Education And Debate

The World Health Organisation: WHO at country level — a little impact, no strategy

BMJ 1994; 309 doi: (Published 17 December 1994) Cite this as: BMJ 1994;309:1636
  1. Fiona Godlee
  1. British Medical Journal, London WC1H 9JR, assistant editor.
  1. Correspondence to: Department of Ambulatory Care and Prevention, Harvard Medical School, 126 Brookline Avenue, Boston, MA 02215, USA.

    WHO at country level—a little impact, no strategy

    The acid test of WHO's effect on the world's health is its impact at country level. Unless it has an impact there, all of its declarations, its debates at the World Health Assembly, its conferences, its pamphlets, its political manouvering in Geneva and the regions, all of these come to nothing. Working as it does through national governments, WHO insists that it has no role in directly managing or delivering health care. Judging WHO's impact in individual countries is therefore difficult—its approaches are largely indirect, and initiatives may take years to bear fruit. But from the meagre resources that WHO makes available at country level it is clear why its country operations are criticised as the weakest link in an already weak chain of influence from its headquarters in Geneva to the people in its member states. Poorly funded, undertrained, and with no clear strategy to follow, its staff at country level stand little chance of making an impact.

    The Implementation gap

    WHO's aims are in the best tradition of sustainable intervention—to help countries to build up their own health care infrastructure and professional expertise. As laid down in its constitution, WHO works through national ministries of health. The arrangement has its advantages. Because of it, WHO is accepted in all member countries and avoids the charge of neocolonial interventionalism. But it also combines with WHO's financial woes to create what commentators are calling WHO's “implementation gap.” WHO has neither the mandate nor the means to implement its own programmes. It is entirely dependent on the receptiveness and effectiveness of national ministries of health.

    In some regions this leaves WHO all but powerless to act. In Africa, for example, where WHO faces its severest challenges, many governments cannot deliver health care in line with WHO policies. They do not represent their people at …

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