Introduction to comments on ’Outsourcing: how to reform WHO for the 21st century’ Seye Abimbola To cite: Abimbola S. Introduction to comments on ’Outsourcing: how to reform WHO for the 21st century’. BMJ Global Health 2017;2: e000272. doi:10.1136/ bmjgh-2016-000272 Editor-in-Chief, BMJ Global Health, School of Public Health, University of Sydney, Australia Correspondence to Dr Seye Abimbola; [email protected]In 6 months, WHO will have a new Director General, who will likely start off by promising and identifying areas for reforms. One intent of such reforms will likely be to improve effi- ciency within the organisation. The commen- tary by Negin and Dhillon sought to provide one example of how WHO could improve efficiency—outsourcing functions for which WHO may not have a comparative advantage. The article received much attention on social media; it was described by Anant Bhan on Twitter as a provocative argument with some merit, 1 and Laurie Garrett compared outsourcing by WHO to the experience of outsourcing public sector functions, in an ironic tweet: “Yeah, works so well for prisons, security details, food safety.” 2 While the argument for and against out- sourcing have merit, it appears they are not being considered in ongoing conversations about WHO reforms. Contrarily, these discus- sions have seemed to favour an ever- expanding organisation; a preference that certainly has implications for efficiency and effectiveness; implications that are worth taking seriously in a global health landscape with ever-increasing number of actors. We present three important comments on Negin and Dhillon’ s article; all disagreeing with their argument, but nonetheless recognising an urgent need for change at the WHO. Their perspectives will be important for the incoming Director General, as much as Negin and Dhillon’ s response to these comments. Featuring this series of comments and response demonstrates our commitment at BMJ Global Health to being a forum for discus- sion and debate on issues such as this; issues in global health that do not get enough attention. We will do this from time to time. Twitter Follow Seye Abimbola @seyeabimbola Competing interests None declared. Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/ by-nc/4.0/ REFERENCES 1. Bhan A. Tweet. 2016. https://twitter.com/AnantBhan/ status/775589709640822784 2. Garrett L. Tweet. 2016. https://twitter.com/Laurie_ Garrett/status/776787153137364992 Abimbola S. BMJ Glob Health 2017;2:e000272. doi:10.1136/bmjgh-2016-000272 i1 Commentary on January 19, 2022 by guest. Protected by copyright. http://gh.bmj.com/ BMJ Glob Health: first published as 10.1136/bmjgh-2016-000272 on 25 January 2017. Downloaded from on January 19, 2022 by guest. Protected by copyright. http://gh.bmj.com/ BMJ Glob Health: first published as 10.1136/bmjgh-2016-000272 on 25 January 2017. Downloaded from on January 19, 2022 by guest. Protected by copyright. http://gh.bmj.com/ BMJ Glob Health: first published as 10.1136/bmjgh-2016-000272 on 25 January 2017. Downloaded from
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Introduction to comments on’Outsourcing: how to reform WHOfor the 21st century’
Seye Abimbola
To cite: Abimbola S.Introduction to comments on’Outsourcing: how to reformWHO for the 21st century’.BMJ Global Health 2017;2:e000272. doi:10.1136/bmjgh-2016-000272
Editor-in-Chief, BMJ GlobalHealth, School of PublicHealth, University of Sydney,Australia
In 6 months, WHO will have a new DirectorGeneral, who will likely start off by promisingand identifying areas for reforms. One intentof such reforms will likely be to improve effi-ciency within the organisation. The commen-tary by Negin and Dhillon sought to provideone example of how WHO could improveefficiency—outsourcing functions for whichWHO may not have a comparative advantage.The article received much attention onsocial media; it was described by Anant Bhanon Twitter as a provocative argument withsome merit,1 and Laurie Garrett comparedoutsourcing by WHO to the experience ofoutsourcing public sector functions, in anironic tweet: “Yeah, works so well for prisons,security details, food safety.”2
While the argument for and against out-sourcing have merit, it appears they are notbeing considered in ongoing conversationsabout WHO reforms. Contrarily, these discus-sions have seemed to favour an ever-expanding organisation; a preference thatcertainly has implications for efficiency andeffectiveness; implications that are worthtaking seriously in a global health landscapewith ever-increasing number of actors. Wepresent three important comments on Negin
and Dhillon’s article; all disagreeing withtheir argument, but nonetheless recognisingan urgent need for change at the WHO.Their perspectives will be important for theincoming Director General, as much as Neginand Dhillon’s response to these comments.Featuring this series of comments andresponse demonstrates our commitment atBMJ Global Health to being a forum for discus-sion and debate on issues such as this; issues inglobal health that do not get enough attention.We will do this from time to time.
Twitter Follow Seye Abimbola @seyeabimbola
Competing interests None declared.
Open Access This is an Open Access article distributed inaccordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others todistribute, remix, adapt, build upon this work non-commercially, and license their derivative works on differentterms, provided the original work is properly cited and the useis non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
REFERENCES1. Bhan A. Tweet. 2016. https://twitter.com/AnantBhan/
status/7755897096408227842. Garrett L. Tweet. 2016. https://twitter.com/Laurie_
Garrett/status/776787153137364992
Abimbola S. BMJ Glob Health 2017;2:e000272. doi:10.1136/bmjgh-2016-000272 i1
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Comment—WHO’s weakness is nottechnical, but due to lack ofaccountability
David G Legge,1 Claudio Schuftan,2 Fran E Baum,1 Remco van de Pas,3
David Sanders,4 Lori Hanson,1 David McCoy,4 Amit Sengupta1
To cite: Legge DG,Schuftan C, Baum FE, et al.Comment—WHO’s weaknessis not technical, but due tolack of accountability. BMJGlobal Health 2017;2:e000236. doi:10.1136/bmjgh-2016-000236
Received 7 November 2016Accepted 15 December 2016
1People’s Health Movement,Cape Town, South Africa2People’s Health Movement,Ho Chi Minh City, Vietnam3Department of Public Health,Institute of Tropical Medicine,Antwerp, Antwerpen, Belgium4Cape Town, South Africa
Correspondence toDr David G Legge, People’sHealth Movement, Cape Town7705, South Africa;[email protected]
Negin and Dhillon’s proposal that functionspresently carried out by WHO should be‘outsourced’ to the Gates Foundation, theGates-funded Institute for Health Metricsand Evaluation (IHME), Medicins SansFrontieres and national drug regulatoryagencies such as the US Food and DrugAdministration (FDA), lacks evidence, relieson flawed logic and serves to obscure criticalcauses of WHO’s failures, in particular thedonor chokehold.Negin and Dhillon cite a Cochrane review
of outsourcing of healthcare in low-incomeand middle-income countries.1 Yet thisreview found only three studies that met itsinclusion criteria all of which had a lowquality of evidence and showed a high risk ofbias.WHO’s accountability is currently to
donors and governments. OutsourcingWHO’s functions to Gates, IHME, the FDAand Mèdecins Sans Frontières (MSF) wouldfurther attenuate the accountability of WHOfor the public’s health.Negin and Dhillon note that most current
proposals for WHO reform have emphasisedthe need for greater funding from memberstates. ‘However, such a status quo solutionmay not match the magnitude of theproblem and seems unlikely to actually res-onate with funders who question WHO’sefficacy’. This is a misleading account ofthe debate.Most of WHO’s disabilities are the conse-
quence and not the cause of the donorchokehold. Donor dependence contributesto competition within WHO for the attentionof donors which undermines collaborationacross the organisation; programme oversightby donors weakens accountability throughthe management hierarchy; unpredictableand tightly earmarked funding precludes thedevelopment of a coherent and rational staff-ing structure.
The claim that the funders refuse tountie donor funds or increase assessed con-tributions because of concerns about efficacyis a smokescreen. The Director-General hasrepeatedly emphasised the need to untietightly earmarked donor funds. The refusalof the donor nations to untie their voluntarycontributions is directed to controlling theOrganisation in the interests of the donorsand their corporations.Powerful TNCs and their nation state spon-
sors are particularly concerned about WHO’streaty making powers. Large transnationalfood producers are determined to forestallfiscal and regulatory approaches to sugar, fatand salt in addressing diet-related NCDs.2
The most fundamental weakness of WHOlies in its lack of accountability to the popula-tions and communities whose healthdepends on WHO.3 WHO Watch,4 which issponsored by the People’s Health Movement(PHM) and other organisations, is directedto building the constituencies and networkswhich can hold WHO and its member statesto account for their responsibility to protectand promote global health.PHM argues5 that commentators who
present WHO as merely a technical agencyand who fail to consider the wider politicaleconomy of global health governance areeffectively adding their support to those com-mercial and political interests who are deter-mined to prevent WHO from doing its job.
Twitter Follow David Legge @DavidGLegge
Contributors DGL drafted the manuscripit and redrafted itwith input from all other authors. All authors contributed tothe conceptualisation of the paper.
Competing interests None declared.
Provenance and peer review Not commissioned; internallypeer reviewed.
Open Access This is an Open Access article distributed inaccordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to
i2 Legge DG, et al. BMJ Glob Health 2017;2:e000236. doi:10.1136/bmjgh-2016-000236
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on January 19, 2022 by guest. Protected by copyright.
distribute, remix, adapt, build upon this work non-commercially, and licensetheir derivative works on different terms, provided the original work isproperly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
REFERENCES1. Lagarde M, Palmer N. The impact of contracting out on health
outcomes and use of health services in low and middle-incomecountries. Cochrane Database Syst Rev 2009;(4):CD008133.
2. Gornall J. Sugar: spinning a web of influence. BMJ 2015;350:h231.3. Ebola Interim Assessment Panel, Report. Geneva: WHO,
4. WHO Watch. WHO Watch. 2011 (cited 9 April 2011). http://www.ghwatch.org/who-watch
5. People’s Health Movement. Ignoring the political economyof global health governance in considering WHO’sshortcomings obscures major threats to health equity. 2016(cited 12 October 2016). http://www.phmovement.org/en/whoreform
Comment—WHO outsourcing dilemma:for whose benefit, at whose expense?
To cite: Sharma JR, Harper I,Adhikari R, et al. Comment—WHO outsourcingdilemma: for whose benefit, atwhose expense?. BMJ GlobalHealth 2017;2:e000237.doi:10.1136/bmjgh-2016-000237
Received 7 November 2016Accepted 15 December 2016
1School of Social andPolitical Science, Universityof Edinburgh, Edinburgh, UK2Social Science Baha,Kathmandu, Nepal3Malawi University of Scienceand Technology, Limbe,Malawi
Correspondence toDr Jeevan Raj Sharma,School of Social and PoliticalScience, University ofEdinburgh, ChrystalMacmillan Building, GeorgeSquare, Edinburgh EH8 9LD,UK; [email protected]
In recent years, global development andhumanitarian organisations have come underintense scrutiny for failure to provide topeople in need. Critiques are wide ranging,and are driven by a range of issues: from ideo-logical and political differences—the recogni-tion of ultimate authority to intervene;critiques of western imperialism; to the prac-tical—the failure of the system to ‘recognise’the real issues on the ground, to more recentcritiques that focus on lack of effective andefficient response in the face of global crises.The commentary ‘Outsourcing: how to
reform WHO for the 21st century’ argues thatthe WHO has underperformed and is in needof reforms. Established in 1948, at a particularjuncture in world history, the WHO is not con-sidered to be fit for purpose in the context ofrapidly changing global health landscape.While it is easy to agree with the diagnosis
by the authors on the WHO and its under-performance, the model of outsourcing theyput forward comes with its own challenges.What the normative arguments of ‘outsour-cing’, ‘value for money’ and ‘measurableresults’ does do however, is erase any ideo-logical underpinning to the argument andintroduce the market into how it functions.As the authors themselves admit, there islimited evidence to show that contracting outhas the intended impact. Beyond the valuefor money argument, outsourcing will createfurther complexities and uncertainties.Alongside outsourcing comes increasing
political pressure to demonstrate that thedisbursement of resources is linked to per-formance of measurable results. The result is
an increasingly complex chain of subcontrac-tors whose activities the lead agency then strug-gle to manage. Under the outsourcing model,lack of targets will leave subcontractor agentsunaccountable. Thus, targets will have to beintroduced and new monitoring and resultsframeworks will need to be put forward toensure that targets are met. In addition tocreating fragmentation and coordination chal-lenges, there are dangers that outsourcing willproduce short-term measurable results at theexpense of long-term challenges to build localinstitutional capacity.The WHO is not alone in this trajectory.
Many global health and development actors(multilateral; bilateral and other internationalorganisations) increasingly outsource responsi-bilities to others. What is often ignored in theoutsourcing argument is that these intermediar-ies have their own interests and agendas—whichare not always transparent—creating furtheruncertainties for those managing the contracts.Mostly based in the Global North with their
satellite presence in the countries of the South,a few big institutions will be the prime recipientsof contracts, as they will have the experience,language, technical knowhow, relationships andcapacity to comply with the expectations thatare increasingly concerned with value formoney and measurable results. We have to askwho will profit from these arrangements, asfurther layers of bureaucracy are added into thesystem. What should be considered are ways tostrengthen the institutional capacities of organi-sations based in southern countries, not to givecontracts to already bloated northern inter-national organisations and private firms.
Legge DG, et al. BMJ Glob Health 2017;2:e000237. doi:10.1136/bmjgh-2016-000237 i3
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Contributors JRS and IH drafted the manuscript, the ideas for the paper weredeveloped collectively by all authors as coresearchers on the ESRC-DfID fundedproject (ES/K012487/1).
Funding (The authors are associated with an ESRC-DFID funded researchproject (1 May 2014 to 31 October 2016) titled ‘New Norms and Forms ofDevelopment: Brokerage in Maternal and Child Health Service Developmentand Delivery in Nepal and Malawi’).
Competing interests None declared.
Ethics approval Committee of the School of Social and Political Science,Nepal Health Research Council, College of Medicine Research EthicsCommittee.
Provenance and peer review Not commissioned; internally peer reviewed.
Open Access This is an Open Access article distributed in accordance with theterms of the Creative Commons Attribution (CC BY 4.0) license, which permitsothers to distribute, remix, adapt and build upon this work, for commercial use,provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/
Comment —WHO is badly in need ofreform, but it cannot replace NGOslike our own
Joanne Liu
To cite: Liu J. Comment—WHO is badly in need ofreform, but it cannot replaceNGOs like our own. BMJGlobal Health 2017;2:e000238. doi:10.1136/bmjgh-2016-000238
Received 8 November 2016Accepted 15 December 2016
International President,Medecins Sans Frontieres/Doctors Without Borders,Geneva, Switzerland
The authors of the report ‘Outsourcing: howto reform WHO for the 21st century’,published in BMJ Global Health, recommendoutsourcing some key WHO responsibilitiesto other organisations, including MédecinsSans Frontières (MSF). We agree that theWHO is badly in need of reform, but cautionagainst thinking that non-governmental orga-nisations like our own can replace the WHO’sown critical role in the response to epidemics.Ultimately, it is not the response of inter-
national medical experts that can make thecrucial difference to an epidemic response.Instead, it is the way that governments them-selves respond and their willingness to seizethe nettle and make prompt, effective deci-sions that put the health of the populationfirst, above economic or political concerns.The WHO has to play a vital role here, andmust be able and willing to speak truth topower and, where necessary, confront govern-ments—in the affected areas and fartherafield—when there are serious medical gapsand outbreaks of disease. This is made moredifficult by the appointment of the WHOcountry representatives often on the basis ofpolitical considerations instead of compe-tency. This must change in favour of expertisewith clear accountability and responsibility.At present, one of the biggest failings in
the system is that governments are positivelydisincentivised from declaring an outbreakfor fear of disrupting the functioning of thecountry and driving away visitors andinvestors. States should be able to count oninternational solidarity in the face of
overwhelming epidemics and the worldneeds a strong WHO with political couragethat can support national authorities inmaking clear decisions on setting priorities,attributing roles and responsibilities, ensur-ing accountability for the quality of activities,and mobilising the necessary resources.Yes, private international organisations like
ours will continue to provide staff and patientcare to support an epidemic response whenpatients are suffering. However, the reallyimportant national and international politicalwill has to be galvanised by the WHO. In add-ition, the critical infrastructure and technicalinvestments which underpin an effective epi-demic response, such as the development ofproper laboratory facilities and sentinel sur-veillance systems, badly need the support of astrong and empowered WHO.Rather than cutting away at the WHO’s
responsibilities, we need to ensure that it isstronger, braver and enabled to call a spadea spade in a timely fashion. Since the ultim-ate goal is saving lives.
Twitter Follow Joanne Liu @JoanneLiu_MSF
Competing interests None declared.
Provenance and peer review Not commissioned; internallypeer reviewed.
Open Access This is an Open Access article distributed inaccordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others todistribute, remix, adapt, build upon this work non-commercially, and license their derivative works on differentterms, provided the original work is properly cited and the useis non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
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Authors’ response — WHO mustprioritise its roles and then be positionedand supported to execute effectively
Joel Negin,1 Ranu S Dhillon2
To cite: Negin J, Dhillon RS.Authors’ response — WHOmust prioritise its roles andthen be positioned andsupported to executeeffectively. BMJ Global Health2017;2:e000271. doi:10.1136/bmjgh-2016-000271
Accepted 16 December 2016
1Sydney School of PublicHealth, University of Sydney,Sydney, New South Wales,Australia2Division of Global HealthEquity, Brigham andWomen’s Hospital, HarvardMedical School, HarvardUniversity, Cambridge,Massachusetts, USA
We are pleased to see that our article hasincited debate and discussion. While theresponses reflect a wide range of perspectives,what is clear is that there is a need for funda-mental reform in how WHO is organised andfunctions. And, while we offer thoughts onhow this could be carried out, we are lessinclined to ‘sell a solution’ than we are to‘solve a problem.’ Any approach to WHOreform will undoubtedly entail imperfecttrade-offs which can best be understood andnavigated for the overall greatest goodthrough critical discussion from a wide rangeof perspectives as offered by the respondents.Each response offers important insights
and criticisms that serve to further anddeepen the discussion along the key consid-erations that must be weighted: accountabil-ity and ownership, sovereignty and collectiveaction, practicality and efficacy. Liu’s callfor a stronger WHO that can assert globalpolitical leadership in instances of healthcrises, such as epidemics, is exactly the typeof role we feel it should be positioned toserve while being able to coordinate otheragents as well as its own personnel for action.Ideally, WHO can both provide the leader-ship and action directly but the former iswhere its unique positioning and voice isneeded most. As Liu points out, the ultimategoal should be to build strong nationalhealth systems that can lead and act nation-ally and locally with WHO supporting coun-tries in performing both of these roles.Efforts to build adequate health systems indeveloping countries must—finally and actu-ally—be funded, supported and realised.Sharma and colleagues delve into a
number of practical challenges associatedwith outsourcing. We agree that, under theproposed model, managing accountabilityand the increased complexity of contractsand responsibilities will be difficult. Theirpoint about strengthening the capacity of
institutions from the Global South tocompete for such contracts, is well taken andone that we would support. Requirementsaround equity or capacity building should beadded into such contracts. While the‘gaming’ of an outsourcing model is aninherent risk, we would like to see furtherconversation on what may be ‘lesser of evils’options given the inefficacy of currentapproaches.The People’s Health Movement (PHM)
emphasises the need for WHO to remainneutral and accountable. We support thevalues they assert, but are more cynical aboutthe likelihood to realise them at least in theshort-term given the current politicaleconomy surrounding WHO and globalhealth more generally. Similar to Liu’s callfor WHO to have the latitude and position-ing to exert political leadership, we agreewith PHM’s call for it to be protected andpositioned to assert moral leadership, too.Strengthening its ability to carry out thesefunctions, such as treaty negotiation, mayrequire it to prioritise away from technocratictasks such as data collection or drug registra-tion. At the end of the day, WHO must pri-oritise its roles and then be positioned andsupported to execute effectively.
Funding This research received no specific grant from anyfunding agency in the public, commercial or not-for-profitsectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internallypeer reviewed.
Data sharing statement No additional data are available.
Open Access This is an Open Access article distributed inaccordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others todistribute, remix, adapt, build upon this work non-commercially, and license their derivative works on differentterms, provided the original work is properly cited and the useis non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
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Correction: Introduction to comments on ‘Outsourcing:how to reform WHO for the 21st century’
Abimbola S. Introduction to comments on ‘Outsourcing: how to reform WHO forthe 21st century’. BMJ Global Health 2017;2:e000272.The title of this article is incorrect. The correct title is: ‘Comment—WHO is badly
in need of reform, but NGOs like our own cannot replace it’.
Open Access This is an Open Access article distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited andthe use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
BMJ Global Health 2017;0:e000272corr1. doi:10.1136/bmjgh-2016-000272corr1
BMJ Glob Health 2017;0:e000272corr1. doi:10.1136/bmjgh-2016-000272corr1 1
