The African regional office of the World Health Organisation (Afro) has done little to help stem Zimbabwe’s cholera outbreak, critics say, because of mismanagement and cosy relationships with government.
Health activists and academics told the Mail & Guardian that Afro’s response to the outbreak has been disastrously slow, despite the fact that its Southern Africa headquarters are in Harare and that it has a $1.2-billion biennial budget at its disposal.
Afro’s regional director, Dr Luis Sambo, first visited Zimbabwe to review the cholera situation in December 2008, four months after the first cases were reported in August. Outbreak surveillance and systematic coordination of interventions are said by other health sector players to be completely dysfunctional.
Médicins Sans Frontiér’s (MSF) emergency coordinator, Marcus Bachmann says: “There is a problem in the cleanliness and the completeness of the reporting — without a strong surveillance system, you are not able to target and direct limited resources.
“I would understand if [this was] not strong in the beginning of the outbreak, but in the seven months of the outbreak there should be strength in that. Cholera has very rapid kinetics, so you have no time to lose.
“The complete communication and supply chain are not working or working fast enough. And it’s critical because if cholera [medicines] don’t come in time, people lose their lives,” Bachmann says.
He and others point out that Afro cannot blame the lack of funds for its tardiness. Its $1.2-billion allocation is 28% of the entire WHO budget for the 2008-2009 biennial period, making it the best-funded regional office within the system. WHO and government insiders, however, say privately that they regard Afro as the worst-managed office.
Civil society organisations requested a meeting with Afro in October 2008 to “find out what they [Afro] actually do, because they get a very big budget”, according to David Coetzee, senior specialist with the Western Cape provincial department of health and director of the infectious disease epidemiology unit at the University of Cape Town.
Afro responded that they had received only 22% of the $1.2-billion and “50%-100%” of the 2006-2007 biennial funding.
Asked to comment on these vague figures, Dan Epstein of the WHO head office in Geneva was non-plussed. “That doesn’t make sense. They’re having problems distributing the money or something.”
Critics of the body say part of the problem is that Afro’s insistence on working primarily with the Zimbabwean government severely stunts its ability to use the money to help patients. Because the WHO works within the United Nations system, the organisation and its regional offices work most closely with governments and ministries of health rather than civil society organisations.
Although the WHO Geneva office has released several reports regarding the severe impact of the epidemic, neither Geneva nor Afro have voiced any criticism of Robert Mugabe’s false statement that the epidemic is over. Collins Boakye-Agyemang of Afro insists that “regardless of political issues, we try to improve the health of the public”.
Sharon Ekambaram of MSF South Africa counters that this approach means internal politics and layers of bureaucracy trump the health needs of populations. Failure to criticise government inaction is “not just [respecting] sovereignty — it compromises your independence. They would compromise people’s health in respecting sovereignty,” Ekambaram says.
Bachmann says, “WHO-Afro has the responsibility to acknowledge the realities on the ground. In the context of a failing ministry of health, its role should be not only supportive, but more developmental.”
Other observers say that Afro is seen by many as an employment option in retirement and that a network of cronies dominates the organisation.
Neil Cameron, former Director of Infectious Disease at the National Department of Health, worked with Afro during his time at the DoH and noted that “the regional director was inclined, so I’ve heard, to appoint ex-ministers”.
It is difficult to be critical when “you’re sitting in cahoots with the government”, Ekambaram said.
WHO-Afro responds
Collins Boakye-Agyemang of Afro says criticisms like those levelled over the Zimbabwe cholera outbreak stem from a misunderstanding of the organisation’s role.
“One of the wrong perceptions”, he says “is that WHO is an implementing agency.
“The perception is that WHO has to be seen to be providing health in a country. The ordinary people see the agencies, not WHO-Afro. But the tools and guidelines are made by Afro.”
Dan Epstein, spokesperson at WHO headquarters in Geneva, says that accountability concerns are being addressed. The entire organisation is “embarking on a global budgeting and management system that’s designed to make everything completely transparent, and that is in the process of being implemented”, he says.
“The principle behind this, is that … everything will be transparent. You will see how the money is being spent and by whom — down to the last level of detail.”
Epstein concedes that this monitoring and evaluation programme is “having teething problems”, which are “affecting the implementation rate” of all WHO work, “not just in Afro but in other regions”.