In my previous column, I started with an in-depth look at the World Health Organisation’s poor performance during the Covid-19 pandemic. In this article, I’ll continue the deep-dive and consider its mandate and finances.
The World Health Organisation (WHO) is the post-war successor organisation of the International Sanitary Convention of 1892, which itself has its origins in the first of several International Sanitary Conferences, held in 1851.
The original purpose of these conferences was to deal with cholera epidemics which in 1830 and 1847 had killed tens of thousands of people in Europe. At the time, the cause of this disease was unknown. The conferences were the first attempt at establishing a mechanism for international co-operation for disease prevention and control.
Five years after the adoption of the International Sanitary Convention for the control of cholera in 1892, another Convention was established to address the control of plague. In 1926, the Convention was expanded to include provisions against smallpox and typhus.
When the Convention along with several established supra-national health organisations were consolidated into the WHO in 1948, its scope was expanded to include malaria, tuberculosis, venereal diseases, maternal and child health, sanitary engineering, and nutrition. In addition, the WHO was involved in wide-ranging disease prevention and control efforts including mass campaigns against yaws, endemic syphilis, leprosy, and trachoma.
A harbinger
Although the original purpose and focus of the WHO’s predecessors were to combat infectious diseases, the organisation’s constitution was a harbinger of broader ambitions. Its objective was given as ‘the attainment by all peoples of the highest possible level of health’.
It further defined ‘health’ to mean ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.
Until the 1990s, the WHO continued to focus on communicable diseases, with considerable success.
In 1958, the USSR proposed that the organisation lead a smallpox eradication programme. It took less than 20 years to achieve total eradication, with the last known case identified in Somalia in 1977. In 1980, the WHO called a halt to routine smallpox vaccination.
In the 1960s, the WHO promoted mass campaigns against yaws, endemic syphilis, leprosy, and trachoma. It helped control a major cholera pandemic in Asia and the Western Pacific, as well as a large epidemic of yellow fever in Africa.
In 1988, the WHO formulated an ambitious plan to achieve global eradication of poliomyelitis by 2000. Although substantial progress was made, this goal was not achieved. To this day, polio survives in a few countries.
In 1987, WHO launched the Safe Motherhood Initiative, which aimed to reduce maternal morbidity and mortality by 50% by the year 2000. This initiative also did not succeed and maternal health continues to be a major focus of WHO efforts.
Change in focus
It is perhaps not coincidental that around the same time as these failures, the early 1990s, the WHO began to expand its focus to so-called ‘lifestyle diseases’ such as obesity, cardiovascular disease, cancer, and diabetes. It launched programmes promoting healthy living and tobacco-free societies. At the same time, in the wake of the Rio ‘Earth Summit’ in 1992, the WHO launched initiatives addressing the health hazards posed by environmental degradation.
Since there is no vaccine or cure for lifestyle diseases other than a change in lifestyle, its recommendations became increasingly authoritarian and prescriptive. It began to advocate sin taxes, prohibitions, and advertising restrictions.
It also extended its influence into the political sphere, promoting socialised healthcare systems even though they might be inappropriate or unaffordable for many of its member countries.
In its Programme Budget for the two-year period of 2020 and 2021, it outlines its ‘strategic priorities’ as ‘achieving universal health coverage’, ‘addressing health emergencies’, and ‘promoting healthier populations’.
Unlike with communicable disease outbreaks, it is far from clear why promoting healthier populations or universal healthcare require urgent action or international cooperation. These seem like matters best left to individual governments, depending on the democratic wishes of their people.
More worryingly, it would appear that the WHO’s new focus on general health and wellbeing has distracted it from its efforts in more traditional areas such as the eradication of communicable diseases and maternal and child mortality.
WHO spending
Its projected budget for the biennial period of 2020 and 2021 has risen from around $4,4 billion in 2018 and 2019 to just over $4,8 billion, an increase of 9.5%.
Of that, $863 million is dedicated to polio eradication and $889 million to health emergencies, which appears to include communicable diseases. Fully $1 359 million is reserved for promoting universal healthcare. Another $431 million is earmarked for general health and wellbeing, and $209 million set aside for special programmes. Another $1 090 million is budgeted for ‘more effective and efficient WHO better supporting countries (sic)’.
(One hopes that some of that last billion is invested in the capability of creating PDF documents which are searchable and from which one can copy text. It is a nightmare trying to find anything useful in the WHO’s voluminous reports.)
The breakdown in this latest budget obscures much of the detail of the WHO’s planned expenditures. How much, for example, is spent on fighting communicable diseases?
For the 2018 and 2019 period, the budget was much clearer: $903 million to be spent on polio eradication, $805 million dedicated to other communicable diseases, $351 million to non-communicable (lifestyle) diseases, $384 million to ‘promoting health through the life course’, $590 million on health systems, $554 million on health emergencies, $118 million on tropical disease research and research in human reproduction, and $716 on corporate services and enabling functions.
A direct comparison is difficult, but one can make a few observations. Twenty years after the WHO had planned for the final eradication of polio, it is still spending almost half a billion dollars per year on the problem.
In the period from 2018 to 2019, it spent almost as much on healthcare systems and lifestyle diseases as it did on communicable diseases other than polio. In 2020 and 2021, the focus shifted dramatically. Promoting universal healthcare systems is now by far the largest single budget item.
It also appears that the WHO’s administrative overhead increased by a startling 43%.
Lavish salaries
I couldn’t find an indication of staff costs in its latest report, but in the previous two-year period, it spent 37% of its total funding on remuneration, which at the time worked out to a jaw-dropping average salary per employee of $130 000 (R2 million) per year.
Like any self-respecting UN-related organisation, it has its meetings and conferences at luxury resorts in exotic places. It has in the past been slammed for excessive travel expenses, spending more on travel than on HIV/Aids, hepatitis, malaria, and tuberculosis combined. Its latest internal audit reports that travel expenses have since increased.
For some countries, funding this kind of mismanagement had become a grudge buy, and when the controversy over China’s handling of Covid-19 presented an excuse, President Donald Trump wasted no time yanking US funding from the organisation in April 2020. As the largest single donor to the WHO, the US represents 15% of its funding budget.
Given that the WHO is already under-funded, and doesn’t exactly use its resources efficiently, this merely contributed to its ineffectiveness. Richard Horton, editor of the influential medical journal The Lancet told The Guardian that the WHO ‘has been drained of power and resources’.
‘Its coordinating authority and capacity are weak,’ he said. ‘Its ability to direct an international response to a life-threatening epidemic is non-existent.’
Getting worse
The organisations auditors would tend to agree. The Report of the Internal Auditor dated 15 October 2020 was none too complimentary about the organisation’s financial management and readiness to respond to health emergencies.
Instead of getting better as a consequence of widespread criticism, the WHO is getting worse. The auditors found that while 81% of its conclusions in 2018 were either ‘satisfactory’ or ‘partially satisfactory with some improvement required’, in 2019 only 53% of its conclusions reached these modest heights. While the operating effectiveness of internal controls in regional offices and cross-cutting areas were all in the top two brackets in 2018, only 63% remained so in 2019.
The WHO’s financial controls are lax, and its spending inefficient. It spends a huge part of its budget on overheads like maintaining offices, travel and salaries. Its staff live high on the hog, with average incomes higher than the GDP per capita of even the richest country on the planet.
Since it isn’t very well funded in the first place, this mismanagement dilutes the impact of its spending.
The WHO also suffers from a serious case of scope creep. Whereas communicable diseases were once its core focus, its effectiveness has suffered greatly since it began to promote universal healthcare, environmental health, and healthy lifestyles in the 1990s.
All of this critically undermines its ability to fight communicable diseases and respond to health emergencies such as the Covid-19 pandemic, and epidemics in general.
In my next column, I’ll raise another few issues that bedevil the WHO, and, if there aren’t too many left, look at some recommendations for reforming the organisation.
The views of the writer are not necessarily the views of the Daily Friend or the IRR
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