Free and Public

EBOLA AND WHO REFORM: WHO CARES? By Charles Clift, Senior Consulting Fellow, Centre on Global Health Security, Chatham House

The ongoing Ebola story has highlighted the importance of the World Health Organization (WHO) in coordinating international action to combat emerging infectious disease threats. But it has also revealed the deficiencies in its performance which have now allowed a disease outbreak in West Africa to turn into a major international emergency. But in the current crisis in West Africa blame for its performance has been more prevalent than praise. As even its senior officials now admit WHO was too slow to recognize the potential seriousness of the outbreak – while also blaming the cutbacks in its emergency response capability agreed by its member states, as well as the unusual nature of the outbreak which it says caught the international community as a whole on the hop. The officials also point out that WHO is a technical assistance agency: there to help and advise governments on how to respond and supply needed expertise rather than run emergency healthcare operations on its own account.

On the other hand, some NGOs such as MSF, working to combat Ebola on the frontline, have criticized WHO’s slow response. They say that it should have recognized much earlier than it did the need to take the lead in mobilizing funding and personnel from other international actors to strengthen the weak healthcare infrastructures in the affected countries, as well as intensifying its own efforts to support governments with technical assistance and expertise.

Others blame WHO’s slowness and lack of leadership on its fundamental structural problems, which the reform programme launched by Margaret Chan in 2010 was intended to address. These structural problems include both its funding and its unique structure of regional offices which elect their own leaders. Much adverse comment has been directed at the role of WHO’s Africa regional office in Brazzaville which Peter Piot recently described as being staffed with political appointees rather than the most capable people, and the alleged lack of good cooperation between Brazzaville and Geneva. While there is undoubtedly financial stringency in WHO, and a severe shortage of experienced staff in HQ, the case is different with country staffing. The three most affected countries have country office staff exceeding 100 in total, there are nearly 750 in the country offices in the West African region as a whole, and there is nearly 600 staff in the regional headquarters in the Congo. In addition the African region has nearly 2500 contracted staff involved in polio eradication. It is hard to believe that more could not have been done with all these staff on the ground if properly mobilized and managed.

A report on WHO reform published in May this year, based on the deliberations of a working group convened by Chatham House, noted that WHO’s core functions as defined by WHO excluded explicit reference to promoting and maintaining global health security, specifically including its response to disease outbreaks and public health emergencies.

But the report focused mainly on the WHO’s structural problems that the ongoing internal reform process in WHO was not dealing with. The Ebola story illustrates many of these. The report asked: whether WHO really needed six semi-autonomous regional offices? Was this not a recipe for conflict and slow and poor decision-making? And did it need 150 country offices? How did politicization and the politics of patronage adversely affect WHO’s performance, credibility and effectiveness at all three levels of the organization? Was its complex governance structure not the main reason that it spends one third of its budget on administration and management at the expense of its technical programmes? Were there not more efficient ways to do what WHO needed to do? Why was WHO often reluctant to lead rather than to follow its member states? Why did the member states countenance this state of affairs?

The report has evoked practically no response at all – from governments, the academic community, NGOs or anyone else for that matter. Why is this?

A plausible explanation, which was suggested often by one of the members of the Chatham House working group, is that no one cares sufficiently about WHO reform to do anything about it. The status quo is too comfortable, or not sufficiently uncomfortable, for any member state to want to change things.

The weird financing arrangements, whereby 75% or more of WHO’s income is in the form of voluntary contributions, suits member states for different reasons. A few rich countries (and charities such as the Bill and Melinda Gates Foundation), by directing their voluntary contributions in ways of their own choosing, get to control what WHO does in spite of being a small minority in the World Health Assembly, or not in it at all. Yet because of this effective subsidy, poorer countries pay contributions which are a quarter of what they would be if WHO was wholly financed by member state subscriptions. Thus for the great majority of member states WHO membership is a bargain. They get a WHO country office whose budget (paid for by WHO) will normally exceed by a large margin their WHO contribution.

Because WHO regional offices are run as semi-autonomous replicas of WHO in Geneva, ministries of health also get the opportunity to influence appointments to regional and country offices where those chosen can access UN-related salary and benefit packages. Thus it is not just a financial bargain but often carries actual or personal benefits for senior country officials. So there is little mystery about why change should be resisted. Even where it is recognized that a WHO country office may have outlived its utility (in a country like Thailand for instance) it would be a brave politician or official who suggested closing what is essentially a free gift from the international community.

So no mystery there. The non-response of the ‘public interest’ NGO movement is more puzzling on the face of it. But perhaps the answer is not totally dissimilar. These NGOs have no financial stake in WHO and therefore no direct influence on its governance. Many regard the WHO as a forum where they may express their views and the annual World Health Assembly as a perfect gathering of notables in the global health community to pursue advocacy and influence member state delegates. While NGOs may be critical of the WHO, as in the case of Ebola, they also hold it in great esteem as the one international organization with the responsibility of striving for “the attainment by all peoples of the highest possible level of health”. The NGO mindset is therefore to seek to defend this noble objective and, in particular, protect it from political and commercial pressures which are seen as a threat to this mission.

Moreover the WHO secretariat is generally regarded as providing objective technical leadership and support to member states in a world dominated by governments and corporations whose motivations and interests may run counter to health objectives. For that reason NGOs are generally only likely to be critical of the WHO secretariat if it appears to be supine in its dealings with commercial stakeholders, or with governments deemed to be unduly influenced by commercial rather than public health interests.

At the same time NGOs, notably Oxfam, have campaigned actively for member states to increase their secure funding of WHO to protect its core functions, such as those which support enhanced access to essential medicines. But member states have to date paid little heed.

So it seems that the political preconditions for fundamental reforms of WHO funding and governance are absent. Nevertheless the world badly needs a global body that can take on a leadership role in global health policies and help control disease outbreaks before they turn into international crises. The panic engendered by the Ebola crisis should result in a reality check for all concerned. The WHO reform process, begun 4 years ago, does not seem to be on course to deliver a WHO that can be relied upon as fit for purpose.



6 Responses to “EBOLA AND WHO REFORM: WHO CARES? By Charles Clift, Senior Consulting Fellow, Centre on Global Health Security, Chatham House”

  1. This commentary makes an excellent point about the failure re: Ebola being not simply a lack of human public health resources, but of their deployment; and the ways in which WHO reform are not being managed to enhance global health security. There is one oversight, however, and that concerns the ‘non response of public interest NGOs.’ Indeed the People’s Health Movement, Medicus Mundi, Medact and several other such NGOs have been campaigning for financial and policy reform at the WHO (and at its regional offices) for several years. Certainly OXFAM has taken some strong advocacy positions as well, but it is not alone; and the public health NGO sector may be far more activist around the WHO than this commentary suggests.

    • Charles Clift says:

      Thanks Ron. To my knowledge the overwhelming majority of NGO campaigning is about encouraging member states to increase their secure funding of WHO by one means or another, as stated in the blog. A second strong theme is lobbying around WHO’s relations with non-state actors.But I am not aware of lobbying about the dysfunctional nature of WHO’s regional and country structure which, along with budget cuts,seems to be one key factor in explaining why WHO was slow to react to the Ebola challenge.

  2. Simon Wright says:

    Charles, another issue is that NGOs and others have a great deal of commitment to WHO based on its democratic basis. With so few multilaterals and institutions having any democratic legitimacy, we need WHO to be strengthened and its authority reinforced. So many initiatives appear to undermine WHO, that we need to endorse it. The fall in core funding is the responsibility of member states and this is (at least partly) to blame for the 50% cut in its budget for crises such as Ebola.

    • Charles Clift says:

      Thanks Simon. Maybe I didn’t make it clear enough that any failings in WHO performance are a combination of the structure, governance and financing (entirely the responsibility of member states as well as voluntary contributors for the last) and the performance of the secretariat (acting within the constraints imposed by member states and of other voluntary contributors). I think there is more to be said about the meaning of democracy in an international organization as compared to what we understand by democracy at national level. WHO is democratic in the sense that one nation has one vote. But in 2012/13 over 37% of funding for WHO came from other than member states.

  3. John Mahoney says:

    I have worked in country offices in three Regions of the WHO – EMRO, SEARO and WPRO developing mental health systems and have never found Regional Offices to be enablers nor truly supportive of strengthening country offices. Even worse they tend to stifle innovation by designing administrative systems that are complex and delegation, a key management principle, is virtually absent. Regional Offices are completely independent of the HQ in Geneva and would never relinquish their power willingly.
    In my opinion if Regional Offices were not there, most people at Country level would not notice other than life may become much easier.
    Generally staff in WHO HQ in Geneva are technically brilliant but there is no mechanism for implementing its good policies as there is no line management system or accountability to Country level. If International companies designed such governance systems they would quickly go out of business.
    Ministers appoint Regional Directors (RD’s) and as such RD’s see pleasing Ministers as their primary objective as they are also key to their re-election. Without doubt such Ministers also influence senior appointments at Regional and Country level. In addition Local Ministers also have to give their concurrence to all Country Director appointments which they can easily rescind. This gives Ministers of Health at Regional and Country level far too much power and influence.
    The key to the success of the WHO lies in an efficient and competent Country Office staff, appointed on merit not patronage and accountable for the implementation of World Health Organisations Policies. The concurrence of Ministers in all senior appointments needs to end. Corruption is rife in politics in certain parts of the world and WHO an an International organisation needs to be completely transparent.
    The role of Regional Offices, if any, needs a complete rethink and significantly reduced in size, perhaps with a few senior managers (not necessarily doctors) who would be accountable for performance within their Regions. The substantial savings could be reinvested strengthening Country Offices.
    John Mahoney

  4. […] Amidst the tumult of the Ebola crisis, few would know from its response that the World Health Organization (WHO) proclaims itself as “the legitimate inter-governmental authority on global health matters”. In the three affected Ebola countries, the WHO has 100 staff members, while the Region itself has 750 staff. The Regional Office in the Congo has 600 staff, with 2500 contract staff assigned to polio eradicati… […]

Leave a Reply

Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni