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AFRO-NETS> Economist article about WHO


Economist article about WHO
---------------------------
Source: e-drug@healthnet.org


Attached is the controversial article about WHO in last week's Econo-
mist (Economist 1998, 8-15 May, pp91-94).

The client is a so-year-old multinational concern that was once the 
global leader in its sector. Recently, however, it has lost its direct- 
ion. Though the market it serves is still growing rapidly, it is also 
changing in ways that threaten the relevance of the client's tradi-
tional strengths. The client has also suffered over the past decade 
from weak leadership, and rival concerns have been competing for its 
territory. Nevertheless its brand is still strong, and while it may 
never regain its previous monopoly, it can probably be repositioned as 
primus inter pares in the sector. Its rivals need its expertise and it 
should be able to carve out a comfortable niche if it is prepared to 
co-operate with them. This will require a significant change of atti-
tude on the pan of some employees and that, together with the anti-
quated management structure and an ill-advised growth in the number of 
senior managers over the past few years, may indicate the need for some 
corporate downsizing.

The client, of course, is the World Health Organisation (WHO). And the 
thankless task of reforming it has gone to Gro Harlem Brundtland, for-
mer prime minister of Norway, chairman of a seminal environmental re-
port and fully paid-up member of the International Great and Good. Hav-
ing been nominated in January by the organisation's executive board, Dr 
Brundtland will be elected as the WHO'S director general by the World 
Health Assembly (the nearest thing the WHO has to an annual general 
meeting) on May 13th. Formally, she will take up her position on July 
21st. But the bow-wave of her appointment is already sweeping through 
the WHO'S headquarters in Geneva. If they are wise, the organisations 
more notorious time-servers will already be putting their personal pos-
sessions into bin-liners, in order to avoid the rush.

WHO, what and why like many middle-aged organisations (and people), a 
lot of the WHO'S problems stem from the fact that it has not changed 
with the times. The WHO of old was supremely good at fighting infec-
tious diseases. It still is. Though its greatest success, the extinc-
tion of smallpox, happened more than two decades ago, the organisation 
now believes it is on course to eliminate polio possibly by the year 
after next. It hopes to follow that up with three further eradications, 
including leprosy, in the first two decades of the next century. Dr. 
Brundtland's most public initiative so far has been to capitalise on 
this experience by renewing the WHO'S campaign against malaria-or, 
rather, to attempt to capture the leadership of an anti-malaria cam-
paign that the G7 group of industrial nations is expected to launch at 
a meeting in Britain later this month. But even the WHO'S own figures 
suggest that infectious disease is becoming yesterday's problem. Apart 
AIDS and the resurgence of tuberculosis that has accompanied it, tomor-
row's principal causes of ill health in poor countries are expected to 
become progressively more similar to those now found in the rich world. 
This means that chronic, non-communicable (and often non-treatable) 
diseases will predominate. To fight these, the WHO will have to change 
its focus quite markedly, from managing immunisation programmes and 
combating mosquitoes, to helping countries run national health-
insurance systems, tackle urban environmental-health problems and deal 
with rising rates of cancer, cardiovascular disease and mental illness. 
The WHO is behind the times in another way as well. Pans of the organi-
sation seem to be stuck in a 1904/5 public-sector timewarp. They regard 
government action as automatically good, profit as automatically evil, 
and intellectual property as theta. That sometimes makes collaboration 
with the private sector, particularly drug companies, a fraught affair. 
But the age of medicines as a pure public service is over. Even in the 
poorer parts of the world, people will increasingly have to pay their 
own way. (In fact, a far higher proportion of health spending already 
comes directly out of patients' in poor countries than in rich ones.) 
And the drug companies, their discoveries safely protected by patents, 
are the principal source of innovation in modern medicine. Reforming 
these attitudes would not be easy in the best of circumstances, but the 
WHO'S structure will make it harder. Hiroshi Nakajima, Dr. Brundtland's 
predecessor, allowed the organisation to degenerate frequently, it is 
alleged, as a result of cronyism. (The number of executive directors, 
the director general's immediate deputies, increased from five to 12.) 
Dr Nakajima also allowed the WHO'S six regional offices to get out of 
control. These offices, two of which pre-date the WHO'S formation and 
were absorbed into it in 1948, guard their autonomy jealously. Their 
waywardness has always been a trial for directors general, but recently 
things seem to have got worse. Some of the regional offices are now by-
passing the WHO offices in individual countries altogether, and dealing 
directly with health ministries there, so that the WHO'S representa-
tives on the ground frequently do not know what is happening. If any 
bypassing is to take place, it should probably be of the regional of-
fices themselves. Geneva, in other words, should be communicating di-
rectly with its country offices. Reining back the regions will be dif-
ficult (a formal change in their relationship with HQ would require an 
alteration to the WHO'S constitution), but a recent report by the WHO'S 
six principal paymasters supports the idea, and tightening of financial 
controls on the regions may, in practice, do the trick. The autonomy of 
the regions, however, is symptomatic of a wider problem. Without cen-
tral control, related tasks are carried out by bodies that may not talk 
to each other, and new tasks are taken on almost on a whim. Jonathan 
Quick, the director of the WHO'S Essential Drugs Programme (a worthy 
attempt to work out a minimum list of the drugs that should be avail-
able in every country in the world), describes the organisation as be-
ing like a Christmas tree on whose branches new projects are hung at 
random, frequently without regard to what is there already. Lack of 
central control is also a charitable explanation for the WHO'S notori-
ously untransparent decision-making processes. Important policy docu-
ments often remain private. For example, the guidelines on links with 
commercial interests, which were drawn up in the 1980s, have never been 
formally published. Policy resolutions, too, have a tendency to appear 
from nowhere, as happened at the executive board meeting that appointed 
Dr Brundtland. The meeting passed something called the "Revised Drug 
Strategy", even though this had not initially appeared on its agenda. 
This 'Strategy' is no minor idea. It urges member countries to ensure 
that public health rather than commercial interests have primacy in 
pharmaceutical and health policies when they implement the latest in-
ternational agreement on intellectual property. That looks like a 
threat to drug-company patents. Dr Brundtland's first task, therefore, 
is to try to rationalise the WHO'S structure. Though she refuses to 
discuss the details before she takes the reins, the Thatcher of the 
Left (as she was known to Norwegian political commentators) plans to 
flatten the organisation, clarify who does what and make the place more 
open to scrutiny. Reorganisation, however, is useful only if it is a 
precursor to action. That means asking some hard questions about the 
WHO's role in the new century. You can bank on it! Dr Nakajima's reign 
saw the WHO's exclusive franchise on world health eroded. One symptom 
of this was the creation of UNAIDS, a new United Nations programme to 
combat the ravages of the human immunodeficiency virus. The WHO, which 
might, a couple of decades ago, have expected to tackle AIDS alone, is 
merely one of six collaborators in the programme. But the most serious 
threat to the organisation's monopoly is probably the involvement of 
the World Bank in health policy. The Bank's activities have always had 
an impact on world health. Public works, particularly the supply of 
clean water and the removal of sewage together with the reduction of 
poverty, are more important to a population's health than any medical 
intervention, with the possible exception of childhood vaccination. 
Even now, about 8% of the burden of ill-health in low- and middle-
income countries can be blamed on a lack of clean water and sewers, and 
a further 18% on inadequate nutrition. Promoting economic growth - the 
Bank's reason for existing - is therefore the most effective health 
policy that a country can pursue. But, by recognising that the rela-
tionship between health and growth is reciprocal that a healthy work-
force will be more productive than an unhealthy one the Bank has gradu-
ally become more directly involved. That involvement was formalised in 
1993, when the Bank devoted its annual World Development Report to 
health. Now it has its own specialist "network" for Health, Nutrition 
and Population, and manages a $10 billion portfolio of loans specifi-
cally for health-related projects - a portfolio that is growing by $1 
billion to $2 billion a year. This compares with a WHO budget, un-
changed in real terms for 14 years, of $900m and the Bank's ability to 
outmuscle the WHO is not merely financial. Its direct access to coun-
tries finance ministries (the WHO rarely deals with anybody higher up 
the cabinet table than the health minister), means that it can bend the 
ears of the people who matter most, and be reasonably sure that its 
agreements, once made, will not fail through lack of political support. 
It is, for example, in the process of persuading six countries to par-
ticipate in a new vaccine-purchasing scheme that the WHO has been ped-
dling for years without success - and persuading other, richer, coun-
tries to finance it. In addition to its financial and political advan-
tages, the Bank's attitude to health issues is harder edged. The WHO is 
given to grandiose objectives ("Health for all by 2000" was one ludi-
crously unachievable example). By contrast, the Bank's 1993 report in-
troduced the idea of "Disability Adjusted Life Years", or DALYS, which 
quantify the effects of disease. Officially, of course. The WHO has al-
ways welcomed the Bank's initiative (and the DALY was co-invented by 
one of its researchers). But privately, many of its employees were 
scandalised by the idea of measuring the success or failure of a health 
policy by its economic consequences rather than by the ideologically 
pure goal of health for health's sake. As a result of all this, col-
laboration between the WHO and the Bank has broken down completely in 
some countries. One of Dr Brundtland's early objectives is therefore to 
put a stop to that kind of nonsense. She visited the Bank in March, met 
its boss, Jim Wolfensohn, and both sides expressed their determination 
to co-operate. Such co-operation would benefit not only the organisa-
tions, but also their customers, the poor and ill. And it should give 
the WHO a way to come to terms with the most difficult change in the 
world of health: the rise of commercial medicine. The WHO'S main com-
mercial relations with the drug companies have not been all bad. They 
have gone well enough when the firms have been in charitable mood. Sev-
eral schemes depend on donated drugs (Merck's products are helping in 
the campaign against river blindness, and SmithKline Beecham's in that 
against filariasis). But the old guard's suspicions about intellectual 
property have resulted in drug-company fears (not calmed by the Revised 
Drug Strategy that emerged so unexpectedly from the meeting in January) 
that the WHO would like to collude with some of its member states to 
erode their patents. Collaboration with the private sector is essential 
to the WHO'S future. Dr Brundtland has said she will encourage it (the 
only "drug" companies she disapproves of are the tobacco companies). If 
she succeeds, and if she can tailor the organisation to the needs of 
its customers, the WHO should have a bright future. Whether running it 
will prove easier than running Norway remains to be seen. But perhaps 
the WHO can yet be handbagged into shape.

--
Leo Offerhaus MD PhD
Koedijklaan 1a
NL-1406KW Bussum
The Netherlands
Tel: +31-35-6923288
Fax: +31-35-6923290
mailto:lo@euronet.nl  or 
71530.15@CompuServe.com

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