We need a World Health Organisation – but maybe not this one

My one and only encounter with the WHO was in the Solomon Islands in 2009.

I was working with the Solomon Islands Ministry of Health, trying to forecast their budget requirements over the next few years. It was a challenging exercise.

When I arrived in the capital, Honiara, it looked like a tropical paradise. White beaches, palm trees, bougainvillea and all that. Close up, however, it wasn’t quite so idyllic.

The Ministry of Health office in Honiara was mostly a collection of single story fibro buildings standing on metal stumps, scattered somewhat randomly around an untidy compound. Various vehicles were parked haphazardly in the grounds, many of them missing their wheels.

The largest building in the compound was a two story cement brick construction painted dark blue. A rather ostentatious brass plaque by the front door described it as the WHO Country Liaison Office. In fact, the WHO only occupied a small part of the building. It was used by the Ministry’s senior executives and its finance and planning staff. The WHO had donated the building to the Ministry, and were therefore given rent free office space.

The WHO office was on the upper level, at the far end of the corridor, behind a solid metal door with electronic security locks and a watchful video camera high on the wall. It was a stark contrast to the shabby offices in the rest of the building. The security door and camera, and the reinforced glass at the reception desk, were recent additions since the visit of a UN security adviser who operated as if every UN office was located in Baghdad.

The WHO representative in the Solomon Islands was from Ghana. He held court in arctic air conditioning, a little man with a regal bearing, a presence that expects to be noticed. His role was, indeed, almost that of a diplomat, the sole representative of his organisation in this far flung outpost.

I was there to discuss the WHO’s funding for health services in the Solomon Island. He gave me a copy of his budget report. It was less helpful than I’d hoped. There were inconsistencies in the way things had been classified and his grasp of budgeting and reporting principles seemed weak. He waved away questions about bookkeeping processes. It was clear, however, that the WHO contributed relatively little to funding health care in the Solomon Islands, compared to the huge amounts donated by Australia, Japan and a dozen other major donors.

The WHO was established after the second world war, in 1948, on the principle that good health is a human right. Over the years since then, it has eradicated small pox and almost eliminated polio, promoted childhood vaccination, led campaigns against diseases like cholera, TB and typhoid, and funded research on tropical diseases that people in the west have never head of.

The Solomon Islands is a good example of a country that needs an organisation like the WHO. When I was there, it had only 38 doctors for a population of over half a million people, spread across hundreds of remote islands, in small villages without effective communications, electricity, water or sanitation. Travel from Honiara to the main towns is by small plane, or by slow passenger ferries that take a week to make their way around the archipelago. From there to most settlements you need a boat with an outboard motor. Living in a tropical island paradise is not so wonderful if you suddenly become ill.

To compound these challenges, the government had very little money and it had less and less each year as the country’s previously abundant natural resources had declined. The last of the valuable tropical forests had been logged, and the last of the tuna in the surrounding seas had been fished out. Politics and government administration were dominated by tribal and family loyalties, and many things we would consider corruption were regarded as normal behaviour.

In these circumstances the country was heavily dependent on donors and charities to deliver most health services. Almost 60 per cent of all funding for health was provided by organisations like UNICEF and the World Bank, the governments of Australia, Japan and Taiwan, and about a dozen other large donors. Between them they spent huge amounts fighting malaria and TB, providing basic immunisation for babies, and improving water and sanitation facilities in villages. Meanwhile, various church charities operated most hospitals and clinics.

Depending on donors to provide basic government services like health care is not a good long term strategy. My report on future funding for health showed a tidal wave of resources flooding in over the next three years, then crashing down to almost nothing after that. No doubt donors would renew their commitments before that happened, but there were no guarantees. Political and economic changes, and conflicting priorities elsewhere in the world would determine what happened in the Solomon Islands. The Australian government, for example, had made a ten year commitment to support the Ministry of Health. While I was there they decided to make it a five year commitment and had started withdrawing their expert advisers.

The WHO is supposed to help national governments provide health services to their citizens themselves. It could have an important role in these circumstances. The Solomon Islands has certainly benefited from the work done by the WHO in eradicating diseases and developing new treatments, but the organisation could be much more effective.

Like most UN affiliated agencies, it is weighed down with old-fashioned, bureaucratic management, opaque finances and quota driven employment policies, as my encounter with the WHO in Honiara seemed to confirm. And, because it is an international body created and funded by 194 national governments, it is buffeted by ideological and political disputes between its members, and sometimes dictated to by its largest contributors. Most times in the past this has been the US. Certainly not China.

Criticism of WHO effectiveness is not new and there have been proposals for reform. So far little progress has been made. For the sake of people in places like the Solomon Islands, perhaps now is the time.  

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