[Ip-health] Vox: How McKinsey infiltrated the world of global public health

Thiru Balasubramaniam thiru at keionline.org
Fri Dec 13 07:52:40 PST 2019


https://www.vox.com/science-and-health/2019/12/13/21004456/bill-gates-mckinsey-global-public-health-bcg

How McKinsey infiltrated the world of global public health

The Gates Foundation brought billions of dollars to the sector — and a
business-friendly ethos consultants could exploit.

By Julia Belluz and Marine Buissonniere

Dec 13, 2019, 9:10am EST


When Dr. Tedros Adhanom Ghebreyesus took the helm of the World Health
Organization in July 2017, his first speech at headquarters in Geneva
landed on a hopeful audience. WHO staff had seen a recent string of new
bosses, each with a plan to reinvigorate and shake up the organization. The
leaders’ reforms often involved bringing in management consultants, such as
McKinsey, one of the world’s most influential and secretive firms. But
every attempt had ultimately failed to solve WHO’s most vexing — and
decades-old — challenges, like the agency’s problematic financing structure
and related chronic funding shortfalls.

Tedros, as he’s known, suggested things would be different this time. He
seemed to sense the staff’s reform fatigue and their leeriness of external
consultants, reassuring his rank and file: “Any enduring change at WHO will
come from the staff outwards. I do not believe in perpetual reform, and I
think WHO staff are reformed out.”

Dr. Tedros Adhanom Ghebreyesus delivers his first speech as director
general of WHO on May 23, 2017, in Geneva. “I do not believe in perpetual
reform, and I think WHO staff are reformed out,” he said. Fabrice
Coffrini/AFP/Getty Images

But Tedros appears to have embraced change, of a sort. Halfway through his
five-year term, his reform — known as “the transformation” — is still in
progress. And while he has offered WHO staff opportunities to engage in the
process, the agency is also crawling with outside consultants, current and
former WHO staffers told Vox.

“The one thing that WHO staff didn’t want,” a senior official who was
involved in the reform process, “is a McKinsey type of reform,” using the
well-known firm as a shorthand for what they’ve seen consultants bring to
WHO and other health agencies over the years: “musical chairs,” “cost
cutting,” and “debunked management fads.”

In addition to McKinsey, WHO confirmed they’ve worked with five other
consultancies during the transformation: BCG, Deloitte, Preva Group, Seek
Development, and most recently, Deliver Associates, which has a multi-year
contract worth $3.85 million. The total value of the consultant contracts
is about $12 million, at least a quarter of which has been paid for
directly by the Bill and Melinda Gates Foundation, one of the most powerful
players in global health.

Though WHO is a public institution, the details of these engagements, and
Gates’s involvement, aren’t available in the WHO’s budgets or financial
statements. The information that is disclosed on WHO’s website is
incomplete. WHO has a portal with data on contracts the agency processes —
but it excludes those paid for directly by donors like Gates. It’s also
missing information on what, exactly, consultants have been hired to do.

For example, the portal shows WHO’s headquarters awarded McKinsey with
$4.19 million in contracts between 2017 and 2018 — but not whether those
were reform-related. (WHO declined to specify.)

Even agency staff — including officials who have reported directly to
Tedros — say they’ve been left in the dark.

One senior official, who worked at WHO when Tedros’s overhaul started, said
the consultants subjected them to a barrage of questions, on everything
from staff mobility to WHO’s “hierarchies and silos,” and was never told
how the information they shared would ultimately be used. Another told Vox:
“It was like a beehive on the seventh and eighth floors. There were many
people [in] suits. But they don’t talk to us directly.” A third said, “It’s
now been two years [the reform] has been going on. I have no idea what is
happening.”

How consultants are shaping global health

Global health, a field dedicated to improving the health and wellbeing of
the poor and most vulnerable, has quietly developed a penchant for highly
paid management consultants and their business world tools.

According to an internal 2016 McKinsey PowerPoint presentation obtained by
Vox, the firm has been involved in the response to the biggest
international disease outbreaks of recent years, from Mers in Saudi Arabia
to Zika in Brazil. During the 2014-2016 Ebola epidemic in West Africa, both
BCG and McKinsey sent staff to West Africa, to advise WHO and the countries
affected.

These firms worked at Gavi, the Vaccine Alliance — a global public–private
partnership focused on expanding access to immunizations in poor countries
— from its earliest days, helping develop their vaccine financing
strategies. Ditto, the Global Fund (another public-private partnership that
invests in treatment and prevention for infectious diseases like HIV/AIDs,
TB, and malaria), UNITAID, the Gates Foundation, the global health
nonprofit Partners in Health, and the WHO.

Staff from South Sudan’s Health Ministry pose with protective suits during
an Ebola preparedness drill conducted by WHO and the Alliance for
International Medical Action (ALIMA) in Juba, Sudan, on August 14, 2019.
Patric Meinhardt/AFP/Getty Images

The 80-plus global health leaders and staff, current and former consultants
at multiple firms, researchers, health care professionals, and NGO workers
we spoke to for this story described the consultants as “pervasive” and
“ubiquitous.” And many have become wary of consultants’ involvement in the
sector.

But how these secretive businesses, which mostly profit from serving
corporate interests, are shaping global public health is an open question —
and one that’s hard to answer. An additional mystery: How much money —
designated by foundations and governments for improving the health of the
poorest — is being spent on them?

These and other uncertainties concern global health workers and analysts,
many of whom would only speak on the condition of anonymity for fear of
compromising their professional prospects.

While some believe management consultants can help institutions become more
effective, others are dubious, particularly after they’ve seen the
consultants’ interventions fail to help — and in some cases even damage —
institutions. And they’ve begun questioning whether precious resources,
especially money designated to helping save and cure the poorest people in
the world, should be flowing to the highest-paid consultants in the world —
who simultaneously advise industries that are exacerbating public health
problems.

“After 30 years of work at many institutions, nothing done by management
consultants comes to my mind as having been brilliant, and a lot has been
inappropriate and wasteful of time and resources,” said Mukesh Kapila, a
global health pioneer who led the UK’s first HIV/AIDS program, and has
worked with consultants from multiple firms over the decades.

Madhu Pai, who directs McGill University’s global health program, recently
wrote of an African colleague who has had to face “‘kids’ with little or no
experience [coming] all the time to ‘advise’ her government on what to do
about health.” Pai now calls this “global health consulting malpractice.”

The opaque nature of the consulting business means it’s difficult to know
which firms are most influential. While Dalberg, PwC, Accenture, Bain, and
others came up, McKinsey and BCG seem to have an outsized impact on the
global health sector. One measure of that: The two firms have consistently
been among the top five professional services’ contractors at the Gates
Foundation, according to the foundation’s tax returns, even after the
organization vowed to curtail spending on consultants in 2015.

A WHO spokesperson said the agency welcomed the use of consultants. “The
[consulting] companies have supported WHO in areas where we lack in-house
expertise or want to tap the current best-in-class standards,” the person
told Vox. “These are not unreasonable expenditures for an organization of
our size, with a biennial budget of around $6 billion and more than 8,000
staff in almost every country around the world.”

“Since 2017, we have committed $11.509 million to support WHO
transformation efforts,” a Gates Foundation spokesperson said. “WHO sought
these funds to help it implement reforms that had been requested by its
member states.”

BCG declined to comment. A McKinsey spokesperson said, “We are proud of our
work on global public health.”

The latter firm has been in the news lately for advising the Trump
administration to cut spending on food and medical supplies for migrants,
manipulating statistics at Rikers Island prison, and declining to disclose
the client details of Democratic presidential candidate and former McKinsey
staffer Pete Buttigieg’s work, until the lack of transparency became an
issue in the Democratic primary.

In global health, critics are also demanding more transparency from the
firms themselves, and from the organizations that keep hiring consultants —
beginning with the Gates Foundation.

“The rise of the Gates foundation has resulted in more space being created
for management consultancies to solve global health’s problems,” said Devi
Sridhar, chair in global public health at the University of Edinburgh. “The
challenge is trying to follow the money, and figure out the relationships
between funders like Gates, consultancy firms, and the WHO.”

Indeed, the philanthropic juggernaut changed the face of global health. It
also quietly played an instrumental role in launching the field’s
consulting era.

How we got here: The Gates Foundation believes in consultants

In the early part of the 21st century, “international health” was an
often-forgotten, under-funded, public-sector or NGO-supported enterprise,
focused on understanding and fighting the diseases affecting mainly
developing countries. As recently as the 1990s, the WHO was one of a few
key funding sources, alongside other multilateral organizations (like the
World Bank), health-related UN agencies (like UNAIDS), and national
governments (like the UK).

Around the turn of the 21st century, that changed. In 2000, the UN set its
Millennium Development Goals around health-related targets, which the
organization’s 191 member countries agreed to work toward by 2015,
according to a report on the “golden age” of global health funding. The
same year, Group of Eight (G8) countries called for a reduction in
infectious diseases — HIV/AIDS, TB, and malaria — that “threaten to reverse
decades of development.”

In parallel, the US government and American NGOs ramped up their spending
on global health — and so did American philanthropists, most notably Bill
and Melinda Gates and Warren Buffett. Together, the trio formed the Gates
Foundation, based on the belief that improvements in health (as well as
education and development) could happen in low- and middle-income
countries, with the help of science and technology. Since its inception in
2000, the foundation has given out more than $50 billion.

Between 1990 and 2018, investments in development assistance for health
grew more than five-fold, according to the Institute for Health Metrics and
Evaluation, from $7.7 billion to $38.9 billion.

Development assistance for health by source of assistance, 1990–2018. IHME,
2019

Over the period, “international health” became known as “global health,”
and with Gates’s help, the sector gained an unprecedented degree of
visibility. The foundation’s funding helped set up public-private
partnerships like Gavi, which has boosted immunization rates around the
world. The foundation distributed billions of dollars to fight crippling
infectious diseases such as polio, HIV/AIDS, tuberculosis, and malaria.
They also fund media organizations to report more frequently on global
health.

“Gates changed the whole complexion of global health,” said Don de Savigny,
a professor of health systems at the Swiss Tropical and Public Health
Institute and adviser to the WHO. These investments have unquestionably had
a profound impact.

“[Gates funding] has brought remarkable innovation, creativity, and new
ways of organizing and delivering global health,” said Gavin Yamey, a
professor of global health and public policy at Duke University and a Gates
Foundation grantee. “The foundation helped to support the launch of highly
innovative, new forms of global health cooperation that have had a
documented impact.” For example, Yamey said, the foundation contributed
$750 million to launch Gavi, which now estimates that it has averted 13
million deaths.

The foundation also brought a new way of doing things, said Linsey McGoey,
a University of Essex professor and author of the book No Such Thing As a
Free Gift, about the foundation. The three trustees, Bill and Melinda
Gates, and Warren Buffett — two of them titans of corporate America —
wanted to borrow from and work with the private sector. They pursued a
results-based, data-driven approach to health and development — the exact
method consultancies like McKinsey and BCG excel at.

Warren Buffett (right) stands with Bill and Melinda Gates at a news
conference where Buffett spoke about a financial gift to the Gates
Foundation, in New York City, on June 26, 2006. Spencer Platt/Getty Images

“At times, the most effective way to achieve our mission is to work with
consultants who have deep expertise relevant to the problems we’re trying
to solve,” the Gates Foundation told Vox in a statement.

For instance, Gates engaged McKinsey to work with the Nigerian government
and Global Polio Eradication Initiative partners on establishing emergency
operations centers. BCG, according to Gates, helped “organize the
multi-partner effort that led to the development and launch of a safe and
effective vaccine to protect against meningitis A, the first vaccine to be
developed specifically for Africa.”

At WHO, Tedros affirmed that consultants provide the kind of expertise his
organization needs. “If I am building a house,” he told Vox in a statement,
“I will have a vision of what I want it to look like and how I want it to
function, but I won’t attempt to build it myself, I will employ an
architect or an engineer. The same is true of WHO.”

A WHO spokesperson said all relationships with philanthropic foundations
are governed by the WHO’s code of conduct for the agency’s engagement with
non-state actors. Established in 2016, it’s meant to protect WHO from
“conflicts of interest, reputational risks and undue influence.”

But critics like McGoey wonder how much autonomy recipients of Gates’s
money, like WHO, really have. WHO has always been funded by two types of
contributions: “assessed” and “voluntary.” WHO’s member countries have to
pay dues to the agency each year — the assessed contributions — and WHO
staff can direct funding to areas they think should be prioritized.

With assessed contributions, McGoey said, “the WHO typically has more
freedom to spend the money on the most pressing health concerns, rather
than on pet projects specified by a charitable donor.” With voluntary
funding — the type Gates gives — the donations are overwhelmingly specified
for a particular purpose by the donor. In 2018, Gates was again one of the
top three contributors of voluntary funds to WHO’s general fund.

“WHO is faced with budget constraints,” McGoey said. “They’re
under-resourced, and they need financing from somewhere. But they may have
been a little naive in accepting a lot of Gates money, because it does come
with strings attached.”

Those strings can involve hiring consultants, an ex-McKinsey consultant who
worked on global health projects, said. As Gates began regularly paying for
consultants on behalf of institutions like WHO, it created a “reliance” on
the firms. Then, the person said, “it became more of the norm to pull these
same consultants in for strategy.”

Why McKinsey elbowed its way into global health, according to their
internal documents

The rise of consultants in the global health sector wasn’t just driven by
powerful foundations embracing them. The field of global public health has
also been a boon to McKinsey — for new business, talent recruitment and
retention, and public relations.

McKinsey saw an opportunity in the Gates Foundation’s growing influence —
and the “private sector involvement” that came with that — when the firm
was contemplating expanding its global health work, according to internal
planning documents obtained by Vox.

“We are witnessing a transformation in the way the world goes about solving
its toughest and most urgent problems,” read one 2006 document, which was
prepared for McKinsey’s shareholders’ council — the firm’s ultimate
decision-making body, equivalent to a board of directors. The document
singled out “the rise of the global philanthropists” in rationalizing a
global health focus:

In the US alone, individuals will donate $5.5 to $7.4 trillion to
charitable causes between 1998 and 2017. Globally-focused institutions like
the Gates Foundation are leading a sea change in philanthropic giving:
Their founders are actively involved, they distribute far greater sums far
more quickly, they demand measurable results and are pioneering innovative
solutions, on a national and global scale.

McKinsey was interested in more than just pursuing profits. In the
document, McKinsey said it saw itself as “ideally suited” for tackling
cross-cutting problems, such as the HIV epidemic.

“We solve tough problems for a living. We operate fluidly across
geographies and sectors of society. We are objective and fact-based. We are
credible with world leaders and have ‘convening power’ within the private
sector.” The firm could also “‘raise our game’ in tackling important
societal problems” while also having an impact and “delivering inspiring
leadership opportunities for our people,” according to a McKinsey
shareholders’ council meeting presentation in September 2006.

To increase its global health influence, McKinsey had to invest time and
resources. Consultants had to “publish actively, co-host major conferences
and reach [a] level of recognition that we are invited to present/moderate
at all within these areas of expertise.” They had to develop “long-term
partnerships” with “sector leaders” such as the Gates Foundation, Gavi, the
WHO, and the health-focused Clinton Foundation. The internal documents
suggested the firm undertake a mixture of pro bono and discounted fee work.

In 2005-2006, global health activities at McKinsey consisted of 10 to 15
projects per year, according to the documents, and McKinsey hoped this
would turn into 30 projects annually by 2009. Today, the firm’s “social
sector” practice, however, includes among others, the Global Public Health
group, focused on advising “foundations, governments, bilateral and
multilateral agencies, and healthcare companies” with projects in 35
countries.

Consultants told us pro bono contracts often turn into paid work. Or as
author Duff McDonald wrote in his history of McKinsey, The Firm: “Once
[consultants] get the wedge end of a relationship into a company in the
form of one engagement, they usually manage to hammer in the rest. ... To
wit: They never leave.”

The firm declined to comment on the internal documents or provide details
of its current revenues, but an internally published history shared with
Vox estimated the social sector practice made up less than 5 percent of
McKinsey’s overall work in 2009. Today, global public health work
represents less than 1 percent of the firm’s work globally.

Given that McKinsey’s revenue is now $10 billion, the ex-McKinsey
consultant, who worked on global health projects, estimated the firm likely
generates at least $100 million in annual revenue from all social sector
projects.

Even so, McKinsey’s history says social sector projects have had a
“disproportionate impact on the Firm’s external image and internal sense of
purpose.” They’re also a powerful recruiting tool, particularly in an era
when McKinsey is facing tougher questions from a new generation of job
candidates, more energized by the idea of fighting an Ebola outbreak than
helping pharmaceutical companies profit.

Behind closed doors, however, another former McKinsey consultant, who
recently left the firm, explained that getting on these projects is a
competitive slog that requires lobbying. They’re also not as well
remunerated as other positions.

“Externally, they want to put their best face forward — the most inspiring
work,” the consultant said. “Internally, those projects are super hard to
get on. They are in high demand. And when you’re working on social sector
projects, you get paid 75 percent of your full compensation for the
duration of the project. So I think it sends a clear message about how the
work is valued.”

McKinsey would not comment on the details of its global health employees’
compensation. A person familiar with the firm’s recent compensation
structure confirmed the discounted rate but said it may vary depending on a
staffer’s role.

“McKinsey began working on global public health issues three decades ago
because a group of colleagues was passionate about public health and
believed they could make a positive difference,” a firm spokesperson said
in a statement. “This has included helping to end preventable child deaths,
control and eradicate infectious diseases, and enhance emergency response
capabilities, among other important initiatives.”

Global health’s consulting dilemmas

The contributions of McKinsey and other consulting groups to global health
are now being questioned — part of a larger conversation, led by Anand
Giridharadas, an ex-McKinsey consultant and author, about doing right by
the world’s poor, trying to reduce wealth disparities, and saving lives
efficiently and effectively. In conversations with more than 80 people
who’ve worked in global health, including a dozen current and former
consultants, these questions and concerns came up again and again:

How much is spent on consultants, who is paying, and what evidence do we
have that it’s money well invested?

First and foremost, there’s the money question: How much flows to
consultants in global health and who is paying their bills? The answers
speak directly to concerns over transparency and power. You can’t
understand who is influencing global health agendas, and by how much, if
you don’t know who is carrying out the work and how they’re being paid.

Yet it’s impossible to get the full picture. The firms, citing client
privacy, don’t disclose the contract details of their relationships, and
even publicly funded organizations that hire consultants aren’t fully
transparent about their spending.

At WHO, there’s no budget line disclosing the details of the agency’s
management consultant expenses in its financial statements. There’s also no
information about consulting contracts paid for through in-kind donations,
like the consultants’ work on reform paid for by Gates.

“A LOT OF THE INFORMATION IS NOT PUBLIC OR TRANSPARENT”

Foundations like Gates disclose spending on various consultants in their
tax returns, but they are only required to report total annual amounts, not
details about specific contracts or which organizations received donations
in the form of consulting engagements.

This murkiness has frustrated the University of Edinburgh’s Sridhar, who
has been trying to track the investments in management consultants for
global health by international and philanthropic organizations.

“It’s an open secret in global health that all of this is happening,” she
said. “[But] a lot of the information is not public or transparent. And it
matters for accountability, transparency, and to ensure we can follow that
the money is going to where it’s most needed.”

The fragments of public data we do have suggest it’s a staggering amount.
In total, Gates spent more than $300 million on McKinsey and BCG between
2006 and 2017, according to the foundation’s tax returns. That’s more than
the domestic health budget for an entire low-income country, like Haiti.
It’s also roughly half of what the US government spent on McKinsey and BCG
in the last decade.

Many people we spoke to questioned whether the dollars could have had more
of an impact if they were spent elsewhere. “If you could add up the amount
of money [global health] foundations spent on consultants, they could have
funded research and developed a new drug or vaccine,” said one senior
global health official, who has worked directly with consultants on public
health projects.

An ex-consultant, who quit a major firm over a public health project she
thought the firm handled badly, put it: “The harm is you’re taking scarce
research and development resources you could have put into better things.”

Others wondered what evidence supported the investment in consultants.
Global health is a field that’s supposed to be evidence-based, said Anthony
Costello, the former director of the Department of Maternal, Newborn, Child
and Adolescent Health at WHO. But after looking for high-quality randomized
trials on the impact of consultants for his book The Social Edge, and
finding none, he wrote: “One would think company boards sanctioning huge
payments to management gurus would seek evidence of effectiveness. ... The
lack of hard evidence on the impact of management methods raises
multi-billion dollar questions.”

>From that exercise, he told Vox he came away “astonished” about global
health’s reliance on consultants, and “a skeptic of the amount of funding
that goes into [them].”

Since Costello searched for evidence, the only systematic evaluation of the
impact of management consultants on the public sector — a study of the UK’s
National Health Service — found no increase in efficiency from their
services. “The theory [is] if you spend money on consultants, even if only
for strategic advice, it would have some impact on your efficiency. You’d
expect some gain,” said the study’s author, Ian Kirkpatrick, a professor at
the University of York in the United Kingdom, who studies management
consultants. “We actually find there is no gain.”

When consultants’ advice flops in global public health, who is accountable?

The hundreds of millions spent on consultants, and lack of systematic
evidence to support hiring them, is more concerning when you consider one
feature that makes global health different from other areas: When
consultants’ advice fails, it’s the lives of the poor and marginalized on
the line. Or, in the case of McKinsey’s work with UNITAID, an organization
funded mainly by public money, it was a high-profile fundraising initiative
for tuberculosis, HIV/AIDS, and malaria in developing countries that failed.

When UNITAID was created in 2006, it was hailed for establishing a new
funding model through a small tax on airline tickets in some countries. But
by 2007, bringing new countries with significant airline markets on board
was proving difficult. So UNITAID’s chair at the time, Philippe
Douste-Blazy, along with some of his close allies in the tourism business,
came up with an idea: Why not work with the travel industry directly and
offer travelers the possibility of making micro-donations every time they
purchase an airline ticket?

The agency turned to McKinsey to get advice on the idea because, “That was
just the way things worked,” Douste-Blazy wrote in his 2010 book Power in
Numbers. UNITAID was also funded by the Gates Foundation, which, from day
one, paid for McKinsey’s consulting work, according to UNITAID’s publicly
available 2006 board minutes. UNITAID’s board suggested a feasibility study
be done before launching the new fundraising program, known as
“MassiveGood.” Since McKinsey was already working there thanks to Gates,
the firm was the obvious choice.

Consultants at the firm proposed a four-month study for $1 million. In
April 2008, McKinsey presented its analysis to the UNITAID Board. They
didn’t find any fault in UNITAID’s plan; instead, the consultants endorsed
it as a “great idea,” Douste-Blazy wrote. McKinsey’s study projected that
the new fundraising strategy could raise $ 1 billion annually from private
donors, a doubling of UNITAID’s budget. So the board moved ahead with the
plan, allocating a provisional budget of $10 million for the first year,
and $12 million for the second year.

MassiveGood launched with a splash at the United Nations in New York in
2010. Then-UN Secretary-General Ban Ki-moon, Bill Clinton, and director
Spike Lee announced the campaign. Backed by the Gates Foundation, the
scheme was hailed as an innovation in health care financing by major media
outlets.

But McKinsey’s projections were wrong. Travelers did not want to donate
even meager sums to the organization. By July 2010, the foundation had only
raised $14,000 from the new initiative — a sum far less than 1 percent of
the $1 billion McKinsey projected. It didn’t even offset the $11 million
UNITAID wound up paying out for consulting fees, advertising, and legal
expenses.

Several members of the board expressed “concerns that UNITAID had invested
such a large amount of funds with very little return,” and recommended the
initiative be independently assessed. To do so, UNITAID hired yet another
consulting firm, Dalberg. Its study, the costs of which were not made
public, was damning and pointed at flaws in the assumptions and initial
revenue modeling produced by McKinsey.

THE FOUNDATION RAISED $14,000 — FAR LESS THAN 1 PERCENT OF THE $1 BILLION
MCKINSEY PROJECTED

By December 2011, UNITAID’s chair reported that the MassiveGood project had
failed to reach its objectives, and that its board had passed a resolution
to dissolve it. And so MassiveGood — and the millions of US dollars
invested in the project, as well as its proceeds aimed at fighting
HIV/AIDS, malaria, and tuberculosis — were gone. (UNITAID and McKinsey
declined to comment.)

Former UNITAID staff and board members voiced frustration over the
resources that were sucked into what turned out to be a dead-end for the
organization in interviews with Vox. Instead of sending UNITAID in the
right direction with a successful campaign, the exercise risked
discrediting the organization, one ex-staffer said. “Everyone was so
embarrassed by its failure — all these national governments.” The exercise
also raised questions about who is publicly accountable when consultants’
advice fails at organizations funded, wholly or in part, by public money.
“There [was] no accountability,” the ex-staffer said, “about how McKinsey
got it wrong.”

Is it ethical to hire Western consultants if they supplant locals in
developing countries and give out-of-context health advice?

The growing reliance on what are often US consulting firms, Vox learned, is
a symptom of a larger problem at global health organizations: The work is
still done by people in wealthy countries for people in developing
countries, too often without their participation.

“It’s frustrating in 2019 that the flows [of money and knowledge] are
entirely from north to south,” said McGill’s Pai. “It’s understandable this
happened 50, 100 years ago — but why this happens today is an important
question to ask.”

Before Pai moved to Canada from India, he saw firsthand how this imbalance
manifests: External consultants were overwhelmingly favored over hiring
locals with deep expertise on local health problems.

Consultants “are able to talk the language that’s understood by corporate
philanthropies and the private sector — they are comfortable with that way
of thinking but many of them aren’t anywhere close to the ground,” he said.
“The amount of money you’d pay for McKinsey, BCG, or Deloitte [consultants]
— you could probably hire several deeply experienced country experts. But
unfortunately, the national expertise is undervalued.”

Anand Giridharadas, the ex-McKinsey consultant and author, has likened this
phenomenon to a new form of colonization in his recent book, Winners Take
All. “The situation was no longer British colonizers helping themselves to
your country,” he writes. “It was well-suited people with laptops offering
to solve social problems, often pro bono, without needing to know much.”

An early 20th century medical tent in India. Management consulting is
likened to a new form of colonization in ex-consultant Anand Giridharadas’s
recent book, Winners Take All. Culture Club/Getty Images

The well-suited outsiders too often give advice that lacks context — like
pushing high-tech solutions in low-resource places, Sandro Galea, dean of
the Boston University School of Public Health, said. In the mid-aughts, he
recalls management consultants advising government officials in Liberia to
create a system for electronic medical records for the whole population. To
Galea, who was doing research in Liberia at the time, it seemed like a no
brainer: It wouldn’t work.

“I am thinking, there isn’t electricity here for 23 of 24 hours a day,”
Galea said. “Consultants are drawn to flashy technology, but that
technology requires infrastructure, like electricity, that was
non-existent.”

In global health consulting, it’s also sometimes knowledge of health, or
public sector and multilateral organizations, that’s lacking.

One former consultant told Vox about quitting a major consulting firm in
2016 over a public health project gone awry. The ex-consultant, who has
graduate degrees in public health, had been assigned by the firm to a team
where the other members had no health expertise. Together, they were tasked
with making a recommendation about female contraceptives in West Africa.

“THE CONSULTANTS COULD NOT UNDERSTAND OUR HUMANITARIAN BUSINESS”

The team’s leader insisted on pushing a form of birth control the
ex-consultant had warned would never be accepted in the country. “It’s
really hard to learn all the nuances of development quickly, especially if
you’re not humble,” the ex-consultant said. “And I don’t think many
consultants are humble.”

Instead of humility, what’s favored is fast advice and measurable results,
or as BCG describes them, “private-sector approaches.” These approaches
have become “the essential toolkit for solving anything” in “our age of
market supremacy,” Giridharadas writes. But even though they can sometimes
be helpful inside public institutions, they aren’t always a good fit in
global health.

When Mukesh Kapila worked as undersecretary general for the International
Federation of Red Cross and Red Crescent Societies from 2010 to 2012, he
and his team hired consultants to develop a new business strategy for the
organization. “The consultants could not understand our humanitarian
business and their recommendations were completely irrelevant,” he recalls.
“It was a complete failure … a complete and utter waste.” He wound up
ignoring the firm’s advice.

Former WHO executives, with decades of experience at the agency, told Vox
they felt the consultants did not fundamentally understand the organization
and provided business solutions that didn’t make sense. “Consultants have
often found it difficult to ... appreciate decision-making processes at a
multilateral international agency,” one said. “The private sector models
have not been particularly helpful.”

Another ex-official said, “A lot of the recommendations made over the
decades with different consultants coming in and trying to help reform the
WHO — my guess is the majority of the recommendations have not been
implemented and it would be more sensible to find out why the
recommendations were not implemented instead of just repeating or iterating
them.”

Can consultants take credit for solving global health problems while also
working for the industries that exacerbate them?

There’s an even deeper conflict between consultants’ private sector
experiences and their public sector global health work: Their advice has
been linked to some of the most urgent health crises of the last
half-century.

Consider McKinsey’s role in the opioid epidemic, which has taken the lives
of nearly a million Americans since 1999. Court documents that surfaced in
litigation revealed that McKinsey advised two companies on how to increase
sales of prescription opioids, from the early 2000s until at least 2014 —
when the overdose epidemic was already well-known. McKinsey advised Johnson
& Johnson to “get more patients on higher doses of opioids” and study
techniques “for keeping patients on opioids longer,” the New York Times
reported.

The Opioid Spoon Project in New Brunswick, New Jersey, is using sculptures
of bent spoons, similar to ones that might be used to abuse opioids, to
bring attention to the companies they claim helped to create the crisis.
Seth Wenig/AP

McKinsey also worked with OxyContin-maker Purdue Pharma, coming up with
strategies to “counter the emotional messages” of mothers whose children
had overdosed and to overcome “patient pushback” so hesitant doctors could
prescribe more opioids, according to ProPublica. “Our historical work for
clients in this industry was designed to support the legal prescription and
use of our clients’ products,” McKinsey told Vox in a statement. “However,
opioids have had a devastating impact on our communities, and we are no
longer advising any clients on any opioid-specific business.”

McKinsey has also recently egged on another deadly industry — coal. In
2015, their analysis of Poland’s economy encouraged the country to boost
the efficiency and productivity of coal mining in order to help the Central
European country become one of the “world’s most advanced economies.”

In the report, McKinsey consultants suggested one key way to achieve
“double-digit productivity improvement” in coal mining would be to
“eliminate those regulatory barriers that increase effective costs and
decrease labor productivity without improving safety or work conditions.”

For years, the environmental health dangers of Poland’s coal industry have
been documented: Poland’s coal mining industry plays a large role in the
country’s pollution crisis. A 2014 air quality report from the European
Environment Agency, singled out Poland and coal burning as leading
contributors to air pollution in Europe. The same year, the WHO warned that
air pollution is “the single biggest environmental health risk.” Now, 33 of
the 50 most polluted cities and towns in the Europe Union are in Poland,
according to the WHO, earning the country the moniker the “continent’s
capital of smog.”

“[McKinsey’s] advice is completely wrong and anachronistic, even in 2015,”
Zoltán Massay-Kosubek, policy manager at the European Public Health
Alliance, a public health advocacy NGO based in Brussels. “The air wasn’t
cleaner five years ago.”

In 2018, the EU’s highest court even charged Poland with “persistently”
exceeding air pollution limits, endangering human health. That’s why a WHO
bulletin advised doing exactly the opposite of what the McKinsey report
suggested: using tougher regulations on coal to increase the cost and
encourage the shift to cleaner energy sources. (More recently, McKinsey has
done analyses of how the industrial sector and cities can reduce carbon
emissions.)

Meanwhile, consultancies have helped grow the market around the world for
processed foods and beverages, including soda, which has been heavily
linked to the global obesity and diabetes pandemics.

In a 2015 report from BCG — co-developed with the Confederation of Indian
Industries, including the then chairman and CEO of PepsiCo India — the firm
looked at how to increase India’s market for “Fast-Moving Consumer Goods,”
including sugary drinks. The report came out well after discussions about
reducing sugary drinks consumption, and even taxing the products, to curb
disease — something WHO supports — gained prominence. (BCG declined to
comment.)

“THERE IS AN INHERENT TENSION AND CONFLICT OF INTEREST IF WHO IS ENGAGING
CONSULTANCY FIRMS THAT ALSO WORK WITH COMPANIES WHOSE PRODUCTS HARM HEALTH
OUTCOMES”

WHO and other global health agencies “should be avoiding any management
company that has linkages with the food, health care, or tobacco sectors,”
said University of North Carolina Gillings School of Global Public Health
obesity expert Barry Popkin. He pointed out that Bloomberg Philanthropies
has longstanding guidelines around not hiring any company, including
management consulting firms, with ties to industries that undermine their
public health work. The philanthropy has not worked with McKinsey or BCG in
at least the past five years.

Adam Kamradt-Scott, a professor in global health at the University of
Sydney who studies WHO, applauded WHO’s conflict-of-interest policies
around tobacco. But he said despite “calls for the WHO to take a similar
tough stand on the alcohol and sugar industries, we haven’t seen much
progress in that yet.” He added: “There is an inherent tension and conflict
of interest if WHO is engaging consultancy firms that also work with
companies whose products harm health outcomes.” (WHO declined to comment.)

These conflicts are more apparent in a time when there’s greater scrutiny
of how the winners of global capitalism are taking credit for reputedly
solving the problems of the losers.

“The social and humanitarian sectors have been conquered by the idea that
business people and business methods are specially capable of reforming
them and improving people’s lives,” Giridharadas, the ex-consultant and
author, told Vox. “The problem with the winner-take-all approach to solving
public problems is that the winners, McKinsey among them, get to shape what
change is and ignore their role in perpetuating the very problems they
claim to be solving.”

“The winners, McKinsey among them, get to shape what change is and ignore
their role in perpetuating the very problems they claim to be solving,”
said Anand Giridharadas, seen in Washington, DC, on April 9, 2019. Salwan
Georges/Washington Post/Getty Images

In a phone interview, Giridharadas imagined another world, where
consultants took an approach that was truly considerate of health instead
of just maximizing profits. “Imagine if McKinsey advised its pharma clients
not to cling to patents in developing countries that make it so hard to
fight HIV/AIDS. Imagine if it advised food and beverage behemoths to stop
selling the products that cause obesity and heart disease. Imagine if it
actually persuaded its clients to pay their taxes instead of avoiding them
so that national health organizations and organizations like WHO would have
adequate resources.”

For now, McGill’s Madhu Pai said, consultants and their business strategies
remain extremely influential. “The corporate way of thinking has become the
way global health organizations think.”

Do you have a story to share about consultants in global health or the
reforms at WHO? Contact Vox reporter Julia Belluz on email at
julia.belluz at vox.com, Twitter @JuliaofToronto, or via Signal.

Marine Buissonniere is an independent researcher and adviser on
humanitarian issues and global health.


-- 
Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International
41 22 791 6727
thiru at keionline.org


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