[Ip-health] Economist: World Health Organisation-Too big to ail

Thiru Balasubramaniam thiru at keionline.org
Sun Dec 14 22:15:23 PST 2014


World Health OrganisationToo big to ailEbola has laid bare the failings of
the world’s health authorityDec 13th 2014 | GENEVA | From the print edition

PERCHED on a hill in Geneva above the city’s cluster of international
agencies, the modernist headquarters of the World Health Organisation (WHO,
pictured above) seems a manifestation of the organisation’s grand mission:
to lead the world on health. But nearby sits a stinging reminder of its
shortcomings. Visitors to the WHO must first pass the headquarters of
UNAIDS, which was set up separately after a widespread loss of faith in the
WHO’s ability to tackle the AIDS epidemic.

Two decades after that failure, many health experts fear history is
repeating itself. After an outbreak of Ebola was identified in west Africa
in March, the WHO’s response was slow, disorganised and lacking in
leadership. In September Ban Ki-moon, the UN secretary-general, set up an
independent Ebola mission.

Ebola exposed weaknesses in the WHO’s ability to respond to disease
outbreaks. But it also highlighted deeper problems with the WHO, involving
funding, structure and staff. Founded in 1948 to help all people attain
“the highest possible level of health”, everything from obesity to
antibiotic resistance falls within its remit. But its activities cost far
more than can be covered by the dues its 194 member states pay, which are
calculated according to their wealth and population. These sums have not
risen since the 1990s.

The gap has been filled by contributions from rich countries, philanthropic
foundations, other multilateral bodies, non-governmental organisations and
private interests, such as pharmaceutical firms. In the 1990s these made up
around half of the WHO’s budget. Now they provide nearly 80% of it. This
shift makes it hard for the WHO to plan ahead and leaves it exposed to the
ups and downs of the world economy. The financial crisis hit voluntary
contributions. Its two-year budget for 2010-11 was nearly $5 billion; for
2014-15 it is less than $4 billion. (By comparison, America’s Centres for
Disease Control spent nearly $7 billion this year alone.)

The squeeze has seen the WHO continue to spend on chronic diseases and
primary health care—but slash its budget for responding to disease
outbreaks by half. This may have seemed reasonable: year after year,
chronic disease and poor health care are bigger killers. But a rapid
response to Ebola would have been far cheaper in the long run than
scrambling to catch up.

Its reliance on voluntary donations means that the WHO struggles to shift
funding fast—or indeed to decide how to spend a big chunk of its budget in
the first place. Most donations are for specific purposes. The Bill &
Melinda Gates Foundation has given money to fight malaria; Rotary
International bankrolls polio eradication. Both are worthy causes, but the
WHO’s role has been to follow, not to lead. “The director-general is highly
limited in how she can address global health challenges, given that she has
very little control over the budget,” says Steven Hoffman of the University
of Ottawa.

Such earmarking became more common in the 1990s, when donors lost
confidence in the WHO’s decision-making. But the organisation has improved
of late, says Nils Daulaire, a former American representative to it, by
basing its budget on more realistic goals. This is part of a reform process
begun in 2010. In order to wrest back the WHO’s agenda, potential donors
are now approached with a list of programmes that need funding. “We must
have the courage to say ‘no’ to money if it doesn’t match our priorities,”
says Margaret Chan, the director-general. But some doubt that will happen.
“The true test will be how much does the WHO actually reject,” says David
Stuckler of Oxford University. “Cynically, I suspect very little.”

To avoid opposition, the reforms have skirted another of the WHO’s biggest
problems. Under its constitution its six regional offices are largely
autonomous. Their directors are chosen by, and often beholden to, local
ministers of health. Some offices are treated as tools for patronage by
politicians. “The director-general has very little control over the
organisation’s budget, human resources and work in countries, including in
case of emergencies,” says Peter Piot of the London School of Hygiene and
Tropical Medicine.

These institutional weaknesses hampered the WHO’s response to Ebola. Africa
needs the strongest regional office, since its health needs are greatest,
says Dr Piot. Instead it has the weakest: “particularly politicised with
often incompetent people”. Reports of tension between local staff and
headquarters were borne out when Dr Chan eventually replaced the WHO’s top
officials in Guinea, Liberia and Sierra Leone, the countries hardest hit by
the virus.

The WHO’s technical side is meant to arm the organisation against
unreasonable demands from politicians and donors, by providing solid
evidence for the organisation’s policies. But though it was once a world
leader in health research, it is now considered unexceptional. Its
recommendations do not always match the best available evidence, says Mr
Hoffman. Where it has fallen short, others have moved in. The Institute for
Health Metrics and Evaluation at Washington University, for example, was
created in 2007 with money from the Gates Foundation after the WHO’s
statistics were found wanting.

Bureaucracy, budget cuts, political interference and tolerance for
incompetence all make it hard to attract and keep good staff. There are too
many “medocrats”—mediocre bureaucrats with a medical background—says Sophie
Harman of Queen Mary University in London. Asked why he stays at the WHO,
Pierre Formenty, one of its few Ebola experts, cannot come up with a
reason. In 2012 just 0.1% of non-support staff were economists, 1.4%
lawyers and 1.6% social scientists, meaning it is ill-equipped to make
well-rounded arguments for its policies.

As the WHO tries to reform, and the Gates Foundation, World Bank and others
encroach on its turf, many see a need for greater daring. Some have called
for it to be split in two, with separate political and technical agencies.
Others want its overly broad mandate slimmed down. A few want it abolished
altogether. But most think it has a valuable role to play as an accountable
advocate for public health, a forum for research and negotiation, and a
director of health interventions. They just want it to do those things

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