AFRO-NETS> WHO bureaucratic?

[Claudio Schuftan <aviva@netnam.vn>]

WHO bureaucratic?
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WHO's management: struggling to transform a "fossilised bureaucracy" 

Gavin Yamey, deputy physician editor, Best Treatments. 
BMJ Unified, London WC1H 9JR 
mailto:gyamey@bmj.com 

BMJ 2002;325:1170-1173 (16 November)


Gro Brundtland inherited the leadership of an organisation with major 
structural problems. WHO was top heavy, male dominated, and rife with 
cronyism, and staff morale was falling. Has the new management tack-
led these problems? 

On taking office as director general of the World Health Organization 
on 21 July 1998, Gro Brundtland was faced with two enormous tasks to 
restore the organisation's place on the international stage and to 
internally reform a failing United Nations agency. There is little 
doubt that she achieved the former. In this article I consider 
whether her managerial reforms have been successful. 

Summary points 

In the 1990s, WHO was poorly managed, over- centralised, and rife 
with political appointments 

Brundtland established mechanisms to tackle cronyism and raised 
awareness of the need for greater staff diversity 

But WHO is even more centralised now and remains top heavy and domi-
nated by men and representatives of developed countries 

Some WHO staff say that senior management stifles open debate and in-
ternal dissent 

Brundtland has been more successful at raising WHO's profile interna-
tionally than at transforming the organisation internally 


A failing bureaucracy 

Brundtland inherited the leadership of a dysfunctional organisation. 
In a 1995 editorial, Richard Smith, BMJ editor, argued that WHO was 
"overcentralised at headquarters and regions, top heavy, poorly man-
aged, and bureaucratic and smells of corruption."1 Brundtland's re-
form process, said Jon Liden, her communications adviser, had to 
"butt against a fossilized UN bureaucratic structure." 

Under Brundtland's predecessor, Hiroshi Nakajima, the number of top 
ranking posts almost doubled.2 These appointments were widely held to 
be political, rather than based on merit. When Brundtland took of-
fice, for example, there were six assistant director generals. These 
posts, said Julio Frenk, Mexico's minister of health and a former ex-
ecutive director at WHO, were "geopolitical appointments each of the 
permanent members of the UN security council had one." Cronyism was 
widespread, and debased WHO's technical competence. Regional direc-
tors would often assign country representative posts as a reward to 
doctors who had served their national governments.3 

With its regular budget frozen, WHO relied heavily on additional vol-
untary contributions from donors. WHO departments would fight with 
each other for these funds, and over territory, and there was poor 
communication between them. The result, said one programme director 
in 1994, was that "the right hand never knows what the left hand is 
doing."2 The autonomous functioning of the regional offices added to 
WHO's difficulty in acting strategically across the organisation. 

Is WHO flatter and leaner? 

In her first address to WHO staff, Brundtland promised "a flatter 
structure, better communication, more transparency."4 At the centre 
of her reforms was a new organisation of activities into nine (now 
eight) clusters that reflected WHO's priorities. She named nine ex-
ecutive directors, each of whom would head a cluster, and grouped 
them into a government-style cabinet. 

Brundtland has said that this new arrangement is flatter. 5 6 This is 
true only in that there has been no reduction in the most senior 
posts but a big rise in the number of lower level posts (those below 
director level). Brundtland abolished the assistant director general 
posts, but there are now eight executive directors and a chief of 
cabinet. 

Fiona Godlee, author of a BMJ critique of WHO under Nakajima, argued 
that "WHO should shift resources away from Geneva and the regional 
offices into the countries themselves."7 Richard Smith argued that 
"the number of staff in Geneva and regional offices should be cut 
dramatically."1 Yet the opposite has occurred. WHO's human resources 
department said that there has been a sharp rise in the number of 
short term staff at headquarters. And the latest figures for long 
term appointments also show a rise in staff numbers in Geneva 

Denis Aitken, Brundtland's chief of cabinet, argued that these fig-
ures don't reflect where WHO's focus lies: "It is a fallacy to argue 
that because someone is here [at headquarters], it isn't benefiting 
countries." The work that staff does in Geneva, he said, has a direct 
impact on countries. But one senior staff member at WHO said that 
headquarters must be slimmed down, leaving it with a role in stan-
dardising, evaluating, and coordinating activities that happen closer 
to countries themselves. 

Why has there been a dramatic rise in short term appointments at 
headquarters? The rise is due to the 38% increase in voluntary con-
tributions from donors during Brundtland's term. These funds pay for 
specific, time limited projects, and staff can be hired for these 
only on a short term basis. Almost 60% of WHO staff are now on these 
temporary contracts. Although these give WHO flexibility in appoint-
ing staff, a UN inspectorate report warned that such contracts make 
it harder for WHO to hire qualified people in mid-career.8 

WHO's budget also shows no evidence that resources are shifting from 
Geneva to countries (table 2). But it is another fallacy, said Ait-
ken, to think that the division of funds between headquarters, re-
gions, and countries reflects who will actually benefit. "I would 
guess," he said, "that approximately 60-70% of funding is spent on 
country work in one way or another." 

A global budget 

One of Brundtland's innovations is a new way of specifying how funds 
should be spent across WHO. About 18 months before the start of every 
two year budget period, senior managers draw up a strategic plan, 
known as the programme budget, for that period. The budget sets ob-
jectives, allocates funding to achieve these, and defines measures 
that will be used to monitor success. The programme budget for 2002-3 
is the first time that WHO has planned its spending on specific ac-
tivities at both headquarters and regions. One of WHO's structural 
problems is that the regions do their own planning independently, 
preventing WHO from having an organisation-wide strategy. 

The new budget is one of the levers that Brundtland can use to try 
and create "one WHO," but the regions may not buy into the proposal. 
For example, WHO's African region has already developed its opera-
tional plans for 2004-5. The plans are laid out in a highly detailed 
375 page document, which has been written before the organisation-
wide strategic plan on which it is meant to be based. 

Tackling cronyism 

Brundtland can point to a number of measures designed to increase the 
transparency of staff selection. What is harder to show is whether 
these measures are being adhered to and whether they are effective. 

I heard a wide range of views among those I interviewed. One academic 
in international health, who advises WHO, said that "the rules about 
hiring and firing and accountability haven't changed." On the other 
hand, many staff at WHO feel that there has been a genuine attempt to 
clean up the organisation. In recruiting staff at headquarters, for 
example, a selection panel now prepares a shortlist of recommended 
candidates, and testing has been added to interviews. Isabelle Nut-
tall, of WHO's staff association, believes that selection procedures 
are more transparent under Brundtland, but said that the director 
general still appoints the executive directors and special advisers 
directly and that "these appointments are as political as before." 

Brundtland has a greater say than her predecessor in appointing coun-
try representatives and believes that their selection is now a fairer 
process. "It has become a global, more systematic approach," she told 
me, "to building our human resources and using them." 

Communication 

"We need a culture of information sharing," said Brundtland at the 
start of her term.4 This would depend on good communication between 
her executive directors, and between the cabinet and the rest of the 
organisation. 

An external adviser to WHO said that, on first glance, the cabinet 
looks like an improved way of managing WHO, but this is an illusion: 
"Brundtland says, `Look, I'm consulting,' but the consultation does-
n't go very far." The cabinet, he said, does not consult with the 
wider organisation, particularly its technical medical officers. And 
one senior WHO insider says he was shocked by the amount of internal 
fighting within the cabinet. "The reality," he said, "is that there's 
an incredible amount of competition between the executive directors. 
People don't care for a common cause, they want to score points." 
What WHO needs, he said, "is a visionary cultural change, with shar-
ing of ideas and greater consultation." 

One of the reasons for this competition is that WHO's regular budget 
is still frozen, and the executive directors must argue their case 
for spending these limited resources on their own cluster's activi-
ties. "Let's be realistic here," said Liden. "At the top of WHO, some 
of the best brains from a number of cultures, academic traditions, 
and public health schools of thought meet. You are bound to find dis-
agreements and heated discussions. And unless you devise a whole new 
system to fund the organisation, there will always be anxiousness 
about funding for key programmes." 

Representation 

The makeup of Brundtland's first cabinet an equal mix of those from 
developed and developing countries and of women and men sent a strong 
signal that Brundtland wanted to increase diversity within the or-
ganisation. A cabinet meeting in December 1999 agreed that the female 
recruitment rate should be set at 60% "to achieve gender parity in 
the Organization in the coming decade."9 WHO still has a long way to 
go to achieve such parity (fig 1)only 32% of professional staff, and 
only 29% of new recruits, are women. 

Tikki Pang, WHO's director of research policy and cooperation, said 
that only seven of the 36 directors come from the developing world. 
"We very much need more developing country representation in Geneva," 
he said. But he also believes that Brundtland has championed the de-
veloping world in two important ways. "Her successful attempt to link 
health with development and with poverty has shown WHO to be particu-
larly sympathetic to developing countries. And as far as commitment 
to build capacity in research in developing countries, certainly 
she's been a champion." 

WHO should be serving developing countries, said another staff mem-
ber, which is why their inclusion is crucial. "If you can't find ex-
perts in developing countries," she said, "do you exclude them or do 
you say, `Let's all work together and try and bring people's ability 
up'?" At its last meeting, the World Health Assembly, the annual leg-
islative meeting of member states, expressed deep concern at the lack 
of staff from the developing world. It resolved that the director 
general should "ensure that the principles of equitable geographical 
representation, gender balance, and a balance of experts are re-
spected in making appointments."10 

One criticism of Brundtland's reforms is that they could be seen as 
playing to a donor audience rather than to developing countries. In 
many ways, for example, WHO is now being managed in the style of a 
modern business, even borrowing some of its language it has a corpo-
rate strategy, executives, and management support units assigned to 
each cluster. This language, said one WHO staff member, is "managers' 
jargon" aimed at Nordic, American, and British donors. 

And there is one important slogan, she said, that is still championed 
by many in the developing world but that has been "censored" from 
headquarters' language: Health for All 2000. WHO set itself this tar-
get in 1977,11 and a year later announced that primary care would be 
the means to achieve it.12 The organisation now seems embarrassed by 
this unachieved goal (box 1). 


Box 1: The disappearance of Health for All 2000 

In 1977, WHO set itself the goal that by the year 2000 everyone 
should have achieved a level of health that would enable them to lead 
a socially and economically productive life. A year later, at a meet-
ing in Alma Ata, it announced that primary health care, with an em-
phasis on community participation, would be the means to achieve the 
goal.

The goal was never reached, but many people in the developing world 
still see primary care as a powerful tool for social mobilisation. 
Next year marks the 25th anniversary of the Alma Ata meeting. Many 
people will be asking why Health for All 2000 just disappeared with-
out a mention from headquarters. How can we explain this disappear-
ance?

"It became an unfashionable, if not `dirty word' in the 1990s," said 
Kent Buse, assistant professor of international health at Yale Uni-
versity. "Health for All was tied up with a political battle for eq-
uity and inclusion. In the '90s, health policy came to reflect the 
prevailing ideology. An ideology which emphasised health systems re-
forma market oriented approach informed by economic tools and neolib-
eral values."

Since Health for All 2000 was never achieved, says WHO, it is no 
longer an effective advocacy slogan. Brundtland believes that a more 
diverse approach is now needed to improve global health than the one 
advocated at Alma Ata. She sees many of WHO's activities as consti-
tuting primary health care, such as improving health systems, adding 
to the evidence base, and advocating investment in HIV/AIDS, malaria, 
tuberculosis, and childhood diseases. "Enlisting the poor," she said, 
"by investing in their health and in their needs now that's primary 
health care."

But a growing grassroots global health movement, which gathered in 
Dhaka in December 2000 at the People's Health Assembly, is concerned 
that WHO has lost the intersectoral approach laid down by the Alma 
Ata meeting. The movement wants to revitalise the health for all 
strategy. Its charter reaffirms health as a right and demands "a 
radical transformation of the WHO so that it responds to health chal-
lenges in a manner which benefits the poor, avoids vertical ap-
proaches, [and] ensures intersectoral work" (www.phamovement.org).

Today's WHO and the People's Health Assembly want the same thing to 
improve the health of the poor. But they represent very different 
schools of thought on how this is best achieved. 

Atmosphere 

Critics of WHO's management argue that it has sometimes tried to keep 
the organisation "on message" by covering up internal dissent. One 
episode more than any illustrates how the management finds it hard to 
allow internal debate and dissent: publication of the World Health 
Report 2000.13 

The report's authors measured the performance of the healthcare sys-
tems of WHO's 191 member states, creating a league table of good and 
bad performers. Publication of the report caused an outcry. Critics 
argued that the exercise was driven by headquarters with little input 
from, and relevance to, developing countries. 14 15 Daphne Fresle, a 
former member of WHO's essential drugs and medicines policy group, 
resigned from WHO, citing the report as one reason for her departure. 
"I feel embarrassed," she wrote in her resignation letter of 23 De-
cember 2001, "to be associated with this highly criticised product 
whose contribution to better global health care, particularly in the 
countries most in need, is low or non-existent." 

An unhealthy atmosphere surrounded the release of the report. Data 
were kept from many WHO staff until the report was finished. Staff 
who criticised its methods or findings were seen as conspiring to un-
dermine WHO's international credibility. If WHO is a scientific re-
source serving its member states, argued Alan Williams, professor of 
economics at the University of York, "it needs to create a much more 
open intellectual environment for its staff."14 

WHO's executive board asked Brundtland to commission an external re-
view of the report's methods before any repeat of the exercise (box 
2).16 Brundtland's response to this request has been impressive, and 
hopefully heralds a new spirit of openness. 

Box 2: The World Health Report 2000: a valuable exercise? 

Because of the intense controversy surrounding the report, WHO's ex-
ecutive board asked Brundtland to commission an external review of 
its methods. The chair of the review team was Sudhir Anand, professor 
of economics at the University of Oxford. Anand was hardly a safe 
choice, since he has been an outspoken critic of the disability ad-
justed life year (DALY),20 the unit that WHO uses to measure the 
global burden of disease and the effectiveness of health interven-
tions.

Anand believes that the report was ambitious but worthwhile, because 
it provided a benchmark of the performance of health systems world-
wide. This is important, he said, because some countries may spend 
less on their health system and yet get better outputs. But the re-
port's methods were not adequately tested before its publication, and 
their complexity made them inaccessible to many people. "And there 
wasn't enough," he said, "about the policies that countries could use 
to improve their performance."

WHO has responded quickly to the external review by revising its 
methods for measuring health systems performance and by involving 
countries far more in the process of data collection. "WHO's response 
has been most impressive," said Anand. "They've accepted my critical 
report and they're sending people to countries to help with capacity 
building." 

What can WHO can learn from the controversy? Two things, said Pang 
the need to consult with countries more closely at the start of such 
an exercise, and the need to be transparent about the methods used. 

Morale 

WHO's director general has many constituencies, including govern-
ments, the media, and staff. Many of those I interviewed said that 
Brundtland has been a great leader on the world stage, but a poor 
leader of the organisation. Staff at high levels said she gave them 
great freedom and support to develop their programmes, but many staff 
at lower levels feel disenchanted by her management. She boosted 
their morale on arrival, by being highly visible and promising a new 
era of openness and communication, but there was a large gap between 
rhetoric and action. Her increasing isolation from them was matched 
by their falling enthusiasm for her management. In a survey last year 
of 637 WHO staff, 40% rated their morale as bad or very bad.17 

Conclusion 

Brundtland has been far more successful at raising WHO's profile in-
ternationally than at transforming the organisation internally. She 
did establish mechanisms to reduce political appointments and has 
raised awareness of the need to increase staff diversity. But she has 
not fostered openness or internal debate. WHO is more centralised now 
than in the 1990s. It remains top heavy and dominated by men and rep-
resentatives from developed countries. 

A team of consultants who reviewed Brundtland's management reforms 
called them "the worst of both worlds."18 The reforms combined the 
worst aspects of private sector management such as rigid control and 
a focus on short term results to satisfy external stakeholders with 
the worst aspects of public sector governance such as lack of trans-
parency. "Who has the courage," asked the team, "to grapple with root 
causes of the problems?" 

References 

1. Smith R. The WHO: change or die. BMJ 1995; 310: 543-544[Free Full 
Text]. 
2. Godlee F. WHO in crisis. BMJ 1994; 309: 1424-1428[Free Full Text]. 
3. Godlee F. The regionstoo much power, too little effect. BMJ 1994; 
309: 1566-1570[Free Full Text]. 
4. World Health Organization. Dr Brundtland addresses the WHO staff 
and the press, Geneva, Switzerland, 21 July 1998. 
www.who.int/director-general/speeches/1998/index.html (accessed 26 
Oct 2002). 
5. World Health Organization. Dr GH Brundtland: human development 
week. Geneva, WHO: 1999. www.who.int/director-
general/speeches/1999/english/19990304_world_bank.html (accessed 26 
Oct 2002). 
6. World Health Organization. Dr GH Brundtland: WHO the way ahead. 
Geneva, WHO: 1999. www.who.int/director-
general/speeches/1999/english/19990125_eb.html (accessed 26 Oct 
2002). 
7. Godlee F. WHO at country level a little impact, no strategy. BMJ 
1994; 309: 1636-1639[Free Full Text]. 
8. Kapp C. UN inspectorate gives WHO administration a mixed review. 
Lancet 2002; 359: 328. 
9. World Health Organization. Closing the gender gap at WHO. Geneva: 
WHO, 1999. (Cluster Note 99/10.) 
10. World Health Organization. The need for increased representation 
of developing countries in the secretariat and in expert advisory 
panels and committees. Geneva: WHO, 2002. 
www.who.int/gb/EB_WHA/PDF/WHA55/ewha5524.pdf (accessed 26 Oct 2002). 
11. World Health Organisation. Global strategy for Health for All by 
the Year 2000. Geneva: WHO, 1981. 
12. World Health Organization/Unicef. Alma-Ata declaration on primary 
health care. Geneva: WHO, 1978. 
13. World Health Organization. World health report 2000. Health sys-
tems: improving performance. Geneva: WHO, 2000. www.who.int/whr/2000 
(accessed 20 Oct 2002). 
14. Williams A. Science or marketing at WHO? A commentary on `World 
Health 2000.' Health Econ 2001;10:93-100. 
15. Braveman P, Starfield B, Geiger HJ. World health report 2000: how 
it removes equity from the agenda for public health monitoring and 
policy. BMJ 2001; 323: 678-681[Free Full Text]. 
16. World Health Organization. Assessment of health systems' perform-
ance: report of the Scientific Peer Review Group. Geneva: WHO, 2002. 
www.who.int/health-systems-performance/consultation.htm (accessed 26 
Oct 2002). 
17. WHO Staff Association. Job satisfaction survey: the results. Ge-
neva: WHO Staff Association, 2001. 
18. Lerer L, Matzopoulos R. "The worst of both worlds": the manage-
ment reform of the World Health Organization. Int J Health Serv 2001; 
31: 415-438[Medline]. 
19. World Health Organization. Human resources: annual report, 2001. 
Geneva: WHO, 2002. www.who.int/gb/EB_WHA/PDF/WHA55/ea5530.pdf (ac-
cessed 26 Oct 2002). 
20. Anand S, Hanson K. DALYs: efficiency versus equity. World Devel 
1998; 26: 307-310.

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