WHO's management: struggling to transform a “fossilised bureaucracy”
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7373.1170 (Published 16 November 2002) Cite this as: BMJ 2002;325:1170All rapid responses
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It is indeed intersting to note that the epitome of excellence in health care planning is itself in a state of chaos, no wonder are the results of their planning and execution reflecting the same.
Say for example the elimination of leprosy by 2000 by epidemiological manipulation such as the "Single lesion-Single dose ROM treatment" and reduction of the treatment period from two years to one year for multibacillary Leprosy cases were just aimed at reducing the prevalence of leprosy and eventually eliminating. Despite the declining incidence and prevalence rates...has leprosy been eliminated even till date well past the deadline?
This campain has only hampered the funding of Leprosy related projects more than anything else and ineffect making it more difficult for a person to have early diagnosis and treatment before deformities set in.It is not the killing of the Bacilli alone thats important(from an epidemiological point of view it may be), but preventing or limiting deformity and disability is more important. Its not the disease but the consequences of deformities that contribute to social stigma.
The improvement of "HERD" immunity by an overzealous "Pulse Polio" in india has only resulted in over 800 new cases poilo this year that a more than 3 fold increase as compared to the last year.
The "DOTS" for tuberculosis is yet another example for an overenthusiastic need for "newer modality" to impress the press and media. How many farmers in India will leave their fields early in the morning on an empty stomach to get their "blessings" for the day from a DOTS centre ?
These are just a few issues of public health concern that cannot necessary be handled by expert commitees and consultants or elaborate discussion in luxurious hotels in Geneva. The answers probably lie in the mind of the poor Indian farmer with tuberculosis or may be even the grass root level health worker.
Debating over community participation for health issues are easier talked about than practiced...at least thats the immpression that one gets from seeing "WHO" function.
Competing interests:
None declared
Competing interests: No competing interests
ELECTING A DIRECTOR-GENERAL FOR WHO
Dear Dr Yamey,
I am enclosing for you a copy of my note on the state of WHO. I can add to
that by pointing out three specific examples concerning procedures for
appointments at SEARO/WHO. When WHO faced very sharp criticisms on its
major
international initiatives on tuberculosis in India, it attempted to bypass
well argued cases against it by literally blacklisting them and, instead
cultivated the Directors General of Health Services and the Indian Council
of Medical Research, both whom did not have any academic standing in
public
health issues in tuberculosis in the country, to support their
scientifically suspect programme. They were later rewarded in the form of
positions in SEARO. More recently, a secretary of health who, as a
bureaucrat, had been transferred from the department of revenue a few
years
back, was a position for which he has little competence in public health,
was taken into SEARO soon after he retired.
Debabar Banerji
Emeritus Professor JNU,
B-43, Panchsheel Enclave,
New Delhi 110017
Ph 011 6490851
November 7 2002
ELECTING A DIRECTOR-GENERAL FOR WHO
The director-general of the World Health Organization, Dr Gro Harlem
Bruntdland has announced that she will
not seek another term as the DG when the present one expires in July 2003.
This is a significant event. Dr Bruntdland had been a Prime Minister of
Norway. She was later the chairperson of the famous Commission on Global
Environment and Development. Dr Bruntdland's selection had aroused
considerable hopes among concerned public health workers in the poor
countries of the world that she will rectify the sharp deviations from the
visions and goals that are enshrined in the Constitution of the WHO. She
started to perform the task in great earnest. During the six months of her
nomination in January 1998 and the day she took office on July 21, she had
set up a `transition team' led by Ambassador Jonas Store of Norway to
review
the organisation. The Voluntary Health Association of India was one the
organisations whose advice was sought by the transitional team. The VHAI
had
brought together a team of public health scholars from the country, which
prepared a note to express concerns of a poor country like India to the
team about the continuing deviation of WHO from the visions and goals
enshrined in its Constitutions and it recommended the ways of rectifying
them. Mr Store had expressed deep appreciation for VHAI's contributions.
However, contrary to the VHAI's advocacy of WHO returning to the pro-
people
approach in the spirit of the Ala Ata Declaration of Health For All by
2000,
the transitional team opted for what has been aptly described by
Professor
N H Antia of the Foundation for Research on Community Health, Mumbai, as a
`techno-managerial' approach. There was interdependence of function and
structure; the functions identified had pronounced technocentric overtones
in tune with the suggested organsational structure. This has not worked.
This has led to even further deviations from the prime commitments of WHO.
Dr Bruntdland is leaving WHO at a time when that organisation is
facing a
serious crisis., both structurally and functionally. She had commissioned
a
team of consultants, led by Leonard
Leser and Richard Matzopoulos, from the reputed French firm of
consultants,
Health Care Management Initiative, to review the management practices
through which the organisation planned and monitored its performance (1).
The report was not positive. The consultants titled their case study , "
The
Worst of Both the Worlds": The Management Reform of the World Health
Organization, as an allusion to their overwhelming impression that the
senior managers and policymakers of the global "public sector"
institutions
seemed to be adopting what they believed to be the current business
management ideology -- namely that efficiency and productivity are
obtained
through harsh, rigid control and that short-term results to satisfy
external
stakeholders are justifiable at any cost. This approach results in a
cruelty and inflexibility in the institution, extreme resistance from the
staff, and a range of actions and interventions that are clearly not
sustainable. This, according the Leser and Matzopoulos, is certainly not
the
current in most of the private sector: this is the worst of the private
sector management . At the same time WHO exhibits the worst of the "public
sector" in the archaic form of governance, political context of decision
making, and lack of transparency and accountability that are often part of
the U.N. system and the global "public"service. The consultants conclude:
"
We are left reflecting on a way forward and perhaps considering two simple
questions: what are the core business of WHO and who has the courage to
grapple with root causes of the problems?"(1).
Not surprisingly, considering the pronounced structural anomalies,
such
technocentric `catagorical' or `vertical' global programmes as those of
immunization, AIDS, Tuberculosis, Poliomyelitis Eradication and Leprosy
Elimination, that were imposed on the people of the poor countries at the
cost of billions of US dollars, failed to attain even the limited
objectives
that were set for them. In the bargain, the rudimentary infrastructure of
the health services in the poor countries have further suffered from
neglect
because of their preoccupation with trying to implement high priority
global
vertical programmes. Apparently, the flaws of the `techno-managerial'
programmes that are pushed by WHO and other international agencies, such
as
the World Bank, have become so obvious that the government of a country
like
India, which had hitherto been faithfully following the line laid down in
the global vertical programmes, has been impelled to make a forthright
`confession' in the final version of its National Health Policy of 2002
about the degree to which the health services have suffered because of
these
programmes. It says:
.
"Over the last decade or so, the Government has relied upon a `vertical'
implementational structure for its disease control programmes. Through
this,
the system has been able to make a substantial dent in reducing the burden
of diseases. However, such an organisational structure, which requires an
independent manpower for each disease programme, is extremely expensive
and
difficult to sustain. Over a long range, `vertical' structures may only be
affordable which offer a reasonable possibility of elimination or
eradication in a foreseeable time frame...
"It is a widespread perception that that over the last decade and a
half,
the rural health staff has become a vertical structure elusively for the
implementation of family welfare activities. As a result where there is
no
separate vertical structure, there is no service delivery system at all.
The
[ National Health] Policy will address this distortion in the public
health
system.".
During the first four decades, WHO (and UNICEF) had earned
considerable
trust and goodwill from concerned public health workers from poor
countries.
This heritage has been considerably eroded during the past two decades or
so. Despite all her efforts, Dr Bruntdland has not been able to live upto
the trust and goodwill of the poor of the world. It is recognised that
WHO
is a political organisation which is vulnerable to various degrees of
pressure from international and national power structures from time to
time.
This is all the more a reason why those who want work for the unserved and
the underserved ought to make health - in the WHO sense of the term - a
political and social issue, and not merely a process of imposing
prefabricated, scientifically suspect `techno-managerial' package on
hapless peoples of the world through the agency of an organisation the has
`worst of both the worlds'..
Any person who aspires to be the new DG should have proven capability
to
face the formidable task of checking the remorseless decline in the
performance of the organisation. Even more formidable will be the task of
finding an alternative perspective of performance which takes the
organisation towards achieving the lofty goals that are enshrined in the
Constitution of the WHO. The Alma Ata Declaration of 1976 shows the beacon
light to move in that direction. It will require a global vision and
considerable political, social, managerial and public health competence to
meet the job requirement of the DG.
Reference
1.Leser,L and Matzopolos,R. "Worst of Both Worlds": Management
Reforms of
the World Health Organisation. International Journal of Health Services,
vol.31, pp.415-429, 2001.
Competing interests:
None declared
Competing interests: No competing interests