PHA-Exchange> response to Navarro piece on selection of new WHO Director-General"

[claudio at hcmc.netnam.vn]

--- In spiritof1848 at yahoogroups.com, "doglovercccp" <doglovercccp at ...>
wrote:

response from Philip Musgrove re: WHR 2000 "manipulation"

Let me correct something in, and add something to, Navarro's account
of my role in this brouhaha.  First, I did not resign in protest
from WHO.  Perhaps I should have, but I was never formally employed
by WHO, being rather on a two-year secondment from the World Bank.
That secondment was due to end in any case in September 2001, just
over a year after the World Health Report (WHR) was published.  To
leave WHO earlier would have meant asking to return early to the
Bank, and I have the strong impression that, for whatever reason,
the Bank was not eager to take me back ahead of time.  So I stayed
in Geneva, in something of an internal exile within WHO, and worked
on some analyses of health financing, including a contributino to
the work of the Commission on Macroeconomics and Halth.  It is of
course gratifying to have one's integrity praised, esepcially in
view of the unpleasant aspersions that Murray, Frenk and Brundtland
cast my way when they responded to my 2003 article in the Lancet,
but my criticism of the numbers in the 2000 World Health Report
(WHR) didn't cost me my job nor, so far as I can tell, hurt my
professional standing.

Second, some of what is in my Lancet article I didn't discover until
very late in the preparation of the WHR, or even after it appeared.
The one clear instance of manipulation--substituting imputed values
for the reported estimates of "responsiveness" in the cases of
Chile, Mexico and Sri Lanka--was known well before publication, and
I tried to get Julio and Chris Murray to reverse that decision.
Neither listened to me; my written exchange on the subject with
Murray is included in my Lancet article.  That substitution was
definitely manipulation, and unethical; Navarro is right about
that.  He is wrong, however, to think that the motive in any of
those three cases was to push a neoliberal agenda.  In the case of
Sri Lanka, it happened that the team judging that country's health
system responsiveness gave it low marks, and one of the two people
working under Murray on the whole responsiveness exercise happened
to be from Sri Lanka herself.  I am told that she feared being
blamed for the low grade, and criticized personally back home--so
the numbers were changed more as a protective favor to her than for
any political reason.  The excuse that the reported numbers were
inaccurate because of the civil war in Sri Lanka was concocted to
cover this change, notwithstanding that there were civil wsrs in a
number of other countries at the same time that had no effect on the
data.

I cannot prove that my explanation is correct in the cases of Chile
and Mexico, but I offer what I believe to be the actual reasons for
those changes, both of which were local and political but in no way
related to a neoliberal ideology.  The President of the WHO
Executive Board at that time was Jorge Jimenez, ex-Minister of
Health of Chile, and he had some quarrels with Dr. Brundtland, as I
know from personal conversations since Dr. Jimemez is a good friend
of mine.  I am sure that Chile's responsiveness rating was raised in
a naïve attempt to buy Jimemez's good-will.  Incidentally, the team
that estimated those data for Chile was furious at seeing their work
discarded, as I know from another personal converstion with Marcos
Vergara, who headed that team and who is also a friend of mine.  In
the Mexican case I don't have any inside information, but Julio
Frenk was already negotiating to become Mexico's Secretary of
Health, and it is at least suspicious that he agreed to having the
Report give his own country a lower grade on responsiveness than the
team at home thought it deserved.  The only plausible reason I can
find for this is that he wanted a low starting point for his own
administration, so that he would have more room to show improvement.

Third, it is unfair to call the rest of what is wrong with the WHR
numbers for "attainment" and "performance" by the name
of "manipulation".  The problems, as my Lancet piece tried to make
clear, are two-fold: the numbers on responsiveness could not be
compared across countries, and the majority of all kinds of numbers
were not observed but imputed from regressions.  The numbers and the
ranking that resulted from them are simply not to be taken
seriously, and I greatly wish never to hear of any of them again.
(It is particularly discouraging to find those ranking nubmers
occasionally turning up in World Bank reports.  Is the Bank so
desperate for numbers that it doesn't ask whether they mean
anything?)  It is possible there were other instances of real
maniuplation that I never learned about--I have been told that the
first run of the rankings put some tiny country (Andorra? Monaco?
Luxembourg?) at the top, and so some hurried adjustments were made
to give France the #1 spot, but I have no written sources for that
story.  And it is possible that Frenk, Murray or others started with
more of an ideologicla position than appeared to me in my dealings
with them, but I know of no evidence of such views affecting the
outcome of the "performance" exercise.

Navarro thinks the text of the WHR 2000 represents a triumph of
neoliberalism in health policy.  I disagree, while recognizing that
my views are considerably more pro-market than his (but quite anti-
market compared to the Washington Consensus).  At this distance, I
still think there is a lot of good thinking in that text.  I only
wish I could have had some control over the annexes instead of being
responsible only for the text--a job into which I stepped in a
moment of crisis in November 1999 at WHO's request.  The Report
would have been much better received, WHO's reputation for
intellectual honesty would not have suffered, and there would be one
less issue involved in the race for Director General, if that had
been the case.

--Philip Musgrove




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