World Health Organization(WHO): Memories of the Ebola crisis, one year later

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/