Change at last at WHO

Dr Gro Harlem Brundtland has done what most people hoped she would. On her inauguration as director general of the World Health Organisation, she has swept away the existing secretariat (though keeping some members on as advisers), and announced her own carefully chosen cabinet to an increasingly optimistic staff. Of the 10 new appointments, eight come from outside the organisation and six are women.¹ There is an even split between the north and south, and all of the WHO’s six regions are represented. Along with the new cast come plans for a new way of working—reducing overlap and increasing convergence between individual programmes.

The speed of the appointments has taken the organisation by surprise, and one appointment in particular is causing concern. Michael Sholtz, who is to be responsible for health technology, will be in charge of the action programme on essential drugs, the WHO’s key initiative to provide poorer countries with appropriate and affordable drugs. Dr Sholtz comes from the pharmaceutical industry and has little experience of the developing world. Dr Brundtland has portrayed the appointment as providing a liaison between the industry and the WHO. Dr Sholtz will have to prove his allegiance at a tough time for world health, when the development of effective but expensive drugs for AIDS has brought to a head the north-south fight over drug patent rights.

So far the changes all relate to the WHO’s headquarters in Geneva, where Dr Brundtland has executive powers to hire and fire. The more difficult and perhaps more crucial test of her ability will be in dealing with the WHO’s six regions, over which she has no direct control. Regional directors are elected by their constituent countries rather than appointed by the director general, and they can hire and fire staff within their regions. Especially important is their responsibility for appointing country representatives—the WHO’s front liners, who, because of lack of training and resources, form one of the weakest links in the WHO’s chain of influence.

The regions have always presented the WHO’s leaders with a problem. But Dr Brundtland must take them on after 10 years of unchecked autonomy and at a time of strong support from their constituent countries. Regional meetings have become an important forum, especially for developing countries—many of whom feel that their voice at the World Health Assembly has been eroded by northern dominance and by decline in the assembly’s influence.

Dr Brundtland clearly understands the need to woo the regional directors, three of whom were her rivals for the director general’s post. A retreat is planned for the end of the month, which all six regional directors will attend. This seems designed to set the tone for the annual round of regional meetings in September and October and to establish a process for streamlining the currently diverse regional structures and methods of working. The fate of the country representatives is also likely to be on the agenda: Dr Brundtland is understood to want to meet them in person and to strengthen their ties with headquarters. Meanwhile, money is to be made available to install proper communications between the regional offices and headquarters. This will allow frequent video conferences so that regional directors will become actively involved in policy making. In Dr Brundtland’s phrase, there will be one WHO speaking with one voice. If she can achieve this politically difficult internal alliance, the WHO may again at last become an effective advocate for world health.

News p 302