WHO April 2000-04-10 - forskningsradet.no€¦ · Web viewPaper to be presented at the 2nd MULTI Conference at . Vettre Hotell, Asker 17-18 January, 2001. Very preleminray draft

2nd MULTI-conference 3rd session: Ideas in Development

Paper to be presented at the 2nd MULTI Conference at Vettre Hotell, Asker 17-18 January, 2001.

Very preleminray draft. Do not quote or cite!

Steinar Andresen and Stig Schjølset1

The Fridtjof Nansen Institute

Leadership change in the World Health Organization: Has it made any difference?

1 Stig Schjølset provided very useful assistance and colleceted and sytematized material to this study until he left for the Ministry of Environment in June 2000.

Vettre, 18-19 January 2001


ABSTRACT:The effect of leadership change in the World Health OrganizationSteinar Andresen, The Fridtjof Nansen Institute e-mail: [email protected]

The significance of leadership in international organizations is contested. While some maintain that leadership is crucial in moving an organization forward, others maintain that traditional international organizations are mere epi-phenomena, no more than reflections of the underlying power-structure. Thus, within a traditional realist view there is small room for leadership on part of individuals. What lessons stands forth from the WHO in relation to these varying perspectives? Based on the preliminary findings, very little support is lent to the latter perspective. In the WHO leadership does matter. The WHO is a particularly good case in illustrating this as the previous leadership by most standards had a very low score. Although it is clearly premature to draw any robust conclusions on the present regime, in part because it has only been in position for some 2 ½ years, in part because this study is far from finished, there are clear indications of leadership.But what is leadership and how do we measure it? Standard definitions of leadership are fairly straightforward. Leadership is usually confined to individuals, it is relational , between leaders and followers, and there are usually elements of values and or power vested in the leaders in order to get the followers on board. Some normative elements may also be included – unless you want to define Stalin and Hitler as great leaders. What mechanisms can leadership be exerted through, or what kind of leaderships are there? Again, there is a rich arsenal to pick from, but in international relations theory it is common to operate with intellectual leaders, instrumental leaders, structural leaders and directional leaders. Particularly the first two categories are relevant in this case and others will be added. So to the more difficult question of measuring the effects of leadership. One may well think of instances where leadership is exerted but has limited or no effect, but this is not what we usually look for. We want to know whether it has a (positive) effect. If this question cannot be addressed satisfactory, studies of leadership is less relevant. This brings us to the question of the effectiveness of international organizations. This can be measured in number of ways that I shall have more to say about in the paper. Suffice it here to say that this avenue is wrought with methodological challenges associated with the process of tracing causal links. Moreover the way you define effectiveness is closely linked to what you find out about the effectiveness of the relevant organization. The most important point in this connection is that leadership is only one, and usually a fairly small part when explaining the effectiveness of an organization. Needless to say it is also a tall order to trace the effects of leadership to what is happening on the ground level as so many other factors are involved.Where does leave us in relation to the effect of leadership in the WHO since the new leadership was inaugurated in 1998? So far we have little to say about leadership in relation to ‘the amount of health delivered to the peoples of the world’ in this period – although this is of course ‘really’ what we want to know. Too short time has elapsed and the causal chain is too long and complex. We expect to have some more to say about this by looking more at a couple of specific programs, but not a whole lot. Instead of measuring and evaluation leadership in terms of implementation, more emphasis will be placed on organizational restructuring, agenda setting more comprehensive approaches



and fund raising. In itself, improvements along these dimensions are no guarantee of more and better health. They will often represent necessary but not sufficient conditions for a positive development. Organizational restructuring will be discussed both internally and externally. Internally in relation to organizational changes made at the headquarters in Geneva, externally in relation primarily to the six regional offices, but to some extent also the country offices. Agenda setting will be discussed in relation to the new regime’s ability to get health on the international political agenda. A more comprehensive approach to degree of cooperation with other relevant entities, within and outside the UN system, as well as private actors while fund raising relates to the development of the size of the budget, both the ordinary budget as well as the extraordinary budget. Based on our preliminary findings, there has been a positive development along all these dimensions. The ultimate test what this means in practice, however, remains to be seen.



1. The status of this paper

This project will not be finished until April 1, 2001.2 Thus, the present paper is highly preliminary.3 Most of the theoretical and empirical groundwork has been done but I have not yet had the time to systematize it sufficienly for this written presentation. Still, hopefully enough is fleshed out to provide a basis for comments and discussion, which will be helpful in finalizing this project.

Although most time has been spent on traditional desk research, quite a few interviews have also been conducted - essential to come to grips with the ‘real’ story. The following persons and institutions have been interviewed so far: Jonas Gahr Støre, head of the PMs office in Norway and senior policy advsor (right hand) of the present Director General (DG) Dr. Brundtland during her first two years in office. Moreover, head of communication, a senior policy advisor and a head of one of the clusters, all in the Geneva Headquarter. In addition another member of the Dr Brundtland’s transition team, the head of administration in Pan American Health Organization (PAHO) and the head of the division on Health and Nutrition in the World Bank and the WHO Regional Office in Copenhagen. As it is important to bring in the developing country dimension, I will also go to the WHO Regional Office in Kairo in March and also visit the country office there. Finally, I will go to Brussels as the EU is getting increasingly involved in cooperation with WHO. Ideally, a lot of other institutions and country offices should have been visited. This was planned in connection with a follow-up study of the relevance of the socalled ‘systems approach’ in the work of the WHO. Unfortunately this and our related projects were rejected by the Research Council, but we hope to be able to follow up this work at some later stage.

The paper is organized in the following way. First we give an outline of some theoretical and methodological considerations in connection with assessing the effectiveness of international orgaizations. Then we turn to the concept of leadership before we give a brief outline of the history of the WHO and the organizational set up. Then we turn to some of the changes that has been brought about in the WHO as a result of the new leadership before we briefly evaluate the effect of the new regime.4

2 The main reason for this delay is that there was a change of leadership of this project so it was started approximately half a year later than scheduled. 3 Not time to correct all spelling and grmmar due to some technical difficulties. No time to go through the language – as you will see. 4 In the final version a section on UN reform will be added. Moreover, there will be one more lengthy report published at FNI and one shorter and more crisp version will be submitted to Global Goverance. The present version is a ‘loose in-between version’.



2. Theoretical and methodological approach

In order to assess the effect of leadership, we first need a standard of evaluation; how can we decide the performance of a leader, or rather a new team having the formal role of leadership? The formal position(s) provide the opportunities to lead and to change but the individual(s) in question have to carve out the road for them. What has to be accomplished in order to qualify as a good leader? Moreover, what is the role of leadership in the broader framework of explaining the success or failure of an organization? These questions can be grappled with in a number of ways. Here we will discuss the role of leadership in relation to the effectiveness of the organization at hand.5

To some extent we rely on the conceptual framework developed in relation to the study of the effectiveness of international (environmental) regimes.6 The key question we want to answer is whether a regime, or in this case an organization, is able to solve the problems that had caused their establishment; a problem solving approach. Experience from this kind of research has shown that walking down this avenue is wrought with methodological challenges. (Underdal and Young, 2001)

One way to approach this question is to start out by looking at the goal of the organization. Unfortunately the goal is often so broad or ambitious, that little guidance is provided. Consider for example the goal of the WHO as “the attainment by all peoples by of the highest levels of health”. You do not need to be an expert on global health problems to know that the level for health for a large portion of the world’s population is not very good. Does this mean that goal achievement or problem solving on part of the WHO has either been poor or at best modest? Not necessarily, as it gives little meaning to judge the WHO by this general standard. It has to be judged in relation to the adoption of more specific and confined programs and goals. The main methodological problem with this problem solving approach, however, is the fact that we are rarely able to trace the causal links from the organization to the problem(s) at hand as a number of other causal agents will usually play a role. This is highly relevant for the WHO as health is the responsibility of the national governments in any given country, and the WHO has a more advisory rather than an operational role. Moreover, broader technological and economic developments will also make a difference for the development of health and there are multitudes of other relevant international organizations at work that also have an impact on health. Thus, although some of the more specific goals of the WHO may have been achieved, in most cases it would not only be a result of the actions on part of the WHO. Only in very rare instances can the WHO take the sole credit for successful problem solving – or given the sole blame for a fiasco.7 In short, although the impact of the organization on the problem at hand or overall goal achievement is really what we would like to know, under real world circumstances we are simply not able to measure this very precisely. In methodological terms, the validity of this approach is very high but since the reliability is so low, it is difficult to apply in its pure form. This does not mean

5 For a somewhat different appproach in dealing with the effectiveness of the WHO, see Sidiqi, 1995. 6 This may be changed somewhat further down the road. 7 In the most recent budget of the WHO this distinction is explicitly acknowledged as there are overall goals in given areas and more specific, and less ambitious, goals on part of the WHO.



that we discard this approach, but we will apply it with caution and it will not be the main indicator of effectiveness.

An alternative and somewhat less methodological demanding indicator is to study the relevant organization as a causal agent in changing the behavior of relevant target groups. If we can establish a causal link between the organization and behavior of target groups in the sense that it is moving in the ‘right’ direction, we would say that the organization was quite effective. That is, this would not necessarily solve the problem, but the development would move in the right direction. To illustrate the difference between the two perspectives, the problem associated with smoking is solved when there is not one single smoker left in the world while the behavioral approach focuses on reduction of smoking – in both cases ideally linking change to actions undertaken by the WHO. While this approach is relevant to the WHO in instances where behavior of target groups matter, like smoking and HIV/AIDS, in other cases it is less relevant, for example in connection with large vaccination programs.

A third indicator of effectiveness deals with the output produced by an organization. This indicator is the least demanding in methodological terms, but unfortunately it is also the one indicator, which has least to say about whether the organization is truly effective, or not. Regarding international regimes, outputs are decisions, rules and regulations flowing from the regime. In relation to international organizations an important distinction is the one between internal procedural decisions and substantive decisions relating to the adoption of new programs etc. As a point of departure substantive outputs is a necessary but not sufficient condition for effectiveness along the two other dimensions. To illustrate the relation between the indicators. First a decision needs to be taken to fight the use of tobacco, usually a necessary, but not sufficient condition in order to reduce the use of tobacco – a step on the long way to eliminate the problem. There is, however, no inherent logic between the three steps. A given decision may and may not have an effect and the development may also well move in the right direction without a decision taken. Still, our point of departure is that normally relevant decisions represent a first necessary step to alter behavior and reduce problems.

A fourth and even ‘softer’ indicator relevant to effectiveness of international organizations is the ability to get issues on the international political agenda; agenda setting. For an established organization like the WHO, in itself this is not necessary to deal effectively with problems, but we will assume it to be an advantage as the WHO relies on so many actors to cope successfully with various problems. This indicator says nothing about ‘true effectiveness’, but may be highly relevant as factor that may facilitate effective problem solving. The higher up on the international political agenda health is, the higher the probability that necessary action will be taken.

These four factors can be looked at sequentially; first comes agenda setting, then outputs (decisions and programs), behavioral change and finally problem solving. The above relates to the evaluation of performance of an organization like the WHO and in order to evaluate leadership, this broader framework needs to be kept in mind. Recall, however, that our aim of this study is not to evaluate the role of the WHO as such, but to try to



assess the significance of change of leadership. This implies that it is not feasible to use the two more demanding indicators in order to ‘measure’ the effect of a leadership that has only been in position for two years and a half. As we shall see later on, the new leadership may well have taken positive initiatives in various areas, but the new leadership can hardly take the credit for programs that were launched years ago or maybe even decades before it took office. In a similar vein, if other programs show a less positive development, the present WHO leadership can hardly take all the blame for this. Such nuances, however, often tend to disappear in the public debate or in media coverage. In short, we will deal essentially with the last two indicators of effectiveness in this study – at least at this stage.8 Before we specify these indicators into more operational terms, let us first have a look at how to define and apply the concept of leadership.

3. The significance of leadership

First we will comment briefly on the merits and shortcomings of applying a leadership perspective in this particular case. Then we will define leadership and put it in a broader explanatory perspective before we zoom in on the more specific indicators of leadership.

There are both pros and cons’ as to the suitability of applying a leadership perspective in this particular case. Let us look at the pro’s first: - As we shall have more to say about later, the DG has an especially significant and

influential position in WHO compared to many other UN bodies. - The present DG has an international reputation as an effective and determined leader,

with an explicit ambition to make significant reforms during her term in office.- It has been argued that compared to other international organizations the WHO might

be less influenced by the shifting policies and priorities of the important states of the world community (Jacobsen 1973:205).9 If this is true, one could expect that the WHO might be less sensitive to ’external variables’, thus making if easier to assess the importance of an ’internal variable’ like leadership. As we shall see later, the more expansive role of the ‘new’ WHO may have reduced the validity of this argument somewhat.

- According to Jacobsen (1973:213-15), three factors are crucial for whose performance: ”the quality of the DG, the attitude of the leading states, and the quality of the organizational elite”. That is, at this point in time, internal variables were more important than external variables for the effectiveness of WHO.

What are the factors that may contribute to make the study of leadership difficult in the case of WHO? - Dr. Brundland assumed the position as DG in July 1998, after being formally elected

in January the same year. For an organization of WHO’s size and character the more profound effects of organizational reforms can hardly be expected to take place

8 We may try to evaluate some of the programmes launched by the new regime, like the Tobacco Free Initiative, if time permits. 9 The nature of the organization and the strong professional basis are mentioned as reasons for this. The quote is an old one, but in comparative trems, it still seems quite valid based on studies so far.



within such a relatively short period. This is particularly true with regard to overall aims such as ”Health for All”, but also with regard to general evaluations of the effectiveness of the various WHO programs and how the organization is spending its funds.Considering the broad nature of the health issue, it is extremely difficult to control the effect of external variables.

Overall, however, the merits of a leadership approach seem to make sense.

Turning then to the concept of leadership. What is leadership in general terms? According to the Blackwell Encyclopedia of Political Science, leadership may be defined as “the power of one or a few individuals to induce a group to adopt a particular line of policy.” According to the Dictionary of Policy Analysis, leadership is what “enables an individual to shape the collective pattern of behaviour of a group in a direction determined by his or hers own values.”10 These definitions confine leadership to individuals and the relational aspect is stressed, between leaders and followers. They are different in the sense that one relates leadership to power the other to values. This difference has implications for the various types or mechanisms of leadership that is used in the study of international relations (Underdal, 1994, Malnes, 1995 and Young 1998) It is common to differentiate between powerbased leadership, instrumental leadership and intellectual leadership. In our case, instrumental leadership seems to be most relevant. An instruemental leader seeks to find the means to achieve common goals and convince others about “the substantive merits of the specific diagnosis he offers or the cure he prescribes.” (Underdal, 1991) Instrumental leadership is a function of an actors’s positions, skill and energy. Young (1991) identifies four types of instrumental leadership: agenda setters, popularizers, inventors, and brokers.

Before zooming in more specifically on how we will apply the leadership concept in this study, first a few words on the significance of leadership in a broader explanatory perstive of ‘success’ or ‘failure’. One approach is to distinguish between the nature of the problem and problem solving ability. In very simple terms the former implies that we should be aware that there are significant differences between problems, some are malign and other are more benign. (Underdal, 2000) In itself this is a trivial observation but it is often forgotten when judgments about performance is made. Often, there is not a whole lot you can do about the nature of the problem, its structure tends to be rather stable. Leadership is one part of the problem-solving ability perspective, including also factors like the institutional structure of the organization as well as the distribution of power between the members. That is, the more political and institutional energy a problem is attecked with, the higher is the chances of better problem solving. But it is important to bear in mind differences between organizations. Organizations with broad goals, with universal membership and de facto consensus-based, will normally be less effective than smaller regional organizations composed of wealthy countries and in addition having majority voting. That is, more can be expected from an organization like the EU – compared to the UN, including the WHO. Considering the nature of the WHO and the fact that leadership is but a small part explaining success or failure – it simply is not

10 These definitions are borrowed from Malnes, 1992:7.



realistic to expect that leadership will make that much of a differnce. The tendency on part of some analysts to compare actual (modest) achievements with wildly ambitious goals and thereby conclude that they are ineffective, does not give much sense. One has to control for the problem at hand as well as what is feasible under real world circumstances. With this in mind, let us turn to a closer spesification of leadership.

Within the study of leadership in business and management theory, a lot is written but it is usually at a general level and not very useful or relevant in our case.11 A classic on leadership, Selznick (1957) is more useful in exploring the meaning of leadership. According to Selznick (1957:62), there are at least four key tasks leaders are called to perform to provide what he calls ’institutional leadership’ in large-scale organizations. This can be seen as a specification of the broader category of instrumental leadership.

1) The definition of institutional mission and role. It entails a self-assessment to discover the true commitments of the organization, as set by effective internal and external demands. The failure to set aims in the light of these commitments is a major source of irresponsibility in leadership.

2) The institutional embodiment of purpose. The task of leadership is not only to make policy but also to build it into the organization’s social structure. Like the setting of goals, this is a creative task. It means shaping the ’character’ of the organization, sensitizing it to ways of thinking and responding, so that increased reliability in the execution and elaboration of policy will be achieved.

3) The defense of institutional integrity. Institutional survival, properly understood, is a matter of maintaining values and distinctive identity. The fallacy of combining agencies on the basis of logical association of functions is a characteristic result of the failure to take account of institutional integrity.

4) The ordering of internal conflict. Internal interest groups form naturally in large-scale organisations, since the total enterprise is in one sense a polity composed of a number of sub-organizations. The struggle among competing interests always has a high claim on the attention of leadership. In exercising control over the internal balance of power, leadership has a dual task. It must win consent of constituent units, in order to maximize voluntary co-operation, and therefore must permit emergent interest blocs a wide degree of representation. At the same time, in order to hold the helm, it must see that a balance of power appropriate to the fulfillment of key commitments will be maintained.

In his terms, leadership goes beyond efficiency (1) when it sets the basic mission of the organization and (2) when it creates a social organism capable of fulfilling that mission. The attainment of efficiency, in the sense of transforming a basically inefficient organization into one that runs according to modern standards, may itself be a leadership goal. But here the task is a creative one, a matter of reshaping fundamental perspectives and relationships. It should not be confused with routine administrative management of

11 Much of the litterature gives practical advice to the good leader – ‘think creative’, ‘work in team’, ‘create enthusiasm’, ‘delegate responsibility’, etc. Conceptually more interesting but not very applicable in this study due to the high level of abstarction are ‘new-institutionalism’ classics like March & Olson (1989) and Guy Peters (1988).



an organization already fully committed to the premises of rational accounting and discipline (p.135-137). When the goals of the organization is clear-cut, and when most choices can be made on the basis of known and objective technical criteria, the engineer rather than the leader is called for. The limits of organizational engineering become apparent when we must create a structure uniquely adapted to the mission and role of the enterprise. This adaptation goes beyond a tailored combination of uniform elements; it is an asaption in depth, affecting the nature of parts themselves. As this occurs, organization management becomes institutional leadership. The latter’s main responsibility is not so much technical administrative management as the maintenance of institutional integrity (p.137-138). 12 All these categories point to relevant features of instrumental or institutional leadership. However, they are all rather general and we need more specific indicators to measure leadership in our context. First, we need to distinguish between an internal and an external dimension. Internally, the definition of institutional role and mission as well as securing the integrity of the organization is highly relevant. More specifically, the WHO is split in six regional offices and a key goal of the new regime has been to make the WHO into one unified organization. We will discuss the extent to which any progress has been made on this dimension. The same indicators are relevant in relation to the Headquarter of the WHO in Geneva – not least since there has been a considerable reorganization here as a result of the new leadership. Has this improved the institutional role and mission and the integrity of the organization? Internally, it is also important to consider the relation between the DG and the most influential players and most significant donor countries in the organization. More or less in line with the realist notion, our assumption is that the DG cannot accomplish much unless he or she is playing on team with the most influential actors – provided these are reasonably rational and constructive players. More specifically, this also relates to the funding situation – highly relevant for any organization to function effectively. This indicator brings us over to the external dimension as the WHO has an internal and an external budget. Has the new DG been able to increase the external budget? An important goal of the new leadership team has been ‘reaching out’. This means to improve collaboration with other relevant actors; within the UN family, with other relevant international organizations, with volunteer organizations as well as with relevant private business. Finally, an important goal as been to get health on higher on the international agenda; the agenda setting function. Has the new regime been successful on this account?

Summing up, although the effects of leadership under many circumstances can be significant, its role should not be exaggerated. This is especially true for a complex broad purpose and rather weak organization like the WHO functioning in a market with extremely many and often more influential actors. All too often, the ‘success’ or ‘failure’ of an organization is too closely associated with the single responsible leader. Another observation is that to exert effective leadership is more easy in an agenda setting phase than during the stages of implementation where the number of intervening and important

12 See also Bass and Aviolo, 1994. More litterature of more direct relevance to international organizations will be read – and applied in the final version.



actors tend to grow considerably. Finally, these are the more specific indicators of leadership we have chosen to zoom in on: The effect of reorganization: in the HQ and vs. the Regional Offices The development of the economy; internally and externally The effect of the multi-facetted ‘reaching out’ strategy The ability of high level agenda setting

Our main assumption is that leadership contributing to a more unified organization, improved economy, closer cooperation with relevant actors and getting health higher on the political agenda will all pave the way for a potentially more effective organization.

3. History, organizational structure, leaders and accomplishments

3.1. The history of the WHOThe initial proposal for a World Health Organization was forwarded by Brazil and China at the United Nations Conference on International Organization in 1945. A year later, at an International Health Conference in New York, where all the 51 members of the United Nations were present, the WHO constitution was signed. This constitution came into force on 7 April 1948, when the required 26 ratifications were achieved. The 7 th of April is now marked as the World Health Day each year.

The main objective of the WHO, as it was defined in the constitution is ”the attainment by all peoples of the highest possible levels of health”.13 Neither this general objective nor the more specific functions, which were assigned to the organization, did case much controversy among the member states. Achieving consensus about the organizational structure proved however to be more difficult. The trickiest issue concerned the status of the regional organizations. Before the establishment of the WHO, there existed already a number of regional health organizations – most notably the Pan American Sanitary Organization. Although there was general agreement that existing regional organizations should be brought into relationship with the WHO, there remained considerable room for controversy about the degree of autonomy that regional bodies might have (Jacobsen 1973:177).

After prolonged deliberations a rather vaguely formulated compromise was found. The wording in the constitution states that the regional organizations should be ”integral” parts of the WHO, and that existing organizations like the Pan American Sanitary Organization ”shall in due course be integrated in the organization”. These formulations made it possible to reach an agreement on the constitution, and the further discussions could be carried out within the various institutions of the WHO. By the end of 1951, regional organizations were finally established and operational in six geographical areas.14 The organizational shaping of the WHO was then completed, and only minor adjustments have taken place at later stages (Siddiqi 1995:68). As we shall have more to

13 The WHO constitution defines health ”not merly the absence of disease” but as a ”state of compleate physical, mental and social well-being” (WHO Constitution, World Health Organization, Geneva).14 The six regions are the Eastern Mediterranean Region, the Western Pacific Region, the Southeast Asia Region, the European Region, the African Region and the American Region.



say about later, however, the relationship between the regions and the Headquarter in Geneva has not only been smooth.

The ambition of universal membership has made it crucial for the WHO to deal with any problems over membership in a flexible and pragmatic manner. This has also to a large extent been done in practice - something its success in this respect indicates.15 This goal was strongly emphasized by the organization’s ‘founding fathers’ and also written into the WHO Constitution in 1948. Some fifty years later, it is safe to conclude that this aspiration to a large extent has been achieved. From the 26 members in April 1948, the number increased rapidly to 74 in 1950. At this point this was twelve more members than of the United Nations proper. The difference between the WHO and the UN continued to increase the following years, and in 1954 the WHO had 81 members – nineteen more than the UN. This year marks the greatest difference between the size of the two organizations, but WHO did remain the larger one also in the following decades. When the organization celebrated its 25th anniversary in 1973 the WHO had 138 member states, and when it turned 50 in 1998, 191 countries had joined the organization (WHO 2000). The dramatic increase in membership in the WHO, as well as in the UN system in general, is to a large extent a consequence of the increasing number of states in the world. The result is an organization which is much more complex today than fifty years ago, consisting of states with highly different needs and interests. Considering, however, the rather complex organizational structure with six regional offices as well as a number offices in most countries, it has been pointed out that the WHO is a much more complex organization than most other UN organizations. (interview).

The WHO was designed according to the functionalist ideas, which were very influential in the early post-war years. In short, functionalism is based on the belief that politics can be segregated from the technical or ’apolitical’ work of an organization like the WHO.16

As the early problems related to the decentralized structure of the organization had seemingly been solved, the medical experts felt that the organization could embark on the more important and apolitical technical issues. (Ibid.124). Overall, the development in the WHO has been described as an example of a UN agency which – at least in most areas – has avoided politicization of its work and organization. (Williams 1987:29). Nevertheless, the development has been characterized by the formation of different alliances or blocs within the organization – regional as well as political and as we shall see below, the WHO as other international organizations also mirror the political controversies in the outside world, not the least in questions dealing with membership.

15 One example is the Amarican entry into the WHO. The US required that it should be able to withdraw from the WHO at a year’s notice, a reservation which was significant in the light of the absence from the WHO constitution of any provision for terminating membership. Nevertheless, at the WHA in 1948 the US was admitted as a full member of the organization. To some extent, this reflected of course the importence attributed to US participation, both politically and financially. In addition, the pragmatic attitude of the WHA was probably a consequence of the dominance of medical doctors who preferred practical solutions to any strictly legal considerations (Siddiqi 1995:104).16 See for instance David Mitrany (1971) for an intersting presentation of the functionalist approch to international organization.



The first example came already a year after the organization came into being. In 1949 the Soviet Union surprisingly announced that it no longer considered itself a member of the WHO. A ‘domino effect’ and a long series of withdrawals form socialist countries followed this. The Soviet and its allies claimed that the reason was the discriminative attitude from the other member states, and that the organization had not responded to their actual needs. In a broader context, the socialist states’ withdrawal from the WHO was a part of the international development and the Soviet perception of the UN agencies as “enemy tools in the Cold War” (Dallin 1962:64). The official WHO reaction was very subdued: a World Health Assembly (WHA) resolution urged the ‘inactive members’ (the constitution did not provide for withdrawal) to reconsider their decisions and resume active participation. This was also what happened. After Stalin’s death in 1953 the Soviet foreign policy became less hostile to the UN system, and Soviet participation in international organizations expanded markedly in the post-Stalin era. In 1955 Soviet resumed its membership, and the rest of the socialist did the same in the following years (Siddiqi 1995:108).

While the socialist countries were ‘boycotting’ the WHO, the organization was almost totally dominated by the Western countries. This dominance was further strengthened by the exclusion of the People’s Republic of China. After the Chinese revolution in 1949, the country broke into two areas, the Republic of China (Taiwan) and the People’s Republic of China (China). The debate over which of the two governments, Peking or Formosa represented all China appeared repeatedly throughout the UN system. In the 1952 World Health Assembly this debate was settled in favor of the Republic of China (Taiwan), and the People’s Republic was effectively excluded from the organization. This situation continued for over twenty years. However, as the Western dominance in the organization gradually diluted, partly by the re-entry of the socialist countries, and partly by a growing number of developing countries, the WHA’s attitude to this issue changed as well. In 1971 the situation was thus reversed, and the government of the People’s Republic became China’s only legitimate representative of the WHO.

The action against China is one of a very few examples of the ‘politics of exclusion’ in the WHO. Another well-kown case is the suspension of South Africa in 1964, just after the South African government declared apartheid to be its official policy. The WHA referred to this as a ‘special circumstance of failure to adhere to the humanitarian principles governing the World Health Organization’, and decided to deprive the Apartheid State of its voting privileges in the organization. South Africa thus withdrew from the WHO, and became an inactive member until 1994, when it again was restored to full membership rights.



The most troublesome and politicized membership issue in the recent years has clearly been the Palestinian State’s application for membership. In 1988 the PLO declared the formation of a Palestinian State in the occupied West Bank and Gaza. When the PLO applied for WHO membership a year later, ninety-eight countries had already recognized the self-proclaimed state. The application was however met with strong reactions, in particular by the US who threatened to withdraw US founds from the organization. The WHO’s Director-General, Hiroshi Nakajima, also stated that it was ‘most inappropriate’ for the PLO to put WHO programs in jeopardy by making the organization its first target in a drive to win international recognition of its proclamation of statehood (Siddiqi 1995:115). After a highly politicized and high-tempered debate in the WHA the whole issue was deferred. As a concession to PLO and its allies, a detailed study of its request for leadership should be conducted – a study which was issued against strong objections from Israel and the US. Ten years later, the Palestinian State is still not a WHO member.

Still, in comparative UN terms, the WHO has avoided the paralyzing polarization characterizing many UN bodies, although as we have seen time and energy have at times been used more on political than health issues. Let us turn then to the organizational set up of WHO. 3.2 Organizational StructureAs envisaged in the constitution, the central organs of the WHO are the World Health Assembly, the Executive Board, and the Director General and his or her Secretariat. Delegates representing all member of the WHO compose the Assembly. It meets annually and makes decisions on ’important questions’ by a two-thirds majority and on others by simple majority. Each member state has one vote. As with the General Assembly, the egalitarian structure of the Assembly in the WHO makes it a favorite organ of weak states, because it gives them influence over decisions that they lack in other fora (Siddiqi 1995:83). The Assembly is also pointing out the 32 members of the Executive Board, or more correctly: the Assembly chooses 32 countries, which thereafter are responsible to designate the Board Members.

The Executive Board ïs composed of 32 technically qualified individuals, elected for a three years period. They meet at least twice a year, with the main meeting usually in January. They oversee the operation of the WHO, gives effect to the Assembly decisions and nominates the Director General (DG). According to the WHO constitution the Board exercise its powers ”on behalf of the whole Health Assembly”. Nevertheless, as almost all Board members are governmental officials, they normally reflect the viewpoints of their governments (Siddiqi 1995:82). This is said to be particularly true for the developing countries. The distribution of formal power between the Assembly and the Board is skewed somewhat in favor of the former. Most formal decisions have to be made by the Assembly, and the Assembly alone can approve the budget. In many ways the Boards mandate is to act as a steering committee for the assembly. The Board oversees the operation of WHO, sets policy and nominates the DG. The WHA is then to make the formal election of the DG. The control over the nomination process makes the Board the decisive body in this sense. (Peabody 1995:733).



The Secretariat is headed by the Director General, who is appointed by the Assembly on nomination of the Executive Board. The DG appoints all professional staff, although this responsibility is often delegated, and proposes the budget – two authorities that provide enormous discretion over the course of international health activity (Peabody 1995:733). The DG functions as an initiator, controller, and vetoer as far as programmatic decisions are concerned. Neither the Assembly nor the Board exert important policy authority over an elected DG, and the DG’s role in the WHO is probably the strongest and most autonomous of any of the UN special agencies.

The WHO’s decentralized structure is unique for a specialized UN agency, and this is important to understand WHO leadership and policy formulation in its internal milieu. In short, the headquarters in Geneva formulates policy, sets the budget and charts the overall direction. The six regional offices then supervise and coordinate program implementation. The Regional Offices through their program implementation (< biblio >), however, formulate a significant amount of policy. The regional directors are elected by their constituent countries rather than appointed by the DG, and they can hire and fire staff within their regions. The regional directors are also responsible for appointing country representatives – the’s front liners. The country representatives are responsible for overseeing the implementation of national programs, and they report directly to their regional directors. All in all, the regional directors have important institutional roles within the WHO, and they are clearly limiting the centralized control with the organization (BMJ, 1 August 98). (Fiona/limiting role)

Thus, all in all the DG of the WHO has a strong position but the Regional Offices represent a limiting factor.

3.3. LeadersThe organizational structure of the WHO makes the DG more important than in most international organizations. The fact that they have tended to stay in position for a very long period make them – for good or bad – particularly important for the effectiveness of the organization. In fact, in it’s more than 50 years history, WHICH has only had four DGs before Dr. Brundtland took over. The first of them, Dr. Brock Chisholm from Canada, played an important role in defining the mandate and position of the DG. It was during his five years in office that the decentralized organizational structure established. In this process Dr. Chrisholm worked firmly and successfully to avoid a complete fragmentation of the organization. The second DG, Dr. Marcolino G. Candau for Brazil is probably the most influential one in the organization history. He was first elected in 1953, and then reelected three times. During his 20 years in office the organization experienced a rapid growth, and Dr. Canadu initiated several reforms to preserve the cohesion of the organization (Jacobsen 1973:199). The third, Halfdan Mahler from Denmark stayed in position for ten years and was considered to be a good and respected leader. According to most observers, the fourth General Director, Hiroshi Nakajima, who also served for ten years, broke the tendency of essentially good leadership in the WHO.



One observer has noted that: “It is hard to think of any single person in the UN constellation who has done more harm to the effectiveness and the reputation of the world organization”. (Robbins, 1999:30) In fact, dissatisfaction with his work on part of most key members resulted in procedural changes regarding the position of DG. Previously there had been no limitations on number of terms the DG could serve, but during Nakajima’s second term a new procedure was introduced. After two terms the DG had to apply for the job – in open competition with others. As we know, Dr. Brundland won that competition. Through interviews, however, a more nuanced picture is portrayed of Dr. Nakajima; he was a very good scientist and professional, but he was not at all a leader. He was very active on the professional side, but was not able to give priority to leadership and administration. As a result of this, the organization was increasingly fragmented under his regime, both in Geneva and in relation to the Regional Offices. He was also very rarely present and a number of small and rather unruly ‘kings’ emerged. Nevertheless, and in line with our initial perspective, this does not mean that nothing happened under Dr Nakajiiima’s reign, or that ‘all was bad’. The WHO is a large organization with some four thousand employees, and a lot was undoubtedly accomplished. But the fact that he lacked leadership skills and trust, not the least externally, meant that more could have been achieved with a better leader.

What were the implications of his weak leadership for the new DG, Dr. Brundland. It seems it would have a dual effect. On the one hand, it is easier to succeed a ‘failure’than a ‘success’; not a whole lot needs to be done to improve the image and functioning of the organization. On the other hand, if things was as ‘bad’ as many observers claim, organizational restructuring is bound to be a heavy process – not the least in terms of changes of personnel, and giving them new roles and tasks. This wills very likely trigger opposition. Before we take a look at some of the changes that the new leadership has brought about, let us give a few examples of what the WHO has accomplished during its history. Again, our initial perspective should be kept in mind. The WHO is only one among a multitude of national and international actors that has contributed to the following accomplishments. Recall in that connection that the WHO primarily has an advisory function, more than an operational function.

3.4. Key programs and achievements

The Malaria Eradication Program (MEP), launched in 1955, was the first attempt by the WHO to unify public health procedures on a truly universal scale. The program had overwhelming support from the WHO member states, and was a clear indication of the recognition of the’s role in international health co-operation. The advisory role mandated to the WHO by its constitution gave it a unique possibility to advise national



governments on planning, financing, implementing and evaluating health programs. The member countries were thus expected to follow similar advice about malaria eradication, in the same order and at the same time (Siddiqi: 125). Already a few years after the implementation of the MAP it was however clear that the WHO had been overly optimistic about the prospects of malaria eradication. Although the results varied from region to region, being must successful in Americas Region of the WHO and least successful in Africa south of the Sahara, it became more and more evident that the MEP was ineffective in several respects and the program was eventually abandoned in 1969. (Peabody 1995:736; Siddiqi 1995:183).17

Several of the other early WHO programs were however far more successful. Yaws – a crippling, disfiguring disease, which attacks children, and leads to disability – afflicted some 50 million people worldwide in 1948. To combat yaws the WHO developed a program that encompassed research into use of long-acting penicillin, active promotion of the new treatment approach, and direct assistance to governments in designing and carrying out their national approach. Within 15 years, some 50 countries had benefited, and the global burden of yaws was reduced to almost nil (WHO 2000).

The best known example of WHO’s accomplishments is probably the eradication of smallpox. In 1967, when the WHO started international eradication efforts, smallpox was estimated to have afflicted up to 15 million people annually, of who some two million died with millions more left disfigured and sometimes blind. To eliminate the disease the WHO needed to insure that the diagnostic expertise and publish health quarantine system could find every person infected with the variola virus. The WHO was even offering monetary rewards for ‘turning in cases’. When the last case was found in Somalia in 1977, the US$ 300 million program had saved 20 million lives and prevented 100-150 million cases just in the ten first years. The net economic benefit is estimated to be US$ 1 billion annually (Peabody 1995:736).18

At a more general level a quite astonishing achievement with regard to international public health over the past fifty years is the increase in human longevity. In the early 1950s the average life expectancy were about 46 years, in 1996 almost 65 years – an increase by more than 40%. The WHO has probably contributed significantly to this development through disease prevention and control, establishing sandards and norms for health products, through its assistance of national governments and so on.

Summing up, some of the broad lines of the history of the WHO. The WHO is a truly global, inclusive organization with larger membership than the UN General Assembly. Although politicization has not been avoided through its history, overall it seems to have succeeded reasonably well in staying to its initial mission: help to improve the global health, illustrated by some of the examples given above. The organizational set up is 17 The fight against malaria have however not given up with the termination of the MEP. On the contrary, it has continued to be an important priority for the WHO – as the Roll Back Malaria campaign launched by Mrs. Bundtland in 1998 illustrates.18 A number of other more or less successful programs on part of the WHO could be mentioned and the final list and presnettaion will be changed. This section as it stands now is included for illustartive purposes.



fairly traditional, but the position of the DG is unusually strong – with the Regional Offices as a limiting factor. The important role of the DGs has been strengthened by the fact that they have tended to stay in position for a long time.

4. Dr. Brundtland19 in office: internal reforms and improved external image

On her inauguration day as DG she ’swept away’ the existing secretariat, and announced her own carefully chosen cabinet to an increasingly optimistic staff. As one observer concluded a few months later: ”the speed of the appointments has taken the organization by surprise” (BMJ 1 August 1998). Soon after her nomination by WHO’s executive board in January 1998, Mrs. Brundtland commissioned a five person transition team to coordinate analyses of WHO’s activities, structure, and processes. The transition team was headed by Jonas Støre20, based in Geneva and financed by the Norwegian government (BMJ 9 May 1998). The timeframe for the internal restructuring was three months, from 1 August until 1 November 1998 (Brundtland 1998). To assist the more long-term restructuring, a WHO Renewal Found has been set up. This has a three-year framework (1998-2001) with a resource ceiling of $ 10 million. By the end of 1998 almost 7 million dollars had been raised, while it remains more uncertain whether the 10 million dollars target will be reached (Brundtland 1999b: 10; WHO 1999a: 13). The Rockefeller Foundation has donated $ 2.5 million and the Norwegian Government nearly $ 1 million to the Renewal Found (Dove 1998:992). 12 other member states have also given their contributions to the found. It was the first time the Rockefeller Foundation gave money for administrative restructuring. It was said that it was not a personal endorsement of the new DG but to help improve the performance and potential of an important organization.

The most important changes in the reform process will be discussed under four main headings, linked to our indicators of leadership; organizational change, ‘reaching out’, funding and agenda setting.

4.1. Formal organizational and administrative changes A new cabinet structure. All of the existing programs and activities were reorganized

into nine different clusters and the head of each cluster composes the cabinet. Including the DG, the cabinet has thus ten members: six women, seven ’WHO outsiders’, and all of the WHO’s six regions are represented, with an even split between north and south (BMJ 25 July 1998).21 The old structure with the Cold War tradition by which the top WHO echelon of Assistant Directors General represented the Security Council member states was abolished. (Dove 1998:992 in Nature Medicine, Vol.4, No.2). The previous Assistant Director Generals was given temporary positions as Special Advisors, with the understanding that their contracts would not be renewed.

19 A brief account of the biography of Dr. Brundtland will be added later on. 20 Mr. Støre had been her right hand in her position as PM in Norway, as leader of the PM’s office.21 That is, only two of the ‘cabinet members’ were peviously affiliated with the WHO.



A reorganization of 50 programs into 35 departments, which again are grouped into nine clusters.

A new system of Management Support Units has been set up. The intention has been to move the management support closer to the Executive Directors (WHO 1999a: 17). A comprehensive evaluation of the Management Support Units performance should be provided to the Executive Board in January 2000.22

The ‘One WHO’ initiative to create a more unified organization. This is to be achieved through two main processes. First, through better co-ordination between the respective Departments in Geneva. The 10 Executive Directors are now meeting on a weekly basis, and the cabinet is organized more as a traditional state government. All Executive Directors will thus “own the policies that emerge from the cabinet”, as one Executive Director expressed it (Robbins 1999:36). It has moreover been emphasized that it is important to improve the cooperation between the various programs, and most of the new initiatives under the new leadership have been of a crosscutting character (WHO 1999a: 19). Secondly, through better co-ordination between the headquarters and the regional and country offices. The Regional Directors have now regular meetings with the Director-General, and the aim is to harmonize the agendas and programs of the regions and the headquarters (WHO 1999a: 6). For the first time in the WHO history country representatives from all member states have also been brought together in Geneva. During the weeklong meeting in February 1999 the representatives discussed how the organization could be streamlined and what the main priorities of the WHO should be (Brundtland 1999a: 5). Budgetary changes were also made across its regional offices (Nature Med., 4, 874-1998) not only was the Regional Offices given more priority, it was also emphasized that: ”The real untapped resources of this Organization are not located in Geneva or in the regional offices. They are in countries”.23

Several initiatives to upgrade the professional cadre at WHO.24

Go Harlem Brundtland’s first official act was to introduce new financial disclosure rules requiring all senior staff to submit forms detailing financial interests, patents, and positions held in the private sector. With the new set of rules, Mr Brundtland and her team were thus hoping to avoid unfortunate incidents, which have been troubling the organization in the recent past (Dove 1998:992). Moreover, It was said to be a part of "a general ethics initiative at the UN” (bid) not a response to specific incidents. A total of 21 top staff members were affected.

Initiatives to encourage team working. The (internal) memo ”Fourteen points for working together” was circulated to all staff shortly after her inauguration. In the memo GHB emphasized: ”This is a team of colleagues and friends who will depend on each other for advice, experience, the building of consensus, and unity of purpose. We need to know, trust, and help one another, to feel confident and secure in sharing our ideas and speaking our minds. It is an open, participatory process” (BMJ 1 August 1998).

A more active use of the staff rotation system. The aim has been to create a more dynamic and flexible organization. For many staff members this has probably lead to

22 Will find out what happened subsequently. 23 Statement by the Director-General to the Fifty-second World Health Assembly, WHO, A52/3, 18 May 1999, 5. 24 For an elaboration, see Robins, 1997:37-38.



a greater uncertainty, and the increased mobility has been controversial within the organization.25 The internal rotation has been an attempt towards the ‘One WHO’ the new leadership has been aiming for. By asking the Regional Directors to find vacant regional or country positions for professionals in Geneva, the Director-General has indirectly got involved in regional personnel decisions. This is the first time that headquarters has been involved in staff decisions at the regional level, and it might thus be an important step towards a more coherent staff policy for the organization (Robbins 1999:36).

More emphasis on research and knowledge, corporate decision making should be more informed and evidence-based.

The launching of new high profile programs like Roll Back Malaria, Stop Tuberculosis and the Tobacco Free Initiative,

4.2. ‘Reaching out’: to other parts of the UN system and ‘external’ actors

The following quote contains the essence of the new regime along this dimension: ”We have created and recreated partnerships – with the UN family, with the Bretton Woods institutions, with the private sector, with nongovernmental organizations, with research and with civil society”.26

While the WHO had an almost exclusive franchise on world health during the first years of its existence, several other actors have become heavily involed in international health issues, especially over the last two decades. The main challenge to the WHO’s monopoly has probably come from another UN institution, the World Bank.27 The Bank’s activities have of course always had an impact on world health, but as the reciprocal relationship between economic growth and human health has become increasingly clear, the Bank has gradually also become more directly involved in health issues. That involvement was explicitly formalized in 1993, when the Bank devoted its annual World Development Report to health. Currently, the Bank has its own specialized ‘Network for Health, Nutrition and Population’, and manages a $ 10 billion portfolio of loans specifically for health related projects (Economist, 9 May 1998). Compared to the total, WHO budgets of less than $ 2 billion, the Bank has clearly the ability to outmuscle the WHO financially. In addition, the Bank has direct access to countries’ finance ministries, an obvious advantage when to raise political and financial support to health related projects. Although the WHO officially always has welcomed the Bank’s involvement in health issues, the tensions between the two institutions was considerable during Dr Nakajima’s reign. In some countries the collaboration between the WHO and the Bank broke down

25 Personal interview with officials at the Regioal Office in Europe, 17 February 2000.26 Ibid., 6. 27 Although formally belonging to the UN system, the World Bank is clearly a very independet institution. In fact, the Bank in widely seen as separate from the UN system in general (Williams 1987: 160). I know/new/better reference/HOB



completely, and co-operation projects like UNAIDS were jeopardized in many regions. One of the new leadership’s early objectives was thus to “put a stop to that kind of nonsense” (Economist, 9 May 1998). In several of her first speeches and interviews she was thus emphasizing the importance of “reaching out to the rest of the UN family” (Brundtland 1998), and to establish more influential partnerships. As Mrs. Brundtland told the Executive Board in January 1999:

“We need to make a shift. We need to move from our traditional approach which too often has favored our own small-scale projects – to one which gives more emphasis to strategic alliances in which we influence both the thinking and spending of other international actors – and where what we do fits into this broader picture”.

During her first year in office Mrs. Brundtland had several top-level meetings with the World Bank, and her new leadership has indeed turned out to be a turning point in the relation between the two institutions. As Dr. Richard Feachem, until recently the director of health, nutrition and population in the World Bank, pointed out in an interview with the British Medical Journal about a year after Gro Harlem Brundtland had taken office in the WHO:

“The WHO has just elected the best possible leader that it could elect. Dr Gro Harlem Bruntland is fantastic, and her leadership heralds an era where WHO can be a truly powerful and influential agency working for the good of humankind around the world and really making a difference. And the bank’s commitment must be to support that process right down the line” (BMJ 1 May 1999).

During 1998 and with a perfect timing - at least from Mrs Brundtland’s point of view - the WHO and the Wold Bank were also able to announce major co-operative initiatives like Roll Back Malaria, Stop Tuberculosis, and the Tobacco Free Initiative (Abbasi 1999:5). These projects are based on a long-term partnership between the two organizations, and indicate that a significant change has taken place within a short period of time.

Similar initiatives have also been taken towards others UN organizations, such as for example the International Money Found and the World Trade Organization. The General-Directors of the WHO and the WTO have now agreed to meet on a regular basis, at least twice a year, to discuss the health dimension in the on-going global trade negotiations (Brundtland 1999b:9). The economic institutions are so far the most important ones, but also links to other UN organs such as FAO, UNESCO, ILO, The UN reform process and implementation of relevant UN Conferences.28 Voluntary Organizations (Red Cross), and the private sector.

28 For videre utdypning, se ’Collaboration within the UN system and with other intergovernmental organizations’, Report by the Secretariat, WHO, A53/26, 26 April 2000.



It has also been a key objective for Mrs. Brundtland and her team to increase WHO’s partnership with the private sector. The premise is that no UN agency; no non-governmental organization or no health ministry has the reach and distribution of power as multinational food and beverage companies. That is, WHO must work together with the private industry. To achieve this, it has been a clear message under the new leadership that investing in health is also sound economics as well as an investment in international security. This is a message that Mrs. Brundtland has forwarded in several forums and meetings with top-level attendance from Finance Ministers and international business. A key agreement with the private sector so far is the Tobacco Free Initiative, which is sponsored by three major pharmaceutical companies, each of them giving $ 250.000 to tobacco awareness programs over the next three years (Birmingham 1999:249). A similar agreement between public agencies and the private sector has also taken place in a unique attempt to develop a new anti-malaria drug - Medicines for Malaria Venture, MMV. The MMV will operate as a non-profit business, and has a large number of sponsors including for example the WHO, the World Bank, individual governments and the International Federation of Pharmaceutical Manufacturers (IFPMA). When the project was launched in November 1999, Mr. Lodewijk de Vink, President of the IFPMA, stated that he welcomed the “creation of the MMV, which symbolizes the start of a new era of partnership between the research-based pharmaceutical industry and the WHO to bring about real improvements in world health” (IFPMA/WHO 1999).29

4.3 High level agenda setting

It has been a part of Mrs Brundtland’s ambition to raise health issues on the international agenda, and transform the WHO from an interministerial to an intergovernmental and international organization (Robbins 1999:34). This is a long-term process, but it seems as though some important first steps have been taken, both through the improved partnership with other parts of the UN system and in the relations to external actors.

Considering the increased international attention towards the health issues more recently, the following quote is not only the usual UN rhetoric: ”Global public opinion is starting to realize where health belongs. At the core of every community's ’opportunity to secure sustainable economic development for its citizens. At the core of our efforts to combat poverty and foster development for all”.30

The new DG has indeed been able to rise the health issue on the international political agenda. Health has been an important at the last G-7 and G-8 meetings – previously it had never been an issue is such foras. Particularly the relation between health, economy and development has been stressed. These links are not novel, but starting out with health and investigate how important this is for economy and development is more of a novel idea. Convincing calculations of what can be saved and benefited from improved health has also been presented. (Ref). Key actors like the US as well as the EU has stressed the need for more weight on health and echoed many of the new DGs ideas. In short, the

29 To be elaborated with more recent developments, GAVI etc.30 Address by the Director-General to the Fifty-Third World Health Assembly, WHO, Geneva, 15 May, 2000, A53/3, 1.



health issue has reached the international political agenda in a way that it has probably never been before.31

4.4. Funding: Internal and external

When Dr. Brundtland entered office in May 1998 virtually the whole biannual budget for the period 1998-99 had been obligated, leaving only $9 million of a total two-year budget of $842 million to be reprogrammed by the new administration. Thus, the budget for 2000-01 was the first, which was prepared and presented by Mrs Brundtland and her team.

With regard to the regular budget founding, which is the contributions from the WHO member states, the budget proposed a zero real growth. Compared to the budgets under the previous Director-General, which were based on a zero nominal growth – in line with regular UN budget procedures - this was a minor, but significant change. Only during the 1990s, the member states’ contributions to the WHO had declined by 20% in real terms due to the zero nominal growth budgets. For the 2000-2001 budget, the difference between a zero nominal growth and a zero real growth would amount to more than 30 million dollars. Mrs. Brundtland admitted nonetheless that the increase was far below what she desired, but that she feared that a proposal for more dramatically increased contributions would divide the member states at a time when unity was needed to renew and revitalize the organization (WHO 1999b: 5).

When the budget was discussed by the WHO’s Executive Board in January 1999, the result was however, not surprisingly, that a zero real growth turned out to be unacceptable. The Board suggested rather that the budget for the 2000-2001 biannual should follow the zero nominal growth patterns, and the Assembly confirmed this in May the same year. In the final budget the regular funding amounted to $ 843 million, the same as in 1998-1999. It is interesting to note, however, that this happened in spite of the widespread support expressed by most governments for the reforms instituted by the new WHO leadership. An important reason – at least officially – as to why the proposed increase was turned down, was that key donor countries like the US, Japan and Germany feared that if they rewarded WHO with more money, a president would be set for the less deserving among the UN agencies (Financial Times 26 January 1999). This was clearly a major disappointment for Mrs. Brundtland and her team, although she refused to admit so in public at the closing of the Assembly meeting (Financial Times 26 May 1999).

In contrast to the zero nominal growth in the regular budget, the 19% increase in the extrabudgetatry funding for the 2000-2001 biannual seemed quite dramatic. In the budget it was emphasized that the funding from other sources represented a target to aim for rather than actual commitments for voluntary contributions. Many sources were skeptical that this seemingly ambitious goal would be reached. The skeptics have been proved wrong as the extrabudgetary funding has subsequently increased much more than the

31 This will be considerably elaborated.



expected 19% (add figures) and the two budgets are now about to become the same size (add precise figures). 32

Of other main changes in the budget it is important to note that: A shift of regular budget funds toAfrica and Europe has taken place. Compared to the 1998-1999 budget, the headquarters’ share of the total budget are

expected to increase with about 16% in the current biannual (WHO 2000:6). This increase is however solely allocated through the extrabudgetary founding. Looking at the regular budget fonds, there has indeed been a shift to the county level from both headquarters and regional offices. This implies that a larger share of the direct contributions from the WHO members are redirected to the country level, while the activities in the headquarters to a larger extent is financed through the more uncertain extrabudgetary sources.

5. Brief and very tentative discussion: Has the leadership of the new regime made any difference?33

The previous part to a large extent has answered this question. Considering all the internal and external activity and specific measures undertaken it appears that, yes, indeed, leadership has made a difference! Let us briefly summarize some of the main observations from part 4. There has been a profound reorganization both in relation to the Headquarter as well

as in relation to the Regional Offices and most observers seem to hold the opinion that this has been necessary to streamline and focus the organization. Does that mean the goal of one WHO is within reach? This will be discussed below.

It can be documented beyond doubt that health is now much higher on the international political agenda. What this means in practice will be elaborated below.

‘Reaching out’ – which we have here defined as encompassing three different parts: a) more cooperation and joint programs launched with other bodies within the UN system, b) - with other international organizations c) - with private industry. Performance here as described above gives clear indications of a more vital and ambitious organization. Again, it will be elaborated on below.

Economic matters. So far limited success regarding the ordinary budget, but ‘smashing success’ in relation to extra-budget financing.

In sum, we seem to be facing a transformation of an organization that was clearly discredited, fragmented and lacking leadership into one that is alive, ambitious and expansive – not the least due to new leadership. In the following I will discuss briefly why and how this change has come about and also add some nuances to the picture that might not be quite as bright as the points above indicate. WORD OF CAUTION. The

32 The new budget has just been presented and it seems to be a very good guide to evaluate the direction and priorities of the WHO. Unfortunately I have so far only had time to look at it very superficially. 33 I could have elaborated this somewhat more also within the time frame of this paper but I hace chosen not as as some rather important but maybe also sensitive information provided through the interviews need to be checked more closely before it is written down.



following is based on the interviews I have done so far. As I have not yet had time to systematize all of these for this paper, I write this basically out of the top of my head due to time constraint. When the interviews have been carefully gone through, others have been added and compared with more recent written sources, the final conclusions and observations will be more specific and elaborated. The subsequent thoughts are mainly to share with you some of my main preliminary impressions.

We have done quite a few interviews with people in various positions and different degree of closeness to the present DG. None of these have expressed any doubt that the revitalization of the WHO is directly linked to the change in leadership. Although critical remarks have been uttered and important nuances given, on balance there does not seem to be shred of doubt that the new DG with her new team has had a positive effect on the organization. What is the secret behind this success-story? A few brief points should be mentioned. The person Dr. Brundtland has made a big difference. Her reputation and connections

internationally is of a nature that is not common to Directors of UN agencies. This has been particularly helpful in agenda setting and in other external relations.

The quality and work of the transition team is pointed out by many as a key to the early success. The work done by the head of the transition team, Mr. Støre, is by many sniggled out as a crucial factor in explaining success. He was basically a policy person and spent significant amount of time on staff questions and reorganization issues. Other key persons on the transition time helped him effectively on this very demanding task – considering the profound changes made and the size of the organization. Many other organizations have shown an interest in borrowing this ‘transition-team approach’.

Good relations to key actors, in particular the UK, the US and also the EU are mentioned. In the words of one of the interviewed; under real world circumstances you cannot do much unless you are able to work with such actors. This seems to have been achieved without getting into conflict with developing countries – thereby balancing the need for effectiveness and legitimacy.

Let us then move on to our four points presented above. Has the new leadership been able to move the organization towards one WHO? Our preliminary answer is inconclusive. Although a number of steps have been taken in this regard, a lot remains to be done. First, however, it should be pointed out that this model as such does not only has drawbacks but important assets as well. The idea of having regions and country offices with more detailed grasp of the specific problems have many advantages. This being said, streamlining was definitely called for. The direct involvement by the headquarter in relation to the country offices seem to have caused some tensions on part of some Regional Offices as these used to be ‘their’ offices. The fact that the heads of three of the Regional Offices ran for office in competition with the present DG also represent a potential tension, although opinion vary on this point. The Pan American Health Organization (PAHO) stands out as a particular case as it receives only 20% of its funding from the WHO.34 Although the new leadership is generally described positively in PAHO, although there are nuances, it is said quite openly that the new leadership has

34 This history will be added.



not made much of a difference to PAHO, and this perception is confirmed at the Geneva Headquarter. The European regional office seems generally positive while it appears that there are significant differences between the remaining four Regional Offices. All in all, based upon my impression so far – it is still a long way to go, but the distance to a large degree depends upon what the exact meaning of one WHO is meant to be.

What about the situation in Geneva. As noted, there was optimism among staff, but also some worry due to the swiftness of the process and the new rotation system. It appears that after a ‘honeymoon period’, the sky is no longer only blue in Geneva. The nature of the clouds – if they are really there - will be elaborated and detailed in the final version of this study. The picture is much more conclusive regarding the high-level agenda setting. This is a leadership success. However, it may also be a success that may prove difficult to follow up in practice. The successful agenda setting has created high expectations. Other studies have showed that it is much easier to exert leadership in terms of agenda setting compared to actual implementation and ‘delivering’ the goods. (Andersen and Agrawala, 2000) There is no doubt that this agenda setting has led to more money and more programs, but it will be a demanding task to follow up over the long haul – as the new DG and the new regime do not only have good friends. Some wait for the positive tide to turn – and a possible set back will be more noticed when expectations, as well as the profile, is so high. That is, the jury is still out on the lasting effect of the agenda setting. This to a large extent depends upon the ‘reaching out’ strategy and the funding situation. Based on our written material presented above, ‘the reaching out’ strategy is a success as well, but the interviews have brought more nuances here. It is quite clear that the picture is not that idyllic, in relation to for example the World Bank – although the new regime as such is described very positively. There are disagreements over what the mandate; purpose and comparative advantage should be for the two organizations in some instances. It is also some controversy over who should take most credit for various programs, and who should be in the ‘driver’s seat’.35 Many NGOs also find the cooperation with private industry, like the pharmaceuticals, highly controversial, something like going to bed with the enemy. The new regime has a very pragmatic attitude here. These actors cannot be ignored. Cooperation is therefore necessary - although bound to be very demanding. Based on my impression so far, however, the WHO has been quite successful along this dimension. We have not dealt with the link between health and the environment – although functionally it is little doubt that it exists. Although there has been some work done along this dimension, many are disappointed that not more is done - considering the background of the present DG.36 On the other hand, some top officials in Geneva feel that there is already ‘too much going on in the organization’ – so some difficult priorities may be needed further down the road.

In terms of economy, it is clearly a set back that not more has been accomplished in relation to the ordinary budget. This is an uphill struggle even for a leader of Dr.

35 At this stage I am deliberately vague here. Examples will be provided and points will be fleshed out. 36 This view was also expressed at the Headquarter.



Brundtland’s caliber as it has its roots in the whole UN system. Many countries say they would be willing to increase the budget but as the WHO is an integral part of the UN system this is bound to be a part of the broader issue of UN reforms, and not much should be expected here. This has made the extraordinary budget route a tempting – and very successful - alternative. Still, as one person pointed out, this may ultimately lead to ‘Arthur Anderson Health Co’ - not necessarily quite what the founding fathers had envisioned. As the two budgets are getting to be about equal in size, it will pose challenges in terms of priorities, control and the direction of the organization. This does not diminish the accomplishments made by the present regime in increasing the budget, but if the internal budget continues to diminish and the external to increase, this may pose challenges of its own.

6. Some short preliminary conclusions

The overall picture of the accomplishments of the new regime is very positive along most dimensions we have chosen to look at. Externally the picture is quite conclusive; internally it is somewhat more uncertain. Being a Norwegian researcher, essentially using money paid by the Ministry of Foreign Affairs – although channeled through the Research Council –I am glad that there are some clouds out there. That is always the case under real world circumstances. I will specify these clouds later on – if they are real - and learn more about their specific nature, potential consequences and possible remedies. A final observation, two years and a half are a very short time. Optimism was very high initially. It has vaned slightly over time. To get a really realistic picture of the accomplishments – a longer time frame is necessary. It is up to the NFR do decide if they want a more comprehensive picture of the reign of the new regime.



Some of the references

Abbasi, Karan (1999): “The World Bank and world health. Healthcare strategy”, British Medical Journal 3 April 1999.

Andresen, Steinar and S Agrawala (2000), Leaders, Laggards and Pushers in the Climate Regime, The Fridtof Nansen Institute, R: 009, 2000, submitted to Global Environmental Politics, January 2001.

Birmingham, Karen (1999): “Bruntland makes waves in her first six months at the WHO” Nature Medicine, Vol.5, No.3: 249.

Brundtland, Gro Harlem (1998): Address to WHO staff. Geneva 21 July 1998.

Brundtland, Gro Harlem (1999a): Looking ahead for the WHO after a year of change. Statement by the Director-General to the Fifty-second World Health Assembly. Geneva, 18 May 1999.

Brundtland, Gro Harlem (1999b): WHO – the way ahead. Statement by the Director-General to the Executive Board at its 103rd session. Geneva, 25 January 1999.

Dove, Alan (1998) ”Bruntland takes charge and restructures the WHO” Nature Medicine, Vol.4, No.2: 992.

Godlee, Fiona (1998): “Dr Gro Harlem Brundtland is a former prime minister of Norway and has been a leading voice on the environment”, British Medical Jounrnal, 3 January 1998.

IFPMA/WHO (1999): WHO, Partner Agencies and Industry Launch Unique Venture to Develop Malaria Drugs. Press Release 3 November 1999. Geneva: IFPMA/WHO.

Robbins, Anthony (1999): ”Bruntland’s World Health Organization: A Test Case for United Nations Reform” Public Health Reports Vol. 114, No. 1: 30-39.

WHO (1999a): A Progress Report on Then Months of Change. Geneva. WHO (1999b): Proposed programme Budget 2000-2001. Geneva.

Bass, Bernard M. and Bruce J. Avolio (eds.) (1994): Improving Organizational Effectiveness Through Transformational Leadership. Thousand Oaks: Sage Publications.

Philip Selznick (1957): Leadership in Administration. A sociological Interpretation. Berkley, Los Angeles and London: University of California press.

Dallin, Alexander, 1962, The Sovjet Union and the United Nations, London: Methuen.

Peabody, John W., 1995, An Organizational Analysis of the World Health Organization: Narrowing the Gap Between Promise and Performance, Social Science of Medisine, Vol. 40, No. 6, pp 731-742.

Mitrany, D., 1973, ”The Functionalist Approach in Historical Perspective”, Interantional Affairs, Vol. 47, No. 3, pp 532-546.

Dove, Alan (1998) ”Bruntland takes charge and restructures the WHO” Nature Medicine, Vol.4, No.2:992.

Robbins, Anthony (1999): ”Bruntland’s World Health Organization: A Test Case for United Nations Reform” Public Health Reports Vol. 114, No. 1:30-39.

WHO (1998): A Progress Report on Then Months of Change



Underdal, A and O Young (2001)


Documents

WHO April 2000-04-10 - forskningsradet.no€¦ · Web viewPaper to be presented at the 2nd MULTI Conference at . Vettre Hotell, Asker 17-18 January, 2001. Very preleminray draft