Interview with Gro Brundtland

On the day after Gro Brundtland announced that she would not stand for a second term as WHO's leader, Gavin Yamey interviewed her in Geneva

Gro Brundtland, an “energetic blend of doctor, manager, politician, and international activist,”¹ became WHO's director general in July 1998. After a decade of decline for WHO, many people hoped that she would be the organisation's saviour. She certainly had the credentials for the job—a former public health physician, prime minister of Norway, and chair of the World Commission on Environment and Development.

On 23 August this year, Brundtland shocked the global health community by announcing that she would stand down after only one term. I interviewed her in Geneva immediately after the announcement, on the day that she was leaving for the world summit on sustainable development in Johannesburg; what follows is an edited transcript of the interview.

Achievements

Gavin Yamey: You came into office with a clear mandate to reform an ailing organisation. How successful do you feel that you have been?

Gro Brundtland: I think we have managed to do a lot. I did spell out my vision before I was nominated. One of the main things that I said was that we need to anchor health firmly on the political and development agenda. Health was sidetracked, and I knew that if it continued like that it would not become an integrated part of development thinking. People cannot move out of poverty when they are unhealthy. I needed to move the global health agenda much more closely to the development debate, on to the tables of prime ministers and development and finance ministers, not just health ministers.

Doing this involves not just reaching the minds of people who have decision-making power in the broader fields of economics and politics, but also increasing the evidence base so that you have convincing arguments. And to move health towards the development agenda, you need to reach out to other partners, which was another part of my profile. The goal is improving health and development, and it is what governments, civil society, and development partners do together that we need to measure.

Partnerships

GY: You have championed public-private partnerships for health. How is WHO performing as a partner?

GB: We are doing a good job by being the centre of competence, shared experience, and knowledge about what works and what doesn't. WHO is the scientific and expert organ that can give quality opinion about the evidence base, guidelines, norms, and standards, because that is really our core function. All the other partners—including the rest of the UN system and non-governmental organisations—are in fact dependent on a quality stamp from WHO about what is the right evidence and the right standard.

GY: One criticism of WHO in partnerships is that it sometimes finds it difficult to give up control. How would you respond to that?

GB: WHO has responsibility to the international community and to our 191 member states. Being criticised by our partners is like a private company or foundation in England criticising the British government because the government wants to keep a certain control. It has to—because its mandate is democratically based and is dependent on parliamentary decisions and the constitution of Britain. When you work in alliances and you have responsibilities which are overarching and international in nature, and which are dependent on the World Health Assembly and the constitution of WHO, at some point the alliance isn't a bilateral, equal relationship.

Fragmentation of global health

GY: With the development of so many new global health initiatives, like the Global Fund and the Global Alliance on Vaccines and Immunisation, what role is left for WHO?

GB: Without WHO, and a stronger WHO, these institutions would not have credibility. They would not be able to work because governments trust WHO to be the evidence base. WHO needs to be strong and needs to be able to give advice and support to all these institutions if we are going to work well together. I have been giving my support and providing inspiration to all of these new bodies, because I see that they add to the total momentum of what we are able to do. But if WHO's core functions are undermined, we would all be undermined.

GY: Does this fragmentation of global health into many different initiatives concern you?

GB: If you go 30 or 40 years back, some countries had a publicly directed and organised health service and public health function. But there were poor countries, with, frankly, such a weak public sector that all public health was basically private. So the world was a very mixed bag of very different principles and very different histories. WHO was a small international institution trying to help all countries. We are stronger today and with other institutions, which supplement what these national communities can do, we are better set to bridge the gap between the public and the private sector, so that the public sector takes greater responsibility.

WHO's funding

GY: Is there a risk that these initiatives may divert donor funds away from WHO?

GB: Since I came, there has been a 56% increase in voluntary funding to WHO. So WHO has more funding than before, and there is more international health funding through these other mechanisms.

GY: What are the strengths and weaknesses of WHO being funded largely from donors?

GB: That's a difficult issue. When you go back to the early 1980s, 80% of our funding was from the regular budget [dues from WHO's member states] and 20% was voluntary funding from big donors—Britain, Nordic countries, the Netherlands, and the United States. And donors have increased their funding since then. It now means that we have nearly two thirds voluntary funding, and little more than one third regular—now that's a dramatic shift.

GY: Is this an irreversible trend?

GB: I'm afraid so. Who knows if 20 years from now you can have a more enlightened public approach across countries that they start financing the UN system, including the specialised agency for health, at a much more wise level? I hope this will be the case.

I want the money that we get from donors to be part of a normal programme budget process, which we monitor and audit, and use according to the corporate strategy. I hope we can avoid having this money split into regular and voluntary funds. But frankly in this period of time you must realise that those who give the money have to believe that the institution they pay it to is going to use it wisely. Certain of our key donors realise that WHO is needed as a strong institution. To be able to do good work internationally you need a strong WHO—they understand it—and they want to support us in key areas of our budget so that they don't influence the priorities that we have set.

Creating “one WHO”

GY: Your reforms seem to have stopped at headquarters level. Do you feel that there is a need for reform at regional level?

GB: In my mind all the reform work has been orientated towards one WHO. The budget is not a headquarters budget. My budget is for the whole of WHO, the regional offices, and the country offices. Together with the corporate strategy, which applies to all WHO staff wherever they work, this reform process reaches everybody.

GY: What kind of activities should WHO be doing at country level?

GB: The main thing is being a development partner. In addition, we should be advising governments on evidence and global health issues, and advocating the goals and decisions that are made at the World Health Assembly—because they apply to each country. We advise governments on how they can move towards these goals, and we help them mobilise and work with development partners at country level to achieve these goals.

GY: One concern about WHO is that it doesn't allocate resources according to country need. How can this be addressed?

GB: You cannot put all the money into the 30 poorest countries and forget the rest, because those 30 countries are dependent on the knowledge base of all the others in order to be able to move ahead. So there is no way, as you seem to suggest, that WHO should only be active in the very poorest countries—that would undermine our ability to affect the total picture.

But before I came to WHO, there was a big discussion about whether we have a fair distribution of our resources. The answer was no. So there has been a redistribution from the south east Asian and the eastern Mediterranean regions into Africa and a little to Europe, which now has many poor countries—the former Soviet republics. Such redistribution is tough because India, Sri Lanka, and Nepal have their own needs, but the needs are greater in Africa.

Health for All 2000

GY: In 1998 you told the BMJ that, “WHO must give priority to primary care of good quality, which must be available and affordable to all.”² Yet WHO's emphasis on primary care seems to have disappeared. Why is that?

GB: I have to ask you a question first: what is your definition of primary health care?

GY: Here I'm referring to primary health care as a vehicle to achieving Health for All 2000.

GB: Enlisting the poor—by investing in their health and in their needs—now that's primary health care. In my mind we are pursuing the goal of health for all in what we are doing with improving health systems; with adding to the evidence base; with advocating that you need to invest in HIV/AIDS, malaria, tuberculosis, and in childhood diseases.

GY: Was the aspiration and strategy of Health for All 2000 a valuable one?

GB: I think it was because at the time when it was formulated, and a consensus was building around it, it created momentum, confidence, and belief that here is what we have to try to work towards. But it was before the economic crisis of the end of the 1980s and 90s, and the goals were ambitious, so there still is a lot to be done.

Millennium development goals

GY: How do you think the international community can best help the world's poorest countries in reaching the millennium development goals?

GB: That's now the rallying point. As I go to Johannesburg, the millennium development goals are what now binds things together in a consistent fashion. And to reach these, you need to invest more in people—in education, children, health and environmental issues, water, sanitation.

You cannot continue with the idea that rich countries don't need to pay more than 0.1% or 0.15% of their gross domestic product in development assistance. Many countries are spending less, but there are some countries that are now increasing their assistance, like Ireland. The United States has even promised to increase its assistance, which is still far below a reasonable level, so I'm hopeful that there will be a certain realism—an understanding that countries need to come forward with more funding. When all the Nordic countries and Netherlands can pay 0.9% or 1%, I have no respect for other countries saying they cannot even pay 0.5%.

Evaluating health systems

GY: The World Health Report 2000, which evaluated health systems worldwide, caused an outcry. What have you learnt from the controversy surrounding that report?

GB: I knew before that report came out that there would be a lot of turbulence around it, because we were putting together data and analysis that made it possible in some way—although imperfect—to look across national borders and to look at where countries have reached in the attainment of certain goals for their health systems. Unless we start having access to that kind of integrated data that can be compared, and unless nations can start looking at their health systems in that kind of context, we will not move forward. But of course we are working on improving the methodology, and on having more time to work with each country so that they can feel that they are part of the data collection in a more direct way. I think next year we can make a new assessment—not exactly the same kind but based on some of the thinking of the World Health Report 2000. We will have more quality data, as well as input from scientists, from countries, and a lot of new work through the World Health Survey [see www3.who.int/whs].

WHO's leadership

GY: How does running WHO compare to running a country?

GB: We have all kinds of people working here with different backgrounds, from culturally different countries. So that creates a certain difference. However, you are developing policies, trying to advocate, implement and fund them, trying to move an agenda forward. In all those ways it's the same thing—you are a leader and a manager and you are trying to inspire and move things forward.

GY: Have you achieved all you wanted?

GB: I still have things that I am going to achieve within the next year, so when I get to the five year mark, I think I will be able to say yes. Health is on the development agenda—it is part of the G8 summits. There have been malaria and AIDS conferences by African leaders, not only by health ministers. I am trying to launch an alliance on healthy environments for children, because a lot of work is being done by different institutions but it is not pulled together.

GY: Was it a difficult decision not to stand for a second term?

GB: It was difficult. But I'm 63. I had to choose between standing down one year from now or six years from now. I don't want to get into a situation in my life where I am not fully energetic and able to do my job as I would like it.

WHO's future

GY: What do you think your successor's priorities should be?

GB: We are on track in such a way that we are able to support global health goals, the new global health mechanisms, and governments as they move to implement the millennium development goals. So I believe that a successor would be able to continue this work, and of course pursue additional ideas. All this investment that has been made in human resources policy, in the cultural changes based upon the corporate strategy itself, I'm sure will be a good starting point for any new director general.

Conclusion

Brundtland managed the seemingly impossible. She took WHO out of the doldrums and gave it back some international credibility. On the global stage, the organisation has a newfound confidence, negotiating an international treaty on tobacco control and brokering partnerships with a wide spectrum of society. It would now be inconceivable to hold an important meeting on global health without WHO's involvement.

In a globalising world, with its striking health inequalities, WHO now wears many different hats—advocate of the poor, technical and scientific adviser, development partner, and steward of the increasingly disparate global health activities. Yet the organisation is plagued by major problems that prevent it carrying out these roles effectively (box).

Challenges facing the next director general

• Devolving resources from headquarters to countries

• Coordinating activities across the entire organisation, and fostering better working relationships between Geneva and the regions

• Helping the poorest countries to apply for new health funds, and roll out and coordinate new health initiatives—all within the context of health systems strengthening

• Articulating a clear and consistent policy on working in partnerships and doing better at defining their governance

• Nurturing WHO's excellence in normative work, through a process that encourages analysis and criticism, and that is uncorrupted by competing interests

• Persuading donors to channel their voluntary donations into WHO's core activities and exploring new ways of funding WHO

• Fostering better internal and external communication and a culture of openness and debate

• Raising staff morale

One problem is that Brundtland recentralised WHO—she focused its energies on headquarters. For WHO to better advise and support the poorest countries in strengthening their health systems, applying for global health funds, and rolling out new health initiatives, the organisation must surely become weaker centrally and stronger at country level. The regional offices are closer than Geneva is to countries, and are best placed to reach them, yet WHO has still not found a way to harness their geographical advantage, and the regions continue to function independently of any coordinated global strategy.

I agree with Brundtland that we should not judge WHO's success on what the organisation can do on its own, but what it can achieve in partnerships with others. But WHO is struggling in its partner role—it communicates poorly with others, does too little to include civil society, rarely defines a governance structure for its alliances, and has no clear policy guiding its partnership activities. WHO's partners look to the organisation to set global norms and standards; these should be reached through a process that fosters much more criticism, communication, and debate than is currently found.

In 2002, WHO has been revitalised, but it has not yet reached its potential as a major force for improving the health of the poor.