p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 4 1 e1 4 7
Available online at www.sciencedirect.com
Public Health
journal homepage: www.elsevier.com/puhe
WHO: Past, Present and Future
The World Health Organization and Global Health
Governance: post-1990
J. Lidén*
Centre on Global Health Security, Chatham House, 10 St James’s Square, London SW1Y 4LE, United Kingdom
article info
abstract
Article history:
This article takes a historical perspective on the changing position of WHO in the global
Received 7 April 2013
health architecture over the past two decades.
Received in revised form
From the early 1990s a number of weaknesses within the structure and governance of
9 August 2013
the World Health Organization were becoming apparent, as a rapidly changing post Cold
Accepted 9 August 2013
War world placed more complex demands on the international organizations generally,
Available online 1 January 2014
but significantly so in the field of global health.
Keywords:
and played a crucial role in setting global health priorities. However, over the past decade,
History of global health
the organization has to some extent been bypassed for funding, and it lost some of its
Global Health Governance
authority and its ability to set a global health agenda. The reasons for this decline are
The World Health Organization
complex and multifaceted. Some of the main factors include WHO’s inability to reform its
Towards the end of that decade and during the first half of the next, WHO revitalized
core structure, the growing influence of non-governmental actors, a lack of coherence in
the positions, priorities and funding decisions between the health ministries and the
ministries overseeing development assistance in several donor member states, and the
lack of strong leadership of the organization.
ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction
Since 1990, fundamental changes have been seen in both the
wider political and economic context that influences health
outcomes and in the shape of the global health architecture.
To better understand these changes, this article attempts to
draw up a brief chronology of the period.
There are several ways of indicating changing levels of
activity in global health. For the purpose of this article the
author have chosen to make use of three: The amount of
Official Development Assistance (ODA) going to global health;
the amount of innovation in terms of new initiatives/
partnerships/institutions created to engender activity in
global health; and global health outcomes.
It can be argued that these three indicators will emphasize
the fight against infectious diseases and other poverty-related
health problems at the expense of other vital functions of
WHO, like non-communicable diseases, mental health, and
global health policies, standards and regulations. However, as
funding and health outcomes have become a central driver of
global health priorities e and therefore also in shaping the
views of WHO’s successes and weaknesses e it is worth
spending some time looking at the story these three indicators
tell.
* Tel.: þ44 41792446006.
E-mail address: jon.liden@gmail.com.
0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.puhe.2013.08.008
142
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 4 1 e1 4 7
Since 1990, these three indicators all show roughly similar
trends. Together, they tell a story with three fairly distinct
chapters: a period of relative stagnation or even deterioration
in health outcomes, with stagnation in innovation and slow
growth in funding from 1990 to 1997; a period of rapid
expansion of funding, increasing complexity in health architecture and improving health outcomes from 1998 to 2009 and
a period of uncertainty from 2010 onwards.
ODA and non-governmental funding for health increased by
49% from 1990 to 1997, from US$5.74 billion to US$8.54 billion.
Most of this increase came in bilateral funding and in a significant increase in spending on health by the World Bank. This rate
of growth pales in comparison with the funding during the
following years. From 1998 to 2010, ODA and non-governmental
funding for health grew 230%, to US$28.2 billion.1
Similarly, the period from 1990 to 1997 saw only a handful
of new initiatives focused on global health. The period from
1998 to 2010, however, saw the birth of several dozen partnerships, initiatives, foundations and institutions dedicated
to financing, coordinating or implementing global health
programmes, or achieve global health goals.2
The 1990s was dominated by the rapid spread and acceleration of the HIV/AIDS pandemic from 8.9 million people
living with HIV in 1990 to 23.1 million in 1997. AIDS deaths
grew at a similarly rapid pace, from 380,000 in 1990 to 1.2
million seven years later.3 TB incidence grew slightly globally,
but an alarming growth in TB-HIV co-infection gave cause for
concern and the rates of detection and completed treatment
were worryingly low. Figures for malaria e although uncertain
e indicated an increase in drug resistance, a growth in deaths
and a breakdown of control-efforts in many countries.4 Immunization rates of children stagnated at just over 70%
coverage during these years5 and efforts to introduce additional vaccines to the routine immunizations largely failed.6
There was also substantial concern during this period about
the reduction in research and development for new drugs and
diagnostics for tropical diseases.7
These outcomes contrast with the positive results produced especially from 2004 onwards. Over the past ten years a
reduction in new HIV infections and in AIDS mortality, a sharp
decline in TB deaths, a significant reduction in malaria deaths,
a steady increase in routine immunization coverage and the
introduction of several additional vaccines as well as the
arrival and widespread uptake of some important new drugs,
vaccines and diagnostics for several diseases have been seen.
The evolution of the World Health Organization is closely
tied to these trends and WHO has to a large extent been a driver
of them. However, the author will argue that the organization
has also been aversely affected by the rapidly changing landscape in global health, and that its influence and authority over
time have diminished, partly as a result of its own actions, but
mainly as a consequence of forces beyond its control.
The 1990s: a decade of backsliding in global
health
In 1988, Dr Hiroshi Nakajima took over as Director General of
the World Health Organization as Dr Halfdan Mahler stepped
down after 15 years in office.
During Nakajima’s first five-year term, the post World War
II order, which for 40 years had provided stability and predictability in world affairs, unravelled. Some health consequences of the collapse of the Post War world order quickly
became apparent. The most visible was the dramatic increase
in tuberculosis in former Soviet states, as well as a deterioration of a wide range of health indicators in countries facing
political and economic turbulence following the collapse of
the Soviet Union.
WHO was largely unprepared for dealing with the health
fallout of events that were rooted in larger political and
economic developments, in particular since at the time it
had a near exclusive interaction with nation states; states
which governments during the 1990s were often in
continual transition and severely weakened.
The rapid spread of the global HIV pandemic added to the
pressures on WHO. Dr Jonathan Mann, who had built up the
General Program on AIDS within WHO from a one-man
operation when it started in 1986 to a $100 million program,
resigned in 1990, citing ‘major disagreements’ with Nakajima.8 The creation of a UNAIDS Secretariat independently of
WHO in 1996 contributed to a sense that WHO was not
equipped to lead the fight against such a ‘modern’ disease
with its need for a complex, multifaceted response to issues
like discrimination, judicial reform, behavioural change, and
prevention strategies that challenged cultural and religious
norms.9
Nakajima’s focus was instead on using WHO for tasks that
had brought successes for Mahler. He hoped that WHO could
repeat the achievement from the smallpox eradication of the
1970s by creating a global campaign to eradicate polio.
Alarmed by the steep rise in TB cases, WHO from 1995 onwards also promoted the adoption of the directly observed
treatment short-course (DOTS), and in doing so, initiated a
wide-ranging reform of most countries’ TB treatment. While
ultimately successful, these efforts only bore significant fruits
in the following decade, giving Nakajima little credit during
his time in office.
Much attention has been paid to the controversies around
Nakajima’s person and leadership e such as the conflict with
Mann in 1990, a challenge to his re-election in 1992 and the
following accusations of bribery, and a call for his resignation
in 1995 following perceived racist remarks e but significant
structural weaknesses within WHO were threatening the
effectiveness of the institution independently of these scandals and they became increasingly apparent during the 1990s.
Nakajima’s main mistake may have been to fail to address
these weaknesses head-on.10,11
In late 1994, a series of articles in the British Medical
Journal,12 listed the main weaknesses in WHO’s existing
structure and work, only putting into focus what had already
been highlighted in several donor country and UN reports:13
1. WHO’s country work was of greatly varying quality and
impact, and saw little regional strategy and coordination;
2. its regional office structure fostered a lack of global coherence and coordination, added to bureaucracy, drove the
politicization of health issues and promoted cronyism;
3. its extra-budgetary programmes were driven by donor
priorities rather than reflecting global health priorities,
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 4 1 e1 4 7
which led to internal competition for resources within
WHO and weakened the organization’s less tangible or
outcome oriented work, such as its normative-, researchor monitoring activities;
4. its inherent handicaps in addressing the increasingly
complex social, economic and political determinants of
health; and
5. its inability to find constructive working arrangements with
the increasing number of other institutions having a
growing influence on global health policy or outcomes.
The decentralized structure was the result of a compromise at the creation of WHO in 1948, stemming from the need
to integrate the regional health organizations that preceded
WHO, and Nakajima had little power to change the dynamics
of this arrangement.
At the Headquarters in Geneva, he e as his successors e
found it exceedingly hard to unify and discipline his department and programme directors’ competition for extrabudgetary funding and e like his successors e found it difficult to convince donor countries to provide untied funding.
In the 19 years since the BMJ series, these five areas have
remained central to the critique of WHO. Despite several attempts at reform during the past two decades, WHO’s organizational structure and its reliance on extra-budgetary
funding for donor-prioritized programmes remain largely
unchanged. The criticism today is strikingly similar to the one
19 years ago.14 In fact, the past two decades have shown that it
is exceedingly difficult for a Director General to reform the
structure of WHO, and while member states unite in their
criticism of the perceived weaknesses of the organization,
they rarely agree on finding solutions that can permanently
alter the five areas of weakness outlined by Godlee and many
others over the years.
1998e2003: growth and complexity
Dr Gro Harlem Brundtland, who was nominated as Director
General to take over from Nakajima in 1998, had campaigned
on a platform of reform and the need to set clear, strong priorities for global health.
Much faith was placed in Brundtland to revitalize WHO.
She had several qualities that set her apart from Nakajima and
the other candidates she competed with for the Director
General position: She was an outsider and therefore not tied
by debts and loyalties to WHO staff and member states; as a
long-time prime minister of Norway and as the former head of
the World Commission on Environment and Development she
enjoyed a standing and a respect which ensured that she was
listened to by presidents and prime ministers as well as health
ministers; and she was known as a pragmatist who would
never let principle stand in the way of a wanted outcome.
Brundtland’s strategy to restore WHO’s role as a leader in
global health was to set a clear agenda and define global priorities. She believed that once WHO’s thought-leadership was
re-established, it would create a momentum that would
attract resources and place WHO at the head of the table in
discussions with the many new, emerging actors in the global
health arena.15
143
From consultations with more than a dozen countries
about their main health concerns, she chose one priority
among the infectious diseases e malaria e and one among
non-communicable diseases, tobacco control. However, her
overarching goal was to place health at the centre of the global
discussions about development. She knew that only if health
was seen as a global political and economic issue rather than a
humanitarian and local concern, would presidents or prime-,
foreign- and finance ministers really get engaged.
She made no secret of this aim: it was stated in her first
speech to the World Health Assembly, May 1998,16 and
repeated regularly in her speeches throughout her time at
WHO. Having already stated her political plan, she ‘reverse
engineered’ the process to provide scientific backing for it by
setting up a ‘Commission on Macroeconomics and Health’ in
1999. Her plan was nicely aligned with the ‘zeitgeist’ of her day;
her vision fit very well with the work that soon would lead to
the creation of the Millennium Declaration with its eight Millennium Development Goals (MDGs), and it positioned WHO to
play a central role in the initial work to achieve the MDGs.
Rather than creating a leadership from within the ranks of
WHO, Brundtland brought leading academic or policy figures
in their fields to head what she named as ‘clusters’ of activity
within WHO. Many of these individuals commanded much
respect in the world of global health and immediately brought
prestige to the organization e at the cost, however, of some
resentment and non-cooperation among a few existing senior
staff at WHO.
Brundtland quickly recognized that the implementation of
a global health agenda depended on large sums of additional
resources and that these resources lay outside the world of
global health and also outside the remit of the health ministries that made up the governance structures of WHO. She did
not see WHO as an implementing agency, but instead saw its
role as providing direction, leadership, coordination and
technical expertise to those implementing a new, ambitious
health agenda. She therefore made WHO into a convener for
partnerships and initiatives to harness the growing political
support for action in global health.17
The first of these partnerships was Roll Back Malaria,
which was initiated soon after she took office. Subsequently,
Brundtland worked to create or support new initiatives where
she felt there were gaps in the existing health architecture
(Medicines for Malaria Venture, GAVI, the Global TB Drug Facility, the Global Fund), to bring parties together for dialogue
where she felt there were obstacles (pharmaceutical industry
round-tables) and to organize partnerships and alliances
where she felt the many actors in a field needed direction and
coordination (Tobacco-Free Initiative, Partnerships for Health
Sector Development, Global Alliance To Eliminate Lymphatic
Filariasis, Make Pregnancy Safer, Stop TB Partnership, etc.).
While failing to raise the amount of mandatory budgetary
contributions to WHO, Brundtland oversaw a significant
increase in voluntary, extra-budgetary resources to the organization through her period in office. She formulated a strategy to align such resources more closely with the
organization’s priorities and needs.18
The Framework Convention on Tobacco Control, which
was adopted by the World Health Assembly in May 2003, was
the first treaty negotiated under Article 19 of WHO’s
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Constitution. There were great expectations that the
Convention heralded a new era of global policies and treaties
to assist countries in dealing with supranational health issues.
Indeed, Brundtland was forging ahead with what promised to
be a strong global policy on nutrition, but after her departure,
the final policy fell victim to industry pressure and was
weakened to a point where it has become only a shadow of the
strong instrument Brundtland envisaged to help countries’
efforts to control obesity, high blood pressure and other
nutrition-related health issues.
During the last months of her first and only term, a global
outbreak of a so far unknown virus e quickly termed SARS
(Severe Acute Respiratory Syndrome) e tested WHO’s ability
to lead a global response to disease outbreaks. Brundtland’s
forceful response and insistence on immediate and accurate
sharing of transmission data by all countries reaffirmed WHO
as the global authority and coordinator in such global emergencies and forced through a faster and more accurate
reporting system than in the past.19
There is a general consensus, therefore, that Brundtland
was successful in re-establishing WHO’s leadership in setting
a global health agenda, in setting global priorities and in
coordinating global efforts. She managed to confront complex
health-related issues where both causes and solutions lay
outside the medical field by engaging WHO in the political
determinants, such as in the tobacco control issue and in
getting acceptance for the close link between health and
economic development.
However, she made little headway in improving the quality
and uniformity of WHO’s work in countries and was not able
to bring the regional directors behind her efforts to reform the
organization. She also faced persistent resistance among
some WHO staff to Headquarters reforms and to some of the
senior deputies she had brought in.20
Personal health issues21 prevented Brundtland from
seeking a second five-year term in office, and it is therefore
impossible to say to what extent her internal reform efforts
failed or whether they simply were not completed by the time
she stepped down in July 2003.
2003e2012: WHO’s diminishing role in global
health
The Global Health landscape changed considerably between
1998 and 2003. Health had become a central theme on the
international agenda e in particular for the G8. Funding
increased, but this funding was largely channelled outside
WHO. The U.S. President’s Emergency Plan for AIDS Relief
(PEPFAR) not only dwarfed all other sources of funding for any
health intervention except the Global Fund, but it also
engaged technical expertise other than WHO in countries.
Universities like Harvard and Johns Hopkins, NGOs like Partners in Health, Catholic Relief Services and World Vision, and
a raft of consultants, were financed through PEPFAR to provide
strategic advice, technical support and also to large extent to
implement large disease programmes in several development
countries.
The Global Fund’s grant model, which encouraged
countries to procure technical assistance and to engage
NGOs as Principal and Sub Recipients for its grants,
contributed to this boom in non-WHO technical and operational engagement in developing countries. Not only did
WHO in many countries lose out in the ‘competition’ with
NGOs and academic institutions for fast, relevant and highquality advice; many countries were also reluctant to pay
WHO for advice that they had come to expect for free by
WHO Country Offices.
WHO (and to a lesser extent UNAIDS) thus increasingly
voiced its concern that by being enlisted as a technical partner
to the Global Fund, the Fund had imposed an ‘unfunded
mandate’ on the organization.22
Moreover, the Bill and Melinda Gates Foundation became
the single largest non-governmental funder of health research
in infectious and vaccine-preventable diseases (as well as a
major funder of GAVI, the Global Fund and a raft of health
advocacy initiatives and partnerships), and over time, its
money and its growing self confidence and expertise in health
matters made it a strong e if informal e authority in setting
global health priorities and influencing policies.
Jong Wok Lee, who took over as Director General in 2003,
reversed some of Brundtland’s reforms (re-introducing the
pre-Brundtland leadership structure with Assistant Director
Generals, re-centralized some decision-making processes)
and de-emphasized some of Brundtland’s priorities (in
particular an ambitious and aggressive push to improve global
nutrition), while he emulated some practices, such as bringing
outside authorities in certain fields into the senior leadership
(in particular Jim Yong Kim, who was brought in to lead an
ambitious push for expansion of AIDS treatment, the ‘Three
by Five Initiative’).
Lee was, like Nakajima, someone who had a long career at
WHO before he took the helm of the organization. He was by
personality a consensus builder, focusing on technical aspects
of global health rather than the political leadership style of
Brundtland. He was somewhat hampered by having been
elected with a weak mandate (an election stalemate had only
been broken to secure him a 17/15 vote after three tied rounds
of voting in the Executive Board).23
Lee campaigned on providing additional resources to WHO
country offices, but wanted to achieve this through increased
overall funding rather than a large reallocation of funds from
the Geneva Headquarters. This put significant fund-raising
pressures on WHO and some concerns were voiced that it
increased the ‘cherry-picking’ nature of donor priorities,
diffusing a unified global agenda.
Lee’s major focus would be on the ‘Three by Five Initiative’,
and while it did not reach its goal of ensuring that three
million people were receiving AIDS treatment by the end of
2005 (the three million mark was achieved in 2007), it has been
credited with energizing the global effort to provide access to
AIDS treatment and to the goal of achieving universal access
to such treatment.
However, the ‘Three by Five Initiative’ illustrated the
challenges WHO faced by operating in a much more crowded
and complex global health environment. While WHO
strengthened the technical capacity in Geneva, it struggled to
do the same at a sufficient scale in the country offices. WHO,
which had over the past year yielded the position of adviser to
governments to UNAIDS, struggled to draw up the separation
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 4 1 e1 4 7
of responsibilities between the two organizations, leading to
confusion in many countries.
The Global Fund was designed to make funding decisions based on country applications and WHO therefore
found that the organization was ill-equipped to adjust
funding priorities based on requests and priorities from
WHO’s Headquarters. PEPFAR even less so. Moreover, Bill
Gates was for several years sceptical to the entire argument
that providing universal treatment access was a costefficient intervention. In short, with so much new money
available for global health programmes outside WHO’s
sphere of influence, its voice became less one of unquestioned authority but increasingly only one of several
opinions.
This tension has continued to evolve over the past years.
UNITAID, which was created in 2006, although it is hosted by
WHO, makes funding decision through its multistakeholder
Board. The many issue-specific partnerships that have grown
up e in particular Roll Back Malaria and Stop TB Partnership e
provide advocacy and even technical advice independently of
WHO, and are not always fully aligned with WHO’s respective
departments.
NGOs and activist organizations now wield a considerably
larger influence than in the past, partly through their effective
advocacy and partly by being admitted as formal stakeholders
on the Global Fund, GAVI, UNITAID, UNAIDS and partnership
boards.
Even WHO’s leading position in providing health metrics
has been challenged by the creation of the Seattle-based and
partly Gates funded Institute for Health Metrics and Evaluation, set up by Christopher Murray after he left WHO shortly
after Brundtland’s term ended.
The SARS epidemic in 2003 re-established WHO as a global
authority and coordinator on disease outbreaks, and Margaret
Chan, who was elected Director General after Lee’s untimely
death in 2006, re-emphasized this role. Chan, who had led
Hong Kong’s health department through the 1997 avian
influenza epidemic and the SARS episode in 2003, was expected to further strengthen WHO’s role in this field. However,
WHO’s widely criticized reaction to the avian influenza
outbreak in 2009 weakened the organization’s authority also
in this area.24
While there have been some successes in getting international agreements on global health issues, WHO DirectorGenerals subsequent to Brundtland did not attempt bold
global efforts similar to the Tobacco Convention or global
policies or standards on controversial issues. However, a
renewed version of the International Health Regulations was
crafted after the scare provided by the SARS outbreak in 2003
and was approved in 2005.
Some significant initiatives have been undertaken over the
past decade to somehow address important challenges in
global health. The most noteworthy of these may be the
Commission on Social Determinants of Health, the Global
Code of Practice on the International Recruitment of Health
Personnel and the work leading up to a UN General Assembly
Special Session on non-communicable diseases in 2011. Most
recently, WHO has promoted a goal of ‘Universal Health
Coverage’ and has lobbied hard to make this the primary
health goal of what will eventually become a ‘Post 2015
145
Agenda’ to replace the soon expired Millennium Development
Goals.
For all the good work that has gone into these initiatives,
there is a strong feeling expressed in various forms and forums25 that WHO’s actions are ad-hoc and derivative, that the
initiatives are disparate, lack strategic direction and followup. In short, WHO, according to these critics, has lost its way
and is simply staggering around in the dark, devoid of ideas
and clarity of purpose.
While extra-budgetary funding for WHO continued to increase significantly during the years following Brundtland’s
departure (voluntary contributions increased from US$1.5
billion in the 2002e2003 biennium to US$3.6 billion in the
2010e2011 biennium), concern has been raised that there has
not been a proportional ‘return’ on this donor investment in
terms of WHO technical assistance, agenda-setting and
leadership.25
The rise of global health institutions outside the UN system
and an increasing influence of non-governmental actors, such
as foundations and activists, have often been used to explain
WHO’s relative decline.
However, from the standpoint of the WHO HQ leadership,
the often disparate and sometimes conflicting priorities
within WHO member countries themselves, is perceived to
pose a major challenge to the organization’s ability to reform
and to get support and funding for a clear future direction.26
There is a perceived disconnect between the priorities of
health ministries, which govern WHO through its Executive
Board and the World Health Assembly on the one hand, and
Ministries of Foreign Affairs and Departments of Development
Assistance, which provide the bulk of financing for global
health through overseas development assistance, on the
other.
This latter funding is not only channelled through bilateral
aid initiatives, such as PEPFAR; they finance the plethora of
new institutions and initiatives that now to a large extent
drive the global health agenda. They also, crucially for WHO,
provide the bulk of the extra-budgetary funding for the
organization.27
WHO may therefore fall victim to countries which may
have one set of priorities expressed in WHO’s own governing
forums, while their funding to WHO and other institutions
may reflect a different set of priorities.
Too little is known, however, about the correlation or
possible disconnect between individual countries’ voting record and recorded positions on strategic issues in the Executive Board and the World Health Assembly and their funding
record for WHO’s extra-budgetary activities to draw any
conclusions about the validity of such concerns at this stage.
Over the past few years, stagnating contributions combined with an acute financial crisis at WHO Headquarters in
Geneva triggered by the strong Swiss franc, forced significant
staff lay-offs and led to renewed demands for drastic reforms
of the organization.
Over the past two years, the WHO leadership has struggled
to align its governing organs’ priorities with its funding realities. Yet, for its wide scope and considerable detail, the reform efforts do little in terms of prioritizing the use of the
organization’s limited resources and focusing on its comparative strengths.20
146
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 1 4 1 e1 4 7
Nor does it address the key structural weaknesses identified back in the early 1990s, in particular the regional
structure and the varying quality of country offices. While
discussions at this year’s World Health Assembly focused on
WHO’s interaction with non-state actors, the discussion did
not find a formula for how WHO can best function in a by
now considerably more crowded and complex health architecture, where non-governmental organizations play a significant role.
WHO and its defenders describe the organization’s current
weak state as a reflection of its Members States’ diverse and
sometime contradictory needs, opinions and demands.
However, for outside observers, the ongoing, overly technical
reform effort more than anything masks the fact that WHO
over the past decade has lacked a decisive leadership and
visionary ideas to set a clear direction for the global health
agenda and to lead the world towards it.
Conclusion
The growing number of actors with political or economic
power over the past fifteen years, the lack of coherence in the
positions and priorities between health and development
ministries within member states, the unresolved weaknesses
of WHO’s regional structure, and the lack of a visionary leader
of the organization, together pose significant challenges for
WHO as it is seeking to reform itself to a global environment
very different from 20 years ago.
Author statements
Ethical approval
None sought.
Funding
None declared.
Competing interests
None declared.
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one term. Dr Brundtland has in later years revealed to former
colleagues that two specific and potential life-threatening
health conditions convinced her that it would be
irresponsible to continue with the work load and travel
schedule the Director General position demanded.
22. Global Task Team on improving AIDS coordination among
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26. This perception has been described by WHO senior
leadership in conversations with the author.
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challenge of multi-bi financing. PLoS Med 2012;9(9).