E-drug: The Lancet on WHO's African office
------------------------------------------------------------------------
---
[Editorial in this week's Lancet. Cpoied as fair use. KM]
Lancet 2004; 364: 475-6 (7 August)
Pierre Virot
Editorial
WHOs African regional office must evolve or die
A resounding silence surrounds an event to take place at the end of this
month that, in theory at least, has great significance for the health of
the people of Africa. Dr Ebrahim Samba is to step down after serving his
maximum two terms of office as Director of WHO's Africa Region
(WHO/AFRO). A new leader for WHO's governing body in the African region
must therefore be nominated when the Regional Committee meets in
Brazzaville, Republic of Congo, between Aug 31 and Sept 3.
Such disinterest in a new UN health leader in the continent with the
world's most pressing disease burden seems at first glance astonishing.
However, a little familiarity with WHO and its African Office makes the
lack of debate more understandable. Although five candidates have been
put forward for the post, none has mounted a public election campaign
and their names do not even merit mention on WHO's website. In addition,
the political negotiations key to the nomination are taking place behind
closed doors and committee members will vote for their favoured
candidate by secret ballot. The five candidates are Dr D�ogratias
Barakamfitiye (Burundi), Dr Phetsile Kholekile Dlamini (Swaziland), Dr
Evaristo Njelesani (Zambia), Dr Francis Gervase Omaswa (Uganda), and Dr
Lu�s Gomes Sambo (Angola).
Few would envy the job that the new WHO/AFRO Director must take on. This
region has by far the highest disease burden coupled with the lowest
level of economic development in the world, and is besieged by
corruption, poor governance, political instability, and civil strife.
Despite these constraints, it is clear that the regional office could do
better. Indeed many commentators are privately and scathingly critical
of its composition and working practices.
WHO/AFRO's weaknesses are typical of a large organisation: ineffective
and self-serving central management and demoralised and unsupported
rank-and-file staff. At the heart of the regional office's
ineffectiveness is its acting as a political rather than a technical
agency. Recruitment of senior staff is rarely based on competence or
qualification. In particular, appointments of country representatives,
who should coordinate WHO efforts in their countries, are often paybacks
for political or other favours. The regional office thus has strong,
some might say incestuous, relations with African governments at the
ministry level, to the extent that senior health ministry officials see
WHO/AFRO as their future retirement home. As a result, the culture of
leadership within the regional organisation tends to be autocratic,
excessively bureaucratic, and highly centralised--a culture that
dismally fails to motivate staff at the country level.
There is much that WHO can do at the Geneva headquarters, at regional,
and at country level to improve this failing situation. First and
foremost, the damagingly close political ties between WHO/AFRO and the
member-state governments must be loosened and the agency must reorient
its core function towards technical health expertise. Accordingly,
transparent, binding procedures must be put in place to ensure that
country representatives are appointed on the basis of competence and
qualification. There are strong arguments for decentralisation of
WHO/AFRO to at least four or five subregions. Such action could allow
better assessment of the array of health problems within the 46
countries that make up the African region and more tailored support to
struggling country offices.
The overall Director of the region should be selected on the basis of
management expertise and a proven record of leadership in a large
organisation. Moreover, the Director should ensure that funds from WHO
headquarters and donors are channelled effectively to where they are
needed on the basis of evidence rather than ideology or political
expedience. One African doctor emphasised to The Lancet that the
regional office needs to adopt a more analytic and targeted approach to
its work rather than saying, "We are dying, please help us".
The fault, of course, does not rest with WHO/AFRO staff alone, many of
whom make valiant efforts in difficult circumstances. WHO's regionalised
structure, where real, albeit limited, authority is vested in the
regions, is clearly preferable to the more centralised organisation of
other UN agencies, such as the Food and Agriculture Organization where
the regional offices have no independent authority. Nevertheless, WHO's
structure can lead to relations between Geneva and the regions ranging
from strained to indifferent, with the regions allowed to operate as
little fiefdoms presided over by an omnipotent director. WHO's Geneva
headquarters must take a good part of the blame for this poor oversight.
WHO/AFRO, because of its close ties with ministries of health, provides
an excellent potential entry point for the roll-out of initiatives from
WHO headquarters. But as one commentator put it: "People at headquarters
often seem to forget that the Regions exist, while Regions can be
irritated by headquarters acting as if it presumed to know what goes on
at regional level better than [regional office] staff."
Moreover, WHO/AFRO has a very limited core budget and focuses on
vertical donor-driven initiatives, almost certainly because this
strategy is seen as the best way to ensure the agency survives. This
approach is completely at odds with the current trend for the major
funders, the development banks and bilateral donors, to adopt
sector-wide approaches and budget support to health sectors. The
regional office therefore needs solid long-term support from WHO
headquarters to allow WHO/AFRO to evolve into an expert technical agency
to assist these large sector-wide programmes--which is surely a much
healthier survival strategy.
The legal documentation on the procedure for the nomination indicates
that WHO/AFRO expects a new Director of exceptional calibre: "The
candidate must be visionary, dynamic and results-oriented. It is very
important that the candidate possess the ability to communicate both
orally and in writing, in a clear, effective and inspiring way to
varying target groups, including the mass media, political leaders,
other leaders in the public health field, health personnel, a wide range
of academic and professional groups within and outside the health sector
as well as WHO staff. He or she should have personal integrity and a
great capacity to withstand pressures from both official and private
sources on issues that could jeopardize the Organization's interests."
Will WHO/AFRO nominate such a person? Given the lack of transparency and
public debate surrounding the vote, it is impossible to tell. However, a
new nominee gives opportunity for a joint re-examination of relations
between Geneva and Brazzaville to ensure that WHO/AFRO can exploit the
rich resources of Geneva while accepting its oversight and support.
Unless WHO's African office is transformed from a political club to an
effective health agency, its right to existence is questionable. * The
Lancet
--
To send a message to E-Drug, write to: e-drug@healthnet.org
To subscribe or unsubscribe, write to: majordomo@healthnet.org
in the body of the message type: subscribe e-drug OR unsubscribe e-drug
To contact a person, send a message to: e-drug-help@healthnet.org
Information and archives: http://www.essentialdrugs.org/edrug