Restructuring neoliberalism at the World Health Organization

ABSTRACT

Most descriptions of the spread of neoliberal economic policies since the 1980s overlook the significant contribution of international organizations not only to the dissemination of these policies, but also to their making. The scholarship often regards international organizations as passive transmission belts that merely comply with the demands of their member-states. Scholars who do identify the constitutive role of international organizations consider them to be enthusiastic supporters of the neoliberal project. There were cases, however, when international organizations were opposed to neoliberal reforms imposed from above. This paper draws on the experience of the World Health Organization (WHO) to show that in the process of adapting to the emerging neoliberal regime, international bureaucracies actively restructured this regime in accordance with their own institutional cultures. Some neoliberal prescriptions were successfully transmitted, but others were transformed, with the result that the global regime was hardly monolithic and included elements that were introduced by the international bureaucracies themselves. In developing this argument, the paper identifies the adaptive strategies that allow international bureaucracies, in spite of their vulnerability to external forces, to incorporate their own organizational agendas into what has consequently become a more heterogeneous global neoliberal regime.

KEYWORDS:

• World Health Organization
• international organizations
• neoliberalism

Notes

1.This potential convergence between economists, US officials and the World Bank is not unlikely. As others have shown, international organizations are often influenced by Western perceptions through US-trained experts who hold highly-ranked positions in the organizations or serve as influential advisors (Chwieroth, 2008). According to Harvey (2005: 54), ‘The US research universities were and are training grounds for many foreigners who take what they learn back to their countries of origin …as well as into international institutions such as the IMF, the World Bank, and the UN'.

2.However, the significantly different relations between international organizations and their member-states, compared to the relations between states and social forces, particularly capital, make most theories of the state not applicable to the analysis of international organizations. I draw, instead, on sociological theories of organizations that have similarly conceptualized the relations of organizations with the environment. For the most systematic articulations of international organizations as organizations, see Barnett and Finnemore (1999, 2004).

3.A number of scholarly works on international organizations illustrate the ability of international bureaucracies to strategically respond to external demands. Barnett and Coleman (2005) have argued that the range of strategies identified by Oliver was also available to international organizations; Weaver (2008) has described in detail the use of avoidance (or ‘organized hypocrisy') as a central strategy of the World Bank. See also the volume edited by Park and Vetterlein (2010), which effectively identifies the internal and external sources for the emergence, stabilization and contestation of international norms. In turn, Sarfaty (2009) has analyzed a reversed situation, in which civil society organizations fail to strategically reframe their requests in a way compatible with the perceptions of the World Bank.

4.The responses identified here – strategic compliance and strategic resistance – are different from ‘strategic social construction' (Barnett and Coleman, 2005) in an important way. The objective of strategic social construction is to ‘change the preferences of principals to make them consistent with' the values and goals of the organization (Barnett and Coleman, 2005: 602). In contrast, when strategically complying or resisting external expectations, the international organization does not try to change the position of the environment. Rather, the organization reframes the position of the environment so as to present it as already consistent with the preferences of the organization.

5.For the empirical analysis, I rely on primary archival sources and public documents that I collected at the library of the WHO in Geneva, the library of the regional office of the WHO (Pan American Health Organization or PAHO) in Washington, DC, and at the national archives in the US, the UK and Canada. Particularly helpful were the topical minutes of the annual World Health Assemblies and biannual Executive Board meetings. I observed one World Health Assembly – in May 2008. Between March 2008 and May 2009, I conducted 24 semi-structured interviews (each one–two hours long), in Geneva, New York and Washington, DC. The interviews were with officials of the WHO (from a number of programs and initiatives, including the Drug Action Programme, Quality Assurance and Safety of Medicines, Roll Back Malaria, HIV/AIDS, and Tobacco Free Initiative), the World Bank, UNAIDS, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and a number of public-private partnerships, local and transnational health activists, and representatives of companies and their associations.

6.See http://www.who.int/about/en.

7.The discussion here focuses on the WHO headquarters in Geneva, Switzerland. The WHO member-states are also divided into six geographical regions, each having a regional office.

8.Following the argument made in this article, it is likely that as participants in the making of the ‘Washington Consensus', the IMF and the World Bank were not passive recipients of ideas developed by the US Treasury Department, but that they incorporated ideas compatible with their own organizational cultures.

9.While cost-effectiveness is not a neoliberal principle per se, it is compatible with the neoliberal tendency for economic reductionism as well as with the neoliberal interest in population-level outcomes that do not account for equitable distribution.

10.Aide Memoire on the WHO. Meeting of UN Ad Hoc Committee on UN Finances at Geneva on 20–21 April 1966. FO 371/189916. UK National Archives.

11.Effective leadership is an important condition for strategic adaptation. However, the influence of leaders should not be reduced to their personal characteristics (Haas, 1964; Cox, 1969). Scholars of organizations have identified two types of institutional conditions that enable agents to introduce change in their environment in spite of organizational constraints (DiMaggio, 1988). The first is field-level institutional characteristics (Battilana, Leca and Boxenbaum, 2009: 74), including organizational autonomy and lax supervision by the environment. Second, actors' institutional characteristics, including ‘the social position an actor occupies within an organizational field', also play a role (Battilana, Leca and Boxenbaum, 2009: 75). In particular, effective leadership in the form of strategic adaptation depends on the leader's social position both within the organization and within the environment. (1) Strategic response is more likely to occur when the institutional conditions allow for strong leadership, which provide the actor with the means to transform the organization without such attempts being paralyzed by external opposition or internal debates. At the WHO, the institutional conditions have allowed Directors-General to effectively shape the direction of the organization, through control over the budget planning, the creation of new divisions and the hiring of new recruits. (2) Strategic response is more likely to occur when the leaders are partially embedded in the exogenous environment. This partial embeddedness is important because it allows leaders to function as bridges between the organization and the broader environment. Brundtland was familiar with and appreciative of the neoliberal logic that she was expected to navigate. Being part of the external logic meant that she could adopt, at least in part, the new exogenous principles and was in possession of or able to gain sufficient knowledge of the new environment to be able to manipulate it (Chorev, 2012).

12.WHO Document (May 1998) A51/VR/6, p. 102. PAHO Library.

13.‘Challenges and Opportunities for the Health Leaders of Today'. Address by Dr Gro Harlem Brundtland, the Director-General of the WHO, to the 53rd World Health Assembly. 15 May 2000. Washington, DC: PAHO Library.

14.The literature on the WHO that analyzes the transition in the 1990s describes some of the policies that are also described below. However, many see the policy shifts under Brundtland as a capitulation to the neoliberal logic (Banerji, 1999; Thomas and Weber, 2006; Brown, Cueto and Fee, 2004). Others, on the contrary, underplay the role of external pressures (Kamradt-Scott, 2010). In both cases, the literature overlooks the strategic aspects of these policies, which are emphasized here.

15.WHO Document (2002) A55/VR/5, p. 109. WHO Library.

16.WHO Document (2002) WHA55/A/SR/5. WHO Library.

17.Interview by the author with Dr Steven Phillips, Medical Director, Global Issues and Projects, Exxon Mobil Corporation, Washington, DC, 11 January 2009.

18.The WHO staff relied on concern with the effect of disease on poverty to reject other World Bank health policy recommendations as well, including user fees (WHO, 1993). The WHO staff justified its opposition to this practice, which it found harmful and discriminatory, by arguing that it undermined the pursuit of economic betterment, both at the household and national levels (WHO, 2005a, 2005b).

19.WHO Document (2000) A53/4. PAHO Library.

20.WHO Document (2000) A53/4. PAHO Library.

21.Brown (1999); interview by the author with Allen Schapira, formerly at the WHO Roll Back Malaria Department, Geneva, Switzerland, 31 May 2008.

22.In improving its relations with for-profit companies, the WHO bureaucracy followed the call by the US government for private sector involvement in the United Nations system. The WHO bureaucracy was also influenced by the Rockefeller Foundation and the Bill and Melinda Gates Foundation, which began to condition their grants to the WHO on the organization making partnerships with the private sector (WHO, 1999a).

23.Interview by the author with Germán Velásquez, Drug Action Programme, World Health Organization, Geneva, Switzerland, 3 June 2008.

24.Notably, the authors of the WHO report chose to ignore the fact that intellectual property rights have often been perceived by critics as inconsistent with free trade principles and are, therefore, a sign of the developed countries' hypocrisy.

25.Indirectly, the report also criticized the World Bank's position against the provision of anti-AIDS drugs, which economists considered to be not cost-effective (World Bank, 1992). Thanks to generic manufacturing, the price of AIDS drugs dropped sharply, from more than $10,000 per patient per year to less than $80 today, making treatment also cost-effective (Médecins Sans Frontières, 2010).

26.Interview by the author with Germán Velásquez, Drug Action Programme, World Health Organization, Geneva, Switzerland, 3 June 2008.

27.Interview by the author with Lembit Rägo, Quality Assurance and Safety of Medicines, WHO, 27 May 2008.

28.Interview by the author with Katherine Deland, Tobacco Free Initiative, WHO, Geneva, Switzerland, 2 June 2008.

29.Interview by the author with Katherine Deland, Tobacco Free Initiative, WHO, Geneva, Switzerland, 2 June 2008; see also Brundtland, 2000a.

30.Interview by the author with Katherine Deland, Free Tobacco Initiative, WHO, Geneva, Switzerland, 2 June 2008.

31.United Nations Ad Hoc Inter-Agency Task Force on Tobacco Control. Report of the Sixth Session. Geneva, Switzerland. 30 November–1 December 2005.

32.WHO Document (1986) EB77/SR/9, p. 129, WHO Library.

33.Interview by the author with Badara Samb, Health Systems Strengthening, Department of HIV/AIDS, WHO, Geneva, Switzerland, 3 June 2008; Shiffman, 2008.

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