The Ebola crisis exposed the failings of WHO.
If the experience of the past year
teaches us anything, it is that the World Health Organization(WHO), which used
to be the north star of disease control and eradication, has become just one
star in a constellation. The Ebola crisis, which has now killed over 8,000
people,1 has exposed the failings of WHO - the world’s ailing health
authority. The agency faces criticisms from different quarters because it did
very little to stop Ebola from raging out of control in West Africa in 2014.
It is worth bearing in mind that
WHO’s mission is to lead the world on health. But the agency has continued to
disappoint the world when it comes to managing sudden disease outbreaks or
epidemics such as HIV and Ebola. As a matter of fact, UNAIDS was set up two
decades ago because of WHO’s inability to tackle the AIDs epidemic. Many
experts argues that history repeated itself last year with the Ebola outbreak
in West Africa, in which WHO’s response was not only slow but also disorganized
and lacking in leadership. Thus the Ebola crisis brought to the limelight the
deeper problems being faced by the agency. Most of these problems have a lot to
do with funding, structure and staff.2
From a functional point of view,
WHO was founded in 1948 to help people
attain and enjoy the highest standard of health possible.3 Hence
WHO’s role as they relate to ensuring the highest possible level of health
covered everything from helping individuals and countries in managing
epidemics, communicable diseases, obesity, and antibiotic resistance, among
others. To be able to achieve this feat, WHO
obviously needs adequate funding and, fortunately, its 194 member
countries pay dues to support the agency. However, because these dues are
calculated according to the member countries’ wealth and population (and the
sums has not risen since the 1990s), they are not adequate to cover the cost of
WHO’s activities and programs each year.
So to generate more funds, WHO solicits contributions from rich countries,
nongovernmental organizations and private interests(such as pharmaceutical
firms), philanthropic organizations (such as the Gates Foundation), and other
multilateral bodies. Nearly 50 percent of WHO’s budget in the 1990s was made up
of donations from these agencies and countries. But today, their donations
constitute as much as 80 percent of WHO’s budget. The implication of this is
evident: WHO is exposed to the ups and downs of the world economy which makes
it hard for it to plan ahead. For instance, voluntary contributions to WHO was hit hard by the financial crisis of the last decade. For the 2010 -2011 fiscal year, WHO’s budget was nearly $5 billion. This went down
to less than $4 billion in the 2014-2015 fiscal years. Compare this value to
U.S.’s Centers for Disease Control budget: in 2014 alone, the agency spent
nearly $7 billion.4
This squeeze on WHO’s finances has
forced it to slash its budget for responding to disease outbreaks by half,
while spending more resources on chronic diseases and primary health care. And,
because chronic diseases and poor healthcare kill more people each year, WHO’s
strategy seemed reasonable. However, in the long run, a rapid response to a
disease outbreak like Ebola by WHO would
have been cheaper than scrambling to catch up.
Because WHO relies so much on
voluntary donations, it faces the challenge of deciding how to spend a big
chunk of its budget as well as how to shift funds fast. This is because most of
the donations it receives are for specific purposes. Rotary International had
given money to the agency to fight polio;5 while the Bill &
Melinda Gates Foundation bankrolls malaria eradication.6 With fair
justification, both are worthy causes. But because WHO’s role in each case has
been to follow, and not to lead, its director-general has very little control
over the budget. Hence, she was highly
limited in how she can address global health challenges.
The above forms of fund
“earmarking” was common in the 1990s. That was the period when donors lost
confidence in the WHO’s decision-making practice. On the positive side, the
agency had made some improvements in its decision-making process: it now basis
its budget on more realistic goals – a part of the reform process the agency
initiated in 2010. In line with this, WHO claims that they will begin to rejects funds from donors if it does not match
their priorities.7 But some
doubt that the agency will have enough courage to say “no” to such donors.
On their own terms
Without putting it in so many
words, another of WHO’s biggest problems has a lot to do with its
administration. This is because the agency’s constitution made its six regional
offices to be largely autonomous. This means that it is a host country’s local
ministers of health who chose the agency’s directors, and not the
director-general. This further means that these directors are beholden to the
local ministers of health, and not to WHO’s director general. So naturally, the
local politicians often treat some of WHO’s offices as tools for patronage. Thus
WHO’s director-general is basically ham-stringed: s/he has very little control
over the agency’s work in host countries (including in case of emergencies),
its budget and human resources.8
WHO’s response to Ebola was
hampered by these institutional weaknesses. Broadly speaking, because Africa’s
health needs are greatest, the continent needs the strongest WHO regional office. Unfortunately, Africa has the weakest: WHO’s
office in Africa is particularly politicized and staffed with often incompetent
people. And any move by the director-general to put competent people at the
agency’s regional offices often generate hostile responses from the politicians
of the affected countries. For instance, when Dr. Margaret Chan(WHO’s director-general) replaced top officials of
the agency in Sierra Leone, Liberia and Guinea in 2014 – the countries hardest
hit by the virus – that change created lots
tension between the local staff and the headquarters.9
It is worth bearing in mind that,
by providing solid evidence for WHO’s policies, its technical side is meant to
arm the agency against unreasonable demands from politicians and donors. WHO,
however, is no longer a world leader in health research as it once was. Broadly
speaking, since WHO’s recommendations these days do not always match the best
available evidence, it is considered an unexceptional organization. As a matter
of fact, the University of Washington used the money donated by the Gates
Foundation to establish the Institute
for Health Metrics and Evaluation in 2007 after WHO’s statistics were found
wanting.10
Fixing a broken system
First, WHO needs to practice what
it preach: its founding mission, which is, to ensure the highest possible level
of health, is not only vague but is also unattainable given its resources. It
will need to change it to something more practical. The agency’s operational
strategy of spending most of its cash on communicable diseases, improving its
own management and promoting universal health coverage need to be enhanced as
well. By dealing with these key issues, the agency allocate its scarce
resources and budget effectively so as appropriately cover items such as
promoting good health through the life-course – one of WHO’s program that cut
across all areas of its work, including the health of women before, during and
after pregnancy; the health of newborns, adolescents and older people, and so
on.11
Second, WHO need to fix its daft
organizational structure. The flow of authority within the agency should be
improved in a way that would make its regional offices, which are where it
spends 20 percent of its budget, accountable to Dr. Margaret Chan(its global
boss), and not to local governments. The implication of this is clear: with
this new arrangement, Dr. Margaret Chan will have enough power to direct WHO’s
operations as well as staff it with seasoned employees, not it current
incompetent political place-men.
Third, the agency must increase its
parlous finances. It is true: the member countries’ dues is inadequate to cover
the organization’s running costs. As a result, it had had to accept voluntary
contributions from charities, drug firms and rich countries. The fact remained
that, in order to implement long-term plans as well as effectively deal
with unpredictable outbreaks of obscure
diseases like Ebola, WHO needs a constant supply of funds. The solution is for
the agency to find more ways to raise money.
With competent employees, this task may
not be too difficult to undertake.
The bottom line
The unhappy truth is that WHO’s failure to lead the response to the Ebola crisis reflects the broader
struggle by the agency in recent years to live up to its mandate to lead the
world on health. From an entirely practical standpoint, WHO’s management should
rethink what the agency is for and how it is financed and run. They should stop
doing the jobs of governments and, instead, focus on the things they cannot
manage alone, such as combating global epidemics, helping poor countries set up
health systems and disseminating the best medical research and policies. Dr
Chan, as the boss of WHO, should stop
allowing politicians from using the agency’s regional offices as a
parking-place for the relations of their allies and friends. The WHO’s boss
should be empowered and emboldened so that she can direct her agency
effectively. This means that she should be given more power to hire and fire
employees when necessary. More
important, though, is this: if the world wants WHO to be capable of dealing
with emergencies like Ebola, it should stop leaving the agency to scrabble for
handouts. Instead, it should pay for it by increasing dues.
References
1Firger J.(2015): Ebola Death Toll Rises in West
Africa While Americans’ Interest Wanes. CBS
News. Retrieved May 19, 2015 from http://www.cbsnews.com/news/ebola-death-toll-rises-in-west-africa-while-us-interest-wanes/
2World Health Organization: Too Big To Ail. (2014,
December 13). The Economist.
Retrieved May 19, 2015 from http://www.economist.com/news/international/21636038-ebola-has-laid-bare-failings-worlds-health-authority-too-big-ail
3World Health Organization(n.d.): About WHO. Retrieved May 19, 2015 from http://www.who.int/about/mission/en/
4World
Health Organization: Too Big To Ail, op. cit., p. 61
6Doughton S., Heim K.(2008): Gates Foundation
Among Donors to Worldwide Malaria Eradication Plan. The Seattle Times. Retrieved June 11, 2015 from http://www.seattletimes.com/business/gates-foundation-among-donors-to-worldwide-malaria-eradication-plan/
7World Health Organization: Too Big To Ail, op.
cit., p. 61
8Ibid
9Ibid
10Ibid
11World Health Organization(2015): Promoting Health Through the Life-Course. Retrieved
June 16, 2015 from http://www.who.int/life-course/en/
