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The WHO and New Public Management: Value for Money or heading for a Cruel Disappointment?

By Remco van de Pas
on January 5, 2018

In the early days of the New Year, i find myself looking into some of the background documents for the upcoming Executive Board (EB) meeting of WHO later this month, EB 142.  After the last special Board meeting in November 2017 (EBSS4), where WHO’s new DG Dr. Tedros discussed a (revised) draft version of WHO’s ambitious 13th Global Programme of Work (2019 – 2023), the question is now how this will translate into an effective resource mobilization strategy to generate the financing needed to implement the 13th GPW. WHO’s relative silence on its chronic financial crisis is telling on the gridlock in global health governance. Let’s see whether the new draft (to be released today), will (finally) offer some more detail on the financial part of the picture for the coming years.

True, to a certain extent, WHO’s financial difficulties for running its operations and organization are not new. Since its initiation in 1948 the organization has been partly dependent on financing by actors other than its member states, e.g. in the early years from the Rockefeller Foundation.  In that sense it is not entirely surprising that its philanthropic “successor”, the Gates Foundation, is paying for approximately 25% of WHO’s overall budget, nowadays. Still, the partnership model in global health and the so called “Trojan multilateralism” trend have “inspired” a shift away from broader systemic goals sought through multilateral cooperation, in recent decades.

It is in this light that the preparatory EB document “Better Value, Better Health” should be read. There is a certain irony in the title because the documents mainly talks about value for money, hardly about any value for health. The value for money trend is part of a continuing push for UN organizations (by their funders) to focus on performance and results.  This ‘New Public Management’ (NPM) approach, since a few decades the business-inspired “mantra” for public organisations and institutes, is now also firmly embraced by WHO under Dr. Tedros, it appears. The document makes it abundantly clear that the aim is to function from now on as a global public institute in a networked, multi-stakeholder manner with its private partners, providing “value for money” (which supposedly will lead, in turn, to better health for the billions).  In the ‘Better Value, Better Health’ document WHO benchmarks itself by mapping 12 other multilateral organizations. As for how they are doing in terms of value for money,  “… all the organizations mapped had incorporated value-for-money principles to varying extents…. all took into account efficiency and effectiveness, but there was no evidence anywhere of an ethics consideration”.

Wait, aren’t we talking here about the main global authority working on health policy norms and guidelines? Shouldn’t public health ethics, defined by WHO itself as “principles of respect, good will, justice and not causing harm” be much more central to such a ‘Better Value’ approach?

Unfortunately, this indicates a broader trend, whereby human rights and health equity –  i.e. an ethical value base for international health cooperation and global health diplomacy, have quietly been sidelined as policy drivers for sustainable development. It is painful to see that the ‘NPM’ discourse has become so dominant in a multilateral public health organization while in many European (domestic) public health constituencies NPM has been considered a ‘cruel disappointment’. Public sector transformation via private sector performance criteria has led to an expanded role for management consultants, an ‘audit society’ and risk management procedures, the typical NPM ‘package’. This is exactly what we now see being pushed through at WHO.  Analysis suggests that within the British Health care System, for example, NPM has failed to deliver on its goals with ‘significant undesirable side effects and misfits between policy announcements and implementation’.

While there is certainly a need for the WHO to work more efficiently and effectively, NPM is not the answer. WHO itself also warns for “over-institutionalizing” Value for Money in the organization. Rather, there must be a constructive public dialogue with its members (and third actors) on what WHO should and should not do, including with respect to its financing. There is currently a large push by many funders for WHO to be more operational, while others argue that its main role should remain norm-setting and evidence-based program guidance.

The key difficulty remains to have the core tasks of WHO properly financed.  Voluntary tied financing and a minor (3%) increase of assessed contributions by Member States complemented with philanthropic funding have perhaps managed to keep WHO afloat in recent years, but drifting in (too) many directions. I would rather argue  that WHO’s normative role is a Global Public Good for which alternative innovative public financing mechanisms should be developed, e.g. via earmarked taxes coordinated between countries, Financial Transaction Taxes or other global levies.

This, however, requires WHO’s member states to be firmly committed to democratic multilateralism, which is far from a given in our current chaotic multi-order. But who knows, perhaps 2018 will be a new start, including for the WHO?

Geneva, over to you!


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