The World Health Organization’s critical challenge: healing itself
“It’s time to stop talking,” Stewart Jessamine, New Zealand’s director of public health and a WHO executive board member, told the delegates. “We have to change.”
Jimmy Kolker, a leading member of the U.S. delegation, told the meeting the WHO must “recognise how crucial this moment is for the future of the organisation, and the resources and the trust that are in the balance.”
For years the WHO has talked about streamlining its complex structure, governance and financing to make it more efficient. Critics say the organisation needs deep reforms to allow it to show clear leadership in promoting health and to respond decisively to disease emergencies that may span many countries. But progress has been painfully slow.
Margaret Chan, Director General of the WHO since 2007, acknowledged the concerns of delegates and agreed with Jessamine: “Yes, it’s time to stop talking,” she said.
She promised to act swiftly on reforming the WHO’s emergency responses. “We are committed to implementing a single programme, with a single line of accountability, a single budget, a single set of business processes, a single cadre of staff and a single set of performance benchmarks,” she said.
The pressure for change has been building after a series of missteps by the global health body. Last year, while still smarting from accusations it overreacted to the 2009-10 H1N1 flu pandemic, the WHO faced withering criticism for not reacting fast enough to the Ebola crisis in West Africa. The organisation’s Lyon-based International Agency for Research on Cancer (IARC) has become a target of ridicule among some health experts for issuing confusing warnings on everything from the air we breathe to the meat we eat to the phones we use. And the WHO is now being questioned about its response to the Zika virus.
Public health specialists, non-governmental organisations and some of the WHO’s biggest donors say the organisation is unwieldy, poor at coordinating responses to epidemics, and too thinly spread. And increasingly it struggles to set its own priorities because many of its donors give it money earmarked for specific projects.
Some experts inside and outside the organisation say those flaws mean the WHO’s lead role in global health is now at risk. Nils Daulaire, who was until recently the U.S. representative on the WHO’s executive board, told Reuters the WHO “is not functioning well” and cannot “survive in its present form for another decade.”
He said global officials who engage with the WHO regard it as bogged down by internal processes and often forced by its members to take on more than its resources can manage.
“I’ve heard from a lot of former colleagues representing other countries that are major contributors to WHO, and other institutions that contribute financially, that either (the WHO) has to get fixed in a relatively short period – five to 10 years – or they’re going to take their marbles and go elsewhere,” said Daulaire.
Reuters spoke to more than a dozen people who know the WHO and its leadership well. All said the world needs the WHO to succeed. But most were also frustrated and even angry with its current state – sentiments that were on open display at January’s meeting in Geneva.
Chan told delegates that she recognised the concerns. “We hear you loud and clear on your expectations on how you would like to see us reform the programme,” she said.
A WHO spokesman, Tarik Jasarevic, told Reuters that changes to the agency’s response systems “are already under way” and would include the establishment of a single programme for outbreaks and emergencies. He said The WHO “is also committed to an independent mechanism of assessment and monitoring of the performance of the organisation, reporting to the governing bodies.”
TOO MANY CHIEFS
The WHO is unique among UN agencies because its structure includes six regional offices, each with its own director elected by regional member states. Beneath them is a sprawling network of around 150 country offices.
Charles Clift, who led a 2014 report for the Centre on Global Health Security at Britain’s Chatham House entitled “What’s the World Health Organization for?,” said the complexity “is one of the main reasons why the WHO, in many ways, is dysfunctional.”
Clift, who was secretary of the WHO’s commission on intellectual property rights, innovation and public health from 2004 to 2006, describes the structure as “not one but seven WHOs” – the Geneva headquarters plus the regional offices whose directors are answerable not to Chan but to their own member states.
The flaws in the structure were evident in the Ebola crisis. Despite repeated warnings by the charity Medecins Sans Frontieres (Doctors Without Borders) that national governments were not on top of the seriousness of Ebola’s spread, WHO officials in Geneva declared the outbreak “relatively small still” in April 2014. It wasn’t until August, when the epidemic was out of control in West Africa, that Chan declared it a global emergency.
“The lack of a direct line of control from Geneva to what was happening at country level was probably one of the main reasons for why they were so slow,” said Clift.
Chan said late last year the WHO had been “overwhelmed” by the Ebola outbreak, which she said “shook this organisation to its core.”
Some health officials fear the current scramble over the Zika virus is another example of the WHO’s lack of coordination. As members of the executive board met in Geneva, the health body’s regional office in the Americas issued an alarming statement. The little-known Zika virus was spreading fast, it said, and threatened to infect millions.
The spread of the virus is thought to correlate with a rise in birth defects in Brazil – but no causal link has been proven.
The regional office’s statement caught WHO’s headquarters by surprise: No one had bothered to tell it the statement was going to appear. The contents of the Zika warning were accurate, WHO staffers say, but as one Geneva-based WHO insider said: “They put it out without telling us.”
A spokesperson for the regional office, the Pan American Health Organization, said that it shares information with WHO headquarters but sometimes acts independently so that it can respond swiftly. In the case of Zika, it issued a statement at the request of a country office to counter misleading local media reports about sexual transmission of the virus, the spokesperson said.
The effect, though, went wider. Just as the WHO’s week-long annual executive board meeting was beginning, the Geneva headquarters found itself unexpectedly fielding urgent inquiries about the Zika virus.
Some board members expressed concern that once again the WHO looked slow-footed on the emergence of a potentially major epidemic. Chan hurried to reassure them. Within days she was moved to convene an emergency expert panel on Zika, saying the mosquito-borne disease had grown from a mild threat and was now “spreading explosively.”
One reason for the lack of streamlined communications was that the regional office PAHO “sees itself as semi-autonomous,” according to the WHO insider. This is partly because PAHO was founded in 1902, more than 40 years before the WHO itself was created.
A spokesperson for PAHO said: “While PAHO has its own constitution, PAHO always coordinates with and informs WHO HQ … While Zika was not an emergency in other regions of WHO, it is for PAHO because most of the member states affected are in the Americas.”
PAHO had treated Zika as an emergency since May 2015, said the spokesperson. WHO headquarters declared Zika a public health emergency only this month.
It’s in cases like this that some countries, such as Britain and the United States, are keen to have clearer lines of authority. But some smaller member states are reluctant, according to Clift, Daulaire and some current WHO staffers. They say this is because less dominant states worry that ceding all power to a central headquarters might mean that their own governments could be chastised by the WHO for failing to report, control or prevent chronic ill-health, infectious disease, or pandemic threats.
There’s another big problem, many people say: The WHO tries to do too much.
It was founded in 1948 – an era in global health when “the entire focus was infectious diseases” and “in some ways life was much simpler,” said Richard Sullivan, a professor of cancer policy and global health at King’s College London.
“It’s important to remember that’s where the WHO came from,” he said. “Non-communicable diseases (such as heart diseases, cancer and diabetes) just weren’t on their radar at all.”
Since then, global health has become far more complex. A quick glance at the WHO’s current “health topics” list shows it offers expertise on a vast array of issues, from sunburn and domestic violence to Crimean-Congo haemorrhagic fever and plague.
On a side table outside the board meeting in Geneva, a pile of discussion documents included everything from the sound management of chemicals to reducing road traffic accidents. There was a “global vaccination action plan,” a paper on pandemic influenza, and a draft policy on “multi-sectoral action for a life course approach to healthy ageing.”
Jeremy Farrar, an infectious disease specialist and director of the UK-based global health charity the Wellcome Trust, says the WHO is floundering because it can’t, or won’t, say no to anything.
“It’s so thinly stretched,” he said. “There’s arguably no organisation on earth that could cover all those (topics) at sufficient depth to be authoritative.”
Farrar argues the best way for the WHO to become “a totally respected organisation” is for it to set top priorities for global health “and do those at a really high level.”
But with member states – the owners and directors of the WHO – requiring it to cover such a vast range of health issues, the WHO’s ability to focus is hampered. Barbara Stocking, a former chief executive of the charity Oxfam UK who chaired an expert panel reviewing the WHO’s response to Ebola last year, said the health body “got distracted” by very broad agendas determined by its members.
Stocking says outbreak response should be the “absolute essence” of the WHO: “If it doesn’t deal with health emergencies across the world, then what is it there for?”
WHO’S PAYING, AND FOR HOW LONG?
The WHO faces another major hurdle in trying to nail down its core functions: It has budget pressures and has lost control of some of its own objectives.
In 2011, hit by the global financial crisis, member states cut the WHO’s budget, reducing it by 13 percent from the previous year. This hurt the WHO’s department for global health security and became “a fundamental driver,” according to Daulaire, of the WHO’s slow response to the Ebola outbreak.
Another change may have had an even bigger impact. Sixteen years ago, the WHO received 49 percent of its money as “assessed contributions” from member states. The WHO could mostly do what it wanted with this money. By 2014, assessed contributions had dropped to about 20 percent of funds the WHO received.
About 80 percent is now made up of “voluntary contributions” (see chart). Some come from member states that want to give extra, others from bodies such as educational institutions, trusts and charities, including the foundations of Microsoft founder Bill Gates and Mike Bloomberg, the financial-information mogul and former New York mayor.
Almost all these donations come with strings attached – stipulations that the money must be used for certain projects or diseases. In all, 93 percent of the money given to the WHO for its health programmes is now “specified” – earmarked – by donors for particular projects.
The largest of the non-government donors by a long way is the Bill & Melinda Gates Foundation. From a standing start a decade ago, it has been contributing between $250 million and $300 million a year. In one year – 2013 – it was the largest donor bar none, overtaking even total contributions from the U.S. government.
The impact of funds from private donors can be seen in WHO spending. One of the Gates Foundation’s priorities is the eradication of polio – a crippling disease that can be prevented with comprehensive vaccination campaigns. A breakdown of the WHO’s finances shows that its polio programme is by far the best-resourced, accounting for 23.5 percent of the WHO’s current programme budget. The next biggest programme is outbreak and crisis response, which gets 15.3 percent.
The WHO can push back against donors’ wishes only so hard – or risk donors taking their money elsewhere. Daulaire said that he has talked to “very senior people at the Gates Foundation” who are studying the WHO’s current state “with a great deal of interest and concern – and they certainly have the capacity and the right to put their money elsewhere.”
Asked whether the Gates Foundation was planning to put its money elsewhere, Steve Landry, its director of multilateral partnerships, said: “The foundation invests in a variety of organisations to improve global health surveillance, build resilient health systems, and strengthen national and global pandemic preparedness. WHO plays an essential and unique role among the partners. Several of our investments in WHO are designed to help it deliver on this mandate.”
The organisation’s fate will depend in large part on the deep-pocketed United States. The current American board member of the WHO is Tom Frieden, the director of the U.S. Centers for Disease Control and Prevention. In Geneva, emerging from the tense morning session on the first day of the January meeting, Frieden said: “The world needs a really strong WHO. If we don’t make these changes now, they are not going to get made.”