[Ip-health] Reuters: Special Report - The World Health Organization's critical challenge: healing itself

Thiru Balasubramaniam thiru at keionline.org
Wed Feb 10 00:26:31 PST 2016


Special Report - The World Health Organization's critical challenge:
healing itself

Mon Feb 8, 2016 12:32pm GMT

By Kate Kelland

GENEVA (Reuters) - When executive board members of the World Health
Organization sat down for their annual meeting in Geneva in January, many
powerful figures spoke forcefully of the need to reform the leading global
authority on health and disease.

"It's time to stop talking," Stewart Jessamine, New Zealand's director of
public health and a WHO executive board member, told the delegates. "We
have to change."

Jimmy Kolker, a leading member of the U.S. delegation, told the meeting the
WHO must "recognise how crucial this moment is for the future of the
organisation, and the resources and the trust that are in the balance."

For years the WHO has talked about streamlining its complex structure,
governance and financing to make it more efficient. Critics say the
organisation needs deep reforms to allow it to show clear leadership in
promoting health and to respond decisively to disease emergencies that may
span many countries. But progress has been painfully slow.

Margaret Chan, Director General of the WHO since 2007, acknowledged the
concerns of delegates and agreed with Jessamine: "Yes, it’s time to stop
talking," she said.

She promised to act swiftly on reforming the WHO’s emergency responses. "We
are committed to implementing a single programme, with a single line of
accountability, a single budget, a single set of business processes, a
single cadre of staff and a single set of performance benchmarks," she said.

The pressure for change has been building after a series of missteps by the
global health body. Last year, while still smarting from accusations it
overreacted to the 2009-10 H1N1 flu pandemic, the WHO faced withering
criticism for not reacting fast enough to the Ebola crisis in West Africa.
The organisation's Lyon-based International Agency for Research on Cancer
(IARC) has become a target of ridicule among some health experts for
issuing confusing warnings on everything from the air we breathe to the
meat we eat to the phones we use. And the WHO is now being questioned about
its response to the Zika virus.

Public health specialists, non-governmental organisations and some of the
WHO’s biggest donors say the organisation is unwieldy, poor at coordinating
responses to epidemics, and too thinly spread. And increasingly it
struggles to set its own priorities because many of its donors give it
money earmarked for specific projects.

Some experts inside and outside the organisation say those flaws mean the
WHO's lead role in global health is now at risk. Nils Daulaire, who was
until recently the U.S. representative on the WHO's executive board, told
Reuters the WHO “is not functioning well” and cannot "survive in its
present form for another decade."

He said global officials who engage with the WHO regard it as bogged down
by internal processes and often forced by its members to take on more than
its resources can manage.

"I've heard from a lot of former colleagues representing other countries
that are major contributors to WHO, and other institutions that contribute
financially, that either (the WHO) has to get fixed in a relatively short
period – five to 10 years – or they're going to take their marbles and go
elsewhere," said Daulaire.

Reuters spoke to more than a dozen people who know the WHO and its
leadership well. All said the world needs the WHO to succeed. But most were
also frustrated and even angry with its current state - sentiments that
were on open display at January's meeting in Geneva.

Chan told delegates that she recognised the concerns. "We hear you loud and
clear on your expectations on how you would like to see us reform the
programme," she said.

A WHO spokesman, Tarik Jasarevic, told Reuters that changes to the agency's
response systems "are already under way" and would include the
establishment of a single programme for outbreaks and emergencies. He said
The WHO "is also committed to an independent mechanism of assessment and
monitoring of the performance of the organisation, reporting to the
governing bodies."


The WHO is unique among UN agencies because its structure includes six
regional offices, each with its own director elected by regional member
states. Beneath them is a sprawling network of around 150 country offices.

Charles Clift, who led a 2014 report for the Centre on Global Health
Security at Britain's Chatham House entitled "What's the World Health
Organization for?," said the complexity "is one of the main reasons why the
WHO, in many ways, is dysfunctional."

Clift, who was secretary of the WHO's commission on intellectual property
rights, innovation and public health from 2004 to 2006, describes the
structure as "not one but seven WHOs" - the Geneva headquarters plus the
regional offices whose directors are answerable not to Chan but to their
own member states.

The flaws in the structure were evident in the Ebola crisis. Despite
repeated warnings by the charity Medecins Sans Frontieres (Doctors Without
Borders) that national governments were not on top of the seriousness of
Ebola's spread, WHO officials in Geneva declared the outbreak "relatively
small still" in April 2014. It wasn't until August, when the epidemic was
out of control in West Africa, that Chan declared it a global emergency.

"The lack of a direct line of control from Geneva to what was happening at
country level was probably one of the main reasons for why they were so
slow," said Clift.

Chan said late last year the WHO had been "overwhelmed" by the Ebola
outbreak, which she said "shook this organisation to its core."

Some health officials fear the current scramble over the Zika virus is
another example of the WHO's lack of coordination. As members of the
executive board met in Geneva, the health body's regional office in the
Americas issued an alarming statement. The little-known Zika virus was
spreading fast, it said, and threatened to infect millions.

The spread of the virus is thought to correlate with a rise in birth
defects in Brazil - but no causal link has been proven. The regional
office's statement caught WHO headquarters by surprise: No one had bothered
to tell it the statement was going to appear. The contents of the Zika
warning were accurate, WHO staffers say, but as one Geneva-based WHO
insider said: "They put it out without telling us."

A spokesperson for the regional office, the Pan American Health
Organization, said that it shares information with WHO headquarters but
sometimes acts independently so that it can respond swiftly. In the case of
Zika, it issued a statement at the request of a country office to counter
misleading local media reports about sexual transmission of the virus, the
spokesperson said.

The effect, though, went wider. Just as the WHO's week-long annual
executive board meeting was beginning, the Geneva headquarters found itself
unexpectedly fielding urgent inquiries about the Zika virus.

Some board members expressed concern that once again the WHO looked
slow-footed on the emergence of a potentially major epidemic. Chan hurried
to reassure them. Within days she was moved to convene an emergency expert
panel on Zika, saying the mosquito-borne disease had grown from a mild
threat and was now "spreading explosively."

One reason for the lack of streamlined communications was that the regional
office PAHO "sees itself as semi-autonomous," according to the WHO insider.
This is partly because PAHO was founded in 1902, more than 40 years before
the WHO itself was created.

A spokesperson for PAHO said: "While PAHO has its own constitution, PAHO
always coordinates with and informs WHO HQ ... While Zika was not an
emergency in other regions of WHO, it is for PAHO because most of the
member states affected are in the Americas."

PAHO had treated Zika as an emergency since May 2015, said the
spokesperson. WHO headquarters declared Zika a public health emergency only
this month.

It's in cases like this that some countries, such as Britain and the United
States, are keen to have clearer lines of authority. But some smaller
member states are reluctant, according to Clift, Daulaire and some current
WHO staffers. They say this is because less dominant states worry that
ceding all power to a central headquarters might mean that their own
governments could be chastised by the WHO for failing to report, control or
prevent chronic ill-health, infectious disease, or pandemic threats.


There's another big problem, many people say: The WHO tries to do too much.

It was founded in 1948 – an era in global health when "the entire focus was
infectious diseases" and "in some ways life was much simpler," said Richard
Sullivan, a professor of cancer policy and global health at King's College

"It's important to remember that's where the WHO came from," he said.
"Non-communicable diseases (such as heart diseases, cancer and diabetes)
just weren't on their radar at all."

Since then, global health has become far more complex. A quick glance at
the WHO's current "health topics" list shows it offers expertise on a vast
array of issues, from sunburn and domestic violence to Crimean-Congo
haemorrhagic fever and plague.

On a side table outside the board meeting in Geneva, a pile of discussion
documents included everything from the sound management of chemicals to
reducing road traffic accidents. There was a "global vaccination action
plan," a paper on pandemic influenza, and a draft policy on "multi-sectoral
action for a life course approach to healthy ageing."

Jeremy Farrar, an infectious disease specialist and director of the
UK-based global health charity the Wellcome Trust, says the WHO is
floundering because it can't, or won't, say no to anything.

"It's so thinly stretched," he said. "There's arguably no organisation on
earth that could cover all those (topics) at sufficient depth to be

Farrar argues the best way for the WHO to become "a totally respected
organisation" is for it to set top priorities for global health "and do
those at a really high level."

But with member states – the owners and directors of the WHO – requiring it
to cover such a vast range of health issues, the WHO's ability to focus is
hampered. Barbara Stocking, a former chief executive of the charity Oxfam
UK who chaired an expert panel reviewing the WHO's response to Ebola last
year, said the health body "got distracted" by very broad agendas
determined by its members.

Stocking says outbreak response should be the "absolute essence" of the
WHO: "If it doesn't deal with health emergencies across the world, then
what is it there for?"


The WHO faces another major hurdle in trying to nail down its core
functions: It has budget pressures and has lost control of some of its own

In 2011, hit by the global financial crisis, member states cut the WHO's
budget, reducing it by 13 percent from the previous year. This hurt the
WHO's department for global health security and became "a fundamental
driver," according to Daulaire, of the WHO's slow response to the Ebola

Another change may have had an even bigger impact. Sixteen years ago, the
WHO received 49 percent of its money as "assessed contributions" from
member states. The WHO could mostly do what it wanted with this money. By
2014, assessed contributions had dropped to about 20 percent of funds the
WHO received.

About 80 percent is now made up of "voluntary contributions." Some come
from member states that want to give extra, others from bodies such as
educational institutions, trusts and charities, including the foundations
of Microsoft founder Bill Gates and Mike Bloomberg, the
financial-information mogul and former New York mayor.

Almost all these donations come with strings attached – stipulations that
the money must be used for certain projects or diseases. In all, 93 percent
of the money given to the WHO for its health programmes is now "specified"
– earmarked – by donors for particular projects.

The largest of the non-government donors by a long way is the Bill &
Melinda Gates Foundation. From a standing start a decade ago, it has been
contributing between $250 million and $300 million a year. In one year –
2013 – it was the largest donor bar none, overtaking even total
contributions from the U.S. government.

The impact of funds from private donors can be seen in WHO spending. One of
the Gates Foundation's priorities is the eradication of polio – a crippling
disease that can be prevented with comprehensive vaccination campaigns. A
breakdown of the WHO's finances shows that its polio programme is by far
the best-resourced, accounting for 23.5 percent of the WHO's current
programme budget. The next biggest programme is outbreak and crisis
response, which gets 15.3 percent.

The WHO can push back against donors' wishes only so hard – or risk donors
taking their money elsewhere. Daulaire said that he has talked to "very
senior people at the Gates Foundation" who are studying the WHO's current
state “with a great deal of interest and concern - and they certainly have
the capacity and the right to put their money elsewhere."

Asked whether the Gates Foundation was planning to put its money elsewhere,
Steve Landry, its director of multilateral partnerships, said: "The
foundation invests in a variety of organisations to improve global health
surveillance, build resilient health systems, and strengthen national and
global pandemic preparedness. WHO plays an essential and unique role among
the partners. Several of our investments in WHO are designed to help it
deliver on this mandate."

The organisation's fate will depend in large part on the deep-pocketed
United States. The current American board member of the WHO is Tom Frieden,
the director of the U.S. Centers for Disease Control and Prevention. In
Geneva, emerging from the tense morning session on the first day of the
January meeting, Frieden said: "The world needs a really strong WHO. If we
don't make these changes now, they are not going to get made."

(Additional reporting by Stephanie Nebehay in Geneva, and Himanshu Ojha and
Stuart McDill in London. Editing by Simon Robinson and Richard Woods)

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