Published online 24 May 2011 | Nature 473, 430-431 (2011) | doi:10.1038/473430a

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Revamp for WHO

Critics call for restructuring of world health body, together with greater focus on fewer issues.

The World Health Assembly, meeting last week, described the WHO as archaic and overextended.Reuters/D. Balibouse

The top decision-making body at the World Health Organization (WHO) — the World Health Assembly — last week backed reforms that might bring the biggest changes to the agency in its 63-year history.

Concerns about the WHO's performance stretch back decades, but the current harsh financial climate and an altered global-health landscape have brought the need for reform to a head. The WHO's member states now want the over­extended agency to focus its activities on a far smaller number of core areas. But some experts think the reforms are unlikely to go far enough, and are calling for an overhaul of the agency's structure and governance.

Just a decade ago, the WHO was the only major global-health player, but it is now struggling to assert its raison d'être against a plethora of powerful and often better-funded new players, among them the Global Fund to Fight AIDS, Tuberculosis and Malaria, the GAVI Alliance and the Bill & Melinda Gates Foundation. Funding for global health has grown enormously over the past decade, from US$5.7 billion in 1990 to $26.9 billion last year, but this money has largely bypassed the WHO because of donors' lack of confidence in the agency (see 'Lost in the crowd'). Indeed, the WHO ran a $300-million deficit in 2010.

The agency suffered another blow last week when, in Geneva, Switzerland, the World Health Assembly's giant annual gathering of health ministers from the WHO's 193 member states fixed its budget for the next two years at $3.96 billion, almost $1 billion less than the $4.8 billion requested by the WHO. One im­mediate impact is to force the agency to shave some 300 of the 2,400 jobs at its Geneva headquarters.

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Margaret Chan, the agency's director-general, last week attributed the WHO's financial woes to reductions in member states' contributions as a result of the global economic crisis. She also blamed the weakness of the dollar — the currency in which the WHO receives its contributions — against the Swiss franc, which it uses to pay staff and other costs at its headquarters. But member states see the crisis as an opportunity to modernize the agency, whose basic structures and procedures date from its creation in a very different world in 1948.

The reform proposal approved by the assembly last week lacks specifics, and is most significant as a green light for what will be complex negotiations. But its appraisal of the WHO is not glowing — it depicts the agency as archaic, overextended and lacking adequate assessment of its programmes and staff.

"The WHO has been trying to do too much; we need greater focus," concedes Andrew Cassels, director of Chan's office. He adds that the WHO under Chan welcomes the proposed reforms, which include calls for management change and for the agency to focus on data collection, developing standards for diseases, treatments and technologies, overseeing reponses to pandemics and longer-term health threats, and strengthening health systems. Cassels also embraces the proposal that the WHO flex its convening power — its capacity to bring together researchers, fieldworkers, public-health experts and politicians — to better coordinate the efforts of all players in global health.

Barry Bloom from the Harvard School of Public Health in Boston, Massachusetts, who authored a recent call for WHO reform in Nature (B. R. Bloom Nature 473, 143–145; 2011), says that overall he is "very pleased" with the thrust of the proposals. Bloom applauds the priority given to the WHO's convening role, and a plan to open the agency up to independent external review for the first time. He and others also support a proposal to establish a forum that would give non-governmental organizations, the drug industry and other stakeholders a say in shaping the WHO's policies. This is critical, say experts, as such stakeholders have key roles in global health. Member states fear a loss of their influence, however, and many observers are concerned at the risk of undue industry sway.

But some experts say the reform plans fail to explicitly address fundamental structural weaknesses in the WHO. One is its inability to set its own priorities. The agency has full control of only the 25% of its budget that comes from membership fees paid by member states. A whopping 75% comes from voluntary contributions — funds that donor countries often earmark for their own pet projects. This skews the WHO's priorities, says Lawrence Gostin, head of the WHO Collaborating Center on Public Health Law and Human Rights at Georgetown University in Washington DC. "Around 60% of the WHO's budget goes on infectious diseases, and just 3.9% on non-communicable diseases and 2.4% on injuries, yet these are a huge global health burden," he notes.

Cassels says that building greater trust in the WHO should result in fewer earmarks. But experts are also concerned that the proposals ignore an elephant in the room: the WHO's byzantine decentralized structure. Its six regional offices are autonomous to an extent seen in no other UN agency, electing their own heads, controlling large amounts of the WHO's funds and largely fixing their own policies. "At present, there are seven WHOs, not one," says Bloom.

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"It's a birth defect" rooted in the WHO's creation from pre-existing regional bodies, says Kelley Lee, an expert on the WHO at the London School of Hygiene and Tropical Medicine. "It adds to the lack of co­hesion and expansive agenda that spreads the WHO's limited resources ever more thinly." Cassels argues, however, that much improvement is possible within the existing decentralized organization. He says that Chan intends to take charge of an effort to "require much stronger monitoring of performance across all of the major offices".

Yet if deeper structural issues are not tackled, reforms will bring only "marginal" change, predicts Derek Yach, senior vice-president of global health and agriculture policy at PepsiCo, headquartered in New York State, who was a cabinet secretary to former WHO director-general Gro Harlem Brundtland. And Lee thinks that fixing the WHO won't be enough to bring coherence to global health funding. "I believe that the biggest problem is that there are now so many institutional players in global health, and that there is a need to reform the whole chaotic landscape, not just one organization. It's like fixing a flat tyre when the whole car needs to be tuned up." 

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  • #62211

    I think both the Pope and the WHA purport to answer he question whether condom use can be effective in preventing HIV infection. They each claim science backs their respective position.

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