On taking office as director general of the World Health Organization on 21 July 1998, Gro Brundtland was faced with two enormous tasks—to restore the organisation's place on the international stage and to internally reform a failing United Nations agency. There is little doubt that she achieved the former. In this article I consider whether her managerial reforms have been successful.

Brundtland inherited the leadership of a dysfunctional organisation. In a 1995 editorial, Richard Smith, BMJ editor, argued that WHO was “overcentralised at headquarters and regions, top heavy, poorly managed, and bureaucratic and smells of corruption.”¹ Brundtland's reform process, said Jon Liden, her communications adviser, had to “butt against a fossilized UN bureaucratic structure.”

Under Brundtland's predecessor, Hiroshi Nakajima, the number of top ranking posts almost doubled.² These appointments were widely held to be political, rather than based on merit. When Brundtland took office, for example, there were six assistant director generals. These posts, said Julio Frenk, Mexico's minister of health and a former executive director at WHO, were “geopolitical appointments—each of the permanent members of the UN security council had one.” Cronyism was widespread, and debased WHO's technical competence. Regional directors would often assign country representative posts as a reward to doctors who had served their national governments.³

With its regular budget frozen, WHO relied heavily on additional voluntary contributions from donors. WHO departments would fight with each other for these funds, and over territory, and there was poor communication between them. The result, said one programme director in 1994, was that “the right hand never knows what the left hand is doing.”² The autonomous functioning of the regional offices added to WHO's difficulty in acting strategically across the organisation.

In her first address to WHO staff, Brundtland promised “a flatter structure, better communication, more transparency.”⁴ At the centre of her reforms was a new organisation of activities into nine (now eight) clusters that reflected WHO's priorities. She named nine executive directors, each of whom would head a cluster, and grouped them into a government-style cabinet.

Brundtland has said that this new arrangement is flatter.^5,6 This is true only in that there has been no reduction in the most senior posts but a big rise in the number of lower level posts (those below director level). Brundtland abolished the assistant director general posts, but there are now eight executive directors and a chief of cabinet.

Fiona Godlee, author of a BMJ critique of WHO under Nakajima, argued that “WHO should shift resources away from Geneva and the regional offices into the countries themselves.”⁷ Richard Smith argued that “the number of staff in Geneva and regional offices should be cut dramatically.”¹ Yet the opposite has occurred—WHO's human resources department said that there has been a sharp rise in the number of short term staff at headquarters. And the latest figures for long term appointments also show a rise in staff numbers in Geneva (table 1).

Table 1 Long term staff appointments at WHO. Source: WHO

Denis Aitken, Brundtland's chief of cabinet, argued that these figures don't reflect where WHO's focus lies: “It is a fallacy to argue that because someone is here [at headquarters], it isn't benefiting countries.” The work that staff does in Geneva, he said, has a direct impact on countries. But one senior staff member at WHO said that headquarters must be slimmed down, leaving it with a role in standardising, evaluating, and coordinating activities that happen closer to countries themselves.

Why has there been a dramatic rise in short term appointments at headquarters? The rise is due to the 38% increase in voluntary contributions from donors during Brundtland's term. These funds pay for specific, time limited projects, and staff can be hired for these only on a short term basis. Almost 60% of WHO staff are now on these temporary contracts. Although these give WHO flexibility in appointing staff, a UN inspectorate report warned that such contracts make it harder for WHO to hire qualified people in mid-career.⁸

WHO's budget also shows no evidence that resources are shifting from Geneva to countries (table 2). But it is another fallacy, said Aitken, to think that the division of funds between headquarters, regions, and countries reflects who will actually benefit. “I would guess,” he said, “that approximately 60-70% of funding is spent on country work in one way or another.”

Table 2 Regular budget of WHO ($000). Source: WHO

One of Brundtland's innovations is a new way of specifying how funds should be spent across WHO. About 18 months before the start of every two year budget period, senior managers draw up a strategic plan, known as the programme budget, for that period. The budget sets objectives, allocates funding to achieve these, and defines measures that will be used to monitor success. The programme budget for 2002-3 is the first time that WHO has planned its spending on specific activities at both headquarters and regions. One of WHO's structural problems is that the regions do their own planning independently, preventing WHO from having an organisation-wide strategy.

The new budget is one of the levers that Brundtland can use to try and create “one WHO,” but the regions may not buy into the proposal. For example, WHO's African region has already developed its operational plans for 2004-5. The plans are laid out in a highly detailed 375 page document, which has been written before the organisation-wide strategic plan on which it is meant to be based.

Brundtland can point to a number of measures designed to increase the transparency of staff selection. What is harder to show is whether these measures are being adhered to and whether they are effective.

I heard a wide range of views among those I interviewed. One academic in international health, who advises WHO, said that “the rules about hiring and firing and accountability haven't changed.” On the other hand, many staff at WHO feel that there has been a genuine attempt to clean up the organisation. In recruiting staff at headquarters, for example, a selection panel now prepares a shortlist of recommended candidates, and testing has been added to interviews. Isabelle Nuttall, of WHO's staff association, believes that selection procedures are more transparent under Brundtland, but said that the director general still appoints the executive directors and special advisers directly and that “these appointments are as political as before.”

Brundtland has a greater say than her predecessor in appointing country representatives and believes that their selection is now a fairer process. “It has become a global, more systematic approach,” she told me, “to building our human resources and using them.”

“We need a culture of information sharing,” said Brundtland at the start of her term.⁴ This would depend on good communication between her executive directors, and between the cabinet and the rest of the organisation.

An external adviser to WHO said that, on first glance, the cabinet looks like an improved way of managing WHO, but this is an illusion: “Brundtland says, ‘Look, I’m consulting,' but the consultation doesn't go very far.” The cabinet, he said, does not consult with the wider organisation, particularly its technical medical officers. And one senior WHO insider says he was shocked by the amount of internal fighting within the cabinet. “The reality,” he said, “is that there's an incredible amount of competition between the executive directors. People don't care for a common cause, they want to score points.” What WHO needs, he said, “is a visionary cultural change, with sharing of ideas and greater consultation.”

One of the reasons for this competition is that WHO's regular budget is still frozen, and the executive directors must argue their case for spending these limited resources on their own cluster's activities. “Let's be realistic here,” said Liden. “At the top of WHO, some of the best brains from a number of cultures, academic traditions, and public health schools of thought meet. You are bound to find disagreements and heated discussions. And unless you devise a whole new system to fund the organisation, there will always be anxiousness about funding for key programmes.”

The makeup of Brundtland's first cabinet—an equal mix of those from developed and developing countries and of women and men—sent a strong signal that Brundtland wanted to increase diversity within the organisation. A cabinet meeting in December 1999 agreed that the female recruitment rate should be set at 60% “to achieve gender parity in the Organization in the coming decade.”⁹ WHO still has a long way to go to achieve such parity (fig 1)—only 32% of professional staff, and only 29% of new recruits, are women.

Figure 1 Representation of women professional staff 1990-200119

Tikki Pang, WHO's director of research policy and cooperation, said that only seven of the 36 directors come from the developing world. “We very much need more developing country representation in Geneva,” he said. But he also believes that Brundtland has championed the developing world in two important ways. “Her successful attempt to link health with development and with poverty has shown WHO to be particularly sympathetic to developing countries. And as far as commitment to build capacity in research in developing countries, certainly she's been a champion.”

WHO should be serving developing countries, said another staff member, which is why their inclusion is crucial. “If you can't find experts in developing countries,” she said, “do you exclude them or do you say, ‘Let’s all work together and try and bring people's ability up'?” At its last meeting, the World Health Assembly, the annual legislative meeting of member states, expressed deep concern at the lack of staff from the developing world. It resolved that the director general should “ensure that the principles of equitable geographical representation, gender balance, and a balance of experts are respected in making appointments.”¹⁰

One criticism of Brundtland's reforms is that they could be seen as playing to a donor audience rather than to developing countries. In many ways, for example, WHO is now being managed in the style of a modern business, even borrowing some of its language—it has a corporate strategy, executives, and management support units assigned to each cluster. This language, said one WHO staff member, is “managers' jargon” aimed at Nordic, American, and British donors.

And there is one important slogan, she said, that is still championed by many in the developing world but that has been “censored” from headquarters' language: Health for All 2000. WHO set itself this target in 1977,¹¹ and a year later announced that primary care would be the means to achieve it.¹² The organisation now seems embarrassed by this unachieved goal (box B1).

Critics of WHO's management argue that it has sometimes tried to keep the organisation “on message” by covering up internal dissent. One episode more than any illustrates how the management finds it hard to allow internal debate and dissent: publication of the World Health Report 2000.¹³

The report's authors measured the performance of the healthcare systems of WHO's 191 member states, creating a league table of good and bad performers. Publication of the report caused an outcry. Critics argued that the exercise was driven by headquarters with little input from, and relevance to, developing countries.^14,15 Daphne Fresle, a former member of WHO's essential drugs and medicines policy group, resigned from WHO, citing the report as one reason for her departure. “I feel embarrassed,” she wrote in her resignation letter of 23 December 2001, “to be associated with this highly criticised product whose contribution to better global health care, particularly in the countries most in need, is low or non-existent.”

An unhealthy atmosphere surrounded the release of the report. Data were kept from many WHO staff until the report was finished. Staff who criticised its methods or findings were seen as conspiring to undermine WHO's international credibility. If WHO is a scientific resource serving its member states, argued Alan Williams, professor of economics at the University of York, “it needs to create a much more open intellectual environment for its staff.”¹⁴

WHO's executive board asked Brundtland to commission an external review of the report's methods before any repeat of the exercise (box B2).¹⁶ Brundtland's response to this request has been impressive, and hopefully heralds a new spirit of openness.

What can WHO can learn from the controversy? Two things, said Pang—the need to consult with countries more closely at the start of such an exercise, and the need to be transparent about the methods used.

WHO's director general has many constituencies, including governments, the media, and staff. Many of those I interviewed said that Brundtland has been a great leader on the world stage, but a poor leader of the organisation. Staff at high levels said she gave them great freedom and support to develop their programmes, but many staff at lower levels feel disenchanted by her management. She boosted their morale on arrival, by being highly visible and promising a new era of openness and communication, but there was a large gap between rhetoric and action. Her increasing isolation from them was matched by their falling enthusiasm for her management. In a survey last year of 637 WHO staff, 40% rated their morale as bad or very bad.¹⁷

Brundtland has been far more successful at raising WHO's profile internationally than at transforming the organisation internally. She did establish mechanisms to reduce political appointments and has raised awareness of the need to increase staff diversity. But she has not fostered openness or internal debate. WHO is more centralised now than in the 1990s. It remains top heavy and dominated by men and representatives from developed countries.

A team of consultants who reviewed Brundtland's management reforms called them “the worst of both worlds.”¹⁸ The reforms combined the worst aspects of private sector management—such as rigid control and a focus on short term results to satisfy external stakeholders—with the worst aspects of public sector governance—such as lack of transparency. “Who has the courage,” asked the team, “to grapple with root causes of the problems?”