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Wednesday, October 8, 2014

WORLD HEALTH ORGANIZATION: CRISIS OF RENEWAL AND MEDICO_BUREAUCRATIC INCOMPETENCE



A QUESTION OF MEDICO-BUREAUCRATIC INCOMPETENCE IN INTERNATIONAL HEALTH: THE CASE OF WHO “RENEWAL” AGENDA.


BY KATELE KALUMBA, ( FIRST AUTHORED IN 1997, BLOGPOSTED 2014)

Former Minister of Health, Zambia (1996-1998 and WHO Executive Board Member, 1994-1998)

I must admit from the outset that the first real study I had of the World Health Organisation’s quest for “Renewal in response to Global Change” was in a manuscript sent to me for a “Forum” debate by the author himself, Derek Yach in early 1996.  In many respects, Derek Yach’s article on current considerations in the development of a new global strategy for health euphemistically called in WHO jargon as a “Renewal of Health for All” and its relevance to South Africa, ( and now to initiatives on the review of the WHO constitution) makes interesting reading . If one read it correctly as an “official”  WHO text written by a Policy Adviser in WHO Central government, it says absolutely all the right things about what is the cutting-edge policy thinking likely to usher in a “renewed” global health strategy.

Previous WHO documentation on the subject appeared to me rather ‘too standard’ and undeserving of a real critical intellectual reflection. Upon reading Yach’s article at first, I dismissed as a wasteful exercise for me. I put it aside until six months later in July 1996 during a “health sector reform review retreat” I organised with my staff upon my being appointed full Cabinet Minister of Health in our Zambian  government. I had been a Deputy Minister of Health for five years then, with the intellectual space to think and attend WHO meetings and read long health dissertations by many international health specialists who sought my comments. But as a full Cabinet Minister and without a Deputy Minister appointed to support me for the rest of our government’s tenure of office until elections, little time was available for me to engage into  esoteric thinking about global health. I had done a lot reading on international health work as member on the WHO Executive Board prior to my Cabinet appointment.

During the retreat, I had chance to read again Yach’s article. It provoked my critical thinking about international health work and forced me a few months later to review critically, the Executive Board’s final Working Group’s Report of 1993 on “WHO Response to Global Change”. I recalled the document presented to the Ninety-second session but I never contributed in greater detail as a neophyte member of the Executive Board in January 1994.



Much has taken place since that report but Yach’s recounting of it in 1996, and its influence over the direction or agenda that WHO embarked upon even under Gro Brutland’s tenure provoked me to reflect seriously upon the issues captured by both Yach and the Global Response Report. The impact of the thinking contained in the Report and those raised by Yach are central to my Executive Board’s other Group’s activities to review the WHO constitution. As this year , marks the end of my tenure, I felt compelled to articulate my concerns, hopefully precisely and persuasively.

My analysis is divided in two major parts. First, is a critical review of the EB Report on Global Change and the second part is a specific reaction to Yach’s manuscript which seeks to bear relevance to Southern Africa. and, I hope to the Constitution review work.





PART 1.         A DECONSTRUCTIVE REVIEW OF THE 1993 EB REPORT ON WHO RESPONSE TO GLOBAL CHANGE

1.1       THE METHOD OF WORK

The Executive Board Working Group (EBWG) approached its task within its terms of reference provided in decisions of EB 89(19) and EB90 (10). It met five times formally during its work and exchanged views with the Director General and Regional Directors. In its assessment, “ these exchanges contributed significantly to a better understanding of the critical factors underlying the accomplishments and shortcomings of WHO” including the EBWG’s chance to “identify opportunities for improving the effectiveness of the Organization” (p1).

There is no reference in its description of working method of efforts made, if any, to  exchange views with many stakeholders outside the WHO system itself.  As for member country inputs, it appears that the EBWG relied solely on the EB’s “preparatory group” opinion poll of delegates (defined as “Member states”). Nothing much is said about this “survey methodology”  on the Members states definition of issues confronting WHO. As a leader of my country’s delegation in that year to the WHA, I have no official record of such as interview. Therefore, I would assume that this was a “sample” opinion. Nothing is more critical in the area of policy analysis than the method by which information for decision-making is collected. I plead ignorance on scientific credibility of the opinion poll an wish to say nothing about its significance.

1.2       Analytical Paradigm


Two key concepts underlying the definition of problems, their analysis and recommendation of the EBWG are: global change and crisis. The first is empirically assumed to have been precipitated by the end of the “Cold War”. The end of the “Cold War” (CW) precipitated major political, economic realignment of relations globally. It is implied in this definition that it is the end of the CW and nothing else that would explain the assumed realignments in global relations. Suggestions of these realignments are found in growing emphasis on market based economies and democratic reforms. There is increasing stress on individual rights and responsibilities for health, food, housing, education, and political representation. (p1).

What is not clear from the outset in this definition just listed is whether  these could really be shown to have been principally attributable to the end of the “Cold War”. A casual perusal of literature leading to the Alma Ata meeting in 1978 make great reference to similar factors except perhaps to “market economies”. “Popular participation for example, was a key concept then reflecting the need for representation. This says nothing about the structure or form of such representation but that people’s participation in health decision-making was certainly a major principle at the time.

In sum the EBWG puts forward a thesis of “increasing demands” amidst  a “decline in the pace of economic growth, and growing debt”. It is not clear whether these “supply” side problems are also attributable to the end of the “Cold War”. If demanding is increasing while supplying is declining, then the problem must defined as a “crisis”. Students of crisis theory in economics would seriously question whether this situation is a new phenomenon in the welfare economics.

The EBWG proceed by further defining this crisis by the manner in which  “National authorities” have responded to it. “ National authorities [have bee] preoccupied with health sector financing, particularly the rising costs of medical care which threaten the sustainability of cost-effective primary  health care (PHC) interventions” (p1).

One may wish to ask: is that all that has been at the level of response by national authorities? Is there no evidence (even inadequate theoretically and empirically) that governments have dealt broadly with this demand vs supply problem at different points in the last three decades (at least since the 1960s) as a ‘crisis of management and organization’.  Is it not true that  the history of  our last three decades is littered with attempts to reform health systems by a combination of anyone of the following interventions:

a.         reformed methods of financing and delivery?
b)         political and bureaucratic change?
c)         more research and better means for assessing technology  including HSR?

A careful analysis of literature would reveal that the stress on the role of  markets and privatization, incentives, and disincentives, cost control and cost benefit analysis, deductibles and co-payments, various budgeting and organizational schemes , centralization vs decentralization span a  long history of health systems development thinking. The EBWG does not provide us with their assessment of the adequacy of all the various national responses to the “health crisis”.  One would wish to ask, given this history, have all these responses been enough?  Even more cryptically, we could raise the question, “enough for what?”

1.3       MISSION AND DIRECTION OF WHO: CHALLENGES

I wish to offer a critical counterpoint, and perhaps others have already done so, regarding the definition of this “crisis” and the characteristic responses so far advanced. I pose the question: Is it not the case that is , le problematique, national and global responses by institutions such as WHO have focused primarily upon the issues related to the means of medicine and health care and not, upon their goals and ends? The intensity of WHO’s work through the EBWG on Global Change has obscured the poverty of discussion about the purpose and direction of medicine and health care and hence upon the WHO’s own global goals and purposes. Shouldn’t we be considering as one major issue,  the point that the ends of medicine and health care and not only the means for them are at the core of the definition of the “problematique” of global challenge for WHO? Too often, it is taken for granted that the goals of medicine and of its service technology of health care are all well understood and self-evident, needing only sensible implementation. The Report by the EBWG on this is a classic example. It makes WHO seem like the modern equivalent of the tower of Babel!


We are solemnly told by the EBWG that WHO has undeniably helped to improve health status. However, apparently extraneous factors such as rising individual health expectations, the pace of change and WHO’s expanding programme responsibilities are outpacing current resources and institutional capacity. Now, let us understand the somewhat salient criticism of WHO underlying this statement. If the range of health challenges have been increasing globally ; if WHO interventions have positive attributes on health status; would it not be logical, in the first instance to expand WHO programme responsibilities? But if at the same time, these responsive and expanding programme responsibilities are outpacing WHO resources and institutional capacity (p2), where lies the problem? Is it in rising challenges; increasing expectations? Resource depletion? Inadequate Institutional capacity of WHO?  If these questions are unclear, the other way to put it perhaps, is to draw out the point I am trying to make, which is: What are the structural causes of the challenges to which WHO efforts must be or have been a response? Was the end of the Cold War a condition whose occurrence was unpredictable, somewhat  even negatively perceived and costly to WHO? If it was intended that the end of the Cold War would be good in itself, was it known at what price that would come by ? Perhaps let us include in here an ideological question: has the end of the “Cold War” created for the world, better, more peaceful conditions adequate enough to reduce the pre-existing (and perhaps assumed) burdens on the service capacity of  institutions such as WHO? The problematic of the “end of the Cold War” as a framework for  international health policy analysis appears somewhat hanging in the air.

The related question that follows from the EBWG’s analysis refers to rising expectations. On this, one has to deconstruct the term ‘challenge’ as a Derridean ‘misreading’ and instead substitute it with an “accurate” term of  ‘Problem’ in order to appreciate the EWBG’s reference to ‘rising individual health expectations’ as a challenge. Who is driving these expectations? If analytical boldness is required, we can see that the culprits in the text of EBWG are the mushrooming developing countries with not only new and often ecologically driven diseases, but the many such countries spurned by the collapse of the former Soviet Union.  Why such a leap in our inference of the problematic of “rising health expectations”? The following text perhaps lures us to think so:

WHO’s recent attempts to attract resources from other sectors into health and its broader ventures into the general field of development (emphasis mine), have not been fully successful (EBWG, 1993, p2)

Where have been these ‘broader ventures’? No conspiracy theory is needed to answer this question. Simply stated, there has been rising demand in health expectations from developing countries that have required the need for WHO to address broader issues of poverty (development). The jury says these efforts ‘have not been fully successful’, meaning they have failed? Partially failed? May be we should read ‘broader ventures’ as the equivalent of unnecessary WHO ‘health adventurism’ which is the focus of the EBWG’s criticism here. The question remains whether health and development are legitimate scientific questions that should be discussed and invested in under the WHO mandate.

The EBWG perceives the leadership of WHO in health initiatives as threatened by other UN agencies. The objective should be: WHO must lead the way. But a long catalogue of “surgical measures” (p2 para 3.2) are listed by which “ WHO must strengthen its capabilities” to lead. In other words, the EBWG perceived clearly many inadequacies which limits WHO capacity to initiate and lead in international health work. The areas identified as inadequate and requiring strengthening are precisely those in which WHO is supposed to exercise competitive advantage over other UN agencies! One is forced to ask: Has WHO ever been good at these ‘capacity’ issues identified at any point in history before? If yes, at what point and from what causes did that competence fracture?

1.4       MEDICO-BUREAUCRATIC INCOMPETENCE

The irony is that the EBWG says in its ensuing paragraph 3.3 that “ WHO technical staff are of high quality”. It continues, that the capacity of WHO “to assemble world wide technical expertise to assess health needs, analyse major health issues and implement health work is recognized.”
My school teacher would have asked in brackets (by whom?). Two issues  are of interest to us on this: If the capacity referred to is available worldwide outside WHO, what would limit other interested UN agencies to assemble them for precisely similar purposes if they so wished? This does not need any reference to the law of intellectual properties. There is no bonded consultant by WHO,  particularly when the EBWG itself is later in the text, (p7 para. 4.2.2) critical of these consultants and implicitly WHO’s ‘assembling’ capacity in this area.

What really comes out the EBWG analysis on page 2 para 3.3 sums up  a major problematic, perhaps intentionally or unintentionally. First, in its own words, it says:

However, the further strengthening of the role of WHO depends on enhancing the competence, proficiency, and capacity of staff and advisers. 

So what was the ‘high quality’ accolades of WHO staff about earlier? What we are now being told is that WHO is suffering from what I could label “medico-bureaucratic incompetence”. And we are clearly told the reasons why in the same paragraph. These are five major ones:

1.             Critical problems in recruitment policies
2.             Relative technical and managerial weakness of WHO country representatives
3.             Fragmented and compartmentalized management of global, regional and country programs [is this a consequence of lower level weakness?]
4.             The difficulties of effectively rotating personnel between HQ, the regions and interregionally; and
5.             The lack of comprehensive programs for staff evaluation, training, and development, and the under-utilization of the technical capabilities of WHO collaborating centres.


Well, if this was a parastatal company in Zambia, “the country I know best”, it could either be forced into voluntary liquidation or the all powerful engine of market forces in Zambia, the Zambia privatization Agency would either liquidate it, infuse some capital to find a willing buyer and make just a few bucks from it, or sell it at scrap- metal prices. If the analysis of the EBWG is correct, then we really have not one but many structural problems to deal with and no attempt to shift this problem to one level of the hierarchy of WHO would save the situation.

1.5        CONSEQUENCES OF EXTRABUDGETARY FUNDING

The EBWG adds, that WHO has a financial crisis or more precisely, it is faced with “financial constraints (which) remain major obstacles”.(para 3.4) in its core work of “implementing and sustaining health services at the global level and national levels”. But we are immediately reminded of the great  ingenuity demonstrated by WHO “in adjusting to 12 consecutive years of ‘no real growth’ in the regular budget through ‘extra budgetary resources which increased from 1/5  of the budget in 1970 to slightly more than ½ in 1990. What is happening here ? Fewer and fewer countries with means have stopped putting their money into the authorised, legitimate budget of WHO.

There is a policy analytical framework of expressing this feature of financing social policy at any level. Health reforms like any other social policy reform can be distinguished at possible levels among others:  as explicit redistribution or  oblique redistribution (Friedman, K. 1984).  The first generates controversy at some stage before it either gains legitimation as a social right or, at least, formal recognition as an entitlement under administrative law.  In contrast, oblique redistributions initially avoid legitimation controversy upon grounds of redistribution, although disagreement may attach to the immediate policy objectives.

There are many reasons why these 'oblique redistributions' become vulnerable to crises of legitimation. One reason is related to their chief characteristic ‑ their relative invisibility, unchallengeability, inequitableness, unjustifiableness, and probable unaffordability to the society in question.  These characteristics, are related to the administrative origin of oblique redistribution policies.  There are 'invisible' because, they are by‑products of other unarticulated state or extra-state policies.  Access to the benefit structure of such redistributions is selective and sometimes by chance.

In addition, such oblique redistribution 'policies' have 'coercive effects' i.e., they operate as 'policing' instruments.  While impersonal in nature, oblique redistributions unlike explicit ones, are not impartial and lack the accompanying rationale as redistributive policies because they are not intended to have redistributive effects.  In form, they appear fragmented, making virtually impossible a comprehensive, meaningful consideration of their costs and hence affordability to society.


The principle of explicit redistribution, rests upon a legitimation process structured by impersonal, impartial, and challengeable law whose rationale is publicly acceptable and whose outcomes do not incur costs that the society cannot ultimately afford.  In other words, they are products of a political process in which demands by political forces are institutionally mediated.

Extra budgetary funds as pledges from those who have, by -pass the politics of WHA budgets and priorities. Their mandates are secretive, bureaucratic and simply assumed, without the benefit of legitimation, to be necessary funding.

However, the EBWG explicitly state “these extra budgetary programs have created a financial drain on the regular budget programs which must subsidize the extra budgetary activities. Now whose strings are being pulled here and who is pulling them, for what social purposes? Which aspects of the WHO’s “authorised” regular budget activities are sacrificed instead? Who makes these funds available and under what conditions is accessibility to them determined? Someone does not trust WHO regular budget mandates or procedures or something. Or worse still, they want to run WHO from the backdoor of extra budgetary financing which, the cash-strapped WHO considers God-sent and can even boast about it.

1.6       THE CHALLENGE OF REGIONS AND COUNTRY OFFICES

 Regional mandates under WHO practices came under particular scrutiny and criticism by the EBWG. It is stated that the “Constitution envisaged the regional areas established by the WHA and regional organizations as integral part of WHO with the mandate to decide upon matters, of an “exclusively regional character”. How was this exclusiveness to be defined under current ‘global change’ realities? The regions were also to carry out the decisions of the WHA and the Executive Board. The EBWG recommended the need avoid compartmentalization, fragmentation. What structure is being advocated here if not one that is highly centralised? Which medical bureaucracy is closer to the people’s felt needs: Geneva or regions? And since country offices are defined as weak, shouldn’t the solution lie in strengthening the next level to provide closer steering capacity to country offices?

PART II:  DIRECTIONS FOR WHO OR THE QUEST FOR RENEWAL 
2.1       BACKGROUND

In order to better understand this part of the EBWG report, I cross-referenced my study to Derek Yach’s paper. At the end of my review of Yach’s account, I shall connect it to the issues of governance raised by the EBWG.


Yach’s official discourse starts from the premise that Alma Ata Health-for -All goal was a good health if not moral goal justified on account of a universally acceptable and generally understood principle of equity.  The strategy chosen for this goal, primary health care (PHC) was partially, if not poorly implemented by governments particularly in developing countries.  The assumption here being that it was incorrectly understood by societies less endowed with certain  intellectual properties (this is the thesis of capacity problems of illiterate natives). The emphasis on vertical programmes like EPI or diarrheal disease control which appear to have worked in reducing IMR and improving life expectancy  at birth were inadequate in addressing the total requirements of the goal of Health -for-All primary health care strategy.

This means we cannot really speak in terms of Alma Ata as a failed global health vision but only about ineffective implementation of its correct strategy of PHC.This conclusion is justified by Yach  even when vertical programs achieved the results attributed to them by violating the core values and operational principles of “intersectoral, and comprehensive approaches”.  The need therefore for a global health strategy is not of a new vision or in fact strategy but of a “renewal” which in many respects is justified by the “future emerging and persistent threats to health”. Examples of these threats include: macroeconomic policies which distort socio-economic relations, political power relations or (good governance or the real issue of corruption) which create flaws in healthy public policy making including inequity in resource allocation.  They also include demographic trends, and the epidemiological reality of new and re-emerging diseases.  An underlying assumption here is that at some specific point in here, the existence of such threats in form or even character can and do disappear thereby making it possible to achieve particular states of health.

What is the “Renewal” strategy then?  Well, Derek Yach’s  text, if simply deconstructed says: use science in health policy making in what must be comprehensive “evidence based health sector reforms” applying  cost-effective curative and preventive interventions.  The renewal must encourage a pluralistic healthy public policy decision making process for reasons of increased accountability- a new governance concept (Yach’s “partnership” should read: community participation in PHC style language); take advantage of global developments in technology, travel, trade , and ideas intelligently (i.e. scientifically) to make the right choices in terms of  forms of trade, travel, technology, ideas, that would promote or harm health.  In short, do everything because there is an ideal albeit,  appropriate mix and process through which scientific findings related to disease burdens, cost-effective interventions are realised in human, institutional, financial,  political, and community terms in such a way that a “renewed” commitment to Health- for- All would be achieved within a given or exactly known time-span.


The ritual of “renewal” in many African cultures is a dramaturgical event which requires as a condition of success of such renewal, a “cleansing” process.  In Wole Soyinka’s view this renewal and cleansing process acts through a medium on behalf of the community:

The real unvoiced fear is: will the protagonist survive confrontation with forces that exist in that dangerous area of transformation? Entering that micro-cosmos involves a loss of individuation, a self-submergence into universal essence.  It is an act undertaken on behalf of the  community and the welfare of the protagonist is inseparable from that of the total community. (Soyinka, 1979;42)[1]

In Soyinka’s view the outcome of the dramartugical feature  of communal ritual personified in the struggle for life of one individual is a cathartic process in which the protagonist, through physical and symbolic means, reflects the “archetypal struggle of the mortal being and exterior forces” (p.43).  In this role, the protagonist symptomizes the needs of the community for repair.  His transformation unleashes strength for the community hence their full participation in a supportive role.

Levi-Strauss (1963:210,cf.217) has argued that if there is meaning to be found in mythology, it cannot reside in the isolated elements which enter into the composition of a myth, but only in the way those elements are combined. The elements of the science of health are combined in a particularly curious manner, a tradition going back centuries ago. The Greek God of Medicine, Asclepias  was the son of Apollo, the sovereign God of Healing, the sender and stayer of plagues, the God of Light. Asclepias' birth was the stuff of wonder. He had been plucked from the womb of his mother Karoni, while she lay on her funeral pyre.


Kerenyi (1959:72) has described the Asclepias family's healing power as centred around the father and his three daughters:  Iaso (healing) Panakeia (cure-all) and, Hygeia. Iaso and Panakeia were much preferred by Asclepias as apprentice healers. In contrast, while emotionally close to her father, conceptually, Hygeia differed in one  key respect from her famous father Asclepias. Health to Asclepias, Iaso and Panakeia was a process of restoration. In contrast, health for Hygeia,  was a process of living which resulted in an expanding and enhancing of self. In Iaso and Panakeia healing arts, the healer was the active agent in restoring health.  In hygienic health, the person himself was the active ingredient. This difference, led at one time to Asclepius curtly chiding Hygeia, "Striving to better, oft  we mar what's well" (Lear to Cordelia,I,2,371 cf.  Edelstein & Edelstein, 1945)..( ref, Bower, 1977)

2.2       WHO REFORM; BEYOND RENEWAL

In some way, as we attempt to deconstruct WHO’s “Renewal of Health for All” that Derek Yach writes about,  we are tempted to think of the ritual requirements of such a renewal.  Many writers believe that the medium, in this case “WHO” itself must go through a process of cleansing, the form that Soyinka writes about: a loss of its characteristic individuation as a “bio-medical” establishment.  While the logic of Hygeia has long been understood scientifically, it is still the thinking of Iaso and Panakeia which drives the way WHO is approaches any  new Global Strategy for Health.  Yach knows better than most, that it is not the logic of public health but of biomedical technology that dominates the paradigm of health policy thinking within WHO.  If it were not so,  why is there such evident skepticism,  even scientific resentment of the World Bank role in health and its concepts of disease burdens and cost-effective strategies and essential health care packages within WHO bio-medical scientific circles? (postscript, I was a pioneer member of the panel of  external advisors to the World Bank President, Wolfseinestablished 1997 by the HPN Division). The Quality adjusted life years (Qualys) was a feeble counter thesis, Madison Square-type critique of DALYs. The critics were mainly WHO scientists who were caught napping in their old bio-medical panakeian thinking...professorially waiting for new bio-technological breakthroughs particularly as HIV challenged medical orthodoxy.  We all recall the time when the New York Act Ups took the central stage of the Montreal International HIV\AIDS Conference in 1989 in defiance of bio-medical Industrial-Medical Complex in HIV\AIDS.  When the World Development Report 1993 came out, few paid attention to the WHO Health Reports!  WHO has to transform in order for it to embrace a new paradigm of health that Alma Ata  correctly sought to define but which, in my view was high-jacked and conceptually strangled to mean not a particular state but every possible human state. It was, overloaded to the point well-beyond the practical goals of medicine broadly and even specifically understood. I sometimes ask myself the question: why? What went-on at Alma Ata?


These comments and their emphasis on WHO itself in response to Derek Yach’s paper are prompted by  the questions his paper raises but does not answer, questions which suggest that Yach is still writing within a conceptual framework that resists Hygeian logic.  More worrisome, it makes assumptions about the behaviour of political and economic institutions regarding their potential rationality that does not apply even within the institutional logic of WHO.  That WHO is wasteful, its policy making process is often irrational and least of all, participatory.  Yach knows like everyone else that there are poor checks and balances in WHO’s scientific-ethical, and financial management, and in the influence of various “ market” or economic and political “powers”  whose concerns are registered within the many bodies or committees it has spurned.  WHO is thus a very poor advocate of the “global renewal” unless it is transformed into a structure that would reflect a cleansing of its own peculiar form of bio-medical scientific orthodoxy.

2.3       UNDERSTANDING THE WHO SYSTEM

John McKinlay (1979) argued  that social policy denotes a statement of an underlying value system and purposive action adopted by Government, ostensibly on behalf of the public, with the intention of beneficially altering the welfare of citizens through the provision of services, we must proceed to consider some key questions about the process of its development. This concept can be extended to understanding of health policy reform in super-state institutions like WHO.

One key issue that confronts the process of WHO renewal reformism is the question of priority. Ostensibly, the definition of priorities is closely linked to that of definition of  problems. That is, in order to attract public action, an occurrence must be understood to be a health problem for some significant sector of the world. Having witnessed the wrestling surrounding the definition of health priorities for WHO Global Strategy at the WHO Executive Board level, I have been left with no doubt in my Third World mind that ‘might makes it right’.

2.3.1   PRIORITY SETTING


At the level of WHO Executive Board, there are many  processes involved in the definition of priority health problems in ways that would make one’s head go in spirals. The theories they teach at Harvard Business School in decision making, let alone those in Medical Schools are definitely worlds apart from the practice one observes during WHO Executive Board decision- making. The capacity for large delegations by developed country members of the Board affords them chance to actively manipulate the structures and procedures of WHO Executive policy formulation in ways which suggest that actions in a given sphere have practical value for all countries, and are worth pursuing within the means provided or with minimum costs,  and can occur within the basic rules and positions that govern WHO mandate. What one observed in procedural maneuverings of agenda items , rules of procedure etc, are simply classical street smarting. Often big bilateral underwriters of WHO capitalize on the ambiguities of existing policy responses, and offer an alternative range of possibilities often in their favor. Case examples of these practices abound and only the constraints of my  sense of international health diplomacy restrict my finger pointing. At any rate who listens anymore to big power- bashing? The issues of concern must be those defined by countries with the financial and political muscle to make the bloated Executive hierarchy of WHO get up off their pants and listen.

2.3.2   DONOR / RECEPIENT RELATIONSHIP

By and large the facility with which developing country interests can be articulated and the force with which these interests can be pressed on Executive Board or Secretariat is dependent upon the organization structures within which they are expressed. The EBWG criticised the manner resolutions are brought to the floor of the WHA, the only forum where many developing countries seek to express their real concerns.  Ultimately, how collectively developing countries are categorized and for what they might be eligible for, suggest that the problem of definition and prioritization involve labeling and access as two key features of institutional intervention. The label identifying a specific group of beneficiaries in practice becomes congruent with a process of resource distribution. The bargaining power of developing countries on issues that come up on the WHO Executive Board agenda often appears to me as special favours , giving rise to ‘special programmes for countries in greatest need’. These countries are “recipients”, others members of WHO are “donors”. The substantive forms’ of their interests are miles apart although the process must make it appear as though they coincide over some greater altruistic value of good health for all.

2.3..3  DECION MAKING

Hence, apart from the issue of manipulating the definition of health priorities for WHO programmes, the process of decision -making in the WHO Executive Board (forget about the World Health Assembly when developing countries’ delegates go window-shopping  in the fancy streets of Geneva), key policy decisions are made by countries who are consulted well before hand by WHO bureaucrats, those ‘international public servants’ who wield significant  control particularly over WHO budget and its core, commercially significant programmes.

2.3.4   KEY QUESTIONS


In principle, Yach’s ‘renewal reformism” would do us some good to address the question of what might become of the existing relationship between those countries that underwrite the substantive costs of WHO; the sponsored gate -keepers who in the name of scientists, ‘administer’ the bilateral governments’ substantive budget and ‘extra-budgetary’ funding; and the Third World recipients who go to WHO to beg for various forms ‘health welfare services’? This question is important regardless of whether a ‘renewal’ will give rise to a new health parastroika. We have to understand that ‘donors’ , their WHO medical bureaucrats, or recipient countries  have reference points for their actions. Past experience in related institutional settings often provide the parameters for ‘new’ behavior.

2.3.5   INFLUENCE OF BIOMEDICAL INDUSTRY

Put simply, Yach's argument is in one respect anti- reformism which falls victim to what is known as an "orthodox paradox". Measures advocated by Yach and the EBWG itself in 1993 constitute a direct assault on the interests of many WHO and similar UN employees. Yach's ' renewal reformism' puts jobs at risk, as well as diminish opportunities for "side payments" within the political and administrative leadership of many vertical programmes that donor country-specific managers who, under the guise of specific science, socially market to largely developing countries on behalf of their governments. Most such programmes have much to do with the logic of product marketing than strictly speaking, the promotion of health as an ideal global Alma Ata goal. The fact that some health benefits accrue to “beneficiary” countries (even if not sustainable) does not invalidate the point being advanced here.

 At the highest levels of WHO government, biomedical scientific leaders have vested (political) interests in retaining discretion over the allocation of resources to vertical programmes favored by countries, often major industrial powers that actually sponsored their ascendancy to higher office. The observed maneuvering over the agenda of the Constitutional Review Group of the EB in 1997 will, I fear, only direct attention at how to centralise control and limit the power of regions and countries to influence substantively the vision, mission and goals of WHO.  Uncorrupted leadership chosen on scientific merit in pursuit of higher positions within WHO sometimes sounds to me like an alien concept. Bilateral country powers backed by their largely powerful pharmaceutical industrial interests have set up fiefdoms within the programme structures of WHO that makes it generally and perhaps particularly inflexible to change, even in the face of sound scientific  rationale from middle-management  or even junior ranks of WHO as an institution.

2.4 WHO PARADOX OF SELF REFORM


The orthodox paradox therefore is the attempt to use the agencies and personnel of WHO to diminish or dismantle their own power.  My own experience with health reforms since 1991 in the Zambian ‘Civil Service’ indicates how hard this task can be! Yach's renewal reformism would only be sustained within a small technocratic circle such as the EBWG with temporary backing from senior WHO policy leaders, as an interesting exercise in ‘dynamics without change’  as McKinlay put it some years ago now. And, more importantly the discourse has become necessary as the balance of forces within the bilateral countries has fractured forcing a renewal...these countries are now  jostling for particular programme turfs  with related economic significance to their national industries.

At closer examination, Yach's argument is an even more ambivalent one from the vantage point of democratic health governance. It calls for a  "reform syndrome": Morally-clean leaders (clear-minded institutional and global leadership) fully committed to major change, widespread public acceptance or demand for such change by countries, strong WHO steering capacity, largely centralized, weakened opposition to WHO specific biomedical paradigm and a global economic growth policy agenda in which no one gets the worse for it. This is what comes out of the EBWG section four on the so-called “Future directions for WHO”. Now, show me a rotten apple and I will describe to you how it sweetly stinks.

It is a valid argument that no leader, no institution, however committed, can give  adequate attention to more than a short list of its own administrative adjustment to its turf issues at any one time let alone that of the whole world. Both coalition management in the UN-system demanded by the EBWG and Yach's renewal reform and the span of its control require a strong leadership capacity that by its very nature would be anti-democratic. That WHO has seen a good dose of this leadership style already is common knowledge.

2.5       HEALTH PRIORITIES AND COMMERCIAL BENEFIT

What WHO “renewal” argument is suffering from is a crisis of moral conscience which fails to appreciate the fact that when governments and their powerful phamaceutical industrial complexes respond to "popular" health pressures, the poor countries would only benefit to the extent that their priority concerns overlap with those of the somewhat better off. When HIV\AIDS was defined and was believed to be a real  global threat touching upon all countries, Jonathan Mann’s work through the GPA, that once well financed sub-WHO, was appreciably less traumatising than the Belgium sponsored Peter Piot's inherited UNAIDS...a nowhere man's institution.  When the Industrial West perceived threat to HIV was diminished, its interests in the definition of HIV\AIDS as a global health problem could never be again reconciled with the interests of poor countries. Other emerging diseases with better prospects of economy particularly in vaccine and other such products development appear profitably possible and perhaps immediate.


No major industrial country really loses sleep that drugs likely to prolong life of the HIV-infected are beyond the economic means of the majority of the countries with the greatest burden of HIV infection particularly in Sub-Saharan Africa. Dr Ho’s cocktails makes interesting scientific journal reading but health Ministers in the developing world  would be folly to believe that salvation, even if palliative from HIV\AIDS, is just around the corner!  If you asked me who is benefitting from the 'pandemic' of HIV\AIDS, my fingers won't have to search too far. Unless someone's eyes are deliberately closed they would demand for me to be more explicit than this on this particular matter. Individual Mega-Stars in developed countries may be benefiting and can in fact afford these cocktails, more importantly they are good for product marketing.

 It is now common sense that that current discourses of WHO 'renewal' strategy from the Joint-sponsored programme on Human reproduction, to institutional reforms only make sense if they fit within a discourse of making markets emerge. In the political economy of health, there is no win-win situation. Some win others lose. The dismantling of GPA and its replacement with the nowhere man institution of UNAIDS has much to teach us on this point.

2.6       GOVERNANCE AND HEALTH

Finally, the relevance of Yach’s comments to South Africa and, in passing, to Southern Africa (as he shows very little evidence  of regional thinking on this), is  another deconstruction we have to do. It is a case applicable also to the analytical framework adopted by the EBWG.  Yach must know that Governments in Africa like governments elsewhere, want to stay in power.  Public policies are part of the panoply of instruments governments use to gain public acquiescence to political rule. Anell (1995) argues along this line citing the example of Swedish Health Reforms that ,

” Developments within the Swedish health services also reveals some important lessons as regards political incentives in public health services....it is more important for county council politicians that activities are perceived as efficient. With this in mind it may be enough to talk about decentralization, more choices for patients, purchaser-provider split and competition, at least as long as these concepts are associated with high efficiency. In this way critics and the larger public are given the impression that changes to [sic] the better  are well on its [sic] way.(Anell, 1995:22-23)


The systems of rationalisation that governments employ through the activities of state policy scientists including health planners, national or international, are in political terms, bounded discourses , whose logic is provided by the symbols and rites of political rule. The structures they recommend for health service improvement have social consequences. For this reason, among many others, they can only be realized if they coincide with the historically invested nature of political practice in a given country at a particular time. This assessment applies as much to country governments as it does to the UN agencies such as WHO.

Under existing conditions of macroeconomic turbulence, the complex forms of institutional and organizational mediation involved in the 'renewal reformism' and its potential form of implementation, and the crucial role of the balance of bilateral industrial power interests who underwrite much of WHO expenditures must be carefully understood if health policies are to  be structurally adjusted to serve the altruistic goal of the global human interest for better health for all.

If we may just ask about the case of South Africa, what will it take to transform the basis of socio-economic power relations within South Africa, between South Africa and its much poorer regional neighbors, and even further between developed and developing countries in regard to terms of trade and other macro-economic relations, in order that they would be created conditions necessary for key forces to configure themselves in the interest of healthy public policy?  The EBWG tells us such questions are in the realm of WHO adventurism.

The changing goal posts of international health AID does not suggest a commitment to a “Renewal”.  The evidence of cutbacks in foreign aid by countries like the USA, (just listen to the US Congress debates) as at the same time as they push for new conditionalities such as ‘perfect’ democratic governance issues, high technology marketing, all confound a search for a global consensus on what must be a “new” global health vision and strategy.  It is only in the acceptance of the intractability of the issues Yach identifies so correctly that the concept of a “renewal” in the WHO sense, makes sense.  The Health sector reforms efforts currently being undertaken in South Africa in particular, are as comprehensive as there are vulnerable to the same forces that undermined other countries’  earlier attempts at giving Alma Ata Declaration, a real chance. And on similar grounds, this 50 years tinkling around the WHO constitution seems to be a shoveling of cards in the deck of few aces and many jokers.


References
EBWG (1993) Report of the Executive Board Working Group on WHO Response to Global Change, EB92/4
Yach, D (1996) Renewal of Health for All and its Relevance to Southern Africa. Mimeo. WHO, Geneva.
Edelstein, E. J.  And  Edelstein, L (1945): Asclepias, a collection and interpretation of testimonies (2 vols). Baltimore: Johns Hopkins.

Kerenyi, K (1959): Asklepios-archetypal image of a physician’s experience.  (R.  Manheim’s trans.). New York: Viking.
Soyinka, W.  (1979)
Levi-Strauss (1963) Structural Anthropology.  Translated by C.  Jacobson and B.G. Schoepf.  New York: Basic Books.
Anell, Anders, (1995) Decentralisation in the Swedish Health Service: Some Lessons, A Report to WHO. IHE., Lund.
McKinlay, J. (1979) Dynamics without Change,