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The Lancet: WHO's African regional office must evolve or die
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Lancet Editorial (from http://www.thelancet.com)

WHO's African regional office must evolve or die

Pierre Virot

A resounding silence surrounds an event to take place at the end
of this month that, in theory at least, has great significance
for the health of the people of Africa. Dr Ebrahim Samba is to
step down after serving his maximum two terms of office as Di-
rector of WHO's Africa Region (WHO/AFRO). A new leader for WHO's
governing body in the African region must therefore be nominated
when the Regional Committee meets in Brazzaville, Republic of
Congo, between Aug 31 and Sept 3.

Such disinterest in a new UN health leader in the continent with
the world's most pressing disease burden seems at first glance
astonishing. However, a little familiarity with WHO and its Af-
rican Office makes the lack of debate more understandable. Al-
though five candidates have been put forward for the post, none
has mounted a public election campaign and their names do not
even merit mention on WHO's website. In addition, the political
negotiations key to the nomination are taking place behind
closed doors and committee members will vote for their favoured
candidate by secret ballot. The five candidates are Dr Déogra-
tias Barakamfitiye (Burundi), Dr Phetsile Kholekile Dlamini
(Swaziland), Dr Evaristo Njelesani (Zambia), Dr Francis Gervase
Omaswa (Uganda), and Dr Luís Gomes Sambo (Angola).

Few would envy the job that the new WHO/AFRO Director must take
on. This region has by far the highest disease burden coupled
with the lowest level of economic development in the world, and
is besieged by corruption, poor governance, political instabil-
ity, and civil strife. Despite these constraints, it is clear
that the regional office could do better. Indeed many commenta-
tors are privately and scathingly critical of its composition
and working practices.

WHO/AFRO's weaknesses are typical of a large organisation: inef-
fective and self-serving central management and demoralised and
unsupported rank-and-file staff. At the heart of the regional
office's ineffectiveness is its acting as a political rather
than a technical agency. Recruitment of senior staff is rarely
based on competence or qualification. In particular, appoint-
ments of country representatives, who should coordinate WHO ef-
forts in their countries, are often paybacks for political or
other favours. The regional office thus has strong, some might
say incestuous, relations with African governments at the minis-
try level, to the extent that senior health ministry officials
see WHO/AFRO as their future retirement home. As a result, the
culture of leadership within the regional organisation tends to
be autocratic, excessively bureaucratic, and highly centralised-
-a culture that dismally fails to motivate staff at the country
level.

There is much that WHO can do at the Geneva headquarters, at re-
gional, and at country level to improve this failing situation.
First and foremost, the damagingly close political ties between
WHO/AFRO and the member-state governments must be loosened and
the agency must reorient its core function towards technical
health expertise. Accordingly, transparent, binding procedures
must be put in place to ensure that country representatives are
appointed on the basis of competence and qualification. There
are strong arguments for decentralisation of WHO/AFRO to at
least four or five subregions. Such action could allow better
assessment of the array of health problems within the 46 coun-
tries that make up the African region and more tailored support
to struggling country offices.

The overall Director of the region should be selected on the ba-
sis of management expertise and a proven record of leadership in
a large organisation. Moreover, the Director should ensure that
funds from WHO headquarters and donors are channelled effec-
tively to where they are needed on the basis of evidence rather
than ideology or political expedience. One African doctor empha-
sised to The Lancet that the regional office needs to adopt a
more analytic and targeted approach to its work rather than say-
ing, "We are dying, please help us".

The fault, of course, does not rest with WHO/AFRO staff alone,
many of whom make valiant efforts in difficult circumstances.
WHO's regionalised structure, where real, albeit limited, au-
thority is vested in the regions, is clearly preferable to the
more centralised organisation of other UN agencies, such as the
Food and Agriculture Organization where the regional offices
have no independent authority. Nevertheless, WHO's structure can
lead to relations between Geneva and the regions ranging from
strained to indifferent, with the regions allowed to operate as
little fiefdoms presided over by an omnipotent director. WHO's
Geneva headquarters must take a good part of the blame for this
poor oversight. WHO/AFRO, because of its close ties with minis-
tries of health, provides an excellent potential entry point for
the roll-out of initiatives from WHO headquarters. But as one
commentator put it: "People at headquarters often seem to forget
that the Regions exist, while Regions can be irritated by head-
quarters acting as if it presumed to know what goes on at re-
gional level better than [regional office] staff."

Moreover, WHO/AFRO has a very limited core budget and focuses on
vertical donor-driven initiatives, almost certainly because this
strategy is seen as the best way to ensure the agency survives.
This approach is completely at odds with the current trend for
the major funders, the development banks and bilateral donors,
to adopt sector-wide approaches and budget support to health
sectors. The regional office therefore needs solid long-term
support from WHO headquarters to allow WHO/AFRO to evolve into
an expert technical agency to assist these large sector-wide
programmes--which is surely a much healthier survival strategy.

The legal documentation on the procedure for the nomination in-
dicates that WHO/AFRO expects a new Director of exceptional
calibre: "The candidate must be visionary, dynamic and results-
oriented. It is very important that the candidate possess the
ability to communicate both orally and in writing, in a clear,
effective and inspiring way to varying target groups, including
the mass media, political leaders, other leaders in the public
health field, health personnel, a wide range of academic and
professional groups within and outside the health sector as well
as WHO staff. He or she should have personal integrity and a
great capacity to withstand pressures from both official and
private sources on issues that could jeopardize the Organiza-
tion's interests."

Will WHO/AFRO nominate such a person? Given the lack of trans-
parency and public debate surrounding the vote, it is impossible
to tell. However, a new nominee gives opportunity for a joint
re-examination of relations between Geneva and Brazzaville to
ensure that WHO/AFRO can exploit the rich resources of Geneva
while accepting its oversight and support. Unless WHO's African
office is transformed from a political club to an effective
health agency, its right to existence is questionable.
* The Lancet




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