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World Health Organization: Overhaul or Dismantle?

Monday, 7th of November 2016

Suwit Wibulpolprasert and Mushtaque Chowdhury. 

World Health Organization: Overhaul or Dismantle?

American Journal of Public Health November 2016: Vol. 106, No. 11, pp. 1910-1911.

doi: 10.2105/AJPH.2016.303469

Accepted on: Aug 24, 2016

World Health Organization: Overhaul or Dismantle?

Suwit Wibulpolprasert, MD, and Mushtaque Chowdhury, PhD

Suwit Wibulpolprasert is with the International Health Policy Programme, Bangkok, Thailand. Mushtaque Chowdhury is with BRAC (formerly Bangladesh Rural Advancement Committee), Dhaka, Bangladesh and the Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY.

Correspondence should be sent to Mushtaque Chowdhury, Vice Chair, BRAC, 75 Mohakhali, Dhaka 1212, Bangladesh (e-mail: mushtaque.chowdhury@brac.net). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

Note. The views expressed here are those of the authors and do not necessarily reflect those of the organizations with which they are affiliated.

CONTRIBUTORS

Both authors contributed equally to this editorial.

Can the World Health Organization (WHO) still be reformed or must it be reborn? Can it address concretely and effectively the challenges it is facing? This is an important question, not only for the next director-general but perhaps even more for the member states who are the real “owners” of WHO.

 

STRENGTHS

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Like most United Nations agencies, WHO has a checkered history. Its successes are monumental, and so are its failures. The improvements that we see in global health indicators today reflect its nearly seven decades of persistent work.

Smallpox is the first conquest of a major scourge of humankind. Treatment of tuberculosis (called “directly observed treatment, short-course,” or DOTS) is bringing millions of young and older adults back to active life. Vaccination against common infections is a success story for most countries. The 1978 Alma Ata Declaration is still considered the Magna Carta for health. The publication of the International Health Regulations was a concrete step in making the world safer from global pandemic threats. The Framework Convention on Tobacco Control is the first (and, so far, the only) global treaty under the WHO constitution that aims to save people from tobacco-related illnesses and impoverishment. The report of the Commission on Macro-Economics and Health contributed to a significant increase in global health investments. The importance of a multisectoral approach to health was highlighted through the work of the Commission on Social Determinants of Health. The list is long.

WHO possesses the rare and enviable convening power to mobilize the best international experts on short notice. Having the member states as its constituents has given it high social capital and credibility for its norms and standards. Its extensive networks of country offices and collaborating centers allow it almost unlimited access to expertise around the world. Its assessed financial contributions from member states give it at least some degree of financial independence.

 

CHALLENGES

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Despite such credentials, WHO’s claim to global leadership in health matters is challenged by new entrants, such as the World Bank, the Global Fund, bilateral development agencies, private foundations, and other global health partnership programs. WHO’s financial base, although much stronger now, is dwarfed by some of the private foundations. The organization’s image, brightened by some of its iconic leaders such as Halfdan Mahler and Gro Harlem Brundtland, was, unfortunately, tainted by some others. Under globalization, international trade is a major determinant of good health, particularly for low-income countries, but WHO is hampered in negotiating with powerful actors such as the World Trade Organization and the pharmaceutical industries.¹

 

BUREAUCRACY

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WHO sometimes is accused of delay and excessive bureaucracy. When the Thai government needed the government use of patent to allow access to essential medicines, it asked WHO for technical support. After a lapse of several months, the WHO headquarters responded by asking its regional office to provide the support—which the latter was unable to do. It took a few more months for the Geneva, Switzerland, office, after some further prodding, to dispatch a team of experts to Thailand.

WHO’s bureaucratic structure is stultifying. Bureaucrats in WHO enjoy such lucrative benefit packages that they rarely speak out or take risks. Some of the more committed and capable staff simply leave the organization.

 

INERTIA

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WHO is also accused of inertia—it initiates but does not always carry through. The landmark work on the social determinants of health is a case in point. Carefully conducted community-based studies continue to document an immense potential role for other development sectors in improving health. A study carried out in Matlab, Bangladesh, for example, found a clear impact of a women-focused development program, implemented by a nongovernmental organization BRAC, in improving child mortality. The children of mothers who participated in the microfinance and women’s development programs had consistently higher survival experience than others, resulting in the disappearance of socioeconomic inequities in child survival.² The hopes created by the Commission on Social Determinants of Health will fade away without a concerted effort to rally other actors for coordinated action.

 

H1N1

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WHO is a producer and user of global knowledge on health. Its support of research has contributed to its many successes. There have also been some significant problems. In the case of the 2009 H1N1 pandemic, WHO was accused of overplaying the danger to member states, which bought a billion doses of vaccines that lay unused, thus wasting billions of dollars.³

 

EBOLA

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WHO has been losing the confidence of its stakeholders. The recent Ebola crisis is an example. The epidemic killed more than 11 000 people and caused an economic loss of more than $2.8 billion for the West African countries. To many, WHO was more reactive than proactive in foreseeing the epidemic and tackling it. The crisis thus exposed the organization’s weaknesses as a global leader in health emergencies. “At times of crisis, the world doesn’t need file pushers. It needs boots on the ground, whether in fatigues or white coats,” wrote a critic.⁴

 

FINANCIAL TRANSPARENCY

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There are questions about WHO’s management and financial transparency. The organization’s dependence on earmarked funding (about 80% of it $4 billion biennial budget) puts it at the mercy of donors; WHO may toe the line of donors’ interests rather than following its own agenda. A strong director-general needs to demand more country contributions and ensure exemplary financial management.

 

OVERHAUL OR DISMANTLE?

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WHO is physically present in 147 countries with six regional offices. This global infrastructure accounts for 70% of the organization’s budget. Eliminating the regional offices could save significant resources without sacrificing efficiency.

The Framework Convention on Tobacco Control was a major contribution of WHO—although its full implementation remains in question. WHO should use its unique legal powers to push similar global treaties to focus on the right to health, inter- and intracountry inequities, and health promotion, such as the proposed Framework Convention on Global Health⁵ and the Framework Convention on Alcohol Control.

In conclusion, the world needs a strong global health agency, but WHO, in its current state, seems unable to cope with the dynamics of the rapidly changing global health landscape. We repeat what Ford and Piedagnel said back in 2003,

In the face of rising infectious diseases . . . the importance of an international, independent organization that is brave, aggressive, and vocal in its defense of global public health has never been more important.^6(p3)

 

REFERENCES

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1.	K Lee, D Sridhar, M Patel. Bridging the divide: global governance of trade and health. Lancet. 2009;373(9661):416–422. [CrossRef] [Medline]
2.	A Bhuiya, AMR Chowdhury, F Ahmed, AM Adams. Increasing survival and decreasing inequity in rural Bangladesh. In: TG Evans, M Whitehead, F Diderichsen, A Bhuiya, M Wirth, eds. Challenging Inequities in Health. New York, NY: Oxford University Press; 2001: 227–239.
3.	World Health Organization. World Health Organization admits failures in communication during swine pandemic. Available at: http://www.salient-news.com/2010/04/who-admits-failure-communication-during-swine-pandemic. Accessed July 9, 2016.
4.	D Nayyar. It’s time to abolish the UN. Available at: http//www.Sunday-guardian.com/analysis/it’s-time-to-abolish-the-un. Accessed July 9, 2016.
5.	LO Gostin, EA Friedman, K Buse, et al. Towards a framework convention on global health. Bull World Health Organ. 2013;91(10):790–793. [CrossRef] [Medline]
6.	N Ford, J-M Piédagnel. WHO must continue its work on access to medicines in developing countries. Lancet. 2003(9351);361:3.

 

 

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