TCS Daily

Can This Patient Be Saved?

By John Luik - May 24, 2005 12:00 AM

You would think that it would be a time to review past successes and look forward to a progress- filled future of furthering global health. Instead, the 58th Annual World Health Assembly -- the policy setting body of the World Health Organization -- is once again a showcase of not only how badly dysfunctional WHO really is, but how deadly are the consequences of this institutional disarray for the world's poor.

WHO's problems are nothing new, despite the fact that the organization has often been able to escape many of the headlines about stifling bureaucracy, incompetence and corruption that have plagued the United Nations. For instance, over the last decade or so WHO has been criticized in the British medical journal The Lancet for losing "virtually all the public health impetus it enjoyed 10 years ago", has had the competency of its Director General seriously questioned and has been the subject of charges of improper contracting relationships between the organization and companies controlled by members of WHO's Executive Board. This is not to suggest that WHO has not had some successes -- for example, the elimination of smallpox -- but rather that these successes are infrequent and overshadowed by its significant failures.

WHO's problems begin with its organizational structure, a top-heavy, Geneva-based bureaucracy whose professional staff are paid average annual salaries of $160,000. Though the annual World Health Assembly makes WHO look like an accountable democracy, in reality strategic, policy and spending decisions are largely in the hands of WHO's unelected, richly remunerated and largely unaccountable bureaucrats. And these bureaucrats are consistently committed to a global model of Soviet-style centralized planning that seeks to continually expand WHO's reach while failing to develop morally justified and achievable priorities. As public choice theory suggests, this sort of governance structure leads bureaucrats to consider their own interests as primary and to foster a policy agenda that reflects these interests rather than the more legitimate needs of those whom they are meant to serve. What this means is that WHO's agenda is dominated by its staff's perception of global health, health care science and health care priorities, a perception that is often not only ignorant of divergent perspectives but hostile to them as well.

One can see how the interests of WHO's bureaucrats distort its perspective and corrupt its work by looking at how the organization allocates its resources, both historically and currently.

For instance, ten years ago WHO had a biennium budget of $1.8 billion. Of that, 76% went to paying the "base salaries and other costs" of WHO's bureaucrats. Economists Robert Tollison and Richard Wagner have calculated that with the inclusion of overhead costs, for every two dollars WHO spends on programs it spends another eight dollars on salaries and overhead. During that period, 1994-95, WHO spent more money on office supplies ($5.6 million) than on diarrhoeal diseases which are a major source of infant mortality in the developing world. Again, during the same period, WHO allocated more money for health promotion campaigns on seat belts, something called psychosocial health and anti-smoking activities than on combating the malaria which kills about a million children a year, mostly in Africa.

Nor did WHO's bureaucrats spend the small amount of money left over after salaries in an equitable manner. Haiti, one of the world's poorest countries, received per capita WHO spending of 12 cents, while Saudi Arabia, awash in petro dollars, received 9 cents per capita. Kuwait and the United Arab Emirates received respectively 28 and 20 cents per capita from WHO, while Mozambique received 15 cents, Bangladesh 9 cents and Ethiopia 7 cents. Average per capita spending in developed countries like Israel and Hong Kong was comparable to the spending in relatively poor countries in Latin America.

Ten years latter these same bureaucratic distortions are still at work. In the program budget presented to the World Health Assembly for 2006-7, support for WHO's 140 country offices and their bureaucrats consumes $188 million scarce dollars. Of the almost $153 million allocated for arguably WHO's primary mission -- communicable disease prevention and control -- only 42% is to be spent at the country level while 58% is spent on the bureaucracies at the regional and headquarters levels. Human resources management -- that is training and development of WHO's staff -- will consume a staggering $51 million, while infrastructure and logistics will eat up another $130 million for a total of about 6% of WHO's entire budget.

But WHO's problems are not simply a result of its bureaucrats and their penchant for central planning and looking after themselves. They are also due to the way in which the organization has allowed it's policy agenda to be captured by groups of left-leaning political activists whose "policy objectives" -- thinly disguised as health-related and lacking credible scientific backing -- divert WHO's attention and funds away from what should be its primary mission. For example, the fat police, despite the lack of evidence that obesity reduces lifespan, have managed to push through a "global strategy on diet, physical activity and health" with a variety of interventionist proposals. Some of these activists have called for a food treaty modeled on the recent WHO tobacco treaty that would restrict food marketing, raise taxes on so-called unhealthy foods, and require a series of warning labels to distinguish good from bad foods. This in a world where the essential micro-nutrients like iron, zinc, iodine and vitamin A are missing from about half the world's diet.

Or take WHO's action, along with its sister organization the Food and Agriculture Organization, in requiring a host of regulations on food products made with gene-splicing techniques, a move which is based not on science but on WHO's desire to cater to the anti-GM activists. Then, too, there is the notorious failure of WHO's Roll Back Malaria program which in deference to environmentalists' objections to DDT has focused on the management of malaria treatment rather than the elimination of the mosquitoes that cause the disease. All of these decisions point to policies and priorities that are driven by special interest group politics rather than careful science.

Perhaps the most obvious way in which WHO's bureaucratic structure and its capture by interest groups with a political, rather than a health agenda ill serves the sick and poor of the world is found in its making non-communicable, chronic diseases a priority. WHO's expenditure on these conditions and diseases (spread over at least three areas in its budget) such as high blood pressure, elevated cholesterol, cardiovascular disease and cancer, is at least $198 million for the next biennium. This compares with $153 million to be spent on communicable disease prevention and control or the $137 million allocated to malaria. In other words about 6% of WHO's money will be spent on diseases which disproportionately effect the old of the industrialized world as opposed to the desperately poor of the developing world who can only wish that they might live long enough or eat well enough to get cancer or heart disease.

WHO's move to make non-communicable diseases a priority is morally dubious because it ignores the distinctions that should be made to determine how severely limited health care dollars can be spent most efficiently and justly. These distinctions revolve around considerations such as whether the disease is one where a transfer of resources and expertise from the developed to the developing world significantly facilitates its control or eradication, and whether the disease is one that is communicable, preventable and one that robs people of the chance for a life beyond childhood.

In other words, the moral principle for determining how WHO should spend its very limited money should be based on the fact that many people in the developing world die of communicable and preventable diseases before they reach old age. The claims of these people should trump the claims of people in the developed world for alleviation of cancer or heart disease that might at most add two or three years of life for the average person.

For example, as the Lancet has recently noted, of the 130 million babies born each year, about four million die in the first month of life and almost all of these neonatal deaths occur in developing countries that should be the focus of WHO's attention. Yet while WHO spends 58% of its communicable disease prevention budget on its regional and headquarters bureaucracies and almost $ 200 million on the chronic diseases of the industrialized world, the proportion of neonatal child deaths increases.

WHO's mission assumes a moral legitimacy when its work is focused so as to allow Africans with an average life expectancy of 50 to approach the North American and European average of 75-80. To the extent that it spends, under the influence of certain pressure groups, scarce resources on the rich world's non-communicable diseases of old age is the extent that it acts wrongly, signals its terminable decline and loses its reason to be.

The author writes frequently on health care issues.


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