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,
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