Brundtland says she means businessBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7144.1553 (Published 23 May 1998) Cite this as: BMJ 1998;316:1553
At the same time as celebrating its own 50th anniversary, the World Health Organisation last week confirmed the election of Dr Gro Harlem Brundtland, who had formerly been prime minister of Norway three times, as the organisation's fifth director general.
Applause broke out as the audience stood to honour the first woman to take the helm of the WHO. Dr Brundtland launched into her inaugural address, the leitmotiv of which was “hard work ahead.” She said: “The transition from one century to another sees changes which will be faster and more dramatic from an economic, social, and health perspective … WHO can and must change. It must become more effective, more accountable, more transparent, and more receptive to a changing world.”
Dr Brundtland's overall motivation is “making a difference.” Her primary areas of concern for her five year term, which begins on 21 July, are: rolling back communicable and non-communicable diseases (malaria and tobacco were singled out for concentrated campaigns); building sustainable health systems that emphasise a more equitable distribution of the WHO's limited resources to those in greatest need; and developing a broader based, scientifically well founded approach to health advocacy.
Internally, priority will go to research underpinned with solid facts, building technical support, and identifying best practices that are cost effective. Externally, wide ranging partnerships—with WHO's 191 member countries, other UN and international agencies, non-governmental organisations, and the private sector—and political activism will be crucial, Dr Brundtland said, to meet the health challenges linked to the persistence of poverty: “People in developing countries carry over 90% of the disease burden, yet have access to only 10% of the resources used for health. This is unacceptable. This has to change.” She wants health to be put at the top of the world's political agenda and recognised as the key to poverty reduction and human development.
Dr Michel Jancloes, the director of the division for intensified cooperation with countries and peoples in greatest need, commented: “Poverty is a pivotal issue. I feel that all the necessary ingredients are there for WHO to play a proactive role within the UN system in reducing it.”
Dr Brundtland knows what she wants. Achieving such ambitious goals, however, means radical administrative overhauls in a WHO which has become bloated at the top and still allocates its resources according to historical precedents set half a century ago.
As far as reallocating regular budgets to regions is concerned, the push to shift funds that the WHO's executive board initiated in January has already produced concrete, albeit sharply contested, results. After a debate during which one of the six regional representatives reportedly walked out in protest, the World Health Assembly passed a resolution that will benefit the neediest African and European countries in transition, primarily at the expense of South East Asia, by gradually shifting resources over six years starting in 2000. The 48 least developed countries—most of which are in Africa—have been given top priority.
The chairman of committee B, which deals with the WHO's financial matters, Dr Nimal Seripala de Silva from Sri Lanka, said that this decision represented “a very special gift … in which WHO's interests were put above personal or regional concerns. This present will strengthen [Dr Brundtland's] hand” in transforming the WHO from the inside out.
Dr Brundtland spoke out in favour of a flatter internal structure and fewer layers but declined to give any details before actually assuming office. Rumours were rife that funding for the six resource intensive regional offices, some 50 programmes and 10 deputy, assistant, and executive director generals was going to be reduced.
Such radical downsizing could free up funds for the tasks at hand, but some questioned the feasibility and political astuteness of actually doing so. The WHO's deputy director general, Fernando Antezana, suggested that, since many people in top positions are at or over the 60 year old retirement threshold that Dr Brundtland has vowed to respect, streamlining through attrition would be a viable—and perhaps politically less hazardous—approach. More important for translating the areas of concern mentioned above into an efficient and effective structure, however, would be the overall concentration of the organisation's sprawling divisions into a reduced number (possibly four) of clusters.
According to Dr Brundtland's address to the executive board on 18 May after the World Health Assembly, the first cluster will concentrate on building healthy communities and populations; the second will focus on combating ill health (communicable and non-communicable diseases); the third will devote itself to outreach and external relations with virtually the entire spectrum of WHO's stakeholders; and the fourth will be committed to sustainable health systems.
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