On January 22nd, Lancet editor and Twitter afficionado Richard Horton was in a rather grumpy mood. He was attending the 132nd WHO Executive Board meeting in Geneva and, being Richard Horton, he obviously had a number of incisive questions and blunt comments ready for the Board. Generous as always, he informed the world about them through Twitter.
In one particularly blunt tweet, he lashed out at WHO’s Executive Board, accusing it of ‘failed governance’. However, he reserved most of his criticism for the performance of regional and country offices, not for the first time by the way. It’s worth to list some of these tweets in full here to get the picture: (1) Too often, criticism is directed at WHO Headquarters. Instead, look for the ”common irregularities” in regional and country offices. (2) In regional/country offices, you will find staff behaving like “dictators”, with no performance management, fraud, dishonesty, waste. (3) If WHO’s Executive Board is serious about “reform”, it should launch independent audits of regional and country offices. Will it? .. Etc. (Probably lousy breakfast. )
We don’t know whether Horton, a seasoned WHO watcher (see here and here for example) got some clear answers on these questions at the Board Meeting, and of course, one needs to have Horton’s enormous ecological footprint to be able to assess the claims he makes about regional and country offices around the world. Gauging what’s going on in Horton’s brain is risky business even at the best of times, but nevertheless, it seems likely he had – among others – the AFRO regional office in Brazzaville in mind and some African WHO country offices when sending out the grumpy tweets. He probably had other regional and country offices in mind too, but let’s focus here on Africa.
Although Horton is one of the most vocal critics of regional and country offices, he is not alone in this. You often hear similar claims in the corridors of global health conferences or in discussions with global health stakeholders: WHO’s weaknesses are most obvious in the AFRO regional office and in the country support it provides (or fails to provide) in some sub-Saharan African countries. In some processes in which WHO was expected to take the lead or be a key actor, the organization lagged behind other actors in the African region, people ‘in the know’ say. This lackluster performance is part of the reason why WHO lost support, these same voices often argue.
However, even if there seems to be a substantial problem with WHO performance in the African region, it’s a complex issue and the direction of causality is far from clear. Lack of capacity, organizational culture (too bureaucratic; not very pro-active?); staffing policies ( often including political pilotage instead of rewarding technical skills; poaching by Geneva of the more competent people?), financing issues (including the competition between regions for donor funding, and the vertical/horizontal financing trade-off; donor interests…), the link with the perceived key functions of the WHO in general and at regional level, … all these factors play a role. More analysis of the reasons behind the lackluster performance of the AFRO regional office and some country offices thus seems warranted.
Having said that, it’s clear that if the ongoing WHO reform is to be a success for sub-Saharan African countries, the organization needs to delve into this issue, and try to remedy it. Otherwise, further marginalization of the regional office and country offices looms. WHO can’t expect external actors to challenge its performance and provision of assistance in sub-Saharan Africa – the latter often benefit themselves from the relative weakness of WHO there. Moreover, in every partnership there’s always a reluctance to single out a partner for criticism, and this is even more true for smaller actors bent on maintaining a good relationship with WHO. So WHO has to do it, nobody else will do it for the organization.
No doubt a case can be made for strong regional and country offices, if only to be able to provide context-specific support. Needs in the AFRO region are obviously very different from needs in the EURO or SEARO region, and priorities of work will differ. In the EURO region the focus is more on norm setting and policy dialogue within countries, for example, whereas in the AFRO region WHO is considered to provide more development assistance for health (eg polio eradication).
There is definitely a need for technical assistance at country and regional level. True, a regional office which has to cater to DRC as well as to Ghana and Ethiopia, like AFRO, is perhaps too ambitious; regions could be conceived smaller in order to be more coherent – like SADC for example. But anyhow, a proper reform would identify needs at country and regional level, assess the capacity and performance at these levels, and if necessary go for a radical overhaul.
Some regional offices are arguably already fairly strong and (too?) independent; Legge and Horton both consider excessive decentralization as one of the core problems for the organization. But others want more decentralization – the benefits outweigh disadvantages, they claim. But then of course you need a performing regional and lower-level organization and sufficient alignment with the goals of the headquarters.
Let’s see whether the WHO reform, where alignment between global, regional and country offices is high on the agenda, and the new (and already controversial) ‘financing dialogue’ manage to address some of these issues. We sure hope the reform will trigger a positive trend. We all know the global health arena sometimes resembles “survival of the fittest”: if an organization is marginalized and considered relatively weak in a region, other actors will fill the gap. The global health arena has changed too: there is a proliferation of actors now, and leadership and authority depend less on a formal mandate but more on credibility, the capacity to mobilize around shared goals and a stakeholder’s actual contribution. Even perception matters in this new constellation.
As WHO is embarking on a Universal Health Coverage crusade around the world, many countries in sub-Saharan Africa need support in developing health financing strategies. The same is true in many other public health areas, like in the battle against NCDs. Let’s hope the regional and country offices will be up to the task, and that the WHO reform provides them with the tools to play their role. We agree with Legge and many others that a strong and effective WHO is a necessary condition for the global health crisis to be addressed.
In a ‘rising Africa’ era this seems even more urgent.
Conclusion: Reforming the Complex WHO AFRO regional system will be a slow, ponderous process.