WHEN the WHO declared that its goal was to achieve 鈥渉ealth for all by the
year 2000鈥�, nobody seemed to think the idea ridiculous. After all, it was 1978.
AIDS was unknown. The WHO had played a major role in fighting smallpox, which
was eradicated in 1977, and in helping poorer countries to produce essential
drugs cheaply. The WHO was taken seriously.
Today, things could scarcely be more different. The WHO is in crisis. It has
become a bit-part player on the international stage. It is increasingly under
fire for its lack of leadership and failure to modernise. The events of the next
12 months are likely to decide its future.
Next week, the executive board鈥攖he governing body drawn from the WHO鈥檚
member states鈥攇athers in Geneva. The meeting is expected to be tense. The
US is threatening to reduce its contribution, which would leave the organisation
short of $20 million this year. But the WHO is also drawing up its new
global policy for the 21st century. Next week鈥檚 meeting is the last real chance
for the board to make major changes to that policy. And next January, the board
must elect a director-general for the next five years.
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Both the policy and the leadership candidates are being closely scrutinised
by the WHO鈥檚 members. The industrialised countries largely pay for the WHO. Most
of them have been critical of the WHO鈥檚 management for the past five years and
their patience is running out. Some developing countries are also voicing
concern.
The current director-general, Hiroshi Nakajima, is expected to stand for a
third term. His election for a second term, back in 1993, was opposed by most
Western industrialised countries, who blame him for the WHO鈥檚 decline since he
took over in 1988 (This Week, 19 December 1992, p 4). Their views have not
changed. 鈥淥ur position is the same as in 1993,鈥� says one Western diplomatic
source. 鈥淲e do not wish Nakajima to run again.鈥�
Who they would like instead is less clear. The current unofficial shortlist
includes a couple of internal candidates, two of the WHO鈥檚 six regional
directors, a deputy health minister from Zambia, and the director of the UN
Population Fund, Nafis Sadik. There is also excitement, but little evidence,
that Norway鈥檚 former Prime Minister, Gro Harlem Brundtland, might be persuaded
to stand.
But leadership is not the only concern of the WHO鈥檚 critics. They want to
modernise the WHO. Four years ago, the executive board recommended 47 changes in
the organisation. Many of the changes were minor. But the board also asked the
WHO to set itself new, practical targets for the future and to clarify what it
does that other organisations cannot. All eyes are now on the WHO鈥檚
response.
The WHO was once on its own in promoting health around the world. Now it has
gradually been joined by UNICEF, the UN Development Programme, the UN Population
Fund鈥攁nd the World Bank, which argues that a healthy workforce helps a
country鈥檚 economy to grow faster. The World Bank鈥檚 health budget alone is
$2.5 billion this year 鈥攄warfing the WHO鈥檚 annual budget of
$900 million鈥攁nd making it the largest external source of financing
for health in developing countries.
Recently, the WHO has also begun to lose the intellectual initiative to the
World Bank, says Kelley Lee, a health policy researcher at the London School of
Hygiene and Tropical Medicine, who has analysed the WHO鈥檚 work. 鈥淭he bank is
setting the terms of the debate and the WHO is catching up. They should be
taking the lead.鈥�
The WHO鈥檚 1948 mandate was ambitious: 鈥淭he attainment by all peoples of the
highest possible level of health.鈥� Today, critics argue, the organisation should
define its aims more realistically and concentrate on priorities, such as the
health of the poorest one billion people.
But the WHO鈥檚 senior management has decided that 鈥渉ealth for all鈥� should
remain its key goal. Details of the policy have yet to be filled out,
because the organisation is still consulting its members. But the broad aims
include reducing poverty and ensuring that everyone has equal access to
healthcare.
Critics fear that the new policy is no more than a tarted-up version of the
1978 declaration. 鈥淚t鈥檚 like a faded beauty queen,鈥� says one academic outsider.
鈥淭hey are going backwards rather than forwards.鈥� Privately, one British-based
analyst says that instead of being a radical rethink, the policy initiative has
been hijacked as 鈥減art of Nakajima鈥檚 re-election campaign鈥�.
Missing targets
More publicly, the critics think the policy is too broad and lacks specific
targets. In documents circulated by the Dag Hammarskj枚ld Foundation, an
influential Swedish think-tank, for a meeting in Uppsala last April, the policy
was described as 鈥渦nreachable鈥� and 鈥渧ague鈥�.
The clamour for a more tightly focused policy is growing. The WHO鈥檚 core job
has always been to provide information and technical backup. It makes
epidemiological forecasts and gives guidelines on the treatment of diseases. It
also sets standards, such as the safe limits of chemicals in air or water. Since
no one else has a mandate to do these jobs, argue the critics, the WHO should
concentrate on them, and stop trying to be all things to all people. Apart from
these tasks, they say, the WHO should concentrate on major challenges such as
smoking, which will kill 8.4 million people a year by 2020.
The oldest advocates of a sharper focus are the Nordic countries. Australia鈥檚
government has also circulated an informal document calling for the WHO to
鈥渘arrow, not broaden鈥� its mandate. And Neil Boyer, director of health programmes
in the US State Department鈥檚 Bureau of International Organization Affairs, says
that the US thinks the WHO should 鈥渃oncentrate on what it does best鈥�.
The latest鈥攁nd, ironically, toughest鈥攕upport for setting strict
priorities comes from inside the WHO. A group of scientists鈥攖he directors
and managers who run the WHO鈥檚 technical programmes鈥攈as proposed radical
reforms to create a 鈥渘ew WHO鈥�. Like the outside reformers, the directors want
the WHO to have a tighter focus. They also want to streamline the WHO鈥檚
top-heavy management. It proposes halving the number of directors鈥攊ts own
members鈥攁nd reducing the number of assistant directors-general from nine
to five.
So far, the WHO鈥檚 senior management has done nothing about these suggestions,
although Ilona Kickbusch, a director of health promotion and a member of the
group, thinks that the proposals for streamlining are gaining currency. The
response of senior management, however, is still very guarded. 鈥淭here are a
number of areas where most viewpoints converge,鈥� says Denis Aitken, one of three
assistant directors-general appointed by Nakajima to examine the WHO鈥檚
direction. 鈥淗owever, there is not necessarily consensus around all of the
ideas, and our regional and country offices would have different perspectives to
产谤颈苍驳.鈥�
The WHO鈥檚 outside critics are interested in the directors鈥� proposals and
incredulous that middle management has taken the initiative while the
organisation鈥檚 leadership fiddles. 鈥淭he vacuum of thought at the top is being
filled by the programme managers,鈥� says the Western diplomatic source. 鈥淚sn鈥檛 it
amazing that an organisation which is so important, and has the second biggest
budget of the UN agencies, should require a fifth column to come up with ideas
about what the organisation should be doing?鈥�
Not everyone agrees, however, that the WHO should try to do less to achieve
more. One of the WHO鈥檚 traditional tasks鈥攁nd one of its least
glamorous鈥攊s to strengthen basic health care in developing countries. If
the WHO withdraws from such open-ended tasks to concentrate on providing
information, poorer countries fear they will be left with even less help, says
Lee.
Others鈥攊ncluding some members of the directors鈥� group鈥攕uspect
that some rich governments may be advocating a tighter focus because they want
to save money. But the activities that are top of the governments鈥� list of
priorities are not cheap.
Because the WHO has spread its resources so thinly, its technical staff lack
the time to analyse data thoroughly, say health researchers. Almost everyone
agrees that one of the WHO鈥檚 most important tasks is to provide clear and
accurate figures on the causes of death in all countries.
Last year, the WHO published conflicting versions of its own numbers. The
World Health Report estimated that 3 million people died from TB and 2
million from malaria. Two other 1996 reports carrying the WHO鈥檚 logo鈥�
The Global Burden of Disease and Investing in Health Research and
Development鈥� said that there were 2 million deaths from TB and fewer
than 1 million deaths from malaria (This Week, 14 September 1996, p 4). Both
sets of numbers came from the same technical staff. But the lower
numbers鈥攑roduced in a joint effort between the WHO and Harvard
University鈥攚ere subject to rigorous checks to ensure that nobody died
twice.
The WHO loses credibility if it cannot perform its core functions properly,
such as getting its numbers right, argues one American scientist. 鈥淵ou don鈥檛
provide moral leadership if you don鈥檛 pay attention to the facts.鈥�
For all the criticism, almost no one doubts the need for the WHO. They just
want it to do its job better. Passionate defenders of the WHO are also some of
the strongest advocates of change. Dean Jamison, professor of public health at
the University of California, Los Angeles, says the WHO鈥檚 egalitarian commitment
to health for all must be safeguarded at a time when market principles are
changing healthcare.
鈥淚t鈥檚 extremely important [for the WHO] to be exercising moral leadership and
mobilising communities for the highest ethical standards possible,鈥漵ays Jamison.
But, he adds, 鈥渋t had better get itself energetic leadership鈥�, and concentrate
on its greatest strengths. Or as Richard Peto, a leading epidemiologist at the
University of Oxford puts it, the WHO鈥檚 job should be 鈥渢o count the dead by the
year 2000鈥�.
