Closing the Accountability Gap

Consultants have been described as wizards – superior analytical minds who can turn around businesses – but also as pretenders who sell management fads and quasi-academic insights to businesses and governments. In the World Health Organization (WHO), one of our interviewees also described them as ‘priests’ – companies that are hired to transform the organization on the basis of the ‘bible’ – the organizational strategy. Yet, this neutral, detached image as a technical servant to a public organization is misleading. Rather, as we describe in our study of consulting firm engagement at WHO, consultants act as discretionary curators of reform inputs. They filter the knowledge and voices that go into reform proposals, and they are often closely entangled with certain stakeholders and funders, such as the Bill and Melinda Gates Foundation.

In the latest ‘WHO transformation’ (which began in 2017), the organization hired at least six consulting firms, praised by the Director-General as the ‘best firms in the world’. Despite their prominent role in WHO processes and reform efforts, there is a clear accountability gap in their role at WHO. More generally, consultant engagement contributes to a trend towards informal governance and public-private collusions in an organization that looks less and less like a public authority and more like a platform for government and business ‘stakeholders’.

Curating

What do curators do? In the arts, curators assemble objects, performances, or voices into a final exhibit. In business and politics, consulting firms do something similar. When they come to help change WHO – or other international bodies such as the World Trade Organization or the Munich Security Conference – they collect information, interview staff and other stakeholders, and reach for ‘case studies’ of so-called best practices as models for reform. The precise task and scope of work differ from contract to contract, but at least at WHO, many rounds of interviewing and consulting have been reported since the turn of the millennium.

Curating can create conflict when consultants are not perceived as neutral. For example, in a controversial reform of the WHO-hosted public-private partnership Roll Back Malaria, malaria-endemic countries and their allies were side-lined in a Gates Foundation-sponsored consulting mission by McKinsey & Co. The consultants interviewed all kinds of stakeholders, but not malaria endemic countries and barely WHO staff. The best practices they used to design a reform came from the business world instead of public institutions and included firms such as Uber and Alibaba. Their reform proposal became the blueprint for a 2015 revamp of the partnership that, among other innovations, abolished the constituency-based representation of stakeholders such as affected countries or NGOs.

No logo, no transparency

While such processes are controversial, they are also opaque. At WHO, a brutally underfunded organization, a lot of consulting firm services to WHO are gifted by donors and don’t show in the books. And since they count as ‘procurement’ instead of formal civil society collaboration, usual conflict of interest regulations do not apply while WHO struggles even in those areas where such regulations exist as we will elaborate below. Funders may at times co-write the terms of reference, but this is also done informally and not publicly known. Technically, the WHO, as the formal client, buys the consultants’ input and owns the results so that to outsiders, it is not clearly discernible what inputs the consultants generated and through which methodology. Interviewees told us about sitting in organizational meetings and seeing those iconic PowerPoint slides that could only be from a consulting firm, but there was no logo. Reports generated in the consulting processes, when they are made available at all, also tend to remain vague regarding authorship. The reform task force for Roll Back Malaria had McKinsey consultants as key members, but their names were not listed as part of the team.

There is thus a clear accountability deficit in the way consultants work for WHO. Consultants’ personal ties to parties in an organizational controversy might even be plain and criticized (like in the Roll Back Malaria reform), but there is no mechanism to address those. And unless a country holding the external auditor role at WHO decides to investigate consulting arrangements, very little data on these arrangements is publicly available. When an auditor, provided by India, did look into consulting firm activities during Covid-19, they found irregularities in the way in which the consulting contract was awarded. Furthermore, while the consulting firm described its service as ‘pro bono’ work, it still cost the organization millions of dollars, and the contracts the firm negotiated for purchasing protective gowns raised at least questions in terms of value for money. WHO pledged to improve accountability in the aftermath of this report, and arguably, in times of crisis, irregularities might happen more easily. Yet, given the chronic underfunding of the organization, one might also conclude that the organizational crisis has become permanent.

Lots of money, little money

The Gates Foundation, one of the main sponsors of consulting firm services to WHO, has meanwhile decided to insource some management strategy capacity. The foundation runs, so to say, its own internal McKinsey to work on management strategy and organizational development. The reasoning is that even if you hire external strategy consultants, you need to be well-resourced enough to know what kind of service you may need, and will get, from consultants. Fund-strapped organizations like WHO that need to survive on earmarked, project-specific funds will find it more difficult to be an ‘active client’. Consultants may come in to help them sell WHO’s value for money to donors, or signal accounting rigour to keep some income flowing. But even if branded as donated knowledge, the lack of control regarding their services has raised doubts whether, or to what extent, the firms themselves provide value for money to WHO.

More generally, WHO’s dependency on donated resources and external support seems to change its central, one might also say, ‘orchestrator’ role in global health. WHO’s day-to-day work is closely intertwined with ‘outside’ supporters such as the Gates Foundation, and its expert role equally evolves through ongoing osmosis with private sector actors in public health knowledge production. With the rise of multi-stakeholderism and ‘super-public-private-partnerships’, such as the Covid-19 vaccine partnership Covax, WHO often assumes a role less of an orchestrator and more of a legitimizing platform for public-private governance initiatives – and its normative guidance, for example, regarding vaccine allocation, is bypassed by funding and political realities.

In this constellation, overseeing private sector involvement at WHO is not only difficult for the underregulated practice of consulting firm engagement. For the more formalized relationships with non-state actors, the 2016 Framework of Engagement with Nonstate Actors (FENSA) calls for due diligence and safeguards regarding private sector collaborations. Yet, a first evaluation of FENSA’s implementation concluded that FENSA (just like earlier attempts to regulate conflicts of interests at WHO), was hampered by unclear guidance and leadership from management on how to implement it. Quite the contrary, when the current DG took office after FENSA had already been agreed, he hastened to reassure stakeholders that ‘FENSA is not a fence’. WHO keeps struggling with how to win private sector support – for example, when it first accepted a Nestlé donation for the newly established WHO Foundation, but later, after enormous public criticism, refused to take further money from a corporation that has long been criticized for its marketing of breast milk formula.

Today, as states and other donors keep inventing ever new global health initiatives instead of fixing the existing ones, WHO is under competitive pressure to show its special role, demonstrate value for money, but also collaborate with the big players out there. For the moment, states and major blocs such as the European Union do not want to do without a WHO, but neither incumbent nor rising powers invest enough in sustainable public resourcing and oversight. This leaves ample space for consulting firms to frame the conversation on how to think about pressing issues such as climate change, digitalization, or access to medicines.

This post builds on a blog that initially appeared as ‘Wizards, pretenders, or unaccountable curators? How consultants shape policy in underfunded international agencies’ at LSE Impact Blog.