An organizational analysis of the World Health Organization: Narrowing the gap between promise and performance

Vol. 40, No. 6, pp. 731-742, 1995 Elsevier ScienceLtd. Printed in Great Britain

Soc. Sci. Med.

Pergamon

0277-9536(94)00300-9

AN ORGANIZATIONAL ANALYSIS OF THE WORLD HEALTH ORGANIZATION: N A R R O W I N G THE GAP BETWEEN PROMISE A N D PERFORMANCE JOHN W. PEABODY General Internal Medicine Division, Veteran's Administration, West Los Angeles, CA, and RAND, Santa Monica, CA, U.S.A. Abstract--The World Health Organization's (WHO's) nearly half century amelioration of suffering stands as a singular achievement in international cooperation. But after 45 years, the Organization has grown into a complex bureaucracy with an outdated organizational structure. A multidisciplinary framework, which emphasizes organizational theory, yields some insights into these problems. Using this approach, this paper examines the structure, culture, mission, and rules of WHO, and adds a perspective, not otherwise found in the literature, to the growing debate on the future of the Organization. Previous studies of international organizations have explained their behavior as the consequence of the dominant external interests of powerful members. This perspective suggests that organizations like WHO have fewer options and less control of their policies and output. By contrast, there has been very little analysis explaining how international organizations function internally. This paper refutes an exclusively external perspective and shows that the internal organization is also important to understanding WHO. Several conclusions are drawn from this perspective. WHO's organizational myths, as a politically neutral technical agency staffed with uniquely qualified staff, need to be validated and enhanced to attract funding. A new organizational structure, based on an 'open systems' model, is proposed. This strategy would strengthen the WHO Representative Country Offices, redefine staff objectives, close the Regional Offices, and establish open, public elections of the Director General. Traditional WHO culture should only be used for health problems that are well matched to WHO's critical tasks. For more complex social and economic issues, newer, often non-medical, approaches are needed. The internal and external rules, which shape the incentives of WHO staff and leaders, need to be realigned to close the gap between WHO's myths and its day to day work. In the short run it is possible for WHO to do more with its limited budget if it changes its organizational structure; in the long run a reorganized WHO will be able to garner more funding and attract wider international participation.

INTRODUCTION The World Health Organization (WHO), by any measure, stands as a testimonial to the dream of global cooperation and international social justice. Created by the world community in 1948, today it is the acknowledged forum that nations of disparate economic status and divergent ideologies use to reduce and, at times, even eliminate the nearly u n b o u n d e d worldwide burden of h u m a n disease and suffering. But after 45 years, it is also clear that the Organization has grown into a complex bureaucracy with significant inefficiencies, conflicting incentives, and a limited medical paradigm that inhibits its potential. To a very real extent the organization is afflicted with its own success. The eradication of smallpox, in 1977, has emboldened Member States to urge that polio and dracunculiasis (guinea worm) be added to the singular list of diseases eradicated from the globe through international cooperation. Not only are expectations high but demands are increasing. AIDS and HIV, unheard of 12 years ago, has grown into the single largest programme in W H O and already accounts for 33 % of the total 1994-95 budget. Indeed, the overall guiding strategy for the Organization is a surrealistically ambitious goal--Health for All by the Year 2000.

What makes this an impossible goal and sets the stage for the most critical period in the Organization's illustrious history is insufficient funding. Despite increasing demands for collaboration, W H O ' s regular budget has been frozen at zero real growth for over ten years. Fiscal crises, precipitated by members withholding contributions, fluctuations in exchange rates and rising costs for operations, have punctuated this period and made the general shortfall more immediate and a very real threat to programmes. In short, W H O ' s limited resources do not match its ambitious goal [1]. In this context, the Organization faces the possibility that it will lose the global leadership it now possesses and the rest of the world will suffer the loss of W H O ' s unique capabilities--ones that have served it so well and ones that will be needed in the coming century. To avoid these losses W H O must either produce more with less or increase its funding. This paper analyzes this challenge and evaluates ways that it can do both.

APPROACH To study these possible losses and determine where changes are needed, a diagnostic framework is required. Organizational theory provides a suitable 731

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strategy and a new perspective, not found in the literature, that expands the nascent discussion of WHO's future options [2]. The organizational approach is multidisciplinary, reflecting the nature of WHO's challenges, and includes an active discussion of professional organizations [3-5]. Organizational theory, according to one useful definition, tries to explain how coordination in a bureaucracy accomplishes its critical tasks [6]. A brief taxonomy of organizational systems will be helpful to this discussion. Three types of systems are most often described [7]. There is the traditional or 'rational system', which is characterized by a formalized structure, independent of specific individual staff. The rational system envisions a proper organization as one that is scientifically managed so that it can maximize its output. A second type of system rejects this formal approach and considers both the formal and the informal structure of an organization. 'Natural systems' are based on the personal characteristics of staffin the organization and on the behavior of informal cooperatives. The staff are concerned with organizational survival and give the organization a culture and a set of myths. Natural systems, therefore, are highly dependent upon staff and heavily influenced by the head of the organization. One limitation of the natural model is that it does not adequately consider the environmental context in which an organization interacts. The third system, the 'open system' does this. It is analogous to a biologic process--the organization relies on its environment for input, coordinates and interacts amongst its various staff, and produces an output suitable to the milieu in which it exists. Each of these models is relevant to the discussion of the challenges and possible reforms facing the Organization. Using an organizational analysis to understand an institution assumes that how the institution is organized is very important [6]. Social scientists have argued that organizational rules and norms make a difference in what an organization produces. If this is true, WHO cannot be considered a black box that somehow transforms international ideals and national contributions into better world health [8]. Instead, it must be recognized as a professional bureaucracy performing work that is complex, uncertain, and of great social importance [9]. Moreover, the Organization can be better understood, not by relying just on a medical approach that examines changes in health outcomes, but also by using a multidisciplinary organizational approach that looks at the complex interactions that exist inside and outside of the Organization. This paper begins, then, with a brief review of WHO's history and current organization. Next, the structure, goals, culture, and rules of WHO are examined. In closing, the author proposes several reforms drawn from organizational theory and *The author served as a WHO staff member from October 1988 until September 1991.

empirical observations* to add to the growing debate on the direction and evolution of WHO. ORGANIZATIONAL BACKGROUND OF WHO

The World Health Organization is considered one of the best, if not the best, of the specialized United Nations (UN) agencies [8, 10, 11]. WHO's constitution, adopted shortly after World War II, sets out the structure and goals of the Organization. The constitution mandates that WHO serve as the UN's directing and coordinating authority for international health work and that it should encourage worldwide technical cooperation in health matters. WHO, with over 180 Member States, has one of the highest memberships of any UN agency [12]. WHO functions as an intergovernmental agency whose members collaborate "for the attainment by all peoples of the highest possible level of health" [13]. WHO's constitution defines health as "not merely the absence of disease" but as a "state of complete physical, mental and social well being". The Organization has interpreted this as an almost unrestricted directive and this interpretation has allowed WHO to prioritize health policies and establish social priorities; it has also allowed WHO to promote, develop and implement many strategies to attain specific health targets [9, 14]. This was not the case in the early days of WHO, however. Then the emphasis was confined more to consensus building and limited technical interventions. It was not until the 1970s that a broader concept of health emerged and the Organization involved itself in the more complex socio-economic aspects of health. Since its foundation, WHO has been the world leader in formulating professional consensus, setting international technical norms and defining health care standards. Certification by WHO now assures experts from both tropical and temperate countries that immunology nomenclature is uniform and unambiguous, that standards for clean water are available, and that there is a coordinated, up-to-date international classification of diseases (ICD). However, WHO's recent programmes also include scores of other ambitious activities where it does not have the same level of technical ability or appropriate skills. These activities are generally in newer areas, such as health policy and the economic development of health infrastructure, that WHO has become involved with since the 1970s. Today, WHO's programmes range from fields as divergent as managerial development and mental health to the prevention and treatment of diseases from alcoholism to zoonosis. Targeted health activities exist for many groups-rural populations, the environment, women and children, dentistry and cancer patients, and the elderly. All of these just hint at the enormous scope of the Organization's activities [ 15]. This description does not include the programmes coordinated with other specialized agencies, for example the Food and Agricultural Organization,

An organizational analysis of the WHO immunization with The United Nations Children's Fund (UNICEF), or family planning with the United Nations Population Fund (UNFPA). Funding for these programmes has also changed over the past 45 years. W H O ' s regular budget is provided by an assessment of Member and Associate Member States. The assessed contributions are based on a country's ability to pay but, for most, their payment will constitute < 0.01% of the regular W H O budget. In practice, the bulk of the payments comes from a small percentage of countries. For example, the 1992-93 regular budget biennium totaled U.S. $734.9 million [12]. Of this amount, eight developed member-countries contributed approx. 72% of the budget [9]. With a constitutional principle of one-member, one-vote, a perennial source of friction exists in W H O between the countries who pay for programmes and the countries that set the programme agenda. Over the years, and in part to circumvent this problem, donors have turned to extra-budgetary contributions that allow them to have more control over spending. The extra-budgetary funds are paid directly to W H O special programmes or to WHO, through other specialized funding agencies such as the United Nations Development Programme (UNDP) and UNFPA. For example, voluntary contributions to WHO have been the major source of funding for the Global Programme on AIDS [10, 11]. It is important to put the total budget in perspective: According to one headquarters official, the W H O budget constitutes < 3 % of all the multilateral donations for health (in fact, bilateral funding far exceeds all multinational distributions). However, a large percentage of the limited and insufficient budget goes to supporting the internal operations of the Organization. In the 1 January 1992 to 31 December 1993 biennium, expenditures in the Geneva headquarters increased from 33 to 35% of the W H O budget. At the same time the amount spent on supporting country programmes decreased (by a minimum of 10.5%) to U.S.$239 million. At the regional level the budget for one of the six regional offices totals a mere U.S.$56.9 million but serves a population in excess of 2 billion. Like headquarters (HQ), about 40% of this budget goes to running the regional office--leaving just more than one and a half cents for health per person in the region. Another concern, raised by an external auditor, is WHO's continued reliance on borrowed funds. During the most recent biennium, for example, the amount borrowed totaled 51.2 million dollars [16, 17]. Thus, WHO's budget is modest compared to other international health contributions and much of it goes to internal operations including the Regional Offices. W H O increasingly relies on borrowed funds and Member States have not increased their contributions in over ten years.

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WHO'S ORGANIZATIONALSTRUCTURE Behavioral theorists argue that structure influences an organization's outcomes and, therefore, structure defines the organization's agenda [18]. This seems to be the case for WHO. Many W H O publications include the organizational chart and it is known internally by all staffmembers. It specifies the internal chain of command just as clearly as it specifies W H O priorities and programmes to countries. To behavioral theorists, the term 'structure' goes beyond the formal diagrammed structure and priorities and includes concepts of organizational relationships, such as an organization's goals and incentives, its culture and mission, and its myths and rules. The forces that shape these relationships in W H O also define opportunities for change in the Organization. To examine these relationships, WHO's external coordination with Member States is described and then its internal coordination among its staff. After World War II, nations generally agreed to the tenet of equal international representation, regardless of financial contributions or demographics. The World Health Assembly (WHA), the governing body of WHO, reflects this belief and is structured so that each member has one vote. Among other things the Assembly is charged with electing a 31 member Executive Board. The Board oversees the operation of WHO, sets policy and nominates the Director General (DG). The nomination process, however, is closed to the public and the amount of negotiation and politicking before an election might astound the uninitiated. Board members, by rule, act only in their personal capacity and oversee the policy and implementation of programmes. This rule does not mask the reality of international negotiations, particularly during the nomination of the Director General. In the most recent nomination (1993), for example, public comments by W H O executives confirmed that "Third World votes were decisive" [19, 20]. Every Director General nominated by the Board has then been elected by the Assembly, thereby making the Executive Board the decisive body. The DG's term is for five years, with a second and even third term de rigueur for most executives. Although all specialized agencies are under the UN Economic and Social Council, the executive agency heads are independent and free from any centralized control and neither the Assembly nor the Board exert important policy authority over an elected DG. D G ' s are free to make alliances and bargain for support as the director feels compelled. The D G appoints all professional staff, although the director may delegate this responsibility, and proposes the budget--two authorities that provide enormous discretion over the course of international health activities. Thus, the Director General is both very powerful and yet beholden to the undesignated majority that deliver Executive Board votes, but not necessarily to the pursuits of funding

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nations nor to programme outcomes. Happily the triad of policy, funding, and voting does occasionally coincide but, unfortunately, these circumstances do not always occur [9, 11]. Aside from the Director General, WHO's structure is unique for a specialized UN agency. As structure helps explain how the Organization interacts with Member States in the external environment, this structure also explains WHO's leadership and policy formulation in its internal milieu. The Assembly has defined six (roughly) geographic Regional Offices for WHO. Headquarters in Geneva formulates policy, sets the budget and charts the overall direction. The six Regional Offices then supervise and coordinate programme implementation. A significant amount of policy, however, is formulated by the Regional Offices through their programme implementation. This confers authority on the Regional Offices and the Regional Directors (RD). Formalizing this regional authority are the six Regional Committees, analogous bodies to the World Health Assembly, although they have only minor budgetary discretion. But like the Assembly they also elect Regional Directors for five year terms. It is to this unspecified majority that the Regional Directors, like the Director General, owe their position and authority. Thus the unique arrangement of electing the DG and the Regional Directors, which is done behind closed doors, is subject to political tampering and may not be based on sound public health development principles. (In the most recent, 1993, nomination of the DG, an internal auditor's report concluded that there was evidence that such a practice occurred [21],) The last tier in WHO, the WHO Representatives, are stationed in developing countries. Compared to other organization's country representatives, they have little authority. Representatives are appointed by, report directly to, and serve at the pleasure of the Regional Director. They are responsible for overseeing the implementation of national programmes. They have little budgetary control over programme budgets and do not set local policies. Programme implementation, however, can be an enormous task. Many WHO headquarters and regional staff frequently visit countries and provide technical expertise. These visits are further supplemented by consultants. For example, in the Western Pacific Regional Office between 1989 and 1991, there were approx. 70 full time staff working in Manila, 50 in field offices and 220 short term consultants. The overall result is an (internal) organizational structure that is hierarchical at the top, resource constrained at the bottom, with policy determined outside the Developing Country. IS IT A RATIONALOR A NATURALSYSTEMSTRUCTURE? Two of the three organizational models can be used to describe WHO's current structure (the open systems model is taken up later). WHO's organizational plan, developed just after World War II, centered on what

theorists refer to as a rational systems model: organizations were to be instruments designed to attain specific goals. This model assumed that it was possible to scientifically analyze tasks and, with proper management, maximize output [21]. This paralleled the dominant health paradigm of the time that saw disease as a technical problem and it seemed an ideal model for WHO. Staff actions were viewed as purposeful and coordinated. Procedures were formalized so that they could be disaggregated into specialized tasks and hierarchically administered so that any activity became independent of a particular individual. This seemed ideal for WHO and matched its tenets of international equality and capacity. These key features of the rational approach persist in WHO today. The WHO practice of strict departmentalization and line staff authority are two of these features. Theoretical analysis later expanded the rational approach so that it included a set of general rules that govern performance, a hierarchical system of offices and a personnel system that chooses staff for their technical capability [22]. Top down management, therefore, would be held at a premium, with all action emanating from a singular head. In 1948, not only was it the obvious structure for a technical agency to adopt, its very existence confirmed the agency's purpose as a neutral umbrella, with internationally exchangeable professionals, that would consistently produce regular policy directives and maximize health. As later theorists have pointed out, a rational approach conceals many of the ambiguities that exist in a professional organization [3]. The approach is too deceptively simple and ignores the maxim that, although authority may be centralized, ability is inherently decentralized. Managers that operate from a solely rational perspective confuse the authority of office with the authority of expertise [22]. Today, WHO is an organization that adheres to a strict hierarchy and a rigid set of rules that can limit professional creativity and subject staff to excessive authority. Researchers also point out that this leads to staff who define work output by minimal standards of performance [23]. This results in staffthat are narrowly focused and whose functions may become increasingly unrewarding and increasingly constrained. The 'that's not my job' attitude or 'this requires the Director's exceptional approval' phenomenon (both frequently exhibited by the administrative personnel at WHO) are two examples [6]. With rigidity, organizations exhibit a further dysfunctional behavior known as goal displacement. In WHO, processes often become goals in themselves and, as a result, output drops. The consequence is that opportunities for achieving 'Health for All' are irretrievably lost. Robert Merton describes an associated problem found in a highly structured environment that he terms 'trained incapacity': (WHO) employees, rigidly compartmentalized and highly specialized, may be unable to get the big picture for the whole Organization. While initially

An organizational analysis of the WHO skilled, over time many staff become less and less technical, less accountable and hardly efficient [23]. Although W H O is well characterized by the rational model, the natural model also yields two important insights. In a natural system, organizations are defined as collectives that pursue survival such that staff have self-maintenance goals in addition to their output goals. In the extreme, the two sets of goals openly compete and organizations abandon their avowed objectives in order to save themselves. In this model, organizations believe that they are forced to struggle to survive and view threats to their leadership style as threats to funding or even to their programmes. From this perspective, the outside world would be viewed as hostile by WHO. External criticism of W H O sometimes assumes a level of importance that often belies its merit and extraordinary steps are taken to deflect minor assaults instead of pursuing organizational goals. WHO has been known to go to some length to avoid external criticism of its senior management, to adhere to strict diplomatic protocols, to expend valuable resources on defensive strategies, and to pursue less controversial tasks. Some of the recent criticism, leveled at WHO by the press, describes these practices. For example, the Organization can find itself consumed with trivial matters such as the arrival of the D G in a country or the seating arrangements for Regional Directors. W H O staff also become consumed with these tasks, not only diverting their attention from meaningful objectives but changing their work priorities as well. Over time this tends to make staff risk-adverse, never too daring, and certainly not innovative [6, 22]. Above all else, WHO avoids uncertainty--often to the absurdity of actually planting questions (with scripted answers) with members of the Assembly and Regional Committees during designated programme reviews. This same risk-aversion nurtures an Organization that becomes cautious, and drums out innovators, or any other persons who do not conform to a perceived status quo

[23]. A natural systems analysis suggests another problem, first raised by Herbert Simon. Simon's notion of bounded rationality posits that staff members are endowed with a certain, limited capacity and pursue their own self interests within a 'zone of acceptability' defined by the institution [22, 24]. Since the staff members cannot be aware of all alternatives, they willingly settle for an adequate---but not necessarily the best--solution to tasks that must be solved. This process of 'satisficing' means that staff are not interested in finding the sharpest needle in the haystack, just one that will sew [25]. In the highly structured, cautious environment of WHO, staff confront their enormous tasks with limited budgets and rigid organizational structure. The Organization is helpful to staff members because it greatly simplifies their options, but it also forces staff to implement their own self-survival goals. When they do not find the best solution, they settle

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on an available one that at least stitches things together.

GOALS AND TASKS: THE MISSION AND CULTURE OF WHO

Organizational theorists also discuss the importance of an organization's culture and mission. These concepts will help lead to a better understanding of WHO. WHO's goal of 'Health for All' is utopian and unreachable and it also can be described as vague. The former features may be self-evident but 'the attainment of the highest possible level of health' and a 'state of complete physical, mental and social well being' invite many different interpretations by members and prove difficult to translate into programme objectives. While the merit of 'Health for All' is beyond reproach, it is the Organization's search for Xanadu that identifies WHO's extraordinary mission as well as its cultural shortcomings. Goals are often meant to exhort and it can be fairly argued that 'Health for All' was meant to motivate and not necessarily to be attainable. To this extent, targets have been set for the year 2000 and the slogan has provided WHO policy with an orientation that it will use for almost a quarter century [26]. Yet there is also a danger in having a utopian, unreachable goal. When a goal is unattainable it can be demoralizing. It is also likely that the organization will be held accountable to the goal and to the targets that serve as measurement guidelines. Thus, the line between a hortatory and an unrealistic goal is a fine one, particularly if the organization is measured by what it accomplishes rather than what it says. WHO faces this dilemma whenever it emphasizes its operational and programme activities over its leadership and advocacy roles. Political scientists and anthropologists point out that vague goals, common to many public institutions, must be measured against an organization's tasks before determining their utility. Tasks are not linked to goals, as means to an end. The critical tasks of an organization are defined as the set of actions that allow organizations to cope with the problems it intends to solve [6]. Early in its history W H O specified a series of actions that became its critical tasks (behaviors). In WHO's first decade, Y a w s - - a crippling and disfiguring disease of skin, bones, and joints that leads to disability and lost work--afflicted 50 million people. To address Yaws, W H O defined its critical tasks as: (1) the coordinator, holding international symposia; (2) the trainer, offering fellowships to national staff; and (3) the disseminator, prescribing long-acting penicillin. Not only was this approach successful, but these critical tasks became the prototype for many

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successful WHO programmes. Recognizable as the 'Yaws' approach, today it consists of technical meetings, consultative visits, fellowship training, and the provision of supplies. This approach is widely endorsed within the organization. Sometimes successful, for example, in the expanded programme on immunization (EPI), sometimes woefully inadequate, for instance in attempting to eradicate malaria, this collection of tasks now defines WHO's culture. All organizations have a culture. Culture simplifies the number of options and reduces uncertainty. It provides WHO a consistent way of addressing health problems it faces. Not only does WHO have a scripted set of actions but the international community is secure in knowing that WHO has a set of tools (critical tasks) that it can reliably bring to bear on a given problem. When culture is widely shared and warmly endorsed, theorists refer to it as a mission [6, 27]. Selznick refers to this idea of mission as a "distinctive competence", spectacularly illustrated by WHO in the eradication of smallpox in 1977 [22]. It may again prove its merit if polio is eradicated before the end of this century. Already, in EPI for children, which uses the same paradigm, there has been enormous success: in 1974, when EPI began, fewer than 5% of the children in the developing world were fully immunized. Today that number is around 80%, a higher percentage than in some developed countries, including the United States [28]. Unfortunately this culture can be so inculcated that, wrongly applied, it appears to be a 'distinctive incompetence'. This possibility is not a foreign idea to the Organization either. At the 44th World Health Assembly in 1991, the DG called for a 'new paradigm' acknowledging the need to find new approaches to some of the Organization's more intractable problems [29]. AIDS prevention and control, for example, has had limited success using the 'Yaws' approach. By almost any measure WHO's successes in limiting the spread of this disease are modest. In part, this is because WHO's budget does not match the problem of HIV infection or AIDS [30]. But that is only part of the problem in AIDS. Without an effective intervention, sponsoring international meetings, fellowships and equipment has done little to slow the spread of the virus and succeeded only to the degree that there is increased international awareness about HIV. Changes in behavior, the outcome of any AIDS prevention and control programme, have been hard to document until recently and will likely prove even harder to sustain. It seems possible that WHO culture, defined by critical tasks, is a poor match for the HIV pandemic [31]. Is the 'Yaws' culture critically flawed and impractical? WHO's existing culture is most aptly suited to diseases and problems like yaws that have a direct technical intervention available. Even some diseases which have an effective technical intervention, such as measles, have foundered on issues such as cultural acceptance or transportation and delivery that

lie outside of the three-part paradigm [32]. Most health problems facing the Organization are significantly more complicated to address than yaws or measles: malaria and tuberculosis, for example, are diseases that are difficult to treat or prevent because there are no simple technological interventions. HIV is even more problematic because no cure is available and prevention has proven difficult to disseminate. Without an adequate technical solution, these types of diseases need a better culture that the one that is currently available at WHO. Thus, for most health problems, a technical solution is a necessary but not sufficient condition for effective WHO intervention. Regardless of whether the culture is well suited to the problem or not, culture supports WHO's central myth. Myths, as defined by organizational theorists, are not fictions. They are the beliefs, aspirations, ideals and dreams of the Organization [27]. Myths are especially important when goals are vague, as they are in WHO [6]. A legacy of intermittent successes in over 45 years of operation has given WHO two key myths: • The Organization is a politically neutral, technical agency that sets an international standard of social justice by improving health. • The Organization is uniquely qualified to improve health in the vast and complicated international arena of divergent populations besieged by overwhelming diseases. These myths orient the public and give a sense of worthiness to staff carrying out WHO's mission. WHO Directors who have grasped this notion have judiciously sought to bolster and perpetuate the myths [27]. Regular narration of the myths is important and so are the actual success stories since they reinforce scientific professionalism and individual stamina of staff. In the WHO milieu of impossible jobs and overwhelming problems, these forms of perpetuation not only occur but they have been important to its success. What makes these myths especially important to the Organization is that they bridge the gap between impossible goals and pragmatic reality [33]. This is the essence of WHO's culture--and a key to its future. Two success stories that reinforce the myths are illustrative. The first is the eradication of smallpox. To eliminate this disease WHO needed to insure that the diagnostic expertise and public health quarantine system could find every person infected with the variola virus. A disease without borders meant that WHO had no borders. Its approach was often daring, crossing rivalrous boundaries, or even unique, offering monetary rewards for 'turning in cases'. When the last case was found on 26 October 1977 in Somalia, the U.S.$300 million programme had saved 20 million lives and prevented 100-150 million cases in just the first ten years. The net economic return is estimated to be U.S.$1 billion annually [34, 16]. The infant formula story is similarly told, although as Sikkink narrates the tale, WHO did not always lead the charge [35]. In the early 1970s, reports of increased

An organizational analysis of the WHO childhood mortality associated with formulae were coming from Sub-Saharan Africa, but formula producers rejected the charges and continued aggressively promoting their products. Pushed by nongovernmental organizations (NGOs) and activists, the 1974 WHA encouraged Member States to review these promotional practices. By 1980, a mandate was prepared by the WHO secretariat and was passed 118 to 1 (the U.S. voted no). Subsequent NGO monitoring showed that, despite recurrent violations, there had been a significant change in behavior. Three years later Nestle, one of the principal producers, signed a joint agreement expressing its willingness to abide by principles laid out in the WHO mandate. Sikkink reasons that WHO was successful because of the perceived low politicization of WHO and the scientific consensus around the issue [35]. The myth was reaffirmed. MYTH, CULTURE AND WHO'S STAFF

WHO staff have unique qualities that make these myths plausible. They are recruited through a panoply of rules and procedures that attempt to balance an ideal of geographic diversity alongside a desire for the highest level of professional competence. The result, arguably, is that they get neither. There are several reasons that diversity does not occur. Professional staffing in WHO is concentrated in medicine and public health. Most recruits have clinical training, many are trained as physicians, resulting in a remarkably homogenous work force. On the positive side, because health care disciplines share an intellectual heritage, people from far regions of the globe are able to converse in the common language and principles of modern medicine. This 'collegialitythrough-training' provides a single lens for viewing the throng of health care problems. Common refraction can be organizationally efficient when the solutions match the problem. For example, when technical developments were needed in the treatment of tuberculosis, WHO-sponsored research in 1958 showed that well-supervised outpatient treatment was as effective as traditional treatment in a hospital or a sanitarium. However, WHO lacks a multidisciplinary professional staff when it considers non-medical options. Behavioralists argue that domination by a single professional class is just one reason for conformity. Homogeneity is also the result of a highly structured organization [36]. WHO has both a homogenous work force and a rigid structure. Since many health care problems are not amenable to technical-medical solutions, WHO's homogenous staff, confounded by its highly rigid structure, cannot always effectively address the problems it faces. There is another reason diversity does not occur. Many staff, particularly those from developing countries, have financial incentives to remain at WHO. With time, staff from all countries share an increasing number of experiences and simultaneously have fewer

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experiences from their homeland. This general point has been argued by Navarro [37, 38]. He decries a professional medical approach, suggesting that international public health is really a class issue that ignores the poor in developing countries. Staff, originally from developing countries, with a WHO career and salary, receive pay far in excess of national levels and are a privileged class. In international organizations, there might be less incentive for staff to leave and return home to more modest circumstances. Navarro may or may not be correct in arguing that health, in the less developed world, is the outcome of medically and politically determined socio-economic change. Nevertheless developing country WHO staff can lose their developing country perspective. Thus, the ideal of a diverse staff cannot exist because of homogenous training where problems are viewed through a medical lens; where staff work in a rigid organizational structure; and where there is little incentive to offer solutions arising from nontraditional perspectives. What about WHO's desire to obtain the highest level of professional competence? In a professional organization such as WHO, which requires a very high level of training, staff might be motivated primarily by externally-established, professional standards [3]. Critics of organizational theory extend this argument contending that organizational structure has no role in defining output [6]. Instead they use a 'populist' approach where output is determined by the quality of the people. While there may be merit in this argument, this argument is also endogenous: though individuals clearly shape the course of an organization, it is also true that organizations shape individuals [6]. Simon adds that if the critics are right, organizations should not give positions to individuals but instead allow individuals to create their own authority commensurate with their qualities. To analyze these issues more closely requires a look at WHO staff, the Director General, and the Regional Directors of WHO. All senior-level posts serve at the pleasure of the seven elected Directors. The position of Director also confers the authority to regularly reorganize and shuffle programme staff and approve all short-term consultants. Moreover, Directors are permitted to circumvent regulations under 'exceptional circumstances'. Although Directors cannot discharge staff, they can easily send a staff member into bureaucratic obscurity. Few, therefore, would disagree with the assertion that the Director's position exerts a tremendous amount of influence over staff, their morale, and their productivity. Staff appointments by the Director, however, can be made for several reasons. Ostensibly, they are made to fulfill technical requirements. Just as often, they satisfy politics external to the Organization. Member States demand, for example, that in exchange for political support or financial contributions, a countryman or woman be appointed to a particular position. Not surprisingly, the Member States who pay a large percentage of the

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regular budget or donate to the special programmes secure many of the senior positions. It is an unwritten rule, for example, that five oftbe six Assistant Director Generals (ADGs) come from the U.S., the former Soviet Union, France, China and the U.K. [39]. Staff without financial authority (i.e. from Developing Countries) are beholden to the fairness and goodwill of the Director. In fact, in the vast majority of cases, staff receive fair and supportive treatment from their Director. But because of this dependency, staff behavior can become obsequious while incentives become oriented towards incurring favors from the Director rather than accomplishing professional or W H O objectives. This much authority and favoritism invites disincentives and even corruption in the Organization. At the senior levels of the bureaucracy, Directors are judged on their ability to win reelection and are strongly motivated to avoid either embarrassment or external criticism. Ideally, they should be held accountable for their ability to meet the organization's goal. But WHO's goals are vague and loosely coupled with demands of the work. This means that the Director's incentives are to win elections and not to accomplish WHO's vague goals. Better accountability is associated with organizations that publicly define their objectives and use measurable, palpable objectives. And, thus, effective leadership implies that leaders are able to manage the terms by which they will be held accountable. This may not be possible at W H O because Directors currently lack the organizational incentives to do this. With the right incentives, more precisely defined objectives, and an understanding of the Organization's culture and myths, an opportunity could exist for WHO's leaders to accomplish its critical tasks. Unfortunately, the current charges of smuggling and influence peddling (both unproven) now besieging the Organization illustrate how many of these organizational precepts can be violated [17, 40, 20]. Ultimately more damaging to WHO, however, are the attacks on the Organization's myths. There are claims that there is no coherent response to the world's major health problems and no clear vision of health [41]. In an organization with a vague goal and impossible jobs, leadership becomes critical. Leadership must reinforce the myths that WHO is a neutral agency, and an organization capable of extraordinary accomplishments. At the current pace, however, it is entirely possible that history will view the past few years as lost. Worse, future damage may be sustained in the form of frozen budgets and decreased voluntary funding. RULES AND THE BUREAUCRACY

Much has been said about rules or the processes of institutionalization [42]. Organizational rules are helpful if they create a highly standardized routine that lowers the costs of collective action and obviates the need to question authority relations or organizational

purpose. These routines, however, come with the cost of inertia and a resistance to change. WHO's rules, published in a seven-volume procedural manual, rigidly control behavior and staff responses. One reason for all the rules might be the impossible number of tasks. To cope with so much work, procedures are often routinized. When this happens, the general result is that specifications and details tend to be ignored [6]. Though this can happen at WHO, surprisingly, it does not happen very often; this stands as testimony to the professional dedication of many WHO technical and support staff who are both conscientious and altruistic. The scope of the organizational responsibilities, then, does not seem to be an important reason for the many rules at WHO. There are, however, two likely explanations for the legion of W H O rules. First, like other unwieldy bureaucracies, W H O has a seemingly limitless number of hierarchical levels. The result is a clearance procedure that can only be described as labyrinthine. One obvious consequence for those working with W H O is that nothing happens very quickly. Documents traversing this process tend to be the composite of several authors, so at best they are vague; at worst they are misleading. Many countries receiving W H O reports (there are a plethora) sometimes find them outdated, vague or incomplete, or so poorly written that they are not useful [43]. Detailed clearance procedures frequently occur in agencies where goals are vague, where there is a strong desire by management for control, where there is a belief that line-of-authority promotes consistency and efficiency (although there is no empiric evidence that this is true), and where there is an impression that criticism can be avoided at a subordinate level if the supervisor has approved it. The more important factor explaining WHO's many rules relates to the problem of vague organizational goals and multiple task masters. WHO's goals defy concrete output measure: when do we achieve the 'highest possible level of health' or a 'state of complete physical, mental, and social well being'? Since WHO's goals are not concrete, they are open to a wide range of interpretation by different Member States. Natibns alone are not the only principals, there are also the sick, the poor and the disenfranchized. Not surprisingly, this legion of principals has different criteria for measuring the Organization's success, and each supporter of the Organization, whether it provides funding or votes, looks to the Organization to support its own agenda. This creates an almost incomprehensible enigma: members must evaluate an unspecified product and W H O must respond to shifting criteria that measure its success. Again, organizational theories offer some clarification. W H O is a procedural organization, defined here as an organization where it is possible to observe what the organization does but not what it produces [6]. Tasks (behaviors), therefore, are easy to specify but difficult to evaluate--an apt summary of WHO. This

An organizational analysis of the WHO means that WHO can hardly be controlled by Member States unless they set up procedural constraints on its behavior that the Organization must then follow. This process can result in an ever multiplying list of the rules, procedures and demands found in the seven-volume manual [44, 45]. Procedural agencies like WHO are vulnerable to politicians who tell them how to do their job but offer little help when it comes to evaluating how well the job has been done [2]. By following these procedures, an organization can be forced into a downward spiral. Criticism begets more procedural constraints which detracts even further from focusing on specific (health) objectives. Not surprisingly, many WHO staffreported in an informal review that fully half their time was spent pursuing internal procedures unrelated to programme output [46]. WHO senior management face a similar problem. Staff supervision looks at processes and not at accomplishments. Many forms of surveillance have been created including periodic reporting, trip summaries, direct observation of staff, verbal presentations and biannual reports. The weakness of a surveillance approach is that morale suffers. To the extent that this can be empirically observed, excessive supervision is a feature of the WHO bureaucracy. Rules in WHO are more than a distraction. They serve as an accounting device and act as a buffer to the external environment which is perceived as hostile. If criticized, WHO's leaders can point to the organization's adherence to its many rules. Yet rules can only serve as a justification of process, not outcomes. In organizational parlance this makes for looser coupling between WHO's goal and its daily activities. DISCUSSION The World Health Organization's half century amelioration of suffering stands out as a singular achievement in international cooperation [47]. Nevertheless, innumerable health problems, inadequately addressed by the international community, remain and stand as testimony to WHO's limitations and unrealistic goals. The Organization's ability to adjust to these challenges in the next few years will determine the role it will play in solving global health problems in the future. The future direction and role of WHO are attracting more interest, and debate continues over how best to approach reform [2]. By applying established organizational concepts, it is possible to identify WHO's structure, culture, mission, myths and bureaucratic rules and to facilitate reform. Although international organizations (including WHO) have distinctive characteristics, this does not preclude the use of these general concepts. The main distinctive feature of an international organization is that the clients are themselves Member States. However, neither this arrangement nor previous applications of organizational theory are unique. This arrangement is also found in public domestic organizations, such as port authorities or unified

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school districts. These similar organizations have multiple constituencies but they operate in an open environment and they have benefited from investigation of their internal milieu. Institutional authority, in these settings, has relied on the credibility of policies, the legitimacy of actions, and the effectiveness of their output. These qualities give these organizations a measure of their independence from the parochial demands of individual members on whom they must depend for support [27]. Previous studies of international organizations have explained their behavior as the consequence of the dominant external interests of powerful members or coalition of members. This perspective suggests that organizations (like WHO) have fewer options and less control of their policies and output [48]. By contrast, there has been very little analysis in the scientific literature explaining how international organizations function internally. This paper refutes an exclusively external perspective and shows that the internal organization is also important to understanding WHO. Like school districts and port authorities, WHO's interaction with its external environment is highly conditioned by its internal (and outmoded) structure, culture and myths. Thus, organizational theory might offer insights into these limitations and suggest future reforms for other public international institutions. Specifically, organizational analysis offers a perspective on WHO, not been previously found in the literature and suggest several possibilities for reform. What types of changes does an organizational perspective suggest for WHO? Past successes, and possible reluctance to change, have led to two major problems [42]:

(l) Perverse incentives exist for leadership and for Member States and should be eliminated. The Organization needs to develop incentives that align staff and leadership's individual goals closer to the Organization's goals. (2) Employing staff which only draw from the public health and medical culture limits the technical capacity of the Organization. This limited technical capacity prevents WHO from applying the wealth of knowledge available in the world today for solving health care problems.

Reforming the structure (and incentives) of WHO The question of incentives is directly linked to the concept of structure. WHO's organizational structure closely resembles an outdated 'rational systems' model. This hierarchical structure, equating authority with capability, fails to take advantage of many talented staff already working in WHO, limits staff creativity and discourages professional excellence. It encourages 'minimal standards' to define work performance. The 'natural systems' perspective shows

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how WHO staff, focusing on self survival in a world perceived to be hostile, displace the Organization's goals with their own self-interest. Another model exists that might be useful to WHO. Appropriately enough, it views organizations in a biologic framework, shifting attention from hierarchy to process. Referred to as an 'open systems' framework, this viewpoint stresses the complexity of the various parts of the organization and the uncertainty of the environment. WHO needs to be adaptable, to draw from its internal environment of people from around the world, and to interact better in its external milieu of over 180 countries. First, this means giving more authority to WHO Representatives and staffat the country level. The basis for this argument is that successful projects require applications that are uniquely suited to the local needs of Member States. This does not mean, as some will argue, that WHO should become a service organization. Instead technical expertise and effective implementation strategies should be provided through a flexible system that works (with local WHO Representative authority) at the country level. Second, in the open systems context, professional staff must be given specific outcome objectives and thereafter assigned: (1) budget constraints; and (2) policy boundaries. They should be allowed the autonomy to do their work unimpeded by excessive supervision. Evaluation of staff should focus on these outcomes and avoid the deleterious effects of excessive procedural evaluation [50, 51]. This approach is critical because it would reorient the incentives of WHO staff. Using the open systems model of organization would allow staff to work for their own self interest and for WHO's at the same time. This should also eliminate the problem of cross incentives and goal displacement for staff [23]. Such an explicit policy could also reduce the incentives of Directors to over-monitor staff. Third, Regional Offices, over time, should be closed. Early in the Organization's history they were vital to its tasks and its successes, and this structure demonstrated the early decentralization of WHO. If WHO Representatives in Country Offices are allowed to grow and function and the open framework is developed, this will compel the Organization to eliminate an entire layer of the rule-bound bureaucracy. This will reduce costs and increase efficiency. It will also allow for countries to interact directly with HQ to locally adapt and implement policies. Conflicts arising from self survival goals of the regions would be obviated and output goals of the organization would be better aligned with the needs of the countries. This would eliminate the oft-recorded (and observed) friction between HQ and the Regional Offices and make WHO more responsive to urgent health crises [2]. Because most Country Offices are currently limited in their technical

*While these intervals are fairly arbitrary, the idea is to decrease the homogenous perspective of all WHO staff without paying them less or excluding them from headquarters assignments.

capabilities, Regional Office closures would need to be phased in gradually. Regardless of the status of the Regional Offices, economies of scale will always exist for specialists to work in more than one country. This could be done by sharing at either headquarters or the country level. Coordination, therefore, should be carefully planned as Regional Offices are phased out. Finally, structural reform in WHO must offer a way to increase WHO funding. The open system specifies linkages among donor countries, the voting majority, and the Organization. The health of the sick, of women and children, and the downtrodden would seem to be the most natural basis for global consensus formation. But, because of limited resources, this is not the reality and, at times, it engenders just the opposite behavior. To increase funding any new structure for WHO must align the demands of the many with the resources of the few. This is a key point and has three important applications: first, both WHO Directors and the World Health Assembly would need to openly articulate a set of detailed objectives that are acceptable, recognizable, and measurable. Once this is done, they should be used as the standard to evaluate the Organization and the elected Directors. One of the reasons that WHO has not garnered more regular budget funding is that a lack of accountability has widened the gap among payments, promises and performance. Second, elections need to be held publicly and in an open forum. Currently, the Executive Board meeting that nominates the DG is held behind closed doors and in a secret session with the W H A always accepting the Board's recommendation. This entire process should be opened for public debate and carried out around the world, over several months, and not just in Geneva during January. At issue would be the proposals, priorities, and programmes that Director General candidates and their constituencies wish to follow. (The current practice of parceling out special favors and passing special interest programmes is worse than inefficient, it is irresponsible.) Third, as the Regional Offices are phased out, the six ADGs should also be elected in an open election with each of the ADGs coming from and representing one area of the world. Such a public and priority driven approach would align donors and voters in a constructive way, thereby increasing WHO credibility and funding.

Recommendations for expanding technical capacity The limited domain of the current public health culture needs to give way to newer technical capacities that can better address the more intractable health care problems. Its narrow medical orientation limits WHO's technical diversity and professional competence. A multidisciplinary approach is needed to match the complexity of health care problems to the skills and resources available in the world. For example, staff tenure could be limited to ten years or staff could be rotated to their home country every five years for a period of two years*.

An organizational analysis of the WHO Possibilities exist for using multidisciplinary techniques such as linear programming and queuing theory to identify the most efficient use of limited resources in district health care programme development. Prospective randomized trials might look at the question of providing health care insurance while varying user charges [51]. Legal experts have called for W H O to advance a legislative framework for health within countries and to promote international treaties to accomplish its objectives [49]. Economists, combining behavioral and biological determinants, have examined patient care from a behavioral perspective and can help to illuminate essential services and eliminate unnecessary ones [52]. These approaches should be used by WHO. Management sciences, on the other hand, could look at continuous quality improvement and reengineering principles. The Japanese call this approach kaizen and it refers to an ongoing search for ways to make things better and is summarized by the epigram 'every defect is a treasure'; this could be helpful to W H O [53]. The quality of care literature in health and industry offers yet another approach. One finding is that quality can be readily improved when people are assumed to be trying hard and not accused of shirking. Fear, researchers conclude, seems to 'poison' improvement efforts, which are dependent upon understanding sources of inefficiencies, and, even when people are the source, the problem is usually not motivation or effort but poor job design [50, 27]. These types of research findings could prove enormously helpful to WHO in both project implementation and its own internal management (and these ideas coincide with the recommendation for an open W H O structure). Some in W H O have already adopted this new, multidisciplinary technical perspective. Two examples come to mind: the lot quality assurance industrial techniques used for HIV sentinel surveillance, and the cluster sampling statistical technique used by EPI. The point is that new approaches need to be considered by all programmes.

Refining WHO's goal and objectives Specification of the Organization's goal is a more variegated task. This paper has argued that WHO's current strength lies in its myths of being politically neutral and the international leader in public health. These myths are vital and sustain the Organization by bridging the gap between its goal and the practicality of its daily work. To further strengthen the myths and narrow the gap, two more steps should be taken. First, W H O should use the 'Yaws' model (holding international meetings, training national staff, and distributing the technology) on diseases that might fit this model. EPI is an example of where this has been done. Similar problems should be aggressively sought out by the Directors or candidates and then pursued with singular fervor. Communicable disSSM 40/6--B

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eases are an obvious target. Second, for problems without 'magic bullets' that do not fit this mold (the majority of health problems), new or even different approaches are needed. The Global Programme on AIDS is a case where the old culture does not work and there is no technical solution. In this and other socially complex health problems, radical new approaches need to be explored. It is useful to recall that once the smallpox programme looked as if it might succeed, widespread support for its radical approach emerged in the Organization. Possibilities include collaboration with other agencies, local fund raising and recruitment of non-health care personnel. Innovations should emphasize local expertise and W H O Country staff. Any successes that occur using the new, or the old approach, should be acclaimed by the Organization. Retold tales of success are powerful staff motivators and reinforce WHO's myths. Second, to address the problem of productivity, the gap between myth and practicality must be closed. A rule-bound organization serves no one, not the staff who feel frustrated and constrained, nor the principals left wondering about outcomes and mulling over internal processes. Reform is often accompanied by greater control, but greater internal control, generated by external pressures, would do WHO more harm than good [22, 54]. Instead, Member States need to relax procedural reporting and increase monitoring of actual programme outcomes. Thus, the key to closing the gap will be to create specific performance objectives for WHO staff and programmes. Where outcome measures do not exist, WHO should convene expert panels (already a strength of the Organization) to assist in the formulation of indicators. Similarly, Directors need to relax control over staff, replacing the practices of demand and intimidation with incentives and encouragement. A management policy that does not initially underestimate the motivation of the men and women serving WHO would be a good place to start. Ultimately, WHO will be justified by its enhancement of health outcomes and not by the way it runs its Organization [23]. Funding and participation by donor countries and Member States will be the final judgment of WHO's efficacy. As it currently stands, WHO faces the possibility of being overwhelmed by its tasks as it slowly perishes on an inadequate budget. Successful programme selection that supports its myths and brings increased output would increase the Organization's funding. The demand for 'International Health' is simply too great. In the short run, a redesigned organizational structure can increase internal efficiency. It should be less punitive, more flexible, critically evaluated, and encompass a broader range of technical skills. Such a change would allow W H O to increase its output even without more funding. Later, with reform, W H O should be able to attract and command the funding that it will need to sustain itself in the long run.

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Acknowledgements--The author would like to thank Dr Lorraine M. McDonnell, Dr Julie S. DaVanzo and Dr Brian Mittman for their careful review of the manuscript and helpful suggestions. The author also wishes to specifically thank the WHO staff and consultants who reviewed this manuscript and for their many suggestions which improved this paper. All opinions, omissions or errors are those of the author. This investigation is the result of work begun during a class on Organizational Behavior in the RAND Graduate School. Dr Peabody's research is supported, in part, by the National Research Service Award 1 T32 HS 00046-01 from the Agency for Health Care Policy and Research.

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