PHA-Exchange> WHO bureaucratic?

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BMJ 2002;325:1170-1173 ( 16 November )

WHO's management: struggling to transform a "fossilised bureaucracy"

Gavin Yamey
gyamey at bmj.com

Gro Brundtland inherited the leadership of an organisation with major
structural problems. WHO was top heavy, male dominated, and rife with
cronyism, and staff morale was falling. Has the new management tackled these
problems?
On taking office as director general of the World Health Organization on 21
July 1998, Gro Brundtland was faced with two enormous tasks ---
to restore the organisation's place on the international stage and to
internally reform
a failing United Nations agency. There is little doubt that she achieved the
former.
In this article I consider whether her managerial reforms have been
successful.
In the 1990s, WHO was poorly managed, over- centralised, and rife with
political appointments.
Brundtland established mechanisms to tackle cronyism and raised awareness of
the need for greater staff diversity.
But WHO is even more centralised now and remains top heavy and dominated by
men and representatives of developed countries.
Some WHO staff say that senior management stifles open debate and internal
dissent.
Brundtland has been more successful at raising WHO's profile internationally
than at transforming the organisation internally.
Brundtland inherited the leadership of a dysfunctional organisation. In a
1995 editorial, Richard Smith, BMJ editor, argued that WHO was
"overcentralised at headquarters and regions, top heavy, poorly managed, and
bureaucratic and smells of corruption." Brundtland's reform process, said
Jon Liden, her communications adviser, had to "butt against a fossilized UN
bureaucratic structure."
Under Brundtland's predecessor, Hiroshi Nakajima, the number of top ranking
posts almost doubled. These appointments were widely held to be political,
rather than based on merit. When Brundtland took office, for example, there
were six assistant director generals. These posts, said Julio Frenk,
Mexico's minister of health and a former executive director at WHO, were
"geopolitical appointments.
Each of the permanent members of the UN security council had one." Cronyism
was widespread, and debased WHO's technical competence. Regional directors
would often assign country representative posts as a reward to doctors who
had served their national governments.
With its regular budget frozen, WHO relied heavily on additional voluntary
contributions from donors. WHO departments would fight with each other for
these funds, and over territory, and there was poor communication between
them. The result, said one programme director in 1994, was that "the right
hand never knows what the left hand is doing."  The autonomous functioning
of the regional offices added to WHO's difficulty in acting strategically
across the organisation.
Is WHO flatter and leaner?
In her first address to WHO staff, Brundtland promised "a flatter structure,
better communication, more transparency." At the centre of her reforms was
a new organisation of activities into nine (now eight) clusters that
reflected WHO's priorities. She named nine executive directors, each of whom
would head a cluster, and grouped them into a government-style cabinet.
Brundtland has said that this new arrangement is flatter.  This is true
only in that there has been no reduction in the most senior posts but a big
rise in the number of lower level posts (those below director level).
Brundtland abolished the assistant director general posts, but there are now
eight executive directors and a chief of cabinet.
Fiona Godlee, author of a BMJ critique of WHO under Nakajima, argued that
"WHO should shift resources away from Geneva and the regional offices into
the countries themselves."  Richard Smith argued that "the number of staff
in Geneva and regional offices should be cut dramatically."  Yet the
opposite has occurred. WHO's human resources department said that there has
been a sharp rise in the number of short term staff at headquarters. And the
latest
figures for long term appointments also show a rise in staff numbers in
Geneva.
Denis Aitken, Brundtland's chief of cabinet, argued that: "It is a fallacy
to argue that because
someone is here [at headquarters], it isn't benefiting countries." The work
that staff does in Geneva, he said, has a direct impact on countries. But
one senior staff member at WHO said that headquarters must be slimmed down,
leaving it with a role in standardising, evaluating, and coordinating
activities that happen closer to countries themselves.
Why has there been a dramatic rise in short term appointments at
headquarters? The rise is due to the 38% increase in voluntary contributions
from donors during Brundtland's term. These funds pay for specific, time
limited projects, and staff can be hired for these only on a short term
basis. Almost 60% of WHO staff are now on these temporary contracts.
Although these give WHO flexibility in appointing staff, a UN inspectorate
report warned that such contracts make it harder for WHO to hire qualified
people in mid-career.
WHO's budget also shows no evidence that resources are shifting from Geneva
to countries. But it is another fallacy, said Aitken, to think
that the division of funds between headquarters, regions, and countries
reflects who will actually benefit. "I would guess," he said, "that
approximately 60-70% of funding is spent on country work in one way or
another."
A global budget:
One of Brundtland's innovations is a new way of specifying how funds should
be spent across WHO. About 18 months before the start of every two year
budget period, senior managers draw up a strategic plan, known as the
programme budget, for that period. The budget sets objectives, allocates
funding to achieve these, and defines measures that will be used to monitor
success. The programme budget for 2002-3 is the first time that WHO has
planned its spending on specific activities at both headquarters and
regions. One of WHO's structural problems is that the regions do their own
planning independently, preventing WHO from having an organisation-wide
strategy.
The new budget is one of the levers that Brundtland can use to try and
create "one WHO," but the regions may not buy into the proposal. For
example, WHO's African region has already developed its operational plans
for 2004-5. The plans are laid out in a highly detailed 375 page document,
which has been written before the organisation-wide strategic plan on which
it is meant to be based.
Tackling cronyism:
Brundtland can point to a number of measures designed to increase the
transparency of staff selection. What is harder to show is whether these
measures are being adhered to and whether they are effective.
I heard a wide range of views among those I interviewed. One academic in
international health, who advises WHO, said that "the rules about hiring and
firing and accountability haven't changed." On the other hand, many staff at
WHO feel that there has been a genuine attempt to clean up the organisation.
In recruiting staff at headquarters, for example, a selection panel now
prepares a shortlist of recommended candidates, and testing has been added
to interviews. Isabelle Nuttall, of WHO's staff association, believes that
selection procedures are more transparent under Brundtland, but said that
the director general still appoints the executive directors and special
advisers directly and that "these appointments are as political as before."
Brundtland has a greater say than her predecessor in appointing country
representatives and believes that their selection is now a fairer process.
"It has become a global, more systematic approach," she told me, "to
building our human resources and using them."
Communication:
"We need a culture of information sharing," said Brundtland at the start of
her term.  This would depend on good communication between her executive
directors, and between the cabinet and the rest of the organisation.
An external adviser to WHO said that, on first glance, the cabinet looks
like an improved way of managing WHO, but this is an illusion: "Brundtland
says, `Look, I'm consulting,' but the consultation doesn't go very far." The
cabinet, he said, does not consult with the wider organisation, particularly
its technical medical officers. And one senior WHO insider says he was
shocked by the amount of internal fighting within the cabinet. "The
reality," he said, "is that there's an incredible amount of competition
between the executive directors. People don't care for a common cause, they
want to score points." What WHO needs, he said, "is a visionary cultural
change, with sharing of ideas and greater consultation."
One of the reasons for this competition is that WHO's regular budget is
still frozen, and the executive directors must argue their case for spending
these limited resources on their own cluster's activities. "Let's be
realistic here," said Liden. "At the top of WHO, some of the best brains
from a number of cultures, academic traditions, and public health schools of
thought meet. You are bound to find disagreements and heated discussions.
And unless you devise a whole new system to fund the organisation, there
will always be anxiety about funding for key programmes."
Representation:
The makeup of Brundtland's first cabinet reflects an equal mix of those from
developed and developing countries and of women and men . This sent a strong
signal that
Brundtland wanted to increase diversity within the organisation. A cabinet
meeting in December 1999 agreed that the female recruitment rate should be
set at 60% "to achieve gender parity in the Organization in the coming
decade."  WHO still has a long way to go to achieve such parity. Only 32% of
professional staff,
and only 29% of new recruits, are women.
Tikki Pang, WHO's director of research policy and cooperation, said that
only seven of the 36 directors come from the developing world. "We very much
need more developing country representation in Geneva," he said. But he also
believes that Brundtland has championed the developing world in two
important ways. "Her successful attempt to link health with development and
with poverty has shown WHO to be particularly sympathetic to developing
countries. And as far as commitment to build capacity in research in
developing countries, certainly she's been a champion."
WHO should be serving developing countries, said another staff member, which
is why their inclusion is crucial. "If you can't find experts in developing
countries," she said, "do you exclude them or do you say, `Let's all work
together and try and bring people's ability up'?" At its last meeting, the
World Health Assembly, the annual legislative meeting of member states,
expressed deep concern at the lack of staff from the developing world. It
resolved that the director general should "ensure that the principles of
equitable geographical representation, gender balance, and a balance of
experts are respected in making appointments."
One criticism of Brundtland's reforms is that they could be seen as playing
to a donor audience rather than to developing countries. In many ways, for
example, WHO is now being managed in the style of a modern business, even
borrowing some of its language. I t has a corporate strategy,
executives, and management support units assigned to each cluster. This
language, said one WHO staff member, is "managers' jargon" aimed at Nordic,
American, and British donors.
And there is ONE IMPORTANT SLOGAN, she said, that is still championed by
many in the developing world but that HAS BEEN CENSORED from headquarters'
language: "HEALTH FOR ALL 2000". WHO set itself this target in 1977, and a
year later announced that primary care would be the means to achieve it.
The organisation now seems embarrassed by this unachieved goal.
In 1977, WHO set itself the goal that by the year 2000 everyone should have
achieved a level of health that would enable them to lead a socially and
economically productive life. A year later, at a meeting in Alma Ata, it
announced that primary health care, with an emphasis on community
participation, would be the means to achieve the goal.
The goal was never reached, but many people in the developing world still
see primary care as a powerful tool for social mobilisation. Next year marks
the 25th anniversary of the Alma Ata meeting. Many people will be asking why
Health for All 2000 just disappeared without a mention from headquarters.
How can we explain this disappearance?
"It became an unfashionable, if not `dirty word' in the 1990s," said Kent
Buse, assistant professor of international health at Yale University.
"Health for All was tied up with a political battle for equity and
inclusion. In the '90s, health policy came to reflect the prevailing
ideology. An ideology which emphasised health systems reform with
a market-oriented approach informed by economic tools and neoliberal
values."
Since Health for All 2000 was never achieved, says WHO, it is no longer an
effective advocacy slogan. Brundtland believes that a more diverse approach
is now needed to improve global health than the one advocated at Alma Ata.
She sees many of WHO's activities as constituting primary health care, such
as improving health systems, adding to the evidence base, and advocating
investment in HIV/AIDS, malaria, tuberculosis, and childhood diseases.
"Enlisting the poor," she said, "by investing in their health and in their
needs: now that's primary health care."
But a growing grassroots global health movement, which gathered in Dhaka in
December 2000 at THE PEOPLE'S HEALTH ASSEMBLY, is concerned that WHO has
lost the intersectoral approach laid down by the Alma Ata meeting. The
movement wants to revitalise the health for all strategy. Its charter
reaffirms health as a right and demands "a radical transformation of the WHO
so that it responds to health challenges in a manner which benefits the
poor, avoids vertical approaches, [and] ensures intersectoral work"
(www.phamovement.org ).
Today's WHO and the People's Health Assembly want the same thing: to improve
the health of the
poor. But they represent very different schools of thought on how this is
best achieved.
Atmosphere:
Critics of WHO's management argue that it has sometimes tried to keep the
organisation "on message" by covering up internal dissent. One episode more
than any illustrates how the management finds it hard to allow internal
debate and dissent: publication of the World Health Report 2000.
The report's authors measured the performance of the healthcare systems of
WHO's 191 member states, creating a league table of good and bad performers.
Publication of the report caused an outcry. Critics argued that the exercise
was driven by headquarters with little input from, and relevance to,
developing countries. Daphne Fresle, a former member of WHO's
essential drugs and medicines policy group, resigned from WHO, citing the
report as one reason for her departure. "I feel embarrassed," she wrote in
her resignation letter of 23 December 2001, "to be associated with this
highly criticised product whose contribution to better global health care,
particularly in the countries most in need, is low or non-existent."
An unhealthy atmosphere surrounded the release of the report. Data were kept
from many WHO staff until the report was finished. Staff who criticised its
methods or findings were seen as conspiring to undermine WHO's international
credibility. If WHO is a scientific resource serving its member states,
argued Alan Williams, professor of economics at the University of York, "it
needs to create a much more open intellectual environment for its staff."
WHO's executive board asked Brundtland to commission an external review of
the report's methods before any repeat of the exercise.
Brundtland's response to this request has been impressive, and hopefully
heralds a new spirit of openness.
Because of the intense controversy surrounding the report, WHO's executive
board asked Brundtland to commission an external review of its methods. The
chair of the review team was Sudhir Anand, professor of economics at the
University of Oxford. Anand was hardly a safe choice, since he has been an
outspoken critic of the disability adjusted life years (DALY), the unit
that WHO uses to measure the global burden of disease and the effectiveness
of health interventions.
Anand believes that the report was ambitious but worthwhile, because it
provided a benchmark of the performance of health systems worldwide. This is
important, he said, because some countries may spend less on their health
system and yet get better outputs. But the report's methods were not
adequately tested before its publication, and their complexity made them
inaccessible to many people. "And there wasn't enough," he said, "about the
policies that countries could use to improve their performance."
WHO has responded quickly to the external review by revising its methods for
measuring health systems performance and by involving countries far more in
the process of data collection. "WHO's response has been most impressive,"
said Anand. "They've accepted my critical report and they're sending people
to countries to help with capacity building."
What can WHO can learn from the controversy? Two things, said Pang: the need
to consult with
countries more closely at the start of such an exercise, and the need to be
transparent about the methods used.
Morale:
WHO's director general has many constituencies, including governments, the
media, and staff. Many of those I interviewed said that Brundtland has been
a great leader on the world stage, but a poor leader of the organisation.
Staff at high levels said she gave them great freedom and support to develop
their programmes, but many staff at lower levels feel disenchanted by her
management. She boosted their morale on arrival, by being highly visible and
promising a new era of openness and communication, but there was a large gap
between rhetoric and action. Her increasing isolation from them was matched
by their falling enthusiasm for her management. In a survey last year of 637
WHO staff, 40% rated their morale as bad or very bad.
Conclusion:
Brundtland has been far more successful at raising WHO's profile
internationally than at transforming the organisation internally. She did
establish mechanisms to reduce political appointments and has raised
awareness of the need to increase staff diversity. But she has not fostered
openness or internal debate. WHO is more centralised now than in the 1990s.
It remains top heavy and dominated by men and representatives from developed
countries.
A team of consultants who reviewed Brundtland's management reforms called
them "the worst of both worlds." The reforms combined the worst aspects
of private sector management  such as rigid control and a focus on short
term results to satisfy external
stakeholders  with the worst aspects of public sector governance  such as
lack of transparency.
"Who has the courage," asked the team, "to grapple with root causes of the
problems?"