The U.N.'s World Health Organization (WHO) has a unique role to play in global health. As the only membership U.N. entity concerned exclusively with health, it can theoretically provide a forum for health ministers to share information on rapidly transmitted and dangerous infectious diseases, such as avian flu and severe acute respiratory syndrome (SARS). Through its World Health Assembly, WHO can call attention to global health problems and help to establish global health standards.
WHO can facilitate data sharing, although this process has been hobbled by distrust from developing countries, many of which erroneously view the organization as too close to Western business interests. It can also provide approved product lists for medicines, bed nets, condoms, and other health products purchased with public funds, especially for poor countries that lack capacity. Yet historically, it has failed to control quality on drugs and has acted as a bottleneck for other products. While other public and private actors might perform some of these roles more efficiently, WHO, as a multilateral organization, can garner more trust from all states, especially those wary of "Western-guided" development.
Given its lack of accountability and poor performance, WHO desperately needs to reform. WHO has often failed to fulfill its assigned mandates and has been unable to implement the initiatives it has begun. It has sometimes allowed political concerns to undermine its technical expertise. It is no longer equipped to directly implement measures to combat disease because it lacks sufficient staff, the skill set, the correct incentive structure, and adequate financing. Other implementing organs--bilateral initiatives, such as the U.S. President's Malaria Initiative, and private actors, such as the Bill and Melinda Gates Foundation--have grown in number and influence over the past 20 years and are better suited to combating disease than WHO is. The organization should focus on roles in which it enjoys a comparative advantage (e.g., technical coordinator, health advocate or "cheerleader," and secretariat for various private and public agencies) and divest responsibilities not directly related to these roles.
As WHO's single largest financier, the U.S. government has a powerful role to play in WHO reform. It can publicly pressure the organization to stop letting "politics get in the way of fundamental health needs," as it is doing with WHO's continued refusal to grant membership to Taiwan. It can partner with like-minded states to withhold assessed contributions and push for more voluntary ones, making payment contingent on strong performance in WHO's areas of comparative advantage. When WHO fails to measure up, the U.S. government can and should invest its money elsewhere, with the plethora of other actors that now populate the international health arena.
The International Health Arena
Today's international health arena is complex and sprawling, with myriad interconnected actors. At the pinnacle is the World Health Organization. Its policy organ, the World Health Assembly, includes representatives from the 193 WHO member states and meets every year, usually in May. Policies are coordinated by headquarters in Geneva and carried out by six regional offices, 147 country offices, and more than 8,000 staff.
WHO's regional offices operate as the implementing organs for the global body, but often have a high degree of autonomy and their own policy-organ assemblies. For example, WHO's regional office for the Americas goes by the independent-sounding moniker Pan American Health Organization (PAHO) and receives some funding directly from the U.S. government ($56.6 million in assessed contributions in 2007 plus voluntary funding) over which WHO has virtually no control.
WHO members are expected to donate a specified percentage of the overall budget, known as "assessed contributions," based on a formula designed to determine a country's ability to pay. Although members are technically obligated to provide assessed funds, they have often made such contributions contingent on policy reforms.
WHO's $4.2 billion budget for 2008–2009, approved at the May 2007 World Health Assembly, included $959 million for the regular assessed budget (an approximately 5 percent increase over 2006–2007) and $3.3 billion in projected voluntary contributions. Overall, this is a 15 percent increase over 2006–2007. In 2006, the United States' assessed contribution was $101.4 million (set at 22 percent of WHO's total regular budget), and the President's total request for fiscal year 2009 was $106.6 million. The U.S. also provides substantial voluntary contributions annually, including more than $130 million in 2006. By comparison, in 2006, the U.S. government contributed $108.9 million to the United Nations Development Programme (UNDP) and $125.7 million to the United Nations International Children's Emergency Fund (UNICEF), which are more "implementation-driven."
WHO is the most prominent and important international health organization, but it was not the first. When it was launched in 1945, it entered an arena already populated by several multilateral and bilateral institutions, including the Office International d'Hygiene Publique (founded in 1907), the mostly defunct League of Nations Health Organization (1923), the U.N. Relief and Rehabilitation Administration, the Pan American Sanitary Bureau (1902), and the U.S. Malaria Control in War Areas (1942), which later became the Centers for Disease Control and Prevention (CDC), as well as quasi-governmental health organizations such as the International Red Cross (1863) and private charities including the Rockefeller Foundation (1913).
Within the U.N., WHO was later joined by several agencies that included health issues within their mandates. UNICEF was made a permanent agency in 1953, and UNDP was created in 1965, followed by the United Nations Population Fund (UNFPA) in 1969. The U.N. has also created special programs and offices, such as the United Nations Joint Programme on HIV/AIDS (UNAIDS) in 1994 and the Global Fund to fight AIDS, Tuberculosis and Malaria in 2002. The structures of these special programs tend to reflect their focus on implementation. Most include governing boards, but lack representative assemblies. Contributions are generally voluntary, rather than assessed.
Other international agencies also consider "health" within their purview. For example, the World Bank provides loans to developing countries for health-related projects. While the International Monetary Fund does not involve itself in specifics or priorities of health spending, it supports national poverty-reduction strategies that allocate additional spending to HIV/AIDS and other health programs.
The size and scope of bilateral health initiatives have increased significantly over the past decade, primarily with targeted disease-specific programs such as the President's Malaria Initiative (PMI) and the President's Emergency Plan for AIDS Relief. U.S. programs are funded through one or more of the following: the U.S. Department of Health and Human Services, U.S. Agency for International Development (USAID), Department of State, National Institutes of Health, and CDC, and increasingly through the Department of Defense because of cross-connections between health and security. For example, the President's Malaria Initiative is led by the U.S. Agency for International Development but is overseen by a coordinator appointed by the president and an Interagency Steering Group with representatives from USAID, CDC, U.S. Department of Health and Human Services, Department of State, Department of Defense, National Security Council, and Office of Management and Budget.
Outside of the strictly bilateral and multilateral governmental sphere, the picture becomes even more complex. Quasi-governmental organizations (e.g., the International Red Cross), large nonprofit private foundations (e.g., the Bill and Melinda Gates Foundation), nongovernmental organizations (e.g., Oxfam and Médecins Sans Frontières) finance and implement health programs; businesses provide pharmaceutical drugs, medical devices, and health care services at cost or as charitable donations. These nongovernmental actors are becoming more influential and powerful. According to the Hudson Institute's Center for Global Prosperity, private resources (investment, remittances, and philanthropy) account for "over 75 percent of donor countries' entire economic dealings with developing nations." While health aid has been historically dominated by governments, private sector participation is increasing. In 2007, corporations spent more than $5 billion on in-kind medical donations. Since 1994, the Bill and Melinda Gates Foundation has pledged some $9.3 billion for global health out of $17.3 billion in total development aid.
Within the international health arena, actors might be classified as financiers, implementers, vendors, or recipients. Sometimes an organization falls neatly into one category. For example, the Global Fund is a U.N.-coordinated partnership of "governments, civil society, the private sector and affected communities" concerned exclusively with financing efforts against three diseases--AIDS, tuberculosis, and malaria. However, organizations more frequently fall into several categories and play numerous roles. Although each theoretically has its own comparative advantage, mandates and tasks often overlap.
Because it is the principal international agency concerned exclusively with health, we anchor our analysis on the World Health Organization, explaining how it has interacted with myriad agencies and venturing to propose how it could do its job better.
The New International Health Organization
In April 1945, delegates from around the world gathered in San Francisco to hammer out a postwar order and launch the United Nations. Because few countries had the capacity to finance and organize broad-based international health operations and programs, an international body was appealing and seemed necessary. A proposal by the Brazilian and Chinese delegations for a new World Health Organization quickly gained support. In June 1948, delegates from 53 of the U.N.'s 55 member states convened the first World Health Assembly and proclaimed as its mission "the attainment by all peoples of the highest possible level of health." Slogans proclaiming that "germs know no frontiers" and "carry no passports" echoed throughout the first assembly.
WHO's Original Mission. Negotiations over the structure and authority of the new health organization borrowed from the mandate of the Health Organization of the League of Nations. Because participants deemed it to have been too weak to meet many of the world's health needs, they designed WHO with a far more comprehensive role and greater authority to fulfill its mission. Among the 21 functions in its constitution, WHO would:
- Direct and coordinate international health work;
- Establish and maintain collaboration with all international health actors, public and private, deemed "appropriate";
- Provide assistance for emergencies and for "strengthening health services";
- Work to eradicate, not only "epidemic" diseases, but also "endemic and other diseases";
- Establish international nomenclature and standards for health;
- Provide administrative and technical services, including epidemiological data; and
- Even "promote and conduct research."
These functions were supposed to be performed only "upon the request or acceptance of governments" of member states, the organization's financiers and clients. As with any large organization, principal–agent problems quickly arose.
In its early years, the organization strayed little from what most member states considered to be its primary function: eradicating epidemic diseases. This approach of focusing on mass disease prevention and control campaigns is generally categorized as "vertical," rather than "horizontal," which focuses on improving general health.
WHO launched a series of disease-specific programs, which achieved varying degrees of success: the 1952–1964 program against Yaws (a bacterial infection), a 1974 effort against onchocerciasis, the celebrated eradication of smallpox by 1979 (in just over a decade), and a campaign against polio in 1988. The organization's early campaigns against malaria were launched in the mid-1950s in the Americas, Europe, Asia, and Oceania with pilot programs in Africa and were highly effective. By 1970, an estimated 1 billion people no longer lived in malaria-endemic areas, and malaria had been eradicated from 14 wealthier tropical and sub-tropical countries.
These programs succeeded for several reasons. For smallpox and malaria, the nature of the disease had been clearly identified, and methods for prevention and treatment were obvious. Funding was forthcoming from donor countries, at least initially. National governments in recipient countries were eager to participate.
Because paternalistic attitudes overtly pervaded much international aid policy (and WHO was no exception), it was politically acceptable for rich countries to both fund and carry out health campaigns in poorer countries without consulting much with the countries' health leaders. With strong political support from donor and often from recipient nations, WHO did not hesitate to pursue aggressive, vertical strategies with firm timelines and tight management. Expert personnel were recruited from other private and public organizations, and protocols were borrowed from and built upon the strategies implemented by these other organizations.
For example, Brazilian Marcolino Candau, WHO's second director-general, who launched WHO's first major malaria eradication campaigns in 1955, had previously worked under Fred L. Soper, who directed many of the vertical disease control programs at the Rockefeller Foundation and later the Pan American Sanitary Bureau. In the smallpox eradication campaigns of 1966–1979, WHO borrowed scientists from the CDC, the Institute of Sera and Vaccines in Prague, and the Pasteur Institute in Paris, among others.
The strategy yielded positive results, at least initially. Between the early 1960s and the early 1980s, infant mortality and under-five mortality rates fell in sub-Saharan Africa, partly due to successful vertical campaigns. The decline in the infant mortality rate (2.9 deaths per thousand per year) was less than in East Asia/China (3.8 deaths) and the Arab countries (3.4), but greater than in South Asia (2.2).
Even in South Asia, the limited success owed largely to "global initiatives and vertical national programs" against diarrhea and acute respiratory infections. Still, sustaining success critically hinged on the recipient country's economic growth and specifically on governmental and private support for health interventions.
Failure to achieve these goals is a key reason why improvements ultimately languished in sub-Saharan Africa. Economic development in Africa stagnated, with direct implications for future health. By 1999, 32 countries in sub-Saharan Africa were poorer than they had been in 1980, even while countries in other regions were enjoying rapid economic growth.
New Goals and Mission Creep. Despite a reasonable number of successes, questions and criticisms of WHO's approach to international health gathered momentum in the 1970s. Donor countries began to question the wisdom and sustainability of large foreign aid transfers. Newly independent states in Africa were demanding a role in crafting policy. WHO's top-down, "paternalistic" campaigns of the past were growing increasingly unpalatable. These trends crystallized into policy at the September 1978 International Conference on Primary Care held in Alma-Ata (now Almaty), Kazakhstan, where "health for all" and "primary health care" were proclaimed as WHO's new goals. Both goals were subsequently endorsed by the U.N. General Assembly in December 1979.
These two goals revolved around the principles of "equity, community involvement, appropriate technology, and a multisectoral approach." Their practical effect was to broaden WHO's mandate significantly. WHO would no longer focus primarily on disease-specific programs, but would now promote health "development" more broadly by improving health systems, building infrastructure, and fighting chronic diseases.
The Health for All and Primary Health Care initiatives made several important contributions to development discourse and practice. They identified the need to strengthen underlying health systems and thereby improve health capacity, which is essential for any sustainable, long-term development beyond epidemic disease control. They also emphasized the interconnection between health and other development issues, including economic growth and education, and identified the importance of country-level, local ownership. WHO leadership had long recognized the need for such policies, but most WHO member countries had done little to fill policy gaps. In 1948, for example, WHO's Regional Director for South-East Asia, Dr. C. Mani, noted that reducing morbidity from communicable diseases would not be possible "until basic health services [were] strengthened and adequately supervised so as to play their part."
However, given the paucity of competent health care practitioners and the lack of good governance in many nations, the new Health for All ethos enabled, even encouraged, mission creep. WHO expanded into many highly politicized areas where it had less technical ability, managerial competence, or experience, duplicating the efforts of other organizations including the well-funded and managerially more competent World Bank. WHO was often unable to secure adequate funding for success. WHO also failed to recognize or at least acknowledge that the radical changes to existing health-care delivery systems required to achieve "health for all" were ultimately the responsibility of health ministries of national governments, not a global body. Indeed, research by Alex Preker of the World Bank would later show that efforts to provide resources for horizontal health initiatives were far less effective than predicted, partly because they crowded out domestic (national government) health expenditures.
In the wake of the global financial woes of the 1970s and amidst growing distrust of the WHO's ability to allocate funding effectively, the World Health Organization began to lose funding. In 1982, the World Health Assembly voted to freeze the organization's budget. In 1984, the Guttmacher Institute noted that WHO's Special Programme of Research Development and Research Training in Human Reproduction had downsized its goals in response to its reduced funding, including eight budget reductions since 1980. In 1985, the U.S. withheld its entire pledged contribution to WHO's regular budget, partly to protest WHO's recent launch of an essential drugs program partly designed to encourage countries to develop their own pharmaceutical production. The U.S. actively encouraged the director-general to make cuts to the organization's budget.
Meanwhile, supporters of the organization were bemoaning what appeared to be growing politicization of the "sort that [had] plagued other United Nations agencies." For example, following the retirement of director-general Dr. Halfdan Mahler in 1988, a political squabble ensued. Health agency officials alleged that Japan had pressed "third-world governments" to support the candidacy of Dr. Hiroshi Nakajima as Mahler's replacement, "in some cases offering foreign aid projects as inducements."
By the end of 1995, unpaid contributions from all member states had reached $243 million. The organization had been forced to borrow its entire internal reserve of over $175 million, foregoing its ability to respond quickly to health crises and the interest on its reserve. Meanwhile, WHO's extrabudgetary funding, which allowed donors to track the use of their funds more closely, increased from 25 percent of WHO's total budget in the 1970s to 40 percent in 1980 and over 50 percent in 1990.
Even as financial constraints made it increasingly impractical, WHO did little to focus its activities and remained committed to a "full-menu" programming approach. Critics routinely lambasted the organization for spending too much on its own bureaucracy. In 2002, only 40 percent of WHO resources went to countries and regions. Money that did make it to the regions was not being spent efficiently. In many countries, national governments demonstrated little willingness to invest in necessary health resources and infrastructure, and endemic corruption meant that even well-intentioned WHO-directed aid had little impact.
WHO's strong, semi-autonomous regional offices often could more clearly identify and respond to each region's unique problems and were generally perceived to be more representative of local peoples. Yet they also duplicated efforts of the WHO Secretariat and offered little accountability. Because regional directors were elected by member states, they were not directly accountable to the director-general of WHO, were not necessarily subject to the same technical scrutiny as secretariat staff, and tended to be less insulated from local politics.
Recent Reform Efforts. When Dr. Gro Harlem Brundtland, a former prime minister of Norway, became director-general in 1998, the organization was in desperate need of reform. She raised performance standards at WHO's Geneva headquarters, placed more than half of the staff on short-term contracts, and tightened the chain of command between the executive board and what had been "powerful and largely independent units" within the Geneva office. Although WHO did not acknowledge the outright failure of its Health for All campaign, its 1998 evaluation report recognized the initiative's numerous shortcomings. By the end of the report, the phrasing "health for all" had been abandoned for the more qualified language of "health development," with emphasis on ownership by countries themselves. This change in phrasing signaled a subtle, but important clarification of WHO's goals.
Brundtland also renewed WHO's focus on public–private partnerships. Emboldened by resources brought to the table by private NGOs and foundations, as well as donor confidence in these partnerships' responsiveness and flexibility, WHO helped launch several new public–private partnerships within the U.N. system, including Roll Back Malaria, the Global Alliance for Vaccines and Immunization (GAVI), and Stop TB partnership. Brundtland also boosted the organization's long isolated and underfunded Special Programme for Research and Training in Tropical Diseases (TDR) to a more prominent position. WHO helped to create--and joined the boards of--several independent initiatives, including the International AIDS Vaccine Initiative and Medicines for Malaria Venture.
While not without problems, such partnerships allowed WHO to focus on its comparative advantages. In its public–private partnerships, WHO hosted at most a secretariat and in many cases played merely a technical or advisory role. In the Multilateral Initiative on Malaria, a global alliance launched in 1997 to "maximize the impact of scientific research against malaria in Africa," TDR's role (and by extension WHO's role) was limited to helping to "assess the scientific needs and take responsibility for strengthening research capacities." In the Medicines for Malaria Venture, WHO's role was to offer "technical and public health guidance." Management and implementation were left to private and other nongovernmental actors better suited to the tasks.
Dr. Lee Jong-Wook, Brundtland's successor, also corrected some of WHO's many problems when he assumed office in 2003. His recruitment of strong, technically qualified personnel dramatically improved WHO's focus and effectiveness in several key programs. He also continued internal management and finance reforms, with the aim of "putting most of the budget where it was needed--in countries--and building strong accountability mechanisms." By 2005, 60 percent of WHO resources was going directly to countries and regions. Better internal management (WHO reduced administrative costs by 15 percent in 1999) and greater transparency in spending improved donor trust. In 2005, member states increased WHO's regular budget by 4 percent, reversing earlier declines. Extrabudgetary funding continued to increase, accounting for 71 percent of the budget in 2004-2005.
Following Dr. Lee's untimely death in May 2006, Dr. Margaret Chan, a former assistant director for the organization's Communicable Diseases cluster was elected director-general. It is still perhaps too early in Chan's tenure to assess her record. Yet while she publicly acknowledges the need for reform, she at times seems reluctant to tailor WHO's activities to its strengths.
For instance, Chan pledged to assess the performance of WHO's assistant director-generals, introduced travel restrictions for senior staff, and affirmed the need to streamline the number of publications produced by the agency. She also reaffirmed the need for WHO to focus its efforts and work with other actors in international health. Shortly after her election, she signaled strong willingness to coordinate WHO efforts with other agencies and NGOs by spending several weeks meeting with Bill and Melinda Gates and "high-ranking officials at all the major international health agencies" to "identify priorities and decide who is doing what."
In her 2008 address to the World Health Assembly, Chan said that she rejects the full-menu approach for WHO programming and has "a duty to steer the work of this Organization into areas where [its] leadership offers a unique advantage." Yet she has also expressed a desire to resurrect the vision of primary health care articulated in the 1978 Alma-Ata Health for All declaration. Health of All is a bold cheerleading vision, but only individual states can address delivery. Two of the three "global crises"--food security, climate change, and a global influenza epidemic--that she identified in her address lie outside of WHO's expertise or mandate. While lack of food has serious health consequences, it may be better addressed by other U.N. entities, such as the U.N.'s Food and Agriculture Program, World Food Program, UNDP, and World Bank. While climate change may lead to deleterious impacts on health, policy solutions would be outside WHO's sphere of influence.
Recurrent Challenges and Needed Reforms
The World Health Organization has begun a reform process that will hopefully direct it toward roles in which it complements--rather than competes with--the activities of other international health institutions, national health institutions, and private-sector health efforts. Still, the organization faces a long road ahead. Specifically, WHO and its member states need to correct the organization's:
- Ambiguous mandate and overambitious rhetoric,
- Duplication of other agencies' efforts,
- Susceptibility to political influence,
- Failure to focus on results,
- Tendency to exceed its mandate and capabilities, and
- Statist bias.
Ambiguous Mandate and Overambitious Rhetoric. WHO's ambiguous mandate and overambitious rhetoric have translated into a poorly defined, overambitious role. "The almost limitless scope of the international medical field," Melville MacKensie warned in an address at Chatham House in 1950, meant that there were "certain problems that [lent] themselves to international collaboration and others which [did] not." Malaria and cholera--for which the causes, treatments, and preventions were known--were "ripe for international collaboration."
However, research on cancer and leprosy might best be done nationally. It would be difficult, MacKensie acknowledged, "to keep the work of the organization on the right lines…to prevent the development of projects in which we cannot hope to produce adequate results."
A pertinent example is WHO's continued focus on chronic diseases and other "lifestyle" issues, such as substance abuse, high blood pressure, cholesterol, tobacco use, and obesity. These programs divert attention, time, and money from other, more immediate priorities such as epidemic diseases. In 1998, the organization launched the Global Initiative on Primary Prevention of Substance Abuse. In 2002, the World Health Assembly issued a resolution urging member states to collaborate with WHO and calling on the director-general to "develop a global strategy on diet, physical activity and health…for the prevention and control of noncommunicable diseases," which the director-general later fleshed out to include high blood pressure, cholesterol, tobacco use, alcohol abuse, and obesity.
In 2002, WHO also convened an international meeting of medical experts, airline companies, and consumer groups to probe the potential causal link between air travel and venous thromboembolism. The group concluded that the "the risk was not quantifiable because of a lack of data" and "was likely to be small and mainly affect passengers with additional risk factors for venous thromboembolism." Yet the group agreed that WHO and the International Civil Aviation Organization would conduct a series of large clinical studies to consider its impact.
Problems such as diabetes and heart disease predominantly afflict older people in more developed countries: the United States, European countries, and increasingly, countries such as India and China. In less developed countries, many people simply do not live long enough to experience such health problems. Therefore, these problems can be addressed more effectively by (generally wealthier) developed-country governments or nongovernmental agencies. Instead of worrying about "economy-class syndrome (when passengers on long flights develop blood clots in their legs)" and international tobacco control, WHO should "concentrate on the biggest killers in the countries least able to cope without assistance": AIDS, tuberculosis, and malaria, especially in Africa.
Even when formal mandates are complementary, overlapping authorities lead to "an unclear delineation of activities." A relevant example is WHO's decision to reestablish its own HIV Department at the beginning of 2001 --only a year after it helped to found the Accelerated Access Initiative, a public–private partnership of five pharmaceutical companies, WHO, UNAIDS, World Bank, and other U.N. agencies to accelerate and improve access to HIV/AIDS-related care and treatment in the developing world.
This problem is not exclusive to WHO. A third of U.N. initiatives involve more than 10 U.N. agencies, inevitably duplicating administrative efforts and creating overlapping mandates. The World Bank has also been faulted for expanding into areas outside its traditional ambit. By 2001, it had acquired tasks as disparate as Balkan reconstruction, education for girls in Muslim countries, and the fight against AIDS, making its mission so complex as to be unwieldy.
WHO's early efforts at malaria eradication ultimately fell short because donors grew tired of supporting what turned out to be decades-long initiatives. In September 1971, WHO admitted that it had "not been possible to pursue a vigorous campaign to eradicate malaria because of deficiencies in planning, management, administrative problems and particularly lack of government funds." Eradication in all countries, many of which lacked the necessary infrastructure to mount ongoing malaria control measures, proved to be an overambitious, unsustainable goal--much like many of the targets set in later decades.
In some cases, WHO has even launched unfunded programs with the hope that the subsequent media blitz would generate the necessary support. Its drug prequalification program was launched hurriedly, even though it was underresourced and underdeveloped. Yet funding was not forthcoming because the program lacked credibility, and the program languished, poorly funded and poorly implemented.
Duplication of Efforts. At the outset, WHO experienced difficulty in defining its relationship with nonmembers, both states and non-states, including earlier regional initiatives and other U.N. funds, programs, and efforts. Considering their disparate origins and different political imperatives, the difficulty of coordinating efforts between Geneva headquarters and regional offices is not surprising. At its founding, WHO absorbed a host of longstanding regional health programs. Today, regional offices remain largely autonomous, with regional directors appointed by member states rather than the collective assembly, making it difficult for the director-general to correct regional failings, remove duplication, or prioritize expenditures. For instance, a 2004 editorial in The Lancet, a British medical journal, accused the Africa office of "having an ineffective and self-serving management" that acted as a political rather than a technical agency. Although the entire organization was criticized for its staffing decisions, the Africa regional office was singled out in particular for recruiting staff "rarely based on competence or qualification." Outside the U.N. system, poor communication with nonmembers can exacerbate administrative waste and program duplication. WHO attempted to rectify this for its HIV/AIDS initiatives by creating the Global Task Team on Improving AIDS Coordination among Multilateral Institutions and International Donors in 2005.
Yet questions remain unresolved, including which agency will have the final say when initiatives with other U.N. bodies overlap, how to coordinate activities between WHO and its regional offices, and how WHO's chain of command can be enforced. WHO has little ability to demand--and whether it should is questionable--the participation of key bilateral initiatives involved with HIV/AIDS work, such as the President's Emergency Plan for AIDS Relief, even though reducing conflicts, reducing duplication, and bolstering cooperation are in the interests of such initiatives.
Susceptibility to Political Influence. In theory, one benefit of WHO is its "ability to bring scientific evidence to bear in political disputes that often lose sight of facts on the ground." In practice, however, as a membership organization that relies on the funding and cooperation of its members, WHO is often constrained by political disputes that are unrelated to health.
This is especially evident in health crises that involve countries that include de facto authorities that WHO does not recognize. For example, in early March 2003, Taiwan became one of the first authorities in the region to report suspected SARS cases to WHO, offering to share information and cooperate with international organizations and governments fighting the disease. However, because the U.N. regards Taiwan as part of the People's Republic of China, Taiwan's participation is dependent on Beijing, which has consistently refused to let Taiwan become a member state of WHO. During the SARS crisis, WHO officials could only encourage the Taiwanese to contact authorities in Beijing, who had several months earlier refused to allow WHO to investigate a suspected SARS outbreak in China's Guangdong province. Taiwanese authorities were denied access to WHO meetings and WHO's Global Outbreak Alert and Response Network, the organization's rapid global alert and reporting mechanism. According to Taiwanese health professionals, WHO was "hindering all the circulation of disease information" by adhering to its member-state-only policy.
In some cases, WHO has foisted programs on member states without much consultation. For example, WHO did not spend sufficient time or resources developing country-specific plans for its 3 by 5 Initiative, which it launched in 2003 with the aim of treating 3 million people suffering from HIV by the end of 2005. This led it to push some poor country governments, including Sierra Leone and Lesotho, to attempt to treat more HIV/AIDS patients than could be sustained. In South Africa, the government opted to run and fund its own national program independently of WHO because, as it argued among other less credible reasons, WHO set ambitious goals without providing the funding to support those goals.
In other cases, WHO is viewed as too close to national governments and unable to provide impartial, scientific advice. In the 3 by 5 Initiative, participating countries were often "ambivalent" about WHO's role, sometimes seeing WHO as a barrier rather than a facilitator. Development partners in the U.N. system, civil society, and the private sector criticized WHO for "hiding behind government policy, not addressing controversial issues or neglecting other players."
Failure to Focus on Results. All multilateral and even the best bilateral agencies do not measure performance well enough, generally measuring inputs such as how much money is spent rather than how it is spent and whether it achieves the desired goal of lower disease rates. WHO's failure to focus on results is both a cause and a consequence of unavailable (or else poorly interpreted) international health data, exacerbated by a self-perpetuating bureaucracy. At the end of September 2007, The Lancet published papers exposing the United Nations' misuse of scientific information on child mortality, especially in relation to malaria. "UN agencies are willing to play fast and loose with scientific findings in order to further their own institutional interests," the editorial soberly concluded.
In another instance, Roll Back Malaria, the organization's anti-malaria campaign launched in 1998, pledged to halve the incidence of malaria between 1998 and 2010, but lacked a baseline for malaria incidence and did not try to establish one. UNICEF's latest assessment report of the Roll Back Malaria Partnership highlights its success in dispersing antimalarial resources: "Global funding has increased more than tenfold over the past decade…. There has been real progress in scaling up the use of insecticide-treated nets across sub-Saharan Africa." However, it gives scant attention to the impact of such dispersion on actual health indicators, such as infant mortality and life expectancy.
In 2007, WHO announced that it was downgrading its 2006 estimate for the total number of people living with HIV by nearly 7 million, largely because of revised epidemiological methods in India and sub-Saharan Africa. WHO's acknowledgment and correction of the error is commendable, but calls into question the veracity and reliability of other WHO data.
Poor quality, misreported data from member states--which WHO does not adequately monitor--is undoubtedly part of the problem. In 2008, the Lancet published a study revealing disparities between official reports (based on countries' own administrative data) and independent, multi-country surveys of the number of children vaccinated under programs such as the Universal Childhood Immunisation campaign and the Global Alliance on Vaccines and Immunisations (GAVI). According to multi-country surveys, only half as many children (7.4 million) had been vaccinated with the three-dose childhood diphtheria, tetanus, and pertussis vaccine (DPT3) than had been suggested by official reports to WHO and UNICEF (13.9 million). Because GAVI disperses payments in proportion to the number of additional children targeted or reported to have received DPT3, some experts feared countries may have been artificially inflating their numbers. "That's how you get money," Ken Hill, a public health professor at Harvard University who was not linked to the study told the Associated Press. "You exaggerate the number of people who die or who you save...Somehow, numbers always end up bigger than they would be otherwise." In an era of global target-oriented, performance-based initiatives, there is "urgent need," the Lancet authors concluded, "for independent and contestable monitoring of health indicators."
In addition to lapses in technical competency, WHO has sometimes strayed from its commitment to technical objectivity. The organization's often cited The World Health Report 2000 features a health performance index that reflects, as economist Glen Whitman has written, "implicit value judgments and assumptions." According to Whitman, only two of the index's five components are objective measures of actual health attainment.
Until September 2006, WHO refused to actively endorse indoor spraying of DDT to combat malaria, despite evidence that such spraying posed minimal health risks and no environmental risks and was saving thousands of lives annually in Southern Africa and other malarial areas. While it listed DDT as an approved insecticide, it had done nothing to promote its use, favoring alternative methods of malaria prevention. Furthermore, the World Health Assembly has still not repealed a 1997 directive that pushes against the use of all insecticides.
Too often, WHO has concealed its shortcomings instead of acknowledging them, hoping to avoid international embarrassment and the funding cuts that would likely result. When it became clear in late 2005 that the vaunted 3 by 5 initiative would not even approach its goal of treating 3 million people in poor and middle-income countries with anti-retroviral drugs, the organization became strangely quiet about the program. UNAIDS and WHO's 2005 "AIDS Epidemic Update," mentioned it only once, as a parenthetical reference for successful programs in Kenya and Brazil. While treatment gaps were expected to narrow in these countries, they would not do so at a "pace required to effectively contain the epidemic," it admitted. The report failed to ask why, which would have most certainly included a discussion of shortcomings of the 3 by 5 program.
While much of the blame must rest with national governments that failed to deliver treatment, WHO was fully aware of these limitations when it set its unrealistic, politically motivated targets for each country. In November 2005, South Africa's Health Minister Dr. Manto Tshabalala-Msimang bristled at suggestions that it was deliberately denying drugs to people by failing to meet the target set unilaterally by WHO. "[Our] Government is not withholding treatment for opportunistic infections, including ARVs," said Tshabalala-Msimang, "our objective is to promote quality healthcare. We are not just chasing numbers."
Exceeding Its Mandate and Capabilities. For instance, WHO publishes lists of approved "essential medicines," which the World Bank, the Global Fund, and many private sector donors use when determining which drugs to purchase for developing countries. However, WHO does not have the technical capacity to act as a drug authority, at least compared with the U.S. Food and Drug Administration (FDA) or the European Medicines Agency. While WHO has the capacity in principle to analyze drug quality data provided by independent laboratories commissioned by drug companies, it has not always received such data prior to granting approval.
In 2004, WHO withdrew five drugs manufactured by Indian companies from its prequalification list, and the companies voluntarily withdrew seven more. The companies had failed to provide adequate evidence of bioequivalence, which demonstrates that the generic drug works in the same way as the original product. Prior to this withdrawal, developing-country governments and aid organizations had used WHO's list as a guide when buying unproven drugs for the poor, with unknown consequences. Agencies still rely heavily on the WHO list, under the assumption that drug quality is acceptable.
The Pesticides Evaluation Scheme (WHOPES) was another well-intentioned WHO "credentialing" program that lacked the capacity for broad effectiveness. Founded in 1961, WHOPES provides a four-phase evaluation and testing program for approval of insecticides applied to bed nets and used in insecticide residual spraying or larviciding. The program's approval of long-lasting insecticide nets has been criticized for delays in approving nets (an average of two years) and the lack of post-market surveillance, or on-going quality checks after initial approval.
WHO openly acknowledges that "it is not a regulatory authority" and that "the regulatory approval of pesticide products is the sole prerogative of national authorities." Its recommendations are designed to facilitate pesticide registration and use in countries that lack the technical capacity to assess such pesticides on their own or for products that more stringent regulatory authorities have little incentive to assess. For instance, having eradicated its own malaria scourge more than 50 years ago, the U.S. government may be hard pressed to rationalize significant funding for testing different brands of long-lasting insecticide-treated bed nets. Thus, the WHOPES program serves an important function, at least in principle. Still, it is not clear that the program has to be WHO-specific.
Worse, WHO can greatly undermine future health through shortsighted intervention in areas in which it has insufficiently broad expertise, such as intellectual property rights. It is expected that WHO will champion immediate assistance for the poor but immediate public health need is not the only criterion for assessing patent enforcement and drug pricing. WHO Director-General Chan demonstrated her uncertainty when she vacillated on the issue of access and innovation in pharmaceuticals when pressured by the pharmaceutical industry and Western governments on one side and the Thai government and anti-patent NGOs on the other. When Thailand broke patents for several HIV/AIDS drugs and one heart disease medicine in early 2007, she initially seemed to rebuke Thailand, then appeared to support its right to break patents, and then went silent, leaving the situation in limbo. WHO could play a constructive role by driving patent-holding manufacturers to differentiate their prices (lowering prices further in the poorest nations, but raising them in mid-income nations), while appealing to member governments and NGOs to uphold intellectual property rights in mid-income countries.
Statist Bias. As an international governmental body composed of representatives of national governments--many of which are hostile to private markets--WHO sees public goods (and market failures) in more areas than most economists would. For example, it supports claims that pharmaceutical research for diseases that predominantly affect the developing world is a market failure and demands more research funded by taxpayers to provide the "public good" of drug knowledge. It has notably done this for diseases such as malaria, leishmaniasis, and Chagas disease.
While more drugs for more developing-world diseases would be welcome, the major problem of combating most diseases is not the paucity of drugs, but lack of funds to buy and deliver them. These are failures of poverty and governmental inadequacy, not the market. WHO's support of positions anathema to private sector research and development (e.g., its vacillation on intellectual property rights) has probably encouraged at least some large pharmaceutical companies to move away from such research. For example, pharmaceutical company Eli Lilly quietly left HIV/AIDS research many years ago. Companies that develop drugs for neglected diseases are generally unable to garner any profit from these enterprises and often incur losses, which are a considerable disincentive to future research and development.
In much of the world, the private sector provides nearly all health services. In Africa, over half of drugs are bought privately. WHO has been guilty of proposing to reform the private sector, or more often to replace it by state action, without input from the private sector itself. The latest manifestation of this problem is the Global Fund and WHO's Affordable Medicines Facility for Malaria (AMFm). The initiative would provide a $2 billion subsidy to lower the price of malaria drugs in the supply and distribution chains in Africa. Yet neither the Global Fund nor WHO has actively consulted with the main drug makers or the wholesalers that they will use. Some fear that the AMFm may increase drug resistance by subsidizing substandard drugs. At its November 2008 meeting, the Global Fund board approved the pilot for the project. Hopefully, WHO members and Global Fund financiers will demand evidence of success before rolling it out elsewhere.
What Can Be Done?
Although the World Health Organization has historically been an important international health organization, it is not alone. The World Bank has a prominent role in promoting health in developing countries. UNAIDS, the Global Fund, and other international organizations have been created to combat specific diseases. National organizations, such as the CDC and U.S. Food and Drug Administration, are often better equipped to perform certain tasks than WHO. Nongovernmental organizations, such as Médecins Sans Frontières (Doctors Without Borders) and the Gates Foundation, have assumed an increasingly prominent role in influencing international health policy, financing health initiatives, and providing treatment and expertise. However, WHO officials can provide much needed reflection on the role of these independent groups, as has already happened in at least one case. If WHO is to find a place in the increasingly crowded arena of international health, it must reform. Specifically, it should:
- Divest inappropriate roles, missions, and activities;
- Focus the organization's mission around its comparative advantages;
- Enhance the authority and power of the director-general.
Divesting Inappropriate Roles, Missions, and Activities. Compared to the performance of bilateral and private-sector initiatives, the U.N.'s track record is spotty in many instances. WHO is no exception. A 2007 Center for Global Development report found that the President's Emergency Plan for AIDS Relief bested the World Bank and the U.N.-backed Global Fund to Fight AIDS, Tuberculosis and Malaria in channeling aid money into on-the-ground initiatives in Zambia, Uganda, and Mozambique.
When WHO engages in activities for which it is ill-suited, it can do more harm than good. It may set goals for and direct money to policies that are antithetical to the realities on the ground. It may unduly focus on public-sector development initiatives when the private sector is already playing a greater role, squandering valuable time and resources in counterproductive or duplicative initiatives.
To correct these problems, WHO should:
- End its implementation programs. With the Global Fund well-positioned to fulfill the niche of funding distribution and the myriad bilateral and nongovernmental initiatives pursuing disease and issue-specific programs, WHO should shed its implementation programs and instead focus on what it does best: providing technical, clinical, and public health advice to poor countries applying for aid monies and to implementing agencies looking for the most cost-effective ways to use aid monies.
- Leave primary health care to other organizations and governments. Primary health care with its emphasis on local ownership and strengthening the underlying heath systems is a laudable goal. However, it is not a goal best pursued by WHO. The organization needs to acknowledge that responsibility for development initiatives lies first with member states and will depend on their capacity and political will, which do not always match the international "consensus." WHO initiatives have repeatedly languished because countries simply do not have the means (e.g., staff, facilities, expertise, and systems) to implement them, much less in the timeframe proposed by WHO. WHO can provide some technical advice, but the World Bank is better positioned to advise national governments on health systems. The World Bank is also better equipped to provide technical assistance on health financing.
- Cease or greatly constrain its regulatory efforts. WHO is not a drug regulatory authority. It should either stop attempting to assess drug quality or undertake the initiative properly. If it chooses to retain this role, WHO should list only those drugs approved by stringent national agencies, including those of the United States, Canada, the European Union, Japan, and Switzerland, as long as those agencies are prepared and funded to undertake free assessments of drugs made in developing countries. In the past, the FDA has provided free assessments for HIV drugs.
Unlike approval of drugs and other ingestibles for which strict governmental safety approval is desirable, approval of bed nets and other non-ingested products could potentially be undertaken by an NGO. A precedent has been set by numerous environmental approval mechanisms, including the Forestry Stewardship Council, which approves sustainable forest products. Although bed nets and sustainable-forest products are different, it is important to recognize the tradeoff between the costs of safety regulation and the consumer safety benefits accrued therein. If the international community determines that regulating bed net safety is an essential public good that is best served by WHO, the organization should be careful that its endorsement of pesticides and nets is recognized for what it is: a limited guide, not stringent regulatory approval.
In short, WHO should yield to others when they are better positioned or equipped to lead. For health system strengthening, this means the World Bank, which has technical expertise as well as closer, more collaborative relationships with developing-country governments. For private-sector delivery systems, this means the private sector itself. In this area, the organization might consider encouraging the practice of NGO-bidding for the provision of health care services and the administration of programs, rather than delivering those services or administering programs itself. This was done successfully in a pilot program in post-conflict Cambodia and more recently in Afghanistan. Through such decentralization, grounded in evidence-based research, WHO member states can lessen the principal–agent problems experienced during the organization's half-century history.
Focusing on WHO's Comparative Advantages. WHO has certain comparative advantages over other health organizations, including its roles as advocate or "global cheerleader," standard setter, technical advisor, and mediator. As an advocate or global cheerleader, WHO and the U.N. can help raise awareness about and thereby generate funding for developing-world health concerns. As a standard setter, WHO (and the U.N. more generally) benefits from what Gavin Yamey calls "near universal representation" with its 193 members having equal voting power. Although this can make consensus difficult, when consensus is achieved, it carries much influence and under some circumstances (such as health regulations on quarantine) much power.
WHO can also act as a convener, bringing together experts in committees to help to set "norms and standards in advising countries on their implementation at global, regional, national, and local levels." Yet WHO and its member states need to guard carefully against adopting overambitious strategies, such as the Health for All effort.
With the proliferation of financing and implementing health agencies,WHO can also act as a technical advisor and mediator, "engaging new constituencies, such as academies of science…by clearly communicating priorities for developing global public goods" where the private sector is genuinely failing to address health concerns. WHO can also act as a trusted forum for tracking clinical and public health data. Specifically, if WHO notes a rise in drug-resistant malaria in a country (reported by the country or an implementing aid agency and verified by WHO's independent staff), it can advise implementing agencies to switch strategies from first-line to second-line malarial drugs. Most Western countries will trust data provided by the U.S. and other governments, but other countries will oppose such government data for political reasons.
However, even this role need not be WHO-specific. For example, the International Society for Infectious Diseases' Programme for Monitoring Emerging Diseases is a global electronic reporting system for outbreaks of emerging infectious diseases and toxins. The Global Public Health Intelligence Network, an Internet-based early-warning system developed and managed by the Public Health Agency of Canada, gathers and disseminates relevant information on disease outbreaks, infectious diseases, contaminated food and water, bioterrorism and exposure to chemical and radio-nuclear agents, and natural disasters. It also monitors issues related to the safety of products, drugs, and medical devices.
Member states should carefully assess WHO's activities and initiatives to ensure that the organization is best suited to implement them, is not duplicating other efforts, and is contributing to resolving the health problem at hand.
Enhancing the Director-General's Authority and Power. As a membership organization, WHO is constrained by the instructions of its member states. This is to be expected and is often desirable because the organization should be beholden to its financiers and the beneficiaries of its programs. However, within the mandates assigned to WHO by its member states, the director-general should have the authority necessary to carry out the organization's missions. Strong leadership--clear vision backed up by sufficient authority to compel coordination and prioritize organizational activities--is critical to focus the organization on its core strengths. This is particularly necessary considering the great latitude traditionally enjoyed by WHO's regional offices. A strong leader can also work to distance the politics of the organization from its technical work. Even if the director-general fails to deflect political pressure, he or she can "draw attention to the problem and transfer the pressure of politics back to those who would distort the facts or the process."
Throughout its history, the presence of a powerful leader unafraid to dismiss the politically correct status quo has been pivotal to WHO program-specific or organization-wide reform. For example, Arata Kochi appears to have turned around WHO's Global Malaria Program.
Appointed director in 2006, Dr. Kochi fired at least 20 percent of the staff and bluntly criticized the global anti-malaria community: "I said, basically, ‘You are stupid,'" Kochi recalled, ‘[you are] small and inward-looking and fighting each other.'" Kochi created a new WHO malaria department that would serve as the main technical advisory body to Roll Back Malaria's implementing partners, publicly castigated 40 companies for selling artemisinin monotherapies, which had contributed to increased drug resistance in many countries. He drove the World Health Assembly to pass a resolution committing WHO member states to stop the production and marketing of oral artemisinin therapies.
Implementing reforms in these three areas would result in a leaner WHO: an organization that is more focused on the tasks for which it is uniquely suited and that restricts its other activities to coordinating or supporting other well-funded public, joint public–private, and private activities and organizations. Taken together, this framework would be more efficient, less duplicative, more flexible, and more responsive to health priorities in the developed and developing worlds.
While a more focused WHO would require less funding, the financial demands for addressing international health issues writ broadly is unlikely to decline. Donors need to ensure that their money is used effectively and prioritized appropriately among all of the possible actors on the international health stage. Donors should recognize WHO's strengths and weaknesses and demand reform through the World Health Assembly and, if necessary, by leveraging their financial contributions. Ultimately, member states should shift WHO toward a voluntary funding mechanism. Under a voluntary funding mechanism, individual member states could demand and pay on strong performance. They would not be bound to support politically driven programs that divert WHO from its core priorities.
WHO has a role to play, but it should be smaller and more focused. Its current condition is the end product of an ambitious mandate and a half-century of mission creep. Its reformed role as advocate or global cheerleader, standard setter, technical advisor, and mediator should be based on evidence, anchored in integrity, and not swayed by political considerations. It should help to focus and leverage the large influx of private aid by highlighting successful health initiatives and criticizing failures. Its budget should be refocused to fit this new mission and shifted toward voluntary funding to provide member states with a more effective feedback mechanism.
Member-state driven organizations like WHO no longer dominate the international health arena. It is increasingly being filled by well-financed private NGOs, businesses, and foundations focused on initiatives that are better financed, placed, staffed, and equipped to handle many of the missions that WHO has assumed over the past six decades. The organization would do well to nosce te ipsum (know thyself) and acknowledge its weaknesses, divest inappropriate programs, identify its areas of comparative advantage, and move forward playing a focused role.
Roger Bate is the Legatum Fellow in Global Prosperity at AEI. Karen Porter is a former research assistant at AEI.