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Restructuring neoliberalism atthe World Health OrganizationNitsan Chorev aa Brown University, Providence, Rhode Island, USAVersion of record first published: 30 Jul 2012.

To cite this article: Nitsan Chorev (2012): Restructuring neoliberalism atthe World Health Organization, Review of International Political Economy,DOI:10.1080/09692290.2012.690774

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Review of International Political Economy 2012, iFirst: 1–40

Restructuring neoliberalism at the WorldHealth Organization

Nitsan ChorevBrown University, Providence, Rhode Island, USA

ABSTRACT

Most descriptions of the spread of neoliberal economic policies since the1980s overlook the significant contribution of international organizationsnot only to the dissemination of these policies, but also to their making.The scholarship often regards international organizations as passive trans-mission belts that merely comply with the demands of their member-states.Scholars who do identify the constitutive role of international organizationsconsider them to be enthusiastic supporters of the neoliberal project. Therewere cases, however, when international organizations were opposed to ne-oliberal reforms imposed from above. This paper draws on the experienceof the World Health Organization (WHO) to show that in the process ofadapting to the emerging neoliberal regime, international bureaucracies ac-tively restructured this regime in accordance with their own institutionalcultures. Some neoliberal prescriptions were successfully transmitted, butothers were transformed, with the result that the global regime was hardlymonolithic and included elements that were introduced by the internationalbureaucracies themselves. In developing this argument, the paper identi-fies the adaptive strategies that allow international bureaucracies, in spite oftheir vulnerability to external forces, to incorporate their own organizationalagendas into what has consequently become a more heterogeneous globalneoliberal regime.

KEYWORDS

World Health Organization; international organizations; neoliberalism.

INTRODUCTION

The ongoing global financial crisis and current attempts to save the neolib-eral political-economic system from itself have focused renewed atten-tion on the institutions that have established and reproduced neoliberal

Review of International Political EconomyISSN 0969-2290 print/ISSN 1466-4526 online C! 2012, iFirst Taylor & Francis

http://www.tandfonline.comhttp://dx.doi.org/10.1080/09692290.2012.690774

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economic reasoning since the 1980s. When studying the spread of ne-oliberalism, much has been said about the role of international financialinstitutions – the World Bank, the International Monetary Fund (IMF) andthe General Agreement on Tariffs and Trade/World Trade Organization(GATT/WTO) – in pressing countries into compliance with the new worldorder. Other international organizations, including the specialized agen-cies of the United Nations (UN), have also shaped countries’ practices byadvocating policies that were compatible with neoliberal thinking.

In considering the origins of the neoliberal prescriptions advocated byinternational organizations, the literature has typically regarded theseorganizations either as passive vectors subject to the demands of theirmember-states or, when actively participating, as enthusiastic supportersof the neoliberal project. In contrast, this paper argues that in the processof adapting to the emerging neoliberal regime, international bureaucraciesactively restructured it in accordance with their own institutional cultures,which were not necessarily compatible with the original neoliberal prin-ciples. Some neoliberal prescriptions were successfully transmitted, butothers were transformed, with the result that the global regime was hardlymonolithic or coherent and included elements that were introduced bythe international bureaucracies themselves to protect their ideational andmaterial interests.

In short, this paper highlights the endogeneity of global regimes (Halli-day and Carruthers, 2009), in which international organizations also par-ticipate and are able to transform the regimes of which they become a part.Given the dependence of international organizations on their member-states, especially on the wealthy ones, it is far from obvious that interna-tional bureaucracies can participate in the making of the global regime.Therefore, this paper identifies the adaptive strategies available to inter-national organizations that enable them to incorporate their own interestsinto what consequently becomes a more heterogeneous global regime.

The paper explores the restructuring of a global neoliberal logic in linewith international organizations’ own institutional cultures by analyzingone UN agency, the World Health Organization (WHO). The WHO experi-enced severe financial, authority and legitimacy crises in the 1980s due totightened neoliberal pressures on international organizations. The WHObureaucracy responded to these crises by adopting neoliberal-compatiblepolicies. While embracing economic reasoning, prioritizing cost-effectiveprograms, and accepting market-driven solutions and business-friendlyarrangements, however, the WHO bureaucracy was also able to strategi-cally reinterpret the neoliberal prescriptions so that the new policies incor-porated the bureaucracy’s own goals. These included calling for greaterfinancial investment in health, prioritizing the delivery of high-quality es-sential care to all while maintaining a focus on infectious diseases affectingthe poor, supporting access to generic HIV and AIDS drugs, and regulating

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the tobacco sector. In the following two sections, I develop an argument onthe ability of international organizations to shape global regimes throughadaptive strategies. I then describe the WHO’s strategic response to therise of neoliberalism.

THE NEOLIBERAL TURN AND INTERNATIONALORGANIZATIONS

Neoliberal economic theories were first incorporated into political pro-grams in Chile after Augusto Pinochet’s coup in 1973, in the UnitedStates under President Ronald Reagan, and in the United Kingdom un-der Prime Minister Margaret Thatcher. Policies informed by the ne-oliberal ideology were later embraced by many other governments,independently of their political inclinations or their countries’ level ofeconomic development (Harvey, 2005; Evans and Sewell, forthcoming).The two core principles commonly equated with neoliberal thinking aremarket fundamentalism and anti-statism, based on belief in the superi-ority of market-driven competition as the best mechanism of economicallocation, which allows for governmental oversight only in narrowlydefined instances of market failure. Collective and individual wellbe-ing, according to neoliberals, is guaranteed through economic growth,rather than direct governmental interventions in social realms such ashealth or education (Plehwe, Walpen and Neunhoffer, 2005: 2–3; Har-vey, 2005: 2–3; Somers, 2008). In translating these principles into policiesfor developing countries, the US government and international financialinstitutions – in what has become known as the ‘Washington Consen-sus’ (Williamson, 1990) – devised a set of policy instruments aimed atachieving the neoliberal-informed economic objective of growth. Policyinstruments of particular relevance to the discussion included restora-tion of fiscal discipline aimed at a balanced budget, achieved throughreducing expenditures rather than increasing tax revenues; reduction ofbarriers to the flow of commodities, services and capital; privatization(based on the belief that private industry is managed more efficiently thanstate enterprises); deregulation; and protection of property rights.

Many scholars of neoliberalism have emphasized its hegemonic, uni-fied and all-encompassing nature. David Harvey (2005: 3), for example,wrote: ‘There has everywhere been an emphatic turn towards neoliberal-ism in political-economic practices and thinking’. Pierre Bourdieu (1998),in turn, spoke of neoliberalism as a “‘strong discourse” – the way psychi-atric discourse is in an asylum, in Erving Goffman’s analysis’ (see also Gill,1995; Somers and Block, 2005). In response to these totalizing images ofneoliberalism, however, scholars have shown growing appreciation of thediversity one can find across ‘actually existing neoliberalisms’ (Brennerand Theodore, 2002). Fourcade and Babb, for example, identify differences

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between the ‘ideological’ transitions to neoliberalism in Chile and Britain,leading to a monetarist revolution in both countries, and the ‘practical’and less rigid transitions in Mexico and France (Fourcade and Babb, 2002).Monica Prasad (2006), in turn, shows that the ‘more’ neoliberal US andBritain adopted taxation structures that favored capital accumulation overincome redistribution, favored industrial policies that minimized the pres-ence of the state in private industry, and retrenched welfare spending toa much greater extent than the ‘less’ neoliberal France and Germany. Thisdiversity has been most commonly understood as deviation by states froman existing regime imposed from above, with the literature highlighting theinconsistency in the implementation of neoliberalism at the national level(Fourcade and Babb, 2002; Prasad, 2006; Hanley, King and Toth, 2002;Evans and Sewell, forthcoming). As Brenner and Theodore (2002: 361)summarize, ‘Neoliberal programs of capitalist restructuring are rarely, ifever, imposed in pure form’. While allowing for divergence across states,therefore, these accounts still adhere to the view that, at the global level, auniform neoliberal regime exists.

A number of scholars have suggested, in turn, that what is often viewedas divergence from a singular set of ideas and policy prescriptions shouldbe understood as reflecting the diversity of the neoliberal regime itself.Neoliberalism is a plural set of ideas that includes a variety of distinct ne-oliberal constellations (Plehwe, Walpen and Neunhoffer, 2005: 2–3). Whilethe empirical and analytical foci of these claims remain at the state level(Plehwe, Walpen and Neunhoffer, 2005), it invites a consideration of ne-oliberal plurality at the global level as well. This paper shows that thisplurality exists also at the international level and identifies the origins ofsuch plurality – the international organizations.

International organizations play a significant role in studies that lookat how neoliberal policies have been imposed on states from above. Ne-oliberalism is considered a global project because it was spread across theglobe, and also because it was orchestrated and coordinated at the globallevel, through meetings, conferences, international laws, conditional loansand so on (Cox, 1986; Halliday and Carruthers, 2009; Campbell and Ped-ersen, 1996). Scholars have emphasized the coercive and normative rolesof international organizations in imposing neoliberal prescriptions on de-veloping countries. In the wake of a debt crisis that broke out in 1982,first in Mexico and then the entire global South, countries were offeredmuch-needed help in financing their debts if they entered into agreementswith the IMF and the World Bank, but these lending agreements were con-ditioned on market-liberalizing policy reforms (Babb, forthcoming; alsoWade and Veneroso, 1998; Brune, Garrett and Kogut, 2004; Babb and Buira,2005; Chorev and Babb, 2009). Multilateral trade negotiations under theauspices of GATT and, later, the WTO obligated developing countries toopen their markets to exports and foreign investment and to strengthen

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rules protecting intellectual property (Chorev, 2007). Other internationalorganizations, such as the United Nations Commission on InternationalTrade Law (UNCITRAL) (Halliday and Carruthers, 2009) and the Interna-tional Labor Organization (Standing, 2008), have also been influential inadvocating homogenizing neoliberal-compatible policies.

In these accounts, international organizations are often described asacquiescent receivers and passive vectors of existing policy prescriptions,which play no role in the construction of these policies before they aretransmitted elsewhere (Harvey, 2005; Chorev and Babb, 2009). Maybemost explicitly, Peter Gowan (1999: ix) asserts that global neoliberalismhas been driven ‘by the enormous political power placed in the handsof the American state and of US business through the particular typeof international monetary system and associated international financialregime that was constructed – largely by the US government – in theashes of the Bretton Woods system’. Others similarly describe how the‘Bretton Woods institutions . . . were . . . transformed into the agents ofa transnational neoliberalism and were mobilized to institutionalize thisextension of market forces and commodification in the Third World’(Brenner and Theodore, 2002: 350).

In other studies, on the contrary, international organizations areconsidered active, and often central, participants in the construction of thehomogenous regime (Cox, 1986; Halliday and Carruthers, 2009; Abdelal,2007). Robert Cox’s neo-Gramscian analysis, for example, emphasizesa process of ‘consensus formation’ in which ‘central agencies of [majoradvanced capitalist] states . . . interact with each other, sometimes throughformal institutions like the IMF, the World Bank, and the OECD with theirown autonomous bureaucracies’ (Cox, 1986: 259, emphasis added). Scholarsinformed by organizational sociology attribute even more significance tointernational bureaucrats. Sarah Babb’s (2009) analysis of the World Bank’sembrace of market-liberalizing reform, while clearly privileging the role ofthe US government, also considers the influence of changing intellectualfashions among World Bank economists and, importantly, the Bank’s‘overriding interest in perpetuating [its] own survival’ (Babb, 2009: 70).Notably, Babb’s analysis implies an over-determined situation in whichthe position of the different actors – US politicians, economists and WorldBank officials – have all converged in support of neoliberal reforms.1 RawiAbdelal’s analysis of the IMF’s promotion of capital account liberalizationis even more provocative. According to Abdelal (2007: 138), the call forcapital liberalization came from ‘within the management of the Funditself’, while the US Treasury Department was indifferent to the IMF’sinitiatives and Wall Street financial firms were largely uninformed of them.These and similar studies (e.g. Barnett and Finnemore, 2004) share a viewthat is also reflected in the reference to a ‘Washington Consensus’ – thatthe international organizations that actively participated in making and

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disseminating a new global policy regime enthusiastically endorsed theneoliberal principles advocated by US officials. Hence, even scholarswho considered international organizations to be autonomous actors stillexpected policy outcomes to conform to neoliberal principles becauseof the assumption that international officials, too, have supported theneoliberal logic.

In this paper, I argue that while contributing to the spread of the ne-oliberal ideology across the globe, international bureaucracies have notserved as passive transmission belts; moreover, as active participants, theywere not consistently supportive of the global neoliberal project. Instead,international bureaucracies have taken authorship of the policies they ad-vocated, adopting a neoliberal-compatible agenda that would also fit theirown organizational interests and considerations, which were potentiallyin conflict with neoliberal prescriptions. The result was that, also at theinternational level, a variety of ‘actually existing neoliberalisms’ evolved,with each neoliberal version being a reflection of the institutional site inwhich it emerged.

RESTRUCTURING NEOLIBERALISM

How can international bureaucracies restructure neoliberalism in waysthat fit their organizational interests? International bureaucracies mayinfluence the content of global policies only if they have the autonomy todevelop their own interests and the capacity to promote them even whenthose interests clash with the demands of their member-states. On the questionof autonomy, theories of the state in political sociology have long benefitedfrom the realization that state bureaucrats develop an inherent interest inthe functioning of the government and may affect policy outcomes (Block,1977; Evans, Rueschemeyer and Skocpol, 1985) and theories of organiza-tions have similarly shown that corporations have interests that are inde-pendent of the interests of their stakeholders (Albert and Whetten, 1985;Dutton and Dukerich, 1991; Glynn, 2000). A similar theoretical perceptionis useful for analyses of international organizations as well.2 In contrast tothe most prevalent sociological views on international organizations, theseorganizations are not the embodiment of a global ‘cultural core’ (Kruckenand Drori, 2009: 17; Boli and Thomas, 1997; Meyer et al., 1997), and donot simply serve as ‘boards of directors for ruling states’ (Boswell andChase-Dunn, 2000: 238). Rather, as both constructivist and principal-agenttheories in international relations have convincingly argued, internationalbureaucracies are purposive actors, with independent interests andperceptions that cannot be reduced to the demands of their member-states(Barnett and Finnemore, 2004; Nielson and Tierney, 2003; Hawkins et al.,2006).

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The interests of international bureaucracies are both material andideational. International bureaucracies’ material goals include protectingtheir autonomy to make decisions, possessing adequate authority to actbased on those decisions, and having sufficient funds to act effectively.Many of the scholars who assign a relatively active role to internationalorganizations in the construction of global policies tend to focus on ma-terial interests alone. For example, in their analysis of the role played bythe UNCITRAL secretariat in shaping a single global standard on nationalinsolvency systems, Halliday, Block-Lieb and Carruthers (2009) identifythe secretariat’s need for legitimacy and its interest in expanded authorityas the factors that motivated it to reach a consensus among the differentrepresentatives. Their analysis omits, however, the likely possibility thatthe secretariat had an independent position regarding the substance ofglobal bankruptcy rules and that this independent position played a rolein the kind of compromise they advocated.

In addition to material interests, international bureaucracies also holdideational goals; specifically, an independent perception of the organi-zation’s mission and an independent understanding of the best way toachieve that mission (Albert and Whetton, 1985; Jepperson, 1991). Theseideational goals may have numerous origins. Some are historical andtherefore path-dependent, such as the organization’s foundational texts(Harris and Ogbonna, 1999); others are contemporary and potentiallypath-breaking, such as trends in a relevant professional field (Glynn,2000). Ideational goals, even more than material goals, raise the prospectsthat a bureaucracy will not support the same policy prescriptions as itsmember-states.

However, international bureaucracies’ capacity to act according to theirautonomous institutional agendas is compromised by their dependence ontheir member-states. Like states’ dependence on capital and voters, andorganizations’ dependence on their shareholders, international organiza-tions, too, are heavily dependent on external forces, particularly for funds(resource dependence), majority of votes (procedural dependence) and le-gitimacy (normative dependence). Resource dependence stems from thefacts that international organizations need financial resources to surviveand accomplish their goals and that most of them rely on external actorsto provide those funds (Pfeffer and Salancik, 1978; DiMaggio and Powell,1991; Babb, 2009). Because contributions to UN agencies are determinedmostly according to member-states’ capacity to pay, many international or-ganizations have been disproportionately dependent on the US and otherwealthy countries. International organizations are procedurally dependentbecause they require a majority of voting members to agree on policiesand programs and they are therefore vulnerable to the power of mem-bers to withhold their votes. A one-country/one-vote rule, which is com-mon in UN agencies, has created procedural dependence on the majority

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of poor countries, which could potentially counter-balance the resourcedependence on the few wealthy countries. Finally, to generate normativesupport, an organization’s presentation of itself, its mission and its pro-grams have to be accepted as legitimate by all member-states (Suchman,1995; Hurd, 2007). To attain legitimacy, international organizations are ex-pected to conform to three potentially contradictory expectations: theirinitiatives and programs have to follow contemporary global norms andrules, they have to be consistent with their official mandate, and they haveto be seen as neutral rather than serving the interests of particular countries.

Such dependence on external forces raises doubts regarding the capacityof international bureaucracies to act according to their autonomous inter-ests when those clash with external demands. The literature on organiza-tions often considers only two possible responses when an organization’sinterests clash with external expectations. The organization may submitto the pressure and comply with the demands, which suggests lack of ca-pacity, or the organization may resist the pressure. However, internationalbureaucracies may want to avoid both options. Compliance means sacri-ficing the interests of the organization. Resistance can fail or be punished.In contrast, I show that when international bureaucracies face demandsthat are in conflict with their own agendas, the leadership and staff –those who plan the budget, rank program priorities, author position pa-pers, formulate arguments and advocate policies to member-states – tryto minimize the potential tension not by complying with the demands orresisting them, but through what I call ‘strategic’ responses.

Drawing on the work of Christine Oliver (1991), I suggest that interna-tional bureaucracies seek strategies that allow them to adapt to externalpressures in a way that avoids the kind of compliance that would lead tothe sacrifice of their own interests, but that also does not amount to con-frontational resistance.3 These adaptive strategies involve an attempt torestructure or redefine the meaning of the external demands (Oliver, 1991:159). In cases of strategic compliance, the international bureaucracy endorsesthe external ideology only after giving it a meaning that is still compatiblewith external demands, but that can also be reconciled with the organiza-tion’s independent goals. By altering the meaning of the demands beforeadhering to them, the organization can join the external ideological regimewithout undermining its own interests. In cases of strategic resistance, theinternational bureaucracies accept, but do not adhere to, the external prin-ciples. In such cases, international bureaucracies do not reject the dominantlogic, but rather rely on that very logic to justify refusal to comply. By re-framing the dominant logic so that the organization is no longer expectedto conform to it, resistance is achieved without risking retaliation.4 Thiscapacity for strategic restructuring – the translation of exogenous pres-sures to policies that also conform to the organizations’ own institutionalculture – is entirely compatible with the view of political institutions as

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relatively autonomous (Block, 1977) and helps explain their capacity tomaintain some autonomy. It is also compatible with the post-structuralistview that such relative autonomy is manifested in the adherence to anindependent logic that is established and reproduced internally (Bourdieu,1987).

When international bureaucracies employ such strategic responses andare successful, they become mediating forces, rather than passive vectors,and the policies that are then spread from the international organizationto member-states are restructured versions of the original expectations.This, I argue, is what happened to international organizations, includingthe WHO, under neoliberal pressures. While becoming part of the globalneoliberal regime, the WHO bureaucracy employed adaptive strategies inan attempt to fit the neoliberal logic to its own institutional agenda. In thisway, the WHO was able to create its own variance of neoliberal policies.The capacity of international bureaucracies to create divergent versions ofneoliberalism led to a plurality of neoliberalisms at the international level.

STUDYING THE WORLD HEALTH ORGANIZATION

The spread of neoliberalism across international organizations has at-tracted only scarce scholarly attention. The World Bank, the IMF and theWTO are often described as central carriers of neoliberal prescriptions, butonly recently has their own adherence to neoliberal logic been scrutinized(Babb, 2009; Abdelal, 2007). Other international organizations, includingUN agencies, have been largely ignored. Although not as commandingas the international financial institutions, UN agencies matter greatly todeveloping countries. Through financial support, technical assistance, theadvocacy of policies and the initiation of programs, UN agencies influencemany domestic policies in fundamental areas such as human rights, labor,education, health and the environment (Meyer et al., 1997; also Torfasonand Ingram, 2010; Hafner-Burton and Tsutsui, 2005; Schofer and Meyer,2005).

Moreover, the study of a UN agency can shed light on the meansby which international organizations have participated in the creationand dissemination of the neoliberal project in a way that investigationsof the World Bank, the IMF or the WTO may not. First, it provides anopportunity to observe an international organization that was not amongthe makers of the Washington Consensus. Second, important institutionaldifferences between international financial institutions and UN agenciessuggest that we should not apply what we know about the former to thelatter. Finally, the study of UN agencies extends the analysis of the spreadof neoliberalism beyond narrow economic issues to explore a wider rangeof development issues.

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Among UN agencies, the WHO – the agency responsible for globalhealth policies and programs – is of particular interest. It is one of thelargest UN agencies in terms of its budget, the scope of its mandate, thereach of its in-country programs, and the breadth of issues it addresses.Especially in poor countries, the WHO’s technical and operational assis-tance has had substantial impact on which populations have been pro-vided with care and what types of treatments have been recommended.Moreover, because World Bank economists saw global health policies asan important arena for implementing neoliberal reforms, the WHO wasdirectly affected by the spread of neoliberal sentiments and is thereforea particularly vibrant site for studying the spread of neoliberalism at theinternational level. Drawing on evidence from primary archival sources,public documents and interviews, the remainder of this paper documentsthe strategic response of the WHO to external neoliberal demands.5

NEOLIBERALISM AT THE WHO

The WHO’s institutional origins of dependence and agency

The WHO, which was established in 1948, is the ‘directing and coordi-nating authority for health’ within the UN system. The WHO aims to setnorms and standards, articulate policy options, provide technical supportto countries, monitor and assess health trends, shape the health researchagenda, and provide leadership on global health matters in many otherways.6 The WHO considers among its major achievements health ini-tiatives such as the global yaws control program (1952–64), the controlprogram of river blindness in West Africa (launched in 1974), the polioeradication initiative (launched in 1988) and, most famously, the eradi-cation of smallpox (1967–79). The WHO is also actively involved in thedissemination of knowledge and policy options through initiatives suchas the international classification of disease (starting in 1948) and the Es-sential Medicines List (starting in 1977). It contributes to the identification,monitoring and control of outbreaks such as, most recently, SARS, avianflu and swine flu. It is also actively involved in the promotion of specificapproaches to health, such as primary health care (1978) as well as concretepolicies regarding, for example, the treatment of malaria or initiatives toreduce obesity.

The WHO’S three-layered organizational structure includes the WorldHealth Assembly, the Executive Board and a Secretariat headed by aDirector-General.7 The World Health Assembly (WHA) is where coun-try representatives meet once a year to establish policy. The ExecutiveBoard, which has 34 members currently, prepares for the Assembly, in-cluding commenting on the program and budget estimates prepared bythe Director-General, and oversees the implementation of decisions takenby the Assembly. While delegates to the Assembly are representatives of

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their designated states, delegates to the Board, although elected by theAssembly, are expected to act as experts on behalf of the whole Confer-ence. Finally, the Secretariat carries out the organization’s activities. TheDirector-General, who heads the Secretariat, is elected by the Assembly.One of the most significant responsibilities of the Director-General is tosuggest the annual budget, which identifies the organization’s prioritiesand which the World Health Assembly then needs to approve (WHO, 1958;Lee, 2009).

This organizational structure makes the WHO heavily dependent on itsmember-states for their resources, votes and normative support.

For resources, the WHO has relied traditionally on the mandatory con-tributions of member-states, which are calculated according to their abil-ity to pay. This has inevitably created disproportionate dependence onwealthy countries. On the other hand, these mandatory contributions aresuggested by the Director-General and approved by a majority vote in theAssembly. These procedures have effectively curbed the ability of wealthymember-states, which are the minority, to use their payments as bargainingleverage. Since the 1980s, however, there has been a dramatic shift frommandatory to voluntary contributions, which are provided by wealthy na-tions, private foundations or other international organizations (Lee, 2009).Since voluntary contributions are often provided for specific purposes orprograms, they bypass the Assembly and have therefore greatly increasedthe resource dependence of the WHO on the relatively small number ofwealthy members.

Regarding votes, a one-country/one-vote rule at the Assembly has es-tablished, following decolonization, procedural dependence on the largenumber of members from the developing world. The Executive Board,where members are elected to reflect states’ geographical and economicdiversity and where they are expected to serve in their individual capacity,has created an additional layer of procedural dependence that is similarlydivorced from resource dependence. Starting in the 1980s, however, de-veloping countries found it increasingly difficult to maintain a unifiedcoalition of interests. This was partly because the structural dependence ofpoor countries on rich countries intensified with the rise of a global econ-omy and made developing countries reluctant to vote against the positionof rich countries or multinational companies.

Finally, to attain normative support, the WHO was expected to conformto global norms and principles established elsewhere while maintainingneutrality and following the organization’s original mandate.

In short, the WHO was heavily dependent on external forces and, sincethe 1980s, it has been particularly dependent on wealthy countries. Butthe WHO’s position cannot be reduced to the need to satisfy the demandsof member-states. The WHO bureaucracy had independent material andideational goals that it pursued vigorously. The ideational preferences

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of the WHO bureaucracy have often been informed by the WHO Con-stitution, which defines the objective of the WHO to be ‘the attainmentby all peoples of the highest possible level of health’. This objective hasestablished two commitments at the core of the organization’s understand-ing of its mission: to universal access to health services and to quality of thehealth services provided. The scope of that commitment and the under-standing of how best to pursue it depended on, and could be transformedby, the staff’s professional public health ethos and expertise (Weaver andLeiteritz, 2005; Chwieroth, 2008).

Because the WHO bureaucracy holds independent goals, it is not neutraltoward exogenous influences and its position depends on whether or notthe imposed logic is compatible with its own preferences. Dependence hasprevented the WHO bureaucracy from acting irrespectively of members’demands, but a clash with independent goals or principles has providedmotivation to avoid them. One such clash occurred with the emergenceof neoliberal policies. In the late 1990s, following a decade-long period ofcrisis, the WHO adopted strategies in an attempt to fit into the new environ-ment while still protecting its organizational culture. The next two sectionsdescribe the period of crisis and provide a detailed account of the WHO’sattempts at restructuring, rather than complying, with the neoliberal logic.

Initial crisis

In the 1980s, the US government, under the leadership of President RonaldReagan and with pressure from a weary Congress, intensified its attemptsto root out the so-called ‘Third World radicalism’, namely, the developingcountries’ call at the UN, since the 1970s, for a new international economicorder (NIEO) that would lead to greater economic equality between indus-trializing and industrial countries (Krasner, 1985; Murphy, 1984). The crit-icisms aimed at UN initiatives and programs that followed the NIEO logicintensified with the increasing dominance of neoliberal thought, whichpromoted the self-efficiency of the market and was thus directly opposedto the NIEO principles of economic nationalism and to UN agencies’ focuson social development. Critics in the US also targeted what they consid-ered irresponsible budget growth and managerial incompetence in theUN agencies. Consequently, the US government pressed for changes thatwould weaken both the ability of UN agencies to act and the influenceof developing countries over those agencies. The WHO, which had beenhighly regarded in the past, was now resented by the wealthy member-states for its NIEO-compatible policies. A transition period ensued, inwhich the WHO suffered severe authority, financial and leadership crises.

An authority crisis developed when the World Bank became involvedin public health programs. The World Bank’s emergence as a competinghealth agency was one part of the much larger transformation, described

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above, in which the Reagan administration relied on the World Bank andthe IMF to introduce the ‘magic of the marketplace’ to developing coun-tries (Livingston, 1992; Adams, 1993; Babb, 2009). The new World Bankorientation made it increasingly interested in the reorganization of publicsectors, including the health sector, and the Bank sharply increased itsloans for health restructuring, the total sum of which, by 1990, was largerthan the WHO’s entire budget (Yamey, 2002b). The World Bank began tothreaten the authority of the WHO, and not just by initiating its own publichealth programs. During the 1970s and early 1980s, the WHO bureaucracypromoted policies that echoed some of the demands of developing coun-tries. These policies were based on social development as a rationale forintervention. As such, they were concerned with improvements in livingconditions and quality of life as distinct from the objective of economicgrowth, and focused on equity as the primary principle. The questionof affordability was essential for WHO policies, but not the question ofeffectiveness: the population that merited the most attention was identi-fied by its need. Flagship initiatives were poised to achieve the goal ofHealth for All by the Year 2000, and they focused on primary health care:WHO programs advocated the provision of basic services and the use onlyof appropriate and affordable technology (Lee, 2009; Chorev, 2012). TheWorld Bank, in turn, advocated health policies that, given their neoliberalorientation, often contradicted the WHO’s approach.

The World Bank’s position on health policies, which informed the pol-icy recommendations attached to its health loans, was developed in threeseminal publications: Financing Health Services in Developing Countries: AnAgenda for Reform (Akin, Birdsall and Ferranti, 1987); Strengthening HealthServices in Developing Countries through the Private Sector (Griffin, 1989); andWorld Development Report: Investing in Health (World Bank, 1993). Whilesome of the recommendations made in these reports were compatiblewith the WHO’s approach (Abbasi, 1999), the most central ones contra-dicted WHO practices and followed an economic reductionist logic thatreflected the principles of the Washington Consensus.8 First, the WorldBank called for the reduction of public involvement in health services de-livery and instructed many lower-income countries to reduce their publicexpenditures on health. Second, World Bank reports recommended par-tial ‘cost-recovery’ of public health services by charging user fees. Third,the World Bank insisted on an increased reliance on the market to financeand deliver health care and called for some privatization of public health-care services (Lee and Dodgson, 2000; Brown, Cueto and Fee, 2006; Akin,Birdsall and Ferranti, 1987).

In addition to policy recommendations, an equally consequential con-tribution of the World Bank to the transformation in global health per-spectives was the development of a new way of prioritizing health in-terventions. The World Development Report (WDR) (World Bank, 1993)

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introduced the unit of Disability-Adjusted Life Year (DALY) for measur-ing the global burden of a disease (Yamey, 2002a; Lerer and Matzopoulos,2001). The innovation of DALY was in measuring the burden of a diseasenot only by number of years lost due to premature death, but also the num-ber of years of productive life lost to disability, and in that way directly link-ing diseases to the issue of economic productivity, and therefore growth.By comparing the cost required for every ‘DALY saved’ of various healthinterventions, the WDR could rank health services according to their cost-effectiveness, claiming that the most cost-effective should be prioritized.9

Using DALYs, the World Bank inaugurated cost-effectiveness as thenew paradigm to guide global health programs in poor countries (Yamey,2002a; Buse, 1994). This approach explicitly challenged the WHO’s em-phasis during the 1970s and 1980s on equity, where priority in resourceallocation was to be afforded to those most in need. The World Bank calcu-lations found that some health interventions needed by the poor, such asimmunizations, were cost-effective, but this was a matter of chance, not ofmethodological design: while an equitable approach to resource allocationwould have attached weight to the illnesses of more disadvantaged people,DALY calculations did not take into account individuals’ socioeconomiccircumstances (Segall, 2003; Yamey, 2002a).

By the late 1990s, the World Bank had established itself as a dominantauthority in the global health field. The threat to the WHO was twofold: notonly that an organization with much greater resources and influence nowdeveloped its own policies on health, but also that these policies reflected arigid application of neoliberal economic theories and were in conflict withthe WHO’s existing policies.

The WHO’s financial crisis was the result of three related developments.First, following pressure from the US and many European countries, theWHO – which had seen its budget grow at least 10% each year – intro-duced a policy of zero nominal growth in 1993. As a result, during the1990s, mandatory contributions to the WHO declined by 20% in real terms(People’s Health Movement, Medact and Global Equity Gauge Alliance,2008). Second, in 1985, the US Congress unilaterally reduced its relativecontribution and, for a long period, did not pay the full amount of its as-sessed payments (GAO, 1986; Revzin, 1988). Other countries, too, did notpay their dues and the WHO often had to function with a budget muchsmaller than the agreed assessments. In 1996, for example, the rate of col-lection was 77.72%. Total unpaid arrears of contributions to the budgetthat year exceeded $169 million (Beigbeder et al., 1998: 163). This declinein mandatory payments was partly recouped through the third develop-ment: an increase in the voluntary contributions. Between the 1970s and the1990s, voluntary funds increased from about 20% to almost 60% of the totalWHO expenditure (Lee, 2009). While these contributions helped the WHOavoid financial disarray, they also allowed a small number of rich countries

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to bypass the World Health Assembly (Vaughan et al., 1996; Godlee, 1995),which undermined the potential influence of the poor member-states anddeepened the dependence of the WHO upon the wealthy countries.

Finally, under the leadership of Director-General Hiroshi Nakajima, whowas elected with the support of developing countries and against the po-sition of the US, the WHO also suffered from a legitimacy crisis. DuringNakajima’s tenure, from 1988 until 1998, the WHO’s reputation as ‘themost efficient and capably managed of the [UN] Agencies’ was severelydamaged.10 WHO staff and donors found Nakajima too reserved and apoor communicator, and the accusations made against him were often per-sonal (Godlee, 1994a). But there were also serious concerns regarding poormanagement, combined with an autocratic style, and there were charges ofmismanagement, cronyism and corruption (Lerer and Matzopoulos, 2001:421; Brown, Cueto and Fee, 2006; Godlee, 1994a). In 1994, Sweden cut itsgrant in half because management reforms it had called for had not takenplace. Six months later, Britain’s National Audit Office announced that, af-ter 16 years as WHO’s external auditor, it no longer wished to continue andwarned that the bookkeeping of the WHO’s operations in Africa was sosloppy, there was a risk of ‘fraudulent transactions remaining undetectedover long periods’ (Pilkington, 1995; The Guardian, 1994).

With the rise of neoliberalism, then, the WHO was experiencing a grow-ing crisis, with financial difficulties, threatened authority and underminedlegitimacy. Until 1988, under the leadership of Dr Halfdan Mahler, whohad led the WHO reforms in support of the NIEO since 1974, the WHOleadership had fought to preserve its existing agenda despite this man-ifestly changing environment. Between 1988 and 1998, partly due to theproblems encountered by Nakajima, the WHO bureaucracy offered littleby way of adequate response. During that period, analyses in leading med-ical journals described in alarming terms the dire condition of the WHO.Typical titles included ‘What Role for WHO in the 1990s?’ (Lee and Walt,1992), ‘WHO in Crisis’ (Godlee, 1994a), and ‘WHO in Retreat’ (Godlee,1994b). Many concluded that ‘the WHO was no longer setting the interna-tional public health agenda’ (Lerer and Matzopoulos, 2001: 421; Gillies, vonSchoen-Angerer and ‘t Hoen, 2006). But in 1998, under the leadership ofthe new Director-General, Gro Harlem Brundtland, the WHO bureaucracybegan to develop an appropriate response to the shift toward neoliberal-ism, which would allow it to regain the funds, authority and legitimacy ithad lost.

Restructuring neoliberalism

In the late 1990s, in the face of mounting pressures, the World HealthAssembly voted to elect Dr Gro Harlem Brundtland as the WHO Director-General. Brundtland had little public health experience, but she had a

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successful political career as the Prime Minister of Norway and she gainedinternational prominence and respect when she chaired the UN WorldCommission on Environment and Development. This institutional posi-tion was fundamental to her success in strategically adapting to the ne-oliberal logic.11

At the 51st World Health Assembly, when still a Director-General elect,Brundtland promised: ‘WHO can and must change. It must become moreeffective, more accountable, more transparent and more receptive to achanging world’.12 In her address before the Assembly only two yearslater, Brundtland could declare:

Once again, the world turns its attention to . . . the World HealthAssembly. You are the health leaders of the world, and your WorldHealth Organization is the lead agency in health. Ours are the cru-cial issues of the time: health, survival, development, equity, andopportunity. Global public opinion is starting to realize where healthbelongs: at the core of every child’s opportunity to reach his or herfull potential; at the core of every parent’s opportunity to work, tocare and to innovate. It is at the core of every community’s opportu-nity to secure sustainable economic development for its citizens; andat the core of our efforts to combat poverty, and foster developmentfor all.13

Implicit in the speech was recognition of the WHO’s declining repu-tation in previous years. More explicit was Brundtland’s conviction thatthe means to regain the organization’s legitimacy and authority was bylinking the role of the WHO to themes that were compatible with thedominant neoliberal sentiments, particularly economic growth. Indeed,in the late 1990s, the WHO underwent significant programmatic and or-ganizational changes that were designed to revive it by incorporating itinto the new ideological environment. While adapting to the neoliberalthemes of the time, however, the WHO was hardly a passive recipient ofprescriptions imposed from above. Instead, by restructuring those neolib-eral themes into policies and programs somewhat different from what theUS government or the World Bank would have supported, the WHO wasable to preserve its core organizational agenda and to create a plurality ofneoliberal versions at the international level.14

In what follows, I describe four areas that illustrate the capacity of theWHO bureaucracy to strategically adapt to the neoliberal logic: its responseto World Bank policies regarding the public health sector, its response tocost-effectiveness as a favored logic of intervention, its response to newintellectual property rules, and its position on smoking. No other policiesor programs were as central to the WHO at the time as these four (Yamey,2002b), which were at the heart of its attempt for recovery and critical to itsposition on both communicable and non-communicable diseases, and to

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its relations with member-states, other international organizations, busi-nesses, private donors and health activists. The centrality of these issuesis also reflected in the products connected to them, including some of themost influential reports the WHO circulated at the time – Health Systems:Improving Performance (WHO, 2000), Macroeconomics and Health: Investingin Health for Economic Development (Commission on Macroeconomics andHealth (CMH), 2001) and Reducing Risk, Promoting Healthy Life (WHO,2002) – as well as the first global public health treaty.

‘Anchoring health on the development agenda’

Brundtland was forthright and unsentimental in her conviction that theonly way to revive the WHO’s deteriorating position was by actively in-corporating the organization into the neoliberal environment. Brundtlandalso believed that to do so successfully, the WHO had to broaden the rangeof its allies to include effective audiences and to revise its message so thatnew audiences would find it appealing.

Traditionally, the WHO had regarded health ministers as its main audi-ence. However, given the subordinate position of health ministers in mostcountries, they were of little use in delivering the message that health wasa paramount objective. Instead, Brundtland believed that the WHO shouldcommunicate directly with those officials and policy-makers who had in-fluence over the distribution of budgets. As Brundtland wrote in an earlyeditorial in Science, ‘Health ministers need little convincing, but WHO willremind presidents, prime ministers, finance ministers, and science minis-ters that they are health ministers themselves’ (Brundtland, 1998).

How could the WHO persuade influential government officials to careabout health? Brundtland had learned from her experience at the WorldCommission on Environment and Development that an effective wayto earn the support of finance ministers was not to talk about health,but to talk about finance. Hence, the WHO abandoned its long-heldposition that health was an aspect of social development that shouldbe pursued independently of economic concerns and, accepting theneoliberal reduction of social development to economic development,adopted instead the premise that health was good for economic growth(Horton, 2002). Speaking before the Executive Board, Brundtland stated,‘We . . . know that sound investments in health can be one of the mostcost-effective ways of promoting development and progress. Improvinghealth in poor countries leads to increased GDP per capita’ (Brundtland,1999a). She then stressed the importance of making such knowledgepublic for the sake of promoting the WHO agenda:

I believe the international health community, including WHO, hasundersold this fact. In a time . . . where nations are searching for

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ways to make ends meet, we have been sitting on a secret. We haven’tfully seen that this is a powerful message we should take to the politi-cal decision-makers and to the private sector . . . My own experiencetells me that this strategy was instrumental in taking the environ-ment from being a cause just for the already convinced, to becominga real issue of political importance to major players (Brundtland,1999a).

But how could the WHO convince donor countries to ‘[increase] invest-ments in the health of the poor’ as a strategy to promote economic growth(Brundtland, 1999b)? This was a difficult task, as neoliberal economistsconceived of health as an ‘unproductive consumer of public budgets’,while the WHO leadership wanted to argue that wise investment in healthwas ‘key to productivity itself’ (cited in Birmingham, 1999). For the mes-sage to be effective, the promise of development had to be convincing.As Brundtland said in an interview: ‘Anchoring health on the develop-ment agenda . . . involves not just reaching the minds of people who havedecision-making power . . . but also increasing the evidence base so thatyou have convincing arguments’ (Yamey, 2002c). To make the argumentsconvincing, she wanted ‘to stress the importance of health in economicterms’ (cited in Birmingham, 1999). To provide the economic evidenceneeded, the WHO established the Commission on Macroeconomics andHealth (CMH).

This Commission was established in January 2000 and was chaired bythe economist, Jeffrey Sachs, then of Harvard University. Sachs, who wasdescribed by The New York Times as ‘probably the most important economistin the world’ (cited in Banerji, 2002), was especially known for implement-ing economic ‘shock therapy’ – the sudden release of rigid neoliberal re-forms – in developing and transitional countries (Waitzkin, 2003). Othermembers of the Commission included former ministers of finance, andofficers from the World Bank, the IMF, the WTO and the UN DevelopmentProgram (UNDP) (Ashraf, 2001; Brown, Cueto and Fee, 2006). Most of theeconomists in the Commission, including those from the poorer countries,had been educated in prestigious universities in the West. Many of themwere involved in the World Bank’s Investing in Health report (Banerji, 2002;Waitzkin, 2003). Clearly, the Commission was an attempt to coopt leadingeconomists by giving them the task of presenting the WHO’s position.

Brundtland’s instructions to the CMH members made this expectationexplicit: ‘Placing health at the heart of the development agenda. This is thepurpose of the Commission’. She then elaborated, ‘That poverty causesill health is well known. But good health can fuel the engine of devel-opment . . . This is the case we have to make’ (Brundtland, 2000b). Thereport issued by the Commission, Macroeconomics and Health: Investing in

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Health for Economic Development (CMH, 2001), closely followed these in-structions. The report presented evidence that improving the health of thepoor would lead to lowered fertility rates, improved educational perfor-mance, increased labor productivity and improved macroeconomic stabil-ity and, therefore, would contribute to economic growth. The Commissionalso established that for low and middle income countries, investing inhealth and health technologies was one of the most effective means toachieve the desired economic development. As Sachs told delegates to theWorld Health Assembly:

Accomplishing this investment in the life-saving technologies foryour countries, is the sine qua non of ending the poverty trap whichafflicts so many of the poorest countries in the world and is the sinequa non of the economic progress that you so ardently desire anddeserve.15

The policy implications that followed were obvious: the way to achieveeconomic growth was a massive injection of financial resources into healthservices (The Lancet, 2002). Indeed, one of the main proposals of the Com-mission’s report was ‘an expanded aid effort to the world’s poorest coun-tries’ (CMH, 2001: 9).

With the CMH report, which the Executive Board of the World HealthAssembly enthusiastically endorsed,16 the WHO relied on economic exper-tise to grant the field of public health what was then the only justificationfor intervention and ‘investment’ in the developing world: the promiseof economic growth. By relying on such justification, the WHO reversedtwo principles central to its agenda during the 1970s. First, the WHO ac-cepted a view of development that reduced it to its economic dimensionand no longer defended the notion of social development that allowedconcern with individuals’ quality of life independently of the economicrealm. Second, the WHO now focused on the question of overall growthat the national level, rather than on the question of equitable distributionwithin a country (Kickbusch, 2002; Banta, 2002).

However, the CMH report was not a passive capitulation to the eco-nomic reasoning of exogenous forces, but rather a strategic modification ofthat very reasoning. The World Bank emphasized the causal link betweenpoverty and disease to prioritize economic development and downplaythe need for direct attention to the health sector. The CMH report empha-sized the opposite vector, which went from disease to poverty, postulatingthat improved health led to economic development.17 By insisting that im-provement in health was necessary for economic growth, the report turnedthe World Bank’s reasoning on its head. Instead of agreeing with the WorldBank’s call for budget cuts in the public health sector, the WHO used thegoal of economic growth, on the contrary, to call for greater investment inpublic health.18

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In short, the WHO was able to fit its agenda to the new ideological envi-ronment while protecting its core mission by altering the meaning of theneoliberal logic before adopting it. By means of strategic compliance, theWHO established its own version of neoliberalism, which contributed tothe plurality of neoliberal policies across international organizations. Inthis instance, moreover, the economic reasoning used in the CMH reporthelped transform the position of other international organizations andrich donors. The eight Millennium Development Goals, which provideUN member-states with benchmarks for tackling extreme poverty, includethree health-related goals: reducing child mortality, improving maternalhealth, and combating HIV and AIDS, malaria and other diseases. Anddonors have dramatically increased their contributions for health pro-grams, although often to organizations, such as the Global Fund to FightAIDS, Tuberculosis and Malaria, which are independent of the WHO (seebelow).

A cost-effective ‘new universalism’

Even before health was successfully incorporated into the developmentagenda and countries could envision economic benefits arising from in-vestments in health programs, the question arose: which health programsshould be prioritized? The World Bank’s World Development Report priori-tized cost-effectiveness calculations. Following the World Bank, the WHO,too, shifted its priorities from programs designed to serve those most inneed to programs that offered cost-effective interventions. While this shiftsignified a move away from equity considerations, the WHO bureaucracyused it to protect another principle – that of universal access.

In an early indication of this transformation, Brundtland’s transitionteam proposed priorities for the WHO that embraced the World Bank’ssystem of ranking health interventions based on the relative ‘reductionin disease burden from a health intervention in relation to the cost’ (WorldBank, 1993, emphasis added). Two years later, the World Health Report,Health Systems: Improving Performance (WHO, 2000), was prepared by anewly-established WHO unit, Evidence and Information for Policy, whichconsisted mostly of economists, including many of the authors of theWorld Bank’s World Development Report. The World Health Report for-mally endorsed cost-effectiveness as a tool for priority setting. It endorsedthe World Bank’s concept of DALYs to measure the cost of disabilities.Cost-effectiveness was also a central recommendation of the CMH Re-port (CMH, 2001). Most comprehensively, the 2002 World Health Report,Reducing Risks: Promoting Healthy Life, offered a large-scale study of thecost-effectiveness of 170 interventions (WHO, 2002).

The choice of DALYs as the most appropriate measure for choosing prior-ities in health interventions introduced a new articulation of WHO values

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(Lerer and Matzopoulos, 2001; Ollila and Koivusalo, 2002; Yamey, 2002a).On the one hand, cost-effectiveness calculations replaced the WHO’s pre-vious focus on those most in need. The 2000 World Health Report rejectedthe primary health-care approach that was based on simple interventionsonly to the poor and that had dominated WHO programs in the previousdecades. An algorithm in the Report, which offered a list of questions thatshould guide governments in their decision-making, recommended inter-ventions that benefited the poor only if they were cost-effective (WHO,2000: 55). On the other hand, the WHO also rejected rigid neoliberal solu-tions that would rely entirely on the market. Brundtland asserted, ‘WHO’svalues cannot support market-oriented approaches that ration health ser-vices to those with the ability to pay’ because such approaches lead tofurther inequities and because ‘growing bodies of theory and evidenceindicate that markets in health are . . . inefficient as well’ (Brundtland,1999b). Instead, the WHO used the logic of cost-effectiveness to introducea new and potentially broader scope for health interventions. The 2000Report called for a ‘new universalism’, which promised cost-effective in-terventions for everyone:

Rather than all possible care for everyone, or only the simplest andmost basic care for the poor, [‘new universalism’] means delivery toall of high-quality essential care, defined by criteria of effectiveness,cost and social acceptability. It implies explicit choice of prioritiesamong interventions, representing the ethical principle that it maybe necessary and efficient to ration services, but that it is inadmissibleto exclude whole groups of the population.19

This concept of ‘new universalism’ offered guidance for governmentsin the context of scarce resources. According to Brundtland, ‘Clearly, lim-its exist on what governments can finance and on what services theycan deliver. The report intends to stimulate public policies that acknowl-edge these limits – recognizing that if services are to be provided at all,then not all services can be provided’.20 Once the need to set prioritieswas established, Brundtland insisted that in order to protect the princi-ple of universality, ‘the most cost-effective services should be providedfirst’ (Brundtland, 1999b). In short, the WHO used a cost-effective logic topromise remedies for a larger population, including, but not exclusive to,the poor.

Starting in the late 1990s, then, the WHO’s priorities focused on healthproblems that, following neoliberal sensibilities, had a major socioeco-nomic impact on development and for which cost-effective interventionswere available (McCarthy, 2002; Yamey, 2002a). Still, the WHO’s top newpriorities were the three major communicable diseases affecting the poor– malaria, tuberculosis, and (albeit only later) HIV and AIDS. All three ini-tiatives were presented as contributing to development. For example, one

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slogan for the malaria initiative was, ‘Roll Back Malaria, Roll in Develop-ment’, and the first executive director for the Roll Back Malaria initiative,Dr David Nabarro, stated, ‘Malaria is taking costly bites out of Africa . . . Itis feasting on the health and development of African children and it isdraining the life out of African economies’ (cited in Packard, 2009). For allthree diseases, cost-effectiveness determined the choice of the preferredinitiatives. These initiatives often reflected the dominance of the neoliberallogic, including a preference for market-driven solutions, or solutions thatcould transfer responsibility from the public realm to the private sectorby creating the possibility for profit. In the malaria initiative, for exam-ple, the chosen strategy to promote the spread of insecticide-impregnatedbed nets was to build sustainable private for-profit markets or to createa not-for-profit commercial sector.21 Also, all three initiatives were struc-tured as WHO-led partnerships with other international organizations,governments and the private sector: Roll Back Malaria, Stop TB Partner-ship and, for HIV and AIDS, 3-by-5.22 Nevertheless, the WHO bureaucracywas able to adhere to these neoliberal prescriptions while submitting theseprescriptions, at least in part, to its own priorities. In a context in whichfiscally responsible countries were expected to minimize their health in-terventions, the WHO bureaucracy was able, through means of strategiccompliance, to use cost-effective logic to legitimate the principle of provid-ing health services to everyone and to mobilize support for interventionsaffecting the poor, thereby expanding the scope of intervention consideredlegitimate under neoliberalism.

Access to AIDS drugs

The WHO, like other international organizations, was embarrassingly slowin comprehending the scope of the AIDS crisis. The WHO did establish theGlobal Programme on AIDS (GPA) in 1986, which, under the leadershipof Jonathan Mann, was able to draw countries’ attention to the socialand economic implications of the disease, but in 1996, donors decidedto move the responsibility for AIDS to an independent organization, theJoint United Nations Programme on HIV/AIDS (UNAIDS), intentionallymarginalizing the role of the WHO. This was another indication of theWHO’s declining reputation during the 1990s.

Around that time, however, the WHO staff took a proactive positionregarding an international agreement signed by the WTO member-statesin 1994, the Trade-Related Intellectual Property Rights agreement (TRIPS).TRIPS required member-states to pass laws that strengthened companies’patent protection of inventions, and the TRIPS interpretation favored bythe US government limited the allowed scope of exceptions to the new rules(Sell, 2003). This had major implications for the ability of poor countries toafford essential AIDS drugs. Since brand-name AIDS drugs were extremely

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expensive, poor countries could afford them only by locally manufacturingor importing generic, and therefore much cheaper, versions of these drugs.By threatening the future legality of generic manufacturing, TRIPS seemedto block this option.

The potential impact of TRIPS on public health in general, and on accessto antiretroviral drugs (ARVs) for HIV and AIDs in particular, was soondebated at the WHO. At the World Health Assembly in May 1996, Iranstated that it ‘was very much concerned about the impact of the WorldTrade Organization on pharmaceutical industries in developing countries’and sponsored a resolution that asked the Director-General to ‘report onthe impact of the work of the . . . WTO with respect to national drug poli-cies and essential drugs’.23 A year later, the WHO Action Programme onEssential Drugs published a report, Globalization and Access to Drugs: Im-plications of the WTO/TRIPS Agreement (WHO, 1997), which discussed theissue.

The report defended the concept of universal access to essential drugs innormative terms. It stated, ‘Drugs . . . are an integral part of the realizationof a fundamental human right – the right to health’, and that ‘policies pur-sued must aim to make drugs available for all who wish to have them, andat affordable prices’ (WHO, 1997). However, using adaptive strategies, thereport was able to defend the principle of universal access to drugs withoutchallenging the principle of intellectual property protection. Rather thaninsisting that normative concerns should overrule the principles protectedby the WTO, the report suggested that the two were entirely compatible,as they were both concerned with improved access:

This objective [accessibility to drugs] coincides with the general ob-jective of the GATT [General Agreement on Tariffs and Trade] forthe last 40 years – seeking to eliminate barriers to trade so that con-sumers have the greatest possible access to all the goods available inthe world (WHO, 1997).24

Instead of arguing – based, for example, on humanitarian sentiments– for the exclusion of medicines from the realm of trade agreements, thereport suggested that trade agreements, if interpreted correctly, alreadyachieved an appropriate ‘balance between intellectual property and acces-sibility’ (WHO, 1997). The report then provided a detailed legal reading ofvarious provisions in TRIPS to show that the agreement was compatiblewith the health needs of developing countries.

Concretely, the report offered a careful legal interpretation of TRIPS thatshowed that the agreement ‘expressly provides two means of obtainingexceptions and limiting the exclusive rights conferred by the patent onits owner’. The report maintained: ‘These two provisions may be usedto ensure greater accessibility to essential drugs’. The first exception wasthe use of compulsory licensing, in which a government is allowed to

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grant, under certain conditions, a license to a third-party manufacturerto commercialize a patented invention without the consent of the patentholder. The report argued that according to Article 31 of TRIPS, ‘nationalpublic authorities may be allowed, within the conditions laid down in theAgreement, to issue compulsory licenses against the patent owner’s willwhen justified by the public interest’. The second exception was the use ofparallel imports, in which a government is allowed to buy a patented drugfrom a third party who has legitimately bought the patented drug, withoutpermission from the patent owner. According to the WHO report, ‘TheAgreement does not prohibit parallel imports’. In justifying their supportof parallel imports, the authors again drew on the general principles offree trade: ‘From the perspective of trade liberalization, it is consideredthat from the moment the product is marketed, the patent holder can nolonger control its subsequent circulation’ (WHO, 1997).

In this way, the report incorporated the WHO bureaucracy’s preferredinterpretation into the dominant neoliberal principles, rather than trying toreplace them.25 The WHO report did not rely on human rights concerns tojustify protection of access to drugs, did not rely on public health expertiseto challenge the legal agreement, did not criticize the agreement or theagenda of trade liberalization, and did not call for the revision of TRIPS.Instead, the report used the WTO’s own tools of expertise, legal reasoning,to make the case that TRIPS was entirely reconcilable with concerns foraccess to drugs. Consequently, the WHO bureaucracy’s call for access toAIDS drugs could be presented not as reflecting anti-neoliberalism or anti-globalization sentiments, but, to the contrary, as entirely compatible withthem.

The WHO’s strategic resistance by way of a technical-legal interpre-tation of TRIPS did not completely pacify the pharmaceutical sector orthe US government. A letter to the WHO from the vice-president of thePharmaceutical Research and Manufacturers of America considered thereport ‘a deeply flawed document that misleads the public’, and the USgovernment prepared a 17-page paper, ‘pointing out the inaccuracies andfalse implications with which the document is riddled’ (cited in Velasquez,Correa and Balaubramanlam, 2004: 87–8). The US government demandedthat the WHO revise the publication and Brundtland agreed to ask in-dependent experts to review the report. The new version of the report,however, made only inconsequential alterations (WHO, 1999b).

The WHO report was the first to provide a legal interpretation thatallowed the use of TRIPS to defend, rather than prohibit, the manufactur-ing of generic drugs, and it guided the mobilization of others, includingConsumer Project on Technology and Medecins Sans Frontieres.26 Later,following bitter political struggles in South Africa, Brazil, Thailand, theUS and elsewhere, developed countries finally accepted this legal inter-pretation (Shadlen, 2004; Sell and Prakash, 2004; Klug, 2008; Friedman and

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Mottiar, 2005). In November 2001, WTO members signed the Declarationon the TRIPS Agreement and Public Health (the Doha Declaration), which,explicitly drawing on WHO terms, stated:

We agree that the TRIPS Agreement does not and should not preventmembers from taking measures to protect public health . . . We reaf-firm the right of WTO members to use, to the full, the provisions inthe TRIPS Agreement, which provide flexibility for [protecting publichealth and promoting access to medicines for all] (WTO, 2001).

Two years later, the ‘30 August 2003 Decision’ specified the conditionsunder which poor countries without pharmaceutical manufacturing capa-bilities would be allowed to import generic versions of drugs still underpatent.

In subsequent reports and publications, the WHO staff continued tocritically review the effectiveness of these documents (e.g. Turmen andClift, 2006). The WHO also contributed its expertise in support of themanufacturing and funding of generic drugs. For example, in 2002, the12th Expert Committee on the Selection and Use of Essential Medicinesadded 12 ARVs to the WHO list of essential medicines, thereby affirmingthat the WHO considered ARVs to be an essential part of a basic health-care system (Zimmerman, 2002). That year, the WHO Prequalification ofMedicines Programme, which is responsible for examining drugs for pu-rity, safety and efficacy, provocatively added Indian generic versions ofpatented AIDS drugs to its list of safe drugs. The WHO prequalificationof generic drugs allowed the Global Fund to Fight AIDS, Tuberculosis,and Malaria to purchase generic drugs. Prequalification was also used toeffectively dispute the claim that generic drugs were not of proven quality,which the George W. Bush administration used to justify the US govern-ment’s reluctance to purchase them.27

The WHO bureaucracy’s response to TRIPS offers a particularly power-ful illustration of the capacity of international bureaucracies to restructureexternal principles by strategically resisting them. Rather than provoca-tively opposing intellectual property protection, the WHO bureaucracywas able to construct an agreeable legal balance between intellectual prop-erty rights and public health, which, in turn, incorporated concern forpublic health into the existing neoliberal framing.

Anti-smoking campaign

The choice of public-private partnerships as the preferred organizationalform, mentioned above, reflected a significant improvement in the rela-tions of the WHO with the private sector. While accepting business as le-gitimate partners in some cases, however, the WHO was able to restructure

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neoliberal pro-business sentiments to justify its opposition to the tobaccosector.

The World Health Assembly passed a resolution calling for the develop-ment of a binding convention on tobacco control in 1996, but it was only in2003 that the WHO member-states agreed on an international tobacco con-trol treaty aimed at reducing smoking in their countries (Roemer, Taylorand Lariviere, 2005). Due to pressures from governments supporting thetobacco sector, many of the provisions in the convention – including lim-itations on free trade, public smoking bans and ‘shock’ images on healthwarnings – were weaker than supporters had originally hoped. Still, thetreaty contained important provisions intended to discourage smoking,such as banning tobacco advertisements, raising tobacco taxes and print-ing sizable health warnings on cigarette packages.

The WHO bureaucracy’s motivation for targeting smoking was notsolely health-related, as reputational considerations made the tobacco cam-paign uniquely attractive. First, an anti-smoking initiative affirmed theWHO’s new commitment to turning the fight against non-communicablediseases into a legitimate area of WHO involvement. This new commit-ment was the outcome of the WHO’s adoption of DALYs for measuringthe burden of disease. Because DALYs incorporated information on in-dividuals’ years of partial productivity due to disease, rather than onlypremature death, the approach greatly elevated the importance of chronicdiseases. WHO studies that showed that smoking had become one of themajor killers not only in developed countries, but also in developing coun-tries, where 800 million of the world’s 1.25 billion smokers lived, providedevidence for the claim that smoking should be a concern for all WHOmember-states (Taylor and Bettcher, 2000). A second incentive to focus onthe tobacco sector was that the World Bank shared the WHO’s positionon the issue (e.g. Barnum, 1994). The WHO’s collaboration with WorldBank economists ensured that tobacco control measures were viewed ascost-effective, and the WHO relied on a World Bank analysis to assuage theconcern that tobacco control would harm the economy in poor countriesthat were heavily dependent on tobacco revenue (Jha and Chaloupka, 1999;Collin, 2004). The World Bank’s interest also allowed a channel throughwhich to reclaim the WHO’s leadership in a global health matter by com-plementing, rather than contradicting, the World Bank position.28 Finally,since smoking was not a narrowly medical issue, Brundtland hoped itwould attract the attention of policy makers other than health ministers tothe WHO’s efforts. According to Katherine Deland of the WHO TobaccoFree Initiative, ‘All of a sudden there was a tremendous opportunity toexpand WHO’s influence . . . and to affect domestic policy’.29

These incentives aside, an adamant crusade against tobacco companiesbore the risk of damaging the relations with other businesses that theWHO staff had worked hard to cultivate. The WHO bureaucracy was

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able to disassociate its position on tobacco companies from its position onother enterprises by highlighting the tobacco sector’s alleged exceptionalattributes. In particular, the WHO used explicit demonization of the to-bacco sector to assure other industries that its crusade against the tobaccoindustry did not reflect anti-business sentiments, but, on the contrary, thatit reflected an exception to an otherwise business-friendly environment.

Hence, in defending the WHO position, Brundtland likened the role ofthe tobacco industry in creating health problems to that of the mosquitoin causing malaria: both were blood-sucking, disease-spreading parasites(The Economist, 2000). Unlike mosquitoes, moreover, tobacco companieswere not innocent, which provided a villain that was accountable for itsdeeds.30 In these and other criticisms of the tobacco sector, the WHO reliedon the same rationale that it used to justify its engagement with the privatesector, namely, that corporations could be and were socially responsibleand, therefore, potentially ‘part of the solution’. According to neoliberalarguments, corporations were not only able to govern themselves moreefficiently with less government regulation, but also to govern themselvesresponsibly. The WHO was able to make use of these claims against thetobacco sector. Stella Bialous of the WHO Tobacco Free Initiative reported:‘The unique feature of tobacco products – which kill their consumers whenused as directed by the manufacturer – renders the ongoing operations ofthe tobacco companies incompatible with the very notion of CorporateSocial Responsibility’.31

Turning the tobacco industry into a villain was used to justify the reg-ulation of the sector; it was also used to effectively distinguish betweentobacco and other businesses. To differentiate the tobacco industry from le-gitimate business sectors, the WHO used a particularly critical language. Acigarette, Brundtland claimed, ‘is the only product which when used as in-tended, will kill one half of its consumers’ (Giles and Thornhill, 2000), and‘a cigarette is a euphemism for a cleverly crafted product that delivers justthe right amount of nicotine to keep its user addicted for life before killingthe person’ (cited in Williams, 1999). Unlike other commodities, cigaretteswere ‘inherently dangerous products’ designed by tobacco companies tocreate and maintain nicotine addiction. The marketing practices of tobaccocompanies were similarly used to establish the immorality of the indus-try. The tobacco companies targeted young people, women and ‘thoseless advantaged’.32 The WHO staff rejected the claims that smokers knewthe risks or that they were making a deliberate choice, and Brundtlanddescribed smoking as a ‘communicable disease’ that spread through ad-vertising (Giles and Thornhill, 2000). Such distinctions allowed the WHOto be ‘unapologetic about cold-shouldering the tobacco-industry devils’(The Economist, 2000). In short, the WHO’s campaign against the tobaccoindustry was made possible within a neoliberal context through strategicresistance: the WHO avoided justifications that questioned the capacity of

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markets to regulate themselves, drawing instead on justifications that ef-fectively reproduced the neoliberal support of a free market, but identifiedthe tobacco sector as an exception to the general rule.

CONCLUSION: THE LIMITATIONS AND POSSIBILITIESOF ADAPTIVE STRATEGIES

The policies advocated by the WHO bureaucracy in response to pressuresfor policy reforms from the US government and the World Bank suggestthat while submitting to the neoliberal logic, international organizationswere able to restructure that logic in an effort to guard some of their mate-rial or ideational goals. Indeed, the WHO secretariat was not the only inter-national bureaucracy adapting strategically to, and thereby transforming,the new environment. The International Labor Organization (ILO) hasfought against its increasing marginality by getting involved in the devel-opment agenda and by committing member-states, in the ILO Declarationon Fundamental Principles of Rights at Work, only to the least controver-sial ‘core’ labor standards (Standing, 2008). While it is sometimes useful tosimply label such initiatives as ‘neoliberal’, as Standing (2008) does, suchlabeling unjustifiably reproduces a totalizing image of a hegemonic logicand overlooks important variations in the implementation of that logic indifferent international settings. In contrast, acknowledging the diversity inthe implementation of neoliberal-compatible policies across internationalorganizations allows us to appreciate the cacophony that any hegemonicregime is inevitably made of, and provides an opportunity to identify andanalyze the ability of international bureaucracies, like other actors, to alterthe meanings imposed upon them.

The WHO was clearly part of the neoliberal transition that swept in-ternational organizations in the 1980s and the 1990s. The WHO’s turn toneoliberalism was a rational response to a major crisis generated by theUS government across the entire UN system, which threatened the WHO’sfinancial standing, its authority over health issues, and its legitimacy as acompetent and trustworthy organization. In line with some of the neolib-eral maxims, the WHO, under Brundtland’s leadership, began to considerhealth through the lens of economic growth, prioritize cost-effective pro-grams, and accept market-driven solutions and business-friendly arrange-ments. But the WHO’s programs and policies also significantly altered theneoliberal logic. The WHO staff used the concern with economic growthto justify greater financial investment in health and relied on cost-effectivelogic to call for a ‘new universalism’ – the delivery of high-quality essen-tial care to all – while maintaining a focus on infectious diseases affectingthe poor. In addition, while actively seeking improved relations with theprivate sector, the WHO bureaucracy objected to the WTO intellectualproperty rules and strongly supported the regulation of the tobacco sector.

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In making such changes, the WHO accepted many neoliberal prescrip-tions that significantly compromised its previous agenda. Justifying in-vestment in health by referring to economic benefits forced the WHO toabandon the notion that health was an end in itself. While the embraceof cost-effectiveness held the promise of improving the delivery of aidto the developing world, it also meant that there was no longer any for-mal commitment to those most vulnerable. Both ‘new universalism’ andthe regulation of tobacco companies rested on the notion that solutionsto health problems are best found in the market, hence weakening theinfluence of governments, on which the WHO had the most impact. Con-sidering the conduct of tobacco companies an exception also underminedthe legitimate capacity of the WHO, or its member-states, to regulate themarketing practices of other sectors.

There were other internal contradictions and organizational risks inadapting, even strategically, to the neoliberal logic. Most important,changes made in an effort to adapt to the new logic endangered the WHO’sfuture capacity. Presenting health as a major aspect of economic develop-ment, rather than a goal in its own right, for instance, ran the risk thatdonors would invest resources in health only if such investments had theadded benefit of improving economic growth and, possibly, only if it wasmore effective than investing in other sectors. Increased reliance on volun-tary funds raised the issue of sustainability, which has become particularlyrelevant in the current economic situation. Indeed, after raising more than$22 billion in its first 10 years of operation, in November 2011, the GlobalFund announced that it was forced to cancel its 11th round of grant-makingdue to lack of funds. New arrangements also threatened the future of fairrepresentation. The shift of authority away from the World Health Assem-bly due to increased reliance on voluntary, rather than mandatory, fundsmeant that developing countries had possibly lost their most valuablesource of influence in the United Nations: the one-country/one-vote rule.The direct influence of member-states from the developing world furtherdeteriorated with the rise of public-private partnerships as the preferredinstitutional arrangement for global health initiatives. Finally, the internalcontradictions and vulnerabilities also extended to the programs them-selves. The focus on three ‘private’ diseases – HIV and AIDS, malaria, andtuberculosis – came to be seen as coming at the expense of other priorities.33

In particularly harsh terms, an article in the British Medical Journal criticizedthe ‘AIDS industry’ for being too vertical, asserting that ‘far too much isspent on HIV relative to other needs and that this is damaging healthsystems’ (England, 2008).

These limitations notwithstanding, the adaptive strategies employed bythe WHO leadership and staff made the shift toward neoliberalism asconducive as possible to the organization’s global health agenda. Againstunlikely odds, analysts agree that Brundtland’s ‘systematic attempt to

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return WHO to its leadership role’ was successful (Kickbusch,2000). Brown, Cueto and Fee (2006) concluded that she ‘succeededin . . . reposition[ing] WHO as a credible and highly visible contributorto the rapidly changing field of global health’, and Yamey (2002a) stated inthe British Medical Journal that, with Brundtland, the ‘WHO made a come-back to the global political stage’. Horton (2002) reported: ‘Corrupt, bu-reaucratic, inefficient, unresponsive, unaccountable, overly medical, andfar too male. These are some of the more unkind accusations thrown atWHO during the past decade. Brundtland successfully restored WHO’sinternational credibility. WHO has become an agency to be reckoned with’.This paper shows that the recovery of the early 2000s was accomplishedby adhering to the neoliberal logic in a way that made it possible for theWHO bureaucracy to legitimate the centrality of health even in an erafocused on economic growth, to maintain the focus on the three majorkiller diseases affecting vulnerable populations in resource-poor countrieswhile following a cost-effective logic, to support better access to affordablemedicines in spite of more stringent intellectual property protection rules,and to mobilize against the influential tobacco companies.

This paper also identifies the strategies that allowed international bu-reaucracies to protect their agendas in the face of a new ideological era. Itargues that in conditions of dependence on external actors, internationalorganizations that choose not to comply with the demands often do notsimply resist them, but instead use adaptive strategies that reduce the sac-rifices of compliance or the risks of resistance: they adhere to the externaldemands only after giving them a meaning that can also be reconciledwith the organization’s goals, or they reframe the dominant logic so thatthe organization is no longer expected to conform to it.

The deceptively smooth transition of international organizations toneoliberalism through strategic adaptation conceals the creation of afragmented universe, in which each international organization follows itsown version of the neoliberal logic. International organizations were notpassive transmission belts, having no input in the neoliberal reforms dis-seminated at the international and national levels, nor were internationalbureaucracies enthusiastic adherents of one version of neoliberal thoughtas articulated by the so-called Washington Consensus. Instead, interna-tional bureaucracies authored their own neoliberal transition. Adaptivestrategies also contributed to the reformulation of the hegemonic universeinto which international organizations were integrated by making theWorld Bank and the US government, in a small but significant number ofcases, change their original position. The final outcome, as suggested in theintroduction, is that of a collage of ‘actually existing neoliberalisms’ at theglobal level, in which the common term of ‘neoliberalism’ contains a plu-rality of meanings that are diverse, but still logically compatible with eachother.

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The plurality in ‘actually existing neoliberalisms’ shows that the WHOand other international organizations have survived the neoliberal turnin spite of internal contradictions. In addition to internal contradictions,however, another type of threat to the sustainability of adaptive strate-gies is external transformations. The recent financial crisis accelerated thedemise of the neoliberal era and the emergence of a new, albeit still ten-tative, ‘post-Washington Consensus’ order.34 Maybe not surprisingly, theWHO is again facing a number of crises (Chow, 2010), which at least in partreflect the general uncertainty at the global level regarding what is nowexpected of international organizations. This paper suggests that whetherthe WHO survives the current crisis will depend, to a large extent, on itsadaptive strategies.

NOTES

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

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

3 A number of scholarly works on international organizations illustrate the abil-ity of international bureaucracies to strategically respond to external demands.Barnett and Coleman (2005) have argued that the range of strategies identi-fied by Oliver was also available to international organizations; Weaver (2008)has described in detail the use of avoidance (or ‘organized hypocrisy’) as acentral strategy of the World Bank. See also the volume edited by Park andVetterlein (2010), which effectively identifies the internal and external sourcesfor the emergence, stabilization and contestation of international norms. Inturn, Sarfaty (2009) has analyzed a reversed situation, in which civil societyorganizations fail to strategically reframe their requests in a way compatiblewith 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 ‘changethe preferences of principals to make them consistent with’ the values andgoals of the organization (Barnett and Coleman, 2005: 602). In contrast, whenstrategically complying or resisting external expectations, the internationalorganization does not try to change the position of the environment. Rather,

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the organization reframes the position of the environment so as to present it asalready consistent with the preferences of the organization.

5 For the empirical analysis, I rely on primary archival sources and publicdocuments that I collected at the library of the WHO in Geneva, the li-brary of the regional office of the WHO (Pan American Health Organizationor PAHO) in Washington, DC, and at the national archives in the US, theUK and Canada. Particularly helpful were the topical minutes of the annualWorld Health Assemblies and biannual Executive Board meetings. I observedone World Health Assembly – in May 2008. Between March 2008 and May2009, I conducted 24 semi-structured interviews (each one–two hours long),in Geneva, New York and Washington, DC. The interviews were with of-ficials of the WHO (from a number of programs and initiatives, includingthe 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 num-ber of public-private partnerships, local and transnational health activists, andrepresentatives 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, eachhaving a regional office.

8 Following the argument made in this article, it is likely that as participants inthe making of the ‘Washington Consensus’, the IMF and the World Bank werenot passive recipients of ideas developed by the US Treasury Department,but that they incorporated ideas compatible with their own organizationalcultures.

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

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

11 Effective leadership is an important condition for strategic adaptation. How-ever, the influence of leaders should not be reduced to their personal charac-teristics (Haas, 1964; Cox, 1969). Scholars of organizations have identified twotypes of institutional conditions that enable agents to introduce change in theirenvironment in spite of organizational constraints (DiMaggio, 1988). The firstis field-level institutional characteristics (Battilana, Leca and Boxenbaum, 2009:74), including organizational autonomy and lax supervision by the environ-ment. Second, actors’ institutional characteristics, including ‘the social positionan actor occupies within an organizational field’, also play a role (Battilana,Leca and Boxenbaum, 2009: 75). In particular, effective leadership in the formof strategic adaptation depends on the leader’s social position both within theorganization and within the environment. (1) Strategic response is more likelyto occur when the institutional conditions allow for strong leadership, whichprovide the actor with the means to transform the organization without suchattempts being paralyzed by external opposition or internal debates. At theWHO, the institutional conditions have allowed Directors-General to effec-tively shape the direction of the organization, through control over the budgetplanning, the creation of new divisions and the hiring of new recruits. (2) Strate-gic response is more likely to occur when the leaders are partially embeddedin the exogenous environment. This partial embeddedness is important be-cause it allows leaders to function as bridges between the organization and the

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broader environment. Brundtland was familiar with and appreciative of theneoliberal logic that she was expected to navigate. Being part of the externallogic meant that she could adopt, at least in part, the new exogenous princi-ples and was in possession of or able to gain sufficient knowledge of the newenvironment 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 53rdWorld Health Assembly. 15 May 2000. Washington, DC: PAHO Library.

14 The literature on the WHO that analyzes the transition in the 1990s describessome of the policies that are also described below. However, many see thepolicy shifts under Brundtland as a capitulation to the neoliberal logic (Banerji,1999; Thomas and Weber, 2006; Brown, Cueto and Fee, 2004). Others, on thecontrary, underplay the role of external pressures (Kamradt-Scott, 2010). Inboth cases, the literature overlooks the strategic aspects of these policies, whichare 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 itfound harmful and discriminatory, by arguing that it undermined the pursuitof 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 theUnited Nations system. The WHO bureaucracy was also influenced by theRockefeller Foundation and the Bill and Melinda Gates Foundation, whichbegan to condition their grants to the WHO on the organization making part-nerships with the private sector (WHO, 1999a).

23 Interview by the author with German Velasquez, 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 intellectualproperty rights have often been perceived by critics as inconsistent with freetrade principles and are, therefore, a sign of the developed countries’ hypocrisy.

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

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

27 Interview by the author with Lembit Rago, Quality Assurance and Safety ofMedicines, WHO, 27 May 2008.

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

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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. Reportof 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.

34 <http://www.policyinnovations.org/ideas/policy_library/data/01232>(accessed 20 July 2010).

NOTES ON CONTRIBUTOR

Nitsan Chorev is Associate Professor of Sociology at Brown University. She isthe author of Remaking U.S. Trade Policy: From Protectionism to Globalization(Cornell University Press, 2007) and of The World Health Organization betweenNorth and South (Cornell University Press, 2012).

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