lola Dare from the African Council for Sustainable Health Development advances a doubt: "are financial inflows truly inadequate or are they inequitably allocated?"[10]. And Cohen, Former Adviser on Health Policy in the Director's General Office, in an article which strongly criticises the work of the Commission on Macroeconomic and Health, wonders "what makes the Commissioners think that in this age and stage of donor fatigue the rich will fork out huge additional sums of money for poor countries when they are already disillusioned by civil strife in these countries, dictatorship, autocratic governments, political aims at variance with those of the richer countries, and very poor management?"[11]. Therefore, "unless the world as a whole is prepared to invest properly in health and in survival"[12], Africa, as many other countries, will not change its face of maximum poverty and ill-health.

A means to better understand countries' needs, and to provide them with the necessary resources and education, could be to decentralise the Organization as much as possible. While at present Regional Offices are marginal to the work of the Organization, they should be instead perceived as a direct link to the countries and a possibility to reach and get in contact with them. In a phrase, a way to help them.

Concerning the institution of the Cabinet composed of the Executive Director, this has been seen as an undue manifestation of power from the higher ranks of the Organization to the lower ones. The top is too strong, and it excessively interferes with the single programme's work and activities, without leaving them the due autonomy.

Furthermore, in her first speech to WHO Secretariat, Dr Brundtland promised to spend most of her time in Geneva, "I will share with you how I intend to put forward the process of change. I have decided that in this first year I will limit my travel to the essential obligations. I will get to know the organization intimately and guide the change process with your support"[13]. But, in fact, her management has made of her a remote figure in Geneva[14]. Yet there are complaints about her lack of communication with her colleagues at the headquarters. Belgharbi Lahouari, WHO Staff Association Chairman, comments that "maybe she is a visionary far ahead of us, but she needs to share the visions more with us"[15]. Dr Brundtland's character is often defined ironically as not properly 'Mediterranean'. She is described as "an 'iron lady' or a 'walking ice block', not having any personal relationship with her personnel: she never says hi, she never speaks to you nicely, she is actually a very hard lady to work with"[16].

To conclude, Dr Brundtland's promises to give the Organization "a flatter structure, better communication, more transparency"[17] do not seem to have been fulfilled.

Summarising the criticisms about Dr Brundtland's internal reforms, concerning the bureaucratic structure of the Organization[18] and her rigid control over it, the hypothesis assumed by Lerer and Matzopoulos seems interesting, although a little sceptical. The authors believe that the WHO may have adopt the 'worst of both worlds', referring to the public and private one. From the public world, the WHO would have taken an "archaic forms of governance, the political contest of decision-making, and the lack of true transparency and accountability, and the global public service". From the private sector, the WHO would have assumed "efficiency and productivity [that] are obtained through harsh, rigid control and short-term results [that] are justifiable at any cost to satisfy external stakeholders. This approach results in a cruelty and inflexibility in the institution, extreme resistance of the staff, and a range of high-profile actions and interventions that are clearly not sustainable"[19].

 The good news is that, while before the WHO did not have a very good reputation at all, now its international credibility has been restored. The image and relevance of the Organization at the global level has been successfully improved, and this is an achievement that would have been considered almost impossible five years ago.

Two directly connected characteristics of Dr Brundtland's five-year term have especially allowed such an attainment. As I have previously mentioned, the Director-General recognised the importance of replacing health on the international political agenda[20] and the value of international cooperation for health[21].

As far as it concerns the first element, in the message of retirement to the WHO staff, she wrote that "the critical role of health in development has gained wide acceptance. The world has turned its attention to our priorities"[22]. And the day after she announced that she would not have stood for a second term, Gavin Yamey interviewed her in Geneva. To the question "how successful do you think you have been?", she gave an extremely interesting answer: "we needed to anchor health firmly on the political and development agenda. Health was sidetracked, and I knew that if it continued like that it would not become an integrated part of development thinking. People cannot move out of poverty when they are unhealthy. I needed to move the global health agenda much more closely to the development debate, on to the tables of Prime Ministers and Development and Finance Ministers, not just Health Ministers. Doing this involves not just reaching the minds of people who have decision-making power in the broader field of economics and politics, but also increasing the evidence base so that you have convincing arguments"[23].

The success Dr Brundtland achieved under this perspective has been globally recognised. Even Richard Horton, who has accused the WHO with the worst criticisms, can admit that "the existing WHO leadership has done very well in raising health on an international profile"[24]. Kelly Lee, Co-Director of the Centre on Global Change and Health of the London School of Hygiene and Tropical Medicine, says that Dr Brundtland "put health back on the map. I think that will be her legacy"[25].

Regarding to the international cooperation for health, the WHO has been lately collaborating with an increasing number of partners coming from different fields: other specialised agencies of the UN, international organisations, nongovernmental organisations and private sector. Dr Brundtland underlined the need of such a cooperation and tried to reach out and mobilise a range of partners as a means to move health towards the development agenda[26]. At the same time, having health on the international political agenda has been a credential for actors who became eventually interested in creating a new partnership with the WHO. As a positive circle, this trend has brought to an increase of partners willing to enter into a relationship with the WHO, and to an amelioration of WHO's image around the world. So that, nowadays, no international meeting could be convened without the presence of the WHO.

As a consequence of this new trend, which has seen multiple actors raising aside the WHO in the international health arena, many have individuated a risk for the Organization, that is to be loosing its position in that field. There seems to be a confusion about the role that each actor should maintain: basically, who should do be doing what?

Lerer and Matzopoulos, for examples, bring to the attention the fact that "WHO had, in a sense, become a victim of its own advocacy"[27]. By saying that health is a multisectoral issue, the WHO has allowed many different actors to become involved with health. After some time, "the WHO was no longer setting the international public health agenda"[28]. Gill Walt also realises that "WHO, once the main player […] is now one of many. Other UN organizations are concerned with health, the private sector has a firm niche with health"[29]. Lee et al. observe that there is a real confusion of mandate within the UN themselves[30].

For this reason, as Dr Brundtland suggested, the WHO has to individuate its comparative advantage[31]. "What is our comparative advantage? Given our mandate and our human and financial resources, what are the functions that WHO is best placed to carry out more effectively than others?"[32]. Each Organization is to specialise and limits its activities to what it does best and, as a consequence, all the system and international health would be better off. Although many actors are appearing at the horizon, WHO should not loose its strong and authoritative leadership in the international health arena.

As stated in the part dedicated to the functions of the Organization, the comparative advantage of the WHO, with respect to the several actors working in the field, is defined by article 2(a) of the Constitution. The unique and distinguishing task of the WHO is "to act as the directing and coordinating authority on international health work"[33]. As long as this function is well implemented, the credibility and the image of the Organization will not be in danger, and WHO will not loose its position in the arena.

The role of directing and coordinating authority on international health work must be interpreted considering both its technical and political aspect. This means that the WHO should play such a role at two different levels.

First, the WHO should be the directing and coordinating authority on international health work from a technical point of view. The Organization actually owns the necessary characteristics to act as technical point of reference for the member states, which need to solve their health-related problems, and for all the institutions, which play in the health field. As Dr Brundtland said, the WHO is "doing a good job by being the centre of competence, shared experience, and knowledge about what works and what does not. WHO is the scientific and expert organ that can give quality opinion about the evidence base, guidelines, norms and standards, because that is really our core function"[34]. This is the part that the WHO should play in its relationship with other institutions. "All the other partners", Dr Brundtland said, "are in fact dependent on a quality stamp from WHO about what is the right evidence and the right standard […] Without WHO, and a stronger WHO, these institutions would not have credibility. They would not be able to work because governments trust WHO to be the evidence base. WHO needs to be strong and needs to be able to give advice and support to all these institutions if we are going to work well together"[35].

Secondly, the WHO should be the directing and coordinating authority on international health work from a political point of view. The WHO is actually the only Organization which can shake the international health arena and move health to the top of the world's political agenda. Thanks to the last WHO leadership, health has become of interest for those who actually detains the power to act.

As long as the WHO will respond to its comparative advantage, both at technical and political level, it will not loose its leading position in the international health arena. The WHO will always be the keystone for international health issues.

After a five-year term, Dr Brundtland leaves a totally changed and renewed WHO. The reforms she implemented have had positive and negative consequences. Generally speaking, for what I have been told and for what I have read, good achievements seem to have been reached in the external image of the Organization, whereas internal reforms, within the headquarters and at regional and country level, have been more problematic. From now on, one can wonder what a new Director-General will be able to do in order to ameliorate WHO's performance in international health work.

 2.2. What is the new Director-General supposed to do? Issues and challenges.

 Dr Jong Wook Lee will take up the Director-General position in July 2003. It is, therefore, quite difficult to be able to delineate right now his future strategy. However, one can still speculate about what he will do in order to improve and ameliorate WHO. The starting point is his declaration according to which he wants to make WHO more "effective, efficient, and relevant"[36].

For example, one can assume that if Dr Brundtland's term was positively evaluated for her external reforms whilst her internal changes were negatively perceived, Dr Lee will probably have to work hard especially on certain issues within the Organization, such as focusing the attention towards Regional Offices and countries, and on WHO's management culture.

In an interview with the British Medical Journal, Dr Lee actually gave some answers to the challenges that he will have to face once started his new task.

As far as it concerns the problem of centralisation that Dr Brundtland had a hard time with, Dr Lee will implement a series of decentralisation reforms. He set the ambitious goal of deploying 75% of staff and resources to country and regional level by 2005. He affirms that "the extensive decentralisation of programmes and resources that I will introduce will be accompanied by management reforms and capacity building in Regional and Country offices. With greater capacity and decentralised resources, the Regional and Country Offices can take an even greater responsibility for country support"[37]. With respect to the headquarters, its "focus of work will be on setting, directing, monitoring, and coordinating strategic directions on global health issues and the normative functions that support communities and countries as they strive to reach their health goals"[38].

Regarding to the fact that the WHO failed in its advocacy function for the world's poorest people, and that the Organization did not effectively support countries, Dr Lee argues that he "will change the way we work as an organization in support of member states, ensuring that we achieve tangible and measurable health outcomes"[39]. In particular he will "launch an initiative to help member states to close the widening gap in health service provision between the rich and poor, with a focus on planning for human resource development. This will include increased national capacity to provide basic training for health workers, together with sustainable reward systems for health workers and initiatives to alleviate the 'brain drain' from the South"[40].

Finally, as far as it concerns WHO's management culture, its lack of transparency and communication, Dr Lee has the fortune to have worked within the WHO, for 19 years, at all levels – country, regions and headquarters. Therefore, he can define himself as "fully aware of the organisational culture that exists here and the opportunities for transformation that come with changes of leadership. My management style combines accessibility to my staff, confidence and trust in their ability, avoidance of micro-management, and a keen interest in personnel issues. The leadership style that I demonstrate and the staff career development initiative that I have proposed will together help to promote a work environment that encourages openness, communication, and internal debate"[41].

For the rest, Dr Lee can be sure to begin on a strong basis. Health is now firmly on the international political agenda, and partnerships are proliferating. Yet this is a good start which still has to be improved.

Dr Lee will have to continue the work started by Dr Brundtland to support global health goals. On this point, he has already promised to scale up efforts against HIV/AIDS, malaria, and TB[42], which means to work on the Millennium Development Goals.

The new Director-General will also have to pay particular attention to the increasing number of partnership. He should regularise them, meaning to give a definition of governance structure for WHO's alliances, and to have a clear policy guiding these relationships[43]. Furthermore, WHO's comparative advantage should always be borne in mind.

If one wonders whether there will be a total and complete restructuring of the WHO, as it happened with the Transition Team instituted by Dr Brundtland, Dr Lee assured that changes will be introduced smoothly and that the staff will be able to continue its regular work with no confusion[44].

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Edited by Aldo Campana,