Abstract
In The World Health Organization between North and South, Nitsan Chorev uses the case of the World Health Organization (WHO) to explore fundamental questions about when and how organizations change. In particular, her analysis addresses whether the actions of international organizations reflect only the desires of their member states, or whether such organizations act of their own volition. Examining the period of the quest for a New International Economic Order in the 1970s and the rise and heyday of neoliberalism from the 1980s through the 2000s, Chorev argues that international bureaucracies such as the WHO can and do restructure global ideational regimes to suit their own interests through processes of strategic compliance and strategic resistance. In other words, she shows that the behavior of the WHO has not been the result of negotiations between North and South, but is instead due to how, in order to achieve desired outcomes, the WHO secretariat and leadership strategically altered the demands placed on it by member states.
The WHO is the specialized agency within the United Nations (UN) responsible for global health policies and programs. Like most other UN agencies, the WHO’s resources come primarily from the wealthy countries of the global North, but it operates under the principle of one vote per country, giving power to countries of the global South when they are able to form a coalition. Chorev’s book examines two periods reflecting differential power dynamics: the countries of the global South formed a strong coalition during the 1970s during the push for a New International Economic Order, while the countries of the global North have dominated since the rise of neoliberalism in the 1980s.
Chorev develops the concepts of strategic compliance and strategic resistance to understand organizational responses to external challenges, thus moving beyond a compliance/resistance dichotomy. Strategic compliance is when an organization attempts to change the meaning of an external demand before it complies such that the demand more closely matches the organization’s preferences. Specifically, Chorev states that ‘strategic compliance is not about making the exogenous forces change their demands so much as convincing those forces that the original demands were met’ (p. 31). Strategic resistance occurs when the organization sufficiently changes the external demands such that it no longer actually needs to comply with those demands. Together, strategic compliance and strategic resistance make up strategic adaptation. Drawing from organizational theory and the case of the WHO, Chorev argues that strategic adaptation is most likely when the organization has clear goals that do not match new environmental expectations, when external supervision of the organization is minimal, and when the organization has strong, new leadership. More of the book covers strategic compliance than strategic resistance, although Chorev presents evidence for each type of resistance within the environments of the New International Economic Order and neoliberalism. She interprets much of this adaptation through a quintessentially sociological lens: the capacity of international bureaucracies to act in their own interests ‘stems not from formal authority but from practices, particularly the ability to act strategically’ (p. 228). The book’s analysis is based on in-depth interviews, archival research, and secondary materials, from which Chorev presents extensive quotes, particularly from WHO reports and speeches by its leaders.
In 1974, the UN General Assembly passed a resolution calling for a ‘New International Economic Order’. This resolution followed on the heels of decolonization, which had created a number of new (poor) countries and made developing countries the majority of the General Assembly. The goal of the New International Economic Order was to ‘reduce the inequities among states by allowing poor countries to achieve economic and social development, mostly through industrialization and improved terms of trade for primary commodities’ (p. 6). Following its adoption by the General Assembly, all UN agencies were expected to develop an action plan to achieve the New International Economic Order. Accordingly, the WHO distanced itself from the post-World War II biomedical approaches to health that emphasized specific diseases and instead embraced ‘Health for All by 2000’, a plan put forth by Director General Mahler in 1976 to ensure access to primary health care throughout the world. Although the New International Economic Order called for both economic and social development, its main emphasis was economic growth, so the WHO’s emphasis on primary health care reflected strategic adaptation. The WHO deployed strategic resistance in response to the New International Economic Order by first compromising to focus on ‘development’, but then by adapting to target social development, specifically health. In addition, the WHO took a number of other steps within the bounds of the New International Economic Order in order to avoid alienating countries of the global North, who did not support the New International Economic Order.
The debt crisis of the early 1980s shepherded in the era of neoliberal reforms and in general made both developing countries and international organizations more dependent on countries of the North. Not only did this shift bring about the end of the New International Economic Order, but it also corresponded with a number of crises at the WHO related to resources, authority, and leadership. It was only with the election of Gro Harlem Brundtland as director general in 1998 that things began to turn around for the WHO. Brundtland led the strategic response of the WHO to neoliberalism by adapting the WHO’s social logic to an economic logic. Specifically, rather than argue for the importance of health as a social good, the WHO began to justify health investments as a means to ensure economic growth. In acquiescence to neoliberalism, and following the lead of the World Bank, the WHO also began using cost-effectiveness, rather than equity, as the primary criteria for deciding where to make investments in health. Most practically, the latter change led to a reemphasis of disease-specific programming, from which the WHO had shifted away during the 1970s’ focus on primary health care. Importantly, these strategic adaptations contradicted the World Bank’s insistence that governments and international organizations reduce health spending, and instead implied that they should increase such spending. Through these examples and others, Chorev shows how the WHO complied with neoliberal logic, but on its own terms.
The book addresses issues of particular interest to organizational and political sociologists, as well as to other scholars whose research focuses on international organizations. Chorev’s focus on international organizations, and specifically intergovernmental organizations, simultaneously expands the scope of organizational sociology while opening dialogue between sociologists and political scientists. For students just sinking their teeth into the study of organizations, Chorev’s explanation of dominant theories of organizational sociology is thorough, and the book is very clearly written. In addition to its specific focus on the WHO, the book provides excellent background on major global health topics, including the Health for All campaign of the 1970s, the development of international regulations for infant formula and tobacco, the creation of the WHO’s essential drugs list, and the rise of, and global response to, HIV/AIDS. As such, it is an important read for anyone studying global health funding, regimes, and interventions.
At the end of the day, Chorev’s exploration of the WHO from the 1970s through the neoliberal era demonstrates a fundamental tenet of organizational sociology, namely, that organizations are strongly constrained by their environments. Her real contribution is to show the strategic steps that organizational leadership (both individual as well as collective) takes to keep organizations relevant in changing environments, thus demonstrating some of the actual mechanisms through which organizations change.