The title of last week's Global Health Lab, held at the London School of Hygiene and Tropical Medicine, was meant to incite interest, not signal aggression. But some interpreted the symposium as an attack before it had even taken place. I was texted, tweeted, and emailed to encourage diplomacy. None of these rearguard protective manoeuvres turned out to be necessary. By Richard Horton.
In our debate about WHO, led by Gill Walt (from the School), Kathryn Tyson (UK Department of Health), Anders Nordström (Sweden's Ambassador for Global Health), and Martin McKee (Director of ECOHOST), the answer to the question was unambiguously "yes". Of course WHO can survive. But survive as what?
A week before our meeting, a former WHO Director handed me an unpublished document he submitted to Margaret Chan's transition team in 2006. Entitled Competent People-Incompetent Organization, the paper summarised a unique piece of qualitative research: the results of structured interviews among 126 staff members at all levels of WHO.
The findings, written by "someone who grew up believing in WHO and who still does", were an informed invitation to the new leadership. Here was an organisation in which "learning is lost and messengers are shot". WHO was "still one key player in global health", but a "profound transformation of the organisation is needed". There was no "technical vision". WHO had "lost its sense of unity". It was "under-led". "The goals of headquarters are not aligned with those of the Regional Offices". "The organisation has become a wide array of individual projects without focus", a place where there is a "climate of internal competition among programmes."
There was an "apparent dissociation between what top management says and what they do...synergies are lost, duplication is rampant, and turf wars are continuous." "Image has become more important than institutional effectiveness". "There is a general breakdown of accountability". "WHO is relying almost exclusively on management by 'anatomy' and working insufficiently with the 'physiology' of the organisation". The message of the report was that WHO had handed its strategic responsibilities over to others-to the Global Fund, the World Bank, GAVI, and the Bill & Melinda Gates Foundation. To reclaim its role in global health, "WHO must decide first what it wishes to achieve". In the words of its author, this report, "done to help management", "was quickly buried".
That was in 2006. What about today? Gill Walt emphasised that WHO's role was more critical now than ever before. But to survive WHO needed the support of a larger constituency. Countries such as China, India, and Brazil, even Russia, had to take their multilateral responsibilities more seriously. Kathryn Tyson expressed herself clearly: "I'm a fan of Margaret Chan", she said. But WHO needed "tough love". "It does have to change its operating model", she argued. Her personal view was that "it isn't all working swimmingly" at WHO. Take non-communicable diseases: one year after the Political Declaration, what has happened? Too little.
There is no appetite for decisive priority setting. Anders Nordström urged WHO to become more like UNAIDS. The problems facing WHO today have nothing to do with money. The key challenge for WHO is focusing on a few critical functions and delivering those to the highest possible quality. Gaudenz Silberschmidt, an adviser to WHO's Director-General, invited critics to remember that it was "member states [of WHO who] tend to create problems and blame the secretariat".
What might one conclude from this discussion? First, that after an interval of uncertainty, WHO does now have a technical vision, it is clear about what it wants to achieve. Universal health coverage is the agency's unifying mission. Second, to deliver this mission will require decisive leadership, prioritising of functions, and unprecedented attention to quality and performance. And third, WHO needs to realise the potential of its staff. The agency has many talented and highly motivated individuals-people with the knowledge, ideas, skills, and ambition to transform the agency. But those individuals are often lost in a bureaucracy that neither recognises nor rewards initiative and success.
They crave inspirational leadership that will unleash a new era, not of anatomical redescription but of physiological fitness. This is the opportunity that WHO holds in its hands.
The article was published in The Lancet, Volume 380, Issue 9852, Page 1457, 27 October 2012 doi:10.1016/S0140-6736(12)61810-8