Why the world's premier public health organization must change or die.
Among the many victims of Haiti's deadly cholera outbreak may be an unexpected casualty: the World Health Organization. As the epidemic broke out on the island, spreading quickly from rural areas to the capital, Port-au-Prince, the World Health Organization (WHO) and its regional division, the Pan American Health Organization (PAHO), sent expert teams, mapping the epidemic and advising the government on how to best defeat the outbreak. Relief workers hustled to contain the disease in rural areas before it spread to the capital, where living spaces are more compact, sanitation systems are overwhelmed with raw sewage, and more than a million earthquake survivors are still huddled in tent camps. But reach Port-au-Prince it did, and today at least 1,800 Haitians have fallen victim. Cholera, like most any outbreak, demands a nimble, fast-moving, and adaptive response. Unfortunately, that's just about everything the WHO is not. The 11 months since Haiti's earthquake, coupled with the relentless rise of pandemics in impoverished countries in recent years, have made painfully clear that the agency can no longer adequately perform the job of being the world's chief defender against disease.
The WHO -- for 62 years the world's go-to agency on all public health matters -- is today outmoded, underfunded, and overly politicized. In a world of rapid technological change, travel, and trade, the WHO moves with a bureaucracy's speed. Its advice to health officials is too often muddied by the need for consensus. Regional leadership posts are pursued as political prizes. Underfunded and over strapped, the organization has come under attack for being too easily swayed by big pharma. In a world where foundations, NGOs, and the private sector are transforming global health, the WHO has simply not adapted. This isn't just about the WHO losing its edge. Taken together, these myriad dysfunctions are rendering the WHO closer and closer to irrelevancy in the world of global health.
How did it get so bad? When the WHO was created as a U.N. technical agency shortly after World War II, governments' health ministries were the predominant global health authorities. The new U.N. body was meant to serve as a reservoir of expertise and knowledge at the service of countries needing a hand. The WHO essentially became a health consultancy to developing countries, supplying advice, analyses, and best practices, though stopping short of directly implementing health programs. That was an invaluable service at the time. But today, its mission and operations remain largely unchanged.
The WHO's stagnation is juxtaposed with a world of public health that is changing more and more quickly than ever. Legions of new drugs, vaccines, and diagnostics have fortified the medical profession. Governments are no longer the sole stewards of public health; new players are entering the field, both public and private. The eight-year-old Global Fund to Fight AIDS, Tuberculosis and Malaria, for example, is now the go-to coordinator for international funding to combat these diseases. The Bill and Melinda Gates Foundation has revolutionized global health, investing $13 billion in health grants in everything from research into malaria vaccines to treatment of tuberculosis to HIV/AIDS programs on the ground. Even the U.S. government has gotten in on the world of change, forcefully responding to HIV/AIDS in Africa with a $25 billion program that has put some 3.2 million people in treatment in just half a decade. What differentiates these pioneering efforts from the WHO is that they are nimble, well-funded, and less encumbered by red tape. It's hard to see how the WHO can compete.
In fact, in this new atmosphere, where organizations are taking health into their own hands, it's unclear exactly what role the WHO should even play anymore. Offering up its expertise is not as straight forward as it once was; the biggest players in global health aren't asking for assistance as governments once did. Nor can the WHO set its own advising priorities, since its funding comes from donors, primarily national governments. In recent years, the agency's $2.3 billion annual budget has been increasingly divvied up before it ever reaches the WHO, earmarked by donors for their favored causes, be they specific diseases or treatments to fight them. With its limited resources, the WHO is caught in a trap, appealing to donors' interests in fighting specific diseases such as polio, HIV/AIDS, or malaria, while giving broader health priorities -- notably, the development of basic health-care infrastructure -- short shrift. The WHO is no longer setting the agenda of global health; it's struggling to keep up.
The problems extend to personnel. The WHO's greatest resource is its ability to leverage its objective expertise -- to bring in knowledge, draw conclusions, and disseminate them quickly in a way that is unthreatening and apolitical no matter the location. Unfortunately, that very expertise is starting to fade away. Today the organization is critically short on experts to cover cancer and diabetes, two of the most common diseases in an aging world. The WHO's network of HIV/AIDS advisors is at risk of being disbanded altogether if more funding cannot be found. Even with more funding, there would be roadblocks. The U.N. personnel system pushes the organization to uphold a linguistic and geographic balance, which can obstruct and delay the hiring of key experts. Those not hired by the WHO will be quickly snatched up by the new global health players.
The WHO's governance system is also archaic, stemming from an era in which transportation and communications between continents were slow. The WHO is not a singular entity but operates more akin to a federation of six regional offices, each headed by a director who is elected by the countries in such groupings as Africa or Southeast Asia. These six directors wield authority within their zones that can conflict and compete with that of the Geneva-based director-general, complicating messaging and policy coordination. For example, the Pan American Health Organization considers itself to be the dean among the six regions, with a lineage going back 100 years and an independent financial base; PAHO chafes at the thought of being lumped in with WHO and pushes its moniker over the WHO's when operating in the Americas. Most recently, PAHO announced a global health technology initiative with the U.N. Development Program, a broad mission that arguably ought to have been originated from Geneva.
With competition between branches and body, the assignments of WHO country representatives often involve extensive negotiations between the power in Geneva and the power in the region. Key appointments have many a time been blocked not by qualifications of the individuals but for political reasons. Recognizing the need to knit better relations among the regions and Geneva, WHO Director General Margaret Chan and her senior team spend significant amounts of time jetting to consult with the six regional directorates. Progress is being made, but it is precious time that could be saved in a streamlined organization.
Perhaps what's needed is a move away from the region-centric approach toward a strategy that would allow the WHO to devote more resources to country-level work. As it stands today, the WHO staff are typically housed in a country's ministry of health. The WHO could empower its country-based staff to deliver timely, accurate, and actionable advice where it is needed most -- not just at the national policymaking level, but to local health workers in communities. The WHO could become the go-between for donors, facilitating and sharing information and resources between multiple sources in such countries as Ethiopia and Tanzania. In the field, the WHO could offer its product -- expertise -- to the full range of NGOs, bilateral programs, and even private-sector entities. Rather than just advising ministries of health about how to defeat cholera in Haiti or ebola in Africa, for example, a more robust WHO country team could give that advice to the NGOs, both local and international, that are on the ground fighting outbreaks.
Another advantage of this local focus would be the opportunity to forge stronger relationships with the private organizations, such as Doctors without Borders and Partners in Health, that actually implement health programs. Rather than being pushed out by new players in public health, the WHO could bring them under its technical wing now. In fact, the WHO might consider inviting representatives of independent health groups to assume a set of rotating seats on its executive board. It's an idea that has been successfully tried before: The policy committee for UNAIDS, the U.N. agency that advocates for action on the AIDS epidemic, includes five NGO members, including a representative from communities ravaged by the disease. Likewise, the board of the Global Fund to Fight AIDS, Tuberculosis, and Malaria includes voting members from the private sector, foundations, NGOs, and affected communities. Both organizations enjoy greater legitimacy as a result.
For now, the WHO will continue to be tested, both on acute crises and on long-term problems. Today, it is responding to the cholera outbreak in Haiti; next year it might be another crisis. In many of the world's most difficult places, the WHO does still retain its prominence as the chief reference body on health matters. But it is no time for complacency. The recent barrage of health crises has revealed the WHO's value, yet its weaknesses as well. The agency cannot remain underfunded and understaffed, struggling with a system whose origin dates back to the dawn of the antibiotic era. For the WHO to be revived as the world's foremost health authority, it now needs intensive therapy itself.
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