An inside view of the WHO reorganisation

Dr Anthony Piel, who is Director of the WHO Director-General's Cabinet, spoke recently to The Courier about the current restructuring of the World Health Organisation. He began by explaining the background to the proposed reforms and described how the WHO aims to adapt to the changing global environment.

-In 1978, the WHO sponsored a Six tasks major conference in Alma Ata on primary health care. It was agreed there that this approach, based on 'people participation', is the most effective and lowest cost method of tackling health problems. But since 1978 the world has seen enormous changes. The economic situation has worsened and despite health improvements- people are living longer and infant mortality has fallen, for example-there are still marked, and sometimes widening inequalities between rich and poor. Another big change has been the end of the cold war. Under the communist system, efforts were made to offer equality in health service delivery and the model was adopted in a number of other countries. But that model has now gone. Nor is an approach involving unregulated market forces entirely successful. It does not, for example, conform to the concept of equality and it is difficult to talk of a fair and balanced market. There is also a lot more violence and social unrest-particularly in smaller countries-than was the case 20 years ago. The crisis in places such as Bosnia, Somalia and Rwanda impose new and unprecedented demands on WHO. Both the Organisation and individual countries face new challenges as they seek to advance further on the health front.

One of our main purposes must be to become more adaptable to the changing demands of member states. We are now restructuring at headquarters, consolidating programmes so that we can be more efficient and economic. We are asking our six regional offices to undertake similar reforms. We have set up various mechanisms to help make this happen. Internally, we have what we call a global policy council. The regional directors are members and they come to Geneva to discuss major policy issues, so as to ensure that the WHO speaks with a single voice throughout the world. We are also setting up a management executive committee, bringing together the executive managers from each region, together with the assistant directors-general here at HQ, to discuss ways of improving and streamlining management and to take collective managerial decisions.

Attracting voluntary financing

We have, in addition, identified six specific tasks to be undertaken by 'development teams' within a limited timescale. These are; to restate the WHO's mandate and mission in the light of the changes I have just mentioned; to redefine our managerial structures and processes; to define a new public information and communications policy; to outline a new management information network that exploits computer and satellite technology in linking the regions with the HQ; to redefine our personnel policies, with a reexamination of the technical expertise we need, and to look at our operations at country level.

On this last point we are considering what form the WHO presence should take and what should be the minimum of staff needed to run a representative office. We are also locking at links with specific projects and programmes, at the interface with governments, at work undertaken at various levels within the country, and at how all this fits in with a more unified UN system.

Is the fact that the extra budgetary resources of the WHO are higher than the regular budgets a concern for you ?

-Resources are always a concern. I personally think it is right that extra budgetary resources should be more than the regular core budget. The important thing, however, is that when there are extra demands-in other words voluntary contributions on top of the basic payments to the budget - the donors, whose generosity we appreciate of course, do not dictate the priorities to be addressed within a particular country. No-one knows better than the Haitians, for example, what the health priorities of Haiti are. So the issue of extra budgetary resources only becomes a problem if donors try to use them to control the priorities or the means of action.

Some WHO activity, such as our work in standard-setting or developing model primary health care systems, is not particularly attractive to donors. Other areas, however, lend themselves more naturally to extra budgetary contributions: things such as tuberculosis immunisation, human reproduction, tropical disease research and AIDS. So we tend to focus our regular budget on areas where there is limited donor interest while turning to the donor community for voluntary financing to operate other major programmes. Take the example of AIDS. We put about $1 million of our core money into this each year and attract about $80m in voluntary contributions. Without that money, the WHO's work would be greatly reduced.

So there are two answers to your question: yes, we are worried about too much influence being brought to bear where extra resources are concerned, but on the whole, we rely on voluntary contributions to address specific and major health issues such as AIDS.

What about your research policy ?

-Initially, I don't think WHO was particularly strong in this field but, from the late 1960s onwards, we built up several important research areas. The biggest of these was in tropical diseases, partly because we realised that the industrialised world was becoming less interested in this and because we wanted to emphazise the development of new drugs, vaccines and other products. The second big research field was human reproduction, looking for new means of fertility regulation that could be made available to families and were acceptable within their cultural context. Now we have an advisory committee on health research that includes some of the top scientific people, in the world. It meets at least once a year and sets out the broad guidelines of the WHO's research policies.

Interview by H.G.