GENEVA — Diplomacy in the World Health Organization looms larger than it should because it covers not only relations between its secretariat and member states but also relations among the organization’s seven major offices, each with a politically elected head. As the WHO prepares to elect its next director-general to replace Margaret Chan of China a year from now, it is worth considering how the organization acquired its anomalous structure and what, if anything, might be done to improve it.
Hopeful candidates — including Philippe Douste-Blazy of France, Sania Nishtar of Pakistan and Tedros Adhanom Ghebreyesus of Ethiopia — will make their presentations to member states in November 2016. In January 2017, the executive board will propose candidates to the World Health Assembly.
When the World Health Organization’s constitution was drafted in 1946, its goals were quickly agreed upon. But “by far the most controversial questions . . . concerned (1) the arrangements to be made for the establishment and functions of new regional offices or branches of the Organization and (2) the relationship of existing regional health agencies to the Organization,” according to official records.
What is now the Pan American Health Organization pre-existed WHO and had no wish to dissolve into an upstart agency. It insisted on a quasi-autonomous status, which the other regions wanted, too. It was decided therefore that “The Pan American Sanitary Organization . . . shall in due course be integrated with the Organization,” but that never happened.
Instead, the WHO operates with six regional directors, each well connected to their national health ministers, and a director-general, Chan, who needs their agreement on big decisions. Given that regional allegiances can be stronger than global, consensus among the WHO political heads can seem like an achievement in itself. Thus a statement on Ebola reads like a parody of the UN Charter: “We, the Director-General, Deputy Director-General, and Regional Directors of WHO, are making this commitment of collective leadership to Member States and their peoples.”
That stance really ought to go without saying. What is not generally known outside the organization is that the regional divisions echo all the way down to middle management and below. What ought to be decided by a responsible officer must be negotiated with counterparts, entailing too much interoffice travel. In Chan’s office, the deputy director-general, Anarfi Asamoa-Baah of Ghana, and the executive director, Ian Smith of Britain, came in on the temporary transition team of different directors-general. Both have stayed for decades (18 and 13 years, respectively).
In realms where scientific evidence is not the only consideration, access is crucial to influence, evidence can be trumped by hearsay, and body language can prevail over logical argument. In such an environment, it becomes possible to imagine that good diplomacy might be a valid substitute for emergency action.
When that error is pointed out, diplomacy is used to change the subject and to disperse the blame. Senior management returns to its process of structural reform, the technical experts continue their work and the complex layers of administrative diplomacy above them ensure that nothing happens too suddenly. In addition, financing gaps are supplied by the parents of unpaid interns from good universities.
How quickly can the WHO, based on such a convoluted structure, respond to a severe outbreak of disease? One of the first things that the organization did when the Ebola emergency was finally declared, on July 26, 2014, was to move its African regional committee meeting (which was about to elect a new regional director) far from the danger zone in West Africa, where Ebola was spreading fast.
Benin’s foreign minister, Nassirou Arifari Bako, “clarified that the indefinite postponement was an expression of full solidarity to the continental countries, presently battling with EVD,” or Ebola virus disease. The meeting took place in Brazzaville, Republic of the Congo, in November 2014.
During the H1N1 influenza epidemic of 2009, I attended the first meeting of the International Health Regulations emergency committee as an interpreter. On that occasion, the World Health Organization was roundly criticized in public for getting the response wrong. And yet I came out of that meeting — which was chaired by Chan and Keiji Fukuda, assistant director-general for communicable diseases — amazed at the skill, speed and clarity of the participants.
I was proud to be a part of that work, and I still am. There are so many talented, energetic people throughout the organization, some of whom coldly risk their lives, day by day, to stop an epidemic and to save lives. But the immense talent and commitment of the secretariat and member states’ representatives are often frustrated by the organization’s structural ineptitude. Attempts at reform either fail or become administrative ends in themselves, with their own teams and their own jargon.
Still, five moves can be considered:
• The new director-general should seek a mandate to phase out political elections of regional directors, replacing them with appointees who answer to the director-general. Given the importance of the regional posts, the new appointment process must be open to scrutiny.
• Member states should be part of only one regional committee each and not, as with former colonial powers, several of them at once. Failing that, whenever a major health emergency is declared, the director-general should become “commander-in-chief,” issuing direct instructions and resources to countries, with retrospective justification to the governing bodies.
• If people work, they should be paid. Interns should be recruited under the same geographical distribution that governs recruitment of regular staff.
• Frequent-flier benefits should accrue not to the traveler but to the employing organization.
What are the chances of these recommendations happening? Let’s start with the easy ones. Frequent-flier benefits could be switched to accrue to the WHO immediately, reducing its costs and carbon footprint if the director-general so decided. As for interns, the European Commission has paid its interns for decades; political and financial support for extending internships to bright people in poorer countries can be found.
Regional committee membership is a political anachronism, but the diplomatic vanity to defend the current makeup is alive and well.
Phasing out political elections of regional directors? As the speed and complexity of public health work increases, the ineptitude of the WHO’s seven-headed regional system becomes increasingly apparent, but if the Ebola crisis did not prompt moves to change it, only an utter catastrophe could.
Lastly, at the recent 69th World Health Assembly, a new health emergencies program was established. Although the program will not resolve the administrative problems of the WHO, it can override them at crucial moments.