[Ip-health] Financial Times: WHO ponders the who question, not what and why

[Thiru Balasubramaniam]

http://www.ft.com/cms/s/7d87d88a-61f4-11db-af3e-0000779e2340.html


    WHO ponders the who question, not what and why

By Andrew Jack

Published: October 22 2006 19:06 | Last updated: October 22 2006 19:06

/Midnight, 20 October 2008, Geneva: As reports show sharply rising
numbers of patients dying from influenza in south-east Asia, the
director-general of the World Health Organisation convenes a meeting to
raise the pandemic alert to =E2=80=9Cphase 5=E2=80=9D. Governments and comp=
anies brace
themselves for a heavy economic and human cost as hospitals fill
worldwide, travel restrictions are imposed, schools shut and businesses
struggle. /


The scenario may be alarming but it is all too plausible =E2=80=93 and the =
role
the WHO would play in it is key. Driven in part by the awareness the
organisation helped create that a pandemic could spread faster and with
more severe consequences than ever before, the power of the WHO has
grown from that of a technical United Nations agency, little heeded
beyond a narrow circle of health experts, to an institution that wields
considerable power.

Lee Jong-wook, the most recent director-general, helped transform the
role, giving him direct access to world leaders. The soft-spoken South
Korean=E2=80=99s unexpected death in May has sparked a succession battle th=
at
has attracted an unprecedented 13 candidates and a campaign of unusual
intensity and aggression with important international implications.

The intrigue surrounding the choice of a new director has illustrated
starkly the difficulties of the very type of international co-operation
that would need to take place in combating global pandemics.

It has also triggered a round of reflection over the function of the
director-general and the future role of the WHO in a world of
fast-changing health challenges and a multiplicity of new institutions
created to respond.

Derek Yach, head of global health at the Rockefeller Foundation and a
former WHO official, is one of many who argue that the agency should be
more tightly focused on setting standards and reduce its efforts to
implement programmes on the ground. =E2=80=9CIt=E2=80=99s an incredibly exc=
iting time
for global health,=E2=80=9D he says. =E2=80=9CWe now have two big innovativ=
e
partnerships through the Gates and Clinton foundations and a growing
role for the corporate sector and non-profit [organisations]. The WHO
should be less operational, but provide strong clear advocacy on what
should be the priorities.=E2=80=9D

However, as the competing electoral bandwagons have passed through the
capitals of the 34 voting countries on the WHO=E2=80=99s executive board in=
 the
past few weeks, the attention has been elsewhere. =E2=80=9CThe selection of=
 a
new director-general is a political process rather than one based on
competencies,=E2=80=9D says Jerry Norris from the Hudson Institute, a think=
-tank.

There have been allegations that, in order to secure support for one or
other candidate, promises have been made by some countries about
building hospitals and providing other development assistance and, for
example, assurances given that an African would be named as deputy to
several of those fighting for the job.

Eyebrows have been raised by the recent publication of a glossy book on
the WHO=E2=80=99s fight against severe acute respiratory syndrome (Sars) in=
 2003
co-ordinated by Shigeru Omi of Japan, the agency=E2=80=99s regional head fo=
r the
western Pacific, who declared himself a candidate even before Lee died.

Newspapers have criticised Margaret Chan, China=E2=80=99s candidate, for he=
r
role as director of health in Hong Kong during the Sars crisis =E2=80=93
prompting Jeffrey Koplan, former director of the US Centers for Disease
Control, to denounce unprecedented and unjustified mud-slinging.

Pressure groups have pointed out that Julio Frenk, Mexico=E2=80=99s candida=
te,
cut a deal with tobacco companies when he was health minister to help
fund a health insurance scheme, undermining efforts to tackle smoking.

Even the Lancet, the prestigious UK medical journal, has been accused of
bias as a result of its whole-hearted endorsement of Mr Frenk not only
in editorials but by publishing a series of academic articles on health
reforms he undertook in Mexico.

Under the arcane WHO selection rules, the executive board will on
November 6 select by secret ballot just five candidates for detailed
scrutiny. Tactical voting could exclude strong candidates from the
short-list.

Geopolitics looms over the nominees from Burma and Lebanon and whether
the South Korean Ban Ki-moon=E2=80=99s recent appointment as UN
secretary-general means Asia=E2=80=99s current informal quota for top UN jo=
bs is
surpassed. There will be horse-trading, with Frenchmen standing both for
the WHO and the multilateral $10bn (=C2=A35.4bn, =E2=82=AC8bn) Global Fund =
to Fight
Aids, Tuberculosis and Malaria, which selects a new executive director
at the end of this month.

Candidates will need to balance competing interests from public health
experts and governments, with the power under international health
regulations adopted this year to override national sovereignty to urge
travel bans or seek access to sensitive data on infectious diseases.

They will also have to handle tense relationships with industry, amid
conflicts over affordable pharmaceuticals to improve treatment and
demands for ever tougher regulations on tobacco, diet and alcohol to
boost disease prevention.

But there are more fundamental issues concerning the future role of the
WHO itself, which reach well beyond=E2=80=89the=E2=80=89remit=E2=80=89of=E2=
=80=89the=E2=80=89director-general
without considerable backing from member states for broader reform.

The first is to tackle the agency=E2=80=99s unwieldy structure. Just 28 per=
 cent
of the WHO=E2=80=99s budget goes to its Geneva headquarters. The rest funds=
 pet
programmes of donor governments via eight regional offices. These often
undermine the director-general=E2=80=99s authority by making their own seni=
or
staff appointments and launching divergent policies.

=E2=80=9CThe WHO should merge its extra-budgetary accounts into the overall
governance structure of the organisation and put its use to the votes of
the full community of member states,=E2=80=9D says Mr Norris.

The second is to focus on core skills. With funding of just $3.3bn for
the two years 2006-07 =E2=80=93 often compared with the budget of a large U=
S
hospital =E2=80=93 the WHO=E2=80=99s finances, as well as its staffing and =
political
constraints, raise questions over its role in implementing health policy.

=E2=80=9CWe should do what we do best: get data, look at it and build an
international consensus on what to do, setting norms and standards,=E2=80=
=9D
says one senior WHO official. He questions the value of its training,
treatment and neglected-disease research programmes and even its =E2=80=9C3=
 by
5=E2=80=9D programme designed to raise the number of Aids patients on treat=
ment
to 3m by 2005 =E2=80=93 a target that fell well short.

A few of the WHO=E2=80=99s operational activities have strong support. The
agency was instrumental in eradicating smallpox and is close to doing
the same with polio. The network it created is being used to monitor and
fight other infectious diseases, from ebola to pandemic flu.

It has also played an important role in defining lists of essential
medicines and =E2=80=9Cpre-qualifying=E2=80=9D low cost but high quality dr=
ug
manufacture for the developing world.

=E2=80=9CFor setting standards, guidelines, advocacy for new health problem=
s and
epidemic surveillance, the WHO has a clear comparative advantage,=E2=80=9D =
says
Christopher Murray from Harvard University, a former WHO official. =E2=80=
=9CFor
country policy translation, there are many other organisations which may
be better suited.=E2=80=9D

The final task is for the WHO to offer more objective and co-ordinated
advice. Vicious in-fighting in recent years due to political and
academic disagreements has led to contradictory and shifting technical
recommendations on malaria, for instance, while deaths from the parasite
have continued to rise.

That is one area where the new director-general could do much more.
Otherwise, as the attention paid elsewhere to global health and the
importance of that in security and welfare grows, the WHO risks becoming
perversely less relevant.