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E-DRUG: BMJ article: WHO and Brundtland

E-drug: BMJ article: WHO and Brundtland
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BMJ 1998;316:1553 (23 May 1998)

Brundtland says she means business

Adrea Mach, Geneva 

At the same time as celebrating its own 50th anniversary, the World Health
Organisation last week confirmed the election of Dr Gro Harlem Brundtland,
who
had formerly been prime minister of Norway three times, as the
organisation's
fifth director general. 

Applause broke out as the audience stood to honour the first woman to take
the
helm of the WHO. Dr Brundtland launched into her inaugural address, the
leitmotiv of which was "hard work ahead." She said: "The transition from
one
century to another sees changes which will be faster and more dramatic from
an
economic, social, and health perspective . . . WHO can and must change. It
must become more effective, more accountable, more transparent, and more
receptive to a changing world." 

Dr Brundtland's overall motivation is "making a difference." Her primary
areas of
concern for her five year term, which begins on 21 July, are: rolling back
communicable and non-communicable diseases (malaria and tobacco were
singled out for concentrated campaigns); building sustainable health
systems
that emphasise a more equitable distribution of the WHO's limited resources
to
those in greatest need; and developing a broader based, scientifically well
founded approach to health advocacy. 

Internally, priority will go to research underpinned with solid facts,
building
technical support, and identifying best practices that are cost effective.
Externally, wide ranging partnerships--with WHO's 191 member countries,
other
UN and international agencies, non-governmental organisations, and the
private
sector--and political activism will be crucial, Dr Brundtland said, to meet
the
health challenges linked to the persistence of poverty: "People in
developing
countries carry over 90% of the disease burden, yet have access to only 10%
of the resources used for health. This is unacceptable. This has to
change." She
wants health to be put at the top of the world's political agenda and
recognised
as the key to poverty reduction and human development. 

Dr Michel Jancloes, the director of the division for intensified
cooperation with
countries and peoples in greatest need, commented: "Poverty is a pivotal
issue.
I feel that all the necessary ingredients are there for WHO to play a
proactive
role within the UN system in reducing it." 

Dr Brundtland knows what she wants. Achieving such ambitious goals,
however, means radical administrative overhauls in a WHO which has become
bloated at the top and still allocates its resources according to
historical
precedents set half a century ago. 

As far as reallocating regular budgets to regions is concerned, the push to
shift
funds that the WHO's executive board initiated in January has already
produced
concrete, albeit sharply contested, results. After a debate during which
one of
the six regional representatives reportedly walked out in protest, the
World
Health Assembly passed a resolution that will benefit the neediest African
and
European countries in transition, primarily at the expense of South East
Asia, by
gradually shifting resources over six years starting in 2000. The 48 least
developed countries--most of which are in Africa--have been given top
priority. 

The chairman of committee B, which deals with the WHO's financial matters,
Dr
Nimal Seripala de Silva from Sri Lanka, said that this decision represented
"a
very special gift . . . in which WHO's interests were put above personal or
regional concerns. This present will strengthen [Dr Brundtland's] hand" in
transforming the WHO from the inside out. 

Dr Brundtland spoke out in favour of a flatter internal structure and fewer
layers
but declined to give any details before actually assuming office. Rumours
were
rife that funding for the six resource intensive regional offices, some 50
programmes and 10 deputy, assistant, and executive director generals was
going to be reduced. 

Such radical downsizing could free up funds for the tasks at hand, but some
questioned the feasibility and political astuteness of actually doing so.
The
WHO's deputy director general, Fernando Antezana, suggested that, since
many
people in top positions are at or over the 60 year old retirement threshold
that
Dr Brundtland has vowed to respect, streamlining through attrition would be
a
viable--and perhaps politically less hazardous--approach. More important
for
translating the areas of concern mentioned above into an efficient and
effective
structure, however, would be the overall concentration of the
organisation's
sprawling divisions into a reduced number (possibly four) of clusters. 

According to Dr Brundtland's address to the executive board on 18 May after
the World Health Assembly, the first cluster will concentrate on building
healthy
communities and populations; the second will focus on combating ill health
(communicable and non-communicable diseases); the third will devote itself
to
outreach and external relations with virtually the entire spectrum of WHO's
stakeholders; and the fourth will be committed to sustainable health
systems.

Dr Brundtland received a standing ovation.

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