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Subject: E-DRUG: article Economist
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E-DRUG Economist article about WHO

Attached is the controversial article about WHO in last week's 
Economist. The source (Economist 1998, 8-15 May, pp91-94) should be 
quoted. I scanned this at the monitor's request.

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 traditional 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 attitude on the pan of some employees and that,
together with the antiquated 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, former
prime minister of Norway, chairman of a seminal environmental report and
fully paid-up member of the International Great and Good. Having 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 possessions 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 infectious diseases. It still is.
Though its greatest success, the extinction 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 campaign 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, tomorrow'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 combatting 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
organisation seem to be stuck in a 19405 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 ncipal 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 bypassing the WHO offices in individual countries altogether, and
dealing directly with health ministries there, so that the WHO'S
representatives on the ground frequently do not know what is happening. If
any bypassing is to take place, it should probably be of the regional
offices themselves. Geneva,
 in other words, should be communicating directly with its country offices.
Reining back the regions will be difficult (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 central 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 available in every country in the world),
describes the organisation as being 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 notoriously untransparent decision-making processes. Important policy
documents 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 anointed 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 international 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 Al DS 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 sh  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\emdash the Bank's reason for existing\emdash 
is therefore the most effective health policy that a country can pursue.
But, by recognising that the relationship between health and growth is
reciprocal that a healthy work-force will be more productive than an
unhealthy one
the Bank has gradually 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
specifically for health-related projects\emdash a portfolio that is growing
by $1 billion to $2 billion a year.
This compares with a WHO budget, unchanged 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 countries 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 participate in a new vaccine-purchasing scheme that the WHO
has been peddling for years without success\emdash and persuading other,
richer, countries to finance it. In addition to its financial and political
advantages, the Bank's attitude to health issues is
 harder edged. The WHO is given to grandiose objectives ("Health for all by
2000" was one ludicrously unachievable example). By contrast, the Bank's
1993 report introduced the idea of"Disability Adjusted Life Years", or
DALYS, which quantify the effects of disease. Officially, of course. the
WHO has always 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, collaboration 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 organisations, 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 commercial relations with the drug
companies have not been all bad. They have gone well enough when the firms
have been in charitable mood. Several 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
Phone +31-35-6923288 Fax +31-35-6923290
E-mail: LO@EURONET.NL or CompuServe 71530,15
EJCP Only: POB 75552, NL-1070AN Amsterdam

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