What Wind Blew WHO’s Brand Hither?
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 eradication.
Across the ocean, the Centers for Disease Control and Prevention (CDC) is the national public health institute of the United States, headquartered in Georgia. Yet, in the response to the Ebola outbreak in West Africa, the CDC has emerged as the international public face of control, prevention, and treatment of this disease. The WHO’s African office didn’t welcome the CDC’s robust role. Rather, the WHO largely confined itself to the issuance of statistical reports on disease morbidity and mortality, pleading in the process that an insufficiency of funds justified a plodding response that allowed the situation to get out of control. How did this role reversal occur?
The diminution of the WHO brand can be traced to its high water mark in 1977 when it proposed “Health for All by the Year 2000.” This bold initiative was galvanized into operational field programming by the entire global health community. During the period 1977-2000, the OECD/Paris estimates that the community allocated $99 billion in support of its goals, which were largely to build primary care infrastructure in poor countries. At the conclusion of “Health for All in 2000,” the WHO never bothered to issue a report on this extensive global experience which had to have generated a wealth of lessons learned. Despite this vast expenditure of resources, Dr. Paul Farmer has stated that the current Ebola crisis is “a symptom of a weak healthcare system.”
But is due to a lack of donor funds? Dr. Paul Collier, an economist at Oxford University, tracked donor funds released by the Ministry of Finance in Chad. They were designated for rural health clinics. His survey had the modest purpose of finding out how much of the money actually reached the clinics—not whether the clinics spent it well. “Less than 1 percent reached the clinics—99% failed to reach its destination.”
The WHO launched a new effort in 2001, called “Macroeconomics and Health.” The thrust was a formulaic expression: “by expanding coverage to basic health services to the poor through scaling up resources, poverty could be reduced, economic development accelerated, and global security advanced. This could save at least 8 million lives through 2010, and yield a direct economic benefit of $186 billion per year, maybe more.”
When the WHO released the proposal, there wasn’t a single reference to “Health for All” in the main Text, the Notes, the Appendix, or the References. There is no public record of any of the “Macroeconomics and Health” recommendations ever being implemented.
The expansive health programs initiated by the WHO since 1977 can be seen as troublesome reminders of how impermanent values can be when global initiatives of promethean scope can so soon be forgotten and quickly discarded by those who commissioned them.
The WHO is burdened with an antiquated governance structure, constraining its response to Ebola. In 1948, it had 61 Member States supporting WHO through assessed dues. Today, it has 194 Members. The Regular Budget for the current biennium is $944 million, but is effectively reduced to approximately $756 million due to arrears. This is the only budget voted on by Members at the annual assemblies. TheWHO has an Extra Budgetary Account, funded at $3.015 billion by foundations, governments, and corporations. This is its central problem with governance and its difficulties in responding to the Ebola crisis. In order to do so, it needs private contributions to its Extra Budgetary Account.
A former Director General of WHO wrote of his concerns in a 1996 discussion paper on WHO resolutions : “these funds are usually earmarked, the choice of activities is determined by the donor and not by the community of Member States comprising the Organization, and the management of these funds generally escapes the jurisdiction of the Executive Board and Health Assembly.”
The current Director General commented when discussing the Gates Foundation contribution of $300 million to the Extra Budgetary Account: “these dollars come with strings attached, my budget is highly earmarked, it is driven by what I call donor interests.”
Translation: the DGs are referring to a ‘pay to play’ budget.
The WHO’s Regional Directors are elected by Member States in their respective regions. If donors provide funds for Ebola, the money would first go to WHO/Geneva which would apply a fee of at least 13% before allocating it to the African Regional Office. Then, the Regional Director would have more say over their uses than does WHO/Geneva.
The WHO’s sole client in the developing world is ministries of public health. In an official report, WHO described them as: “having the reputation for being among the most bureaucratic and least efficiently managed institutes in the public sector.” Since its Regional Office in Africa is staffed more by ‘friends’ than health professionals, this combination of institutional fragilities foredoomed WHO from an effective response.
As long as the Regular Budget is subordinated to special interest groups funding the Extra Budgetary Account, and Regional Directors are more beholden to their respective Member States rather than to WHO/Geneva, the Organization’s response to global threats such as Ebola will be incomplete. The institutional credentials of the WHO and its governing bodies have tarnished the brand from fulfilling its time-honored role as “the legitimate inter-governmental authority on global health matters.” Without a structural reconstitution of its Mission, that role can be considered one that is gone with the wind.