BMJ  2003;326:1100-1101 (24 May), doi:10.1136/bmj.326.7399.1100

Editorial

New leader, new hope for WHO

Setting an agenda for Jong-Wook Lee

In the mid-1990s the World Health Organization seemed doomed to either "flounder in a morass of petty corruption and ineffective bureacracy"¹ or to die.² Neither of these happened. Instead, Gro Harlem Brundtland, who took office as director general in July 1998, restored the organisation's reputation as a credible force in global health.³ Last week the World Health Assembly approved Jong-Wook Lee as Brundtland's successor. Unlike Brundtland, Lee is not being charged with saving the organisation but with harnessing its potential to transform the lives of the poorest. There are four things he must do to help achieve this.

Think global, act local

Firstly, he must start to close the huge gap between what WHO is doing on the global stage and what is happening at country level. Where Brundtland focused her energies and much of WHO's resources on headquarters—a strategy that was useful for launching new, high profile public-private partnerships—Lee must think globally and act locally.

High profile public-private initiatives are being rolled out in countries with weak public health systems. The poorest countries struggle with epidemics, natural disasters, famine, and wars, and they can barely deliver the most basic of health services. Country support from WHO could help strengthen these health systems, yet WHO's country teams have been chronically underresourced and undermined by poor coordination with Geneva's activities.⁴ WHO needs a long term strategy of investment that should include support for countries to build a public health infrastructure. Many health activists in developing countries believe that the best way for WHO to reinvigorate its country work is to recommit itself to the Health for All initiative.⁵

The regional offices could be the missing link between the global and the local. Regions can help countries to share experience, information, and knowledge and they have a geographical advantage over Geneva in reaching countries. But Lee will inherit an uneasy relation between headquarters and the regional offices,⁶ one that continues to threaten WHO's usefulness and responsiveness locally. Although the roots of this unease run deep, Lee must nevertheless find a way to create a truly organisation wide approach.

Global support and finance

Secondly, Lee must argue the case that the world needs to support and finance WHO now more than ever. New players in global health are commandeering not just the limelight but also the funding—money that is outside the governance of the world's health agency.⁷ Many WHO staff have expressed deep disquiet at the way that the organisation has been sidelined by spin offs of WHO, like the Global Fund and the Global Alliance for Vaccines and Immunisation.⁷ Lee's advocacy and experience with the Stop TB initiative could help to define WHO's place in the new global health landscape. WHO should stake its claim as the agency that will help the poorest countries apply for new health funds and roll out new health initiatives. It should stand up and be counted as the agency that is best placed to coordinate the disparate global health activities, one with an unparalleled reputation for setting global norms and standards, and one that can highlight the stark inequalities within and between countries.

WHO's partnerships

Thirdly, Lee should take stock of WHO's partnerships and ask some crucial questions of them: which ones are having an impact at ground level? Are partnerships diverting resources away from WHO's less "fashionable" but arguably more important core activities? Which partnerships are the most accountable to those that they serve and the best governed? Which have managed to include meaningfully a balance of private, public, and civil society voices? This kind of appraisal is urgently needed. WHO does not have a clear and consistent policy on working in partnerships, and yet it is increasingly entering into them.

Openness in management

Fourthly, Lee needs to create a more open management culture, in which internal debate is encouraged and shared with the rest of the world rather than stifled in an attempt to keep staff "on message." How disturbing that in the run-up to the recent election for director general, a senior policy adviser instructed WHO staff not to discuss their thoughts about the future of WHO publicly.⁸ Why the censorship? Surely the views of WHO's executive and programme directors are of central importance in the debate about where WHO should be heading. Fostering openness, as we recently argued, should also include a commitment to reforming the next election process for director general.⁹

This agenda is achievable—and there is much in Lee's election manifesto that leaves us profoundly optimistic.¹⁰ He has promised to increase the proportion of resources allocated to countries and regions from 67% to at least 75% by 2005 and 80% by 2008. He says he will advocate a substantial increase in investment in public health systems and services. He plans to launch a new initiative to help countries close the widening gap in health service provision between the rich and poor. And he has committed to prioritising WHO's involvement only in partnerships that can show specific and defined roles for all partners, measurable results in terms of health outcomes for the poor, and a focus on action at the local level.

Best Treatments (gyamey{at}bmj.com)

BMJ BMJ Unified, London WC1H 9JR

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Competing interests: The BMJ receives submissions and commissions papers from many authors who work for WHO. KA is involved in decisions about publication of these. KA is a former editor of the Bulletin of the World Health Organization and is at present an editorial adviser.

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4. World Health Organization. Improving WHO performance at country level: "the country focus initiative." Consultation draft. Geneva: WHO, 2002.
5. People's Health Movement. People's charter for health. http://phmovement.org/pdf/charter/phm-pch-english.pdf (accessed 14 May 2003).
6. Feachem R, Medlin C, Daniels D, Dunlop D, Mshinda H, Petko J, et al. Achieving impact: roll back malaria in the next phase. Final report of the external evaluation of Roll Back Malaria. 29 August 2002. http://mosquito.who.int/docs/RBMupdate/2nd/RBM_update_2nd.htm#Eereport (accessed 20 May 2003).
7. Yamey G. Why does the world still need WHO? BMJ 2002;325: 1294-8.[Free Full Text]
8. The Lancet. The rights and wrongs of WHO's policy of censorship. Lancet 2002;360: 1995.[Medline]
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Rapid Responses:

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Expectations from new Director General of WHO

Dinesh Kumar Sharma
bmj.com, 23 May 2003 [Full text]

politics before health for all?

Peter WS Chang
bmj.com, 25 May 2003 [Full text]