The Brundtland era begins

Abstract

WHO's 32-member Executive Board, contrary to much weary scepticism, has voted for a radically transformed future. Subject to approval by the World Health Assembly in May, Gro Harlem Brundtland will become Director-General of WHO on July 21. After a decade of decline, weak leadership, allegations of corruption at all levels, and paranoid defensiveness when any kind of external scrutiny was conducted, WHO now has an opportunity to reclaim its confidence and influence. Brundtland has so far set out a conspicuously political agenda: her targets are poverty, underdevelopment, and social inequality. Her clear emphasis on vulnerable populations is likely to place health high on the global economic agenda. Brundtland sees WHO as the “leading advocate” for public health, providing expertise, setting standards, and leading implementation at the country level. Victory for Brundtland will bring relief and optimism to those who have sought to restore WHO's credibility, such as the Independent Group for Global Health (see Lancet, Sep 13, 1997). But her election marks only the first step in the recovery of WHO. To focus on this period of change, The Lancet this week begins a seven-part series on world health. Gill Walt, of the Health Policy Unit, London School of Hygiene and Tropical Medicine, has been our series editor. On p 432, she reviews the institutional diversity within the international health community and concludes that, despite the apparent growth in the number of actors and agencies, “overall aid is falling—official development assistance decreased by 17% between 1992 and 1997”. Health seems to be a diminishing concern for politicians. They need to be provoked to reconsider their national strategies. That must be Brundtland's first action and her success will be measured, at least in part, by how far she can reverse this investment shortfall. Subsequent articles will examine core and supportive functions of international health organisations; why richer countries, out of simple self-interest, should invest in global health with more enthusiasm (and money) than they do now; the complex role of the World Bank, seen through the example of Bangladesh; the successes and failures of WHO at country level; how the wider public may play an important part in persuading governments to make health a policy priority; and, finally, how we might set about achieving the reforms we all want. There is bound to be further preoccupation with the infrastructure and management of WHO. This subject offers wonderful opportunities for armchair experts to apply their rationalist instincts to a beleaguered UN agency, to invent simplistic organisational flow charts, and to write dogmatic statements about vision, governance, culture, legitimacy, partnership, and other concepts drawn from business-school syllabi. But these issues, important as they might be, should not dominate Brundtland's early months in office. Her attention needs to be directed more towards WHO's programmes; for example, to the continuing burden of infection and to the emergence of noncommunicable disease as a looming threat in the next century. Still, history may have one useful lesson for us here. Much criticism has been directed at the six regional offices of WHO. Should their powerful role be curbed? As administrative centres, they are easy targets. Yet few question the success of the first permanent regional health organisation, the Pan- American Sanitary Bureau established in 1902, and which, through a series of conferences and mergers, became the Pan-American Health Organization in 1958. PAHO remains a strong quasi-independent part of WHO. And PAHO might reasonably act as a template for other regional offices, with the eventual goal being stronger not weaker regions, linked through a federal network to a much slimmed headquarters in Geneva. Effective regional offices could then begin to identify the required level of WHO's presence—its “essential presence”—in each country. Indeed, the location of the central WHO base in a rich and expensive European state sends a signal that is hardly in keeping with Brundtland's refreshing manifesto. One of her first actions might be to rotate the location of her office and Secretariat through the regions, beginning with the continent most in need of WHO's skills—Africa. WHO:where there is no vision, the people perishIn January, 1998, the 32 members of the World Health Organization' Executive Board will gather to elect their next Director-General. Governments have until November to submit candidates and the board's nomination will be sent to the World Health Assembly later that year for their approval. The present incumbent, Hiroshi Nakajima, is the fourth Director-General since WHO was founded in 1946. Many people inside and outside WHO see the impending change of leader as an opportunity to renew their commitment to an organisation that has lost much respect and authority in recent years. Full-Text PDF