Reform of the WHO depends on next week's vital budget debate

BMJ 1998; 316 doi: (Published 09 May 1998) Cite this as: BMJ 1998;316:1407
  1. Fiona Godlee
  1. BMJ

    As the World Health Organisation prepares to celebrate its 50th birthday, one woman looks set to prove that you can teach an old dog new tricks. According to commentators in Geneva, Dr Gro Harlem Brundtland, due to be confirmed next week as the WHO's new director general, has already transformed the atmosphere of the organisation. But how much she can achieve in her first term could depend on the outcome of a debate about the budget at next week's meeting of the World Health Assembly.

    Soon after her nomination by WHO's executive board in January, Dr Brundtland commissioned a five person “transition team” to coordinate analyses of WHO's activities, structure, and processes. Based in Geneva, the team is funded by the Norwegian government and led by Jonas Store, a senior Norwegian diplomat.

    Eleven satellite groups, each headed by external experts, are drafting detailed analyses on key issues. The transition team will report to Dr Brundtland over the next three months, and it will cease functioning when Dr Brundtland takes office on July 21.

    Areas being investigated by satellite groups include staffing, communications, how to develop more effective relations between the secretariat (the director general and her staff) and other key players (the executive board, the assembly, donors, non-governmental organisations, and other UN agencies), and how to place health at the centre of the development agenda—as a vital ingredient of successful development rather than just one result of it. The transition team has also targeted some specific issues for analysis by satellite groups—malaria, tobacco, and mental health. Speaking for the team, Ann Kern explained that these would act as test beds for integrated approaches to improving health and building national capacity.

    But the most important issue, according to commentators in Geneva, is the budget. Changes in the allocation of WHO's limited resources will, they say, be vital if Dr Brundtland is to make a significant impact on the way WHO works. In a crucial debate at next week's meeting, the assembly will consider a recommendation from the executive board to scrap its traditional method of budgetary allocation, which is based largely on historical precedent, and move to a needs based approach. If adopted, the change will mean big gains for Europe and Africa, and big losses for South East Asia and the Western Pacific (see p 1403).

    Not everyone is happy about the proposal. Japan, one of the most influential countries in WHO's Western Pacific region, is understood to have prepared an alternative proposal for presentation during the debate. This would limit the budgetary changes to the 60% of the regional funds that regions are supposed to allocate directly to individual countries, protecting for the time being the funding for regional offices.

    But whatever the assembly decides, Dr Brundtland can do little to alter the budget for the next biennium (1998-9) since this has already been passed by the assembly. Much of the preparatory work has also already been done on the budget for 2000-1. The budget and finance satellite group has been charged with exploring how much room remains for manoeuvre during Dr Brundtland's first five year term. Insiders suggest that this will greatly depend on how much influence she can bring to bear on the regional directors.

    Reaction to Dr Brundtland's initiative has been largely favourable. Most commentators have praised the way she has managed to stimulate analysis of the organisation while keeping her distance. “We are mainly relieved to be at the end of a 10 year nightmare,” said one director. “The confusion and low morale meant everyone was fighting for themselves and things were hopelessly fragmented. We are now looking forward to some clear policy objectives and cohesion.”

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    Dr Brundtland is already making changes at the WHO


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