WHO AFRO reforms: A conversation with Dr. Matshidiso Moeti

At the height of the Ebola outbreak that was sweeping across West Africa, in February 2015, a new director for the World Health Organization’s regional office for Africa stepped in: Dr. Matshidiso Moeti from Botswana.

It would be an understatement to say Moeti came at a particularly challenging time for the regional office. Ebola was still ravaging the three most affected countries, Guinea, Sierra Leone and Liberia. Every single staff member of WHO with a public health background was being tapped and deployed to help in the response, all while the United Nations aid agency was being hammered with criticisms and asked by member states to undergo major reforms.

Moeti proved steadfast. The first woman regional director for Africa made revisions to the office’s structure and way of working. In the two years she’s been in office, Moeti has driven strict reforms at the regional level, as well as across WHO’s country offices in Africa, with a focus on results, transparency and accountability.

“My primary interest is to manage toward results,” she told Devex at the sidelines of the 70th World Health Assembly that took place in Geneva from May 22-31. “When a staff member decides, ‘I’m going to organize a meeting,’ he should be clear that he’s going to get the result out of convening those people, what result is he going to get, and that he’s going to be able to follow up and make sure that’s delivered.”

Devex spoke with Moeti to take stock of the reforms and her confidence in her office’s response, should the region face another public health emergency. Our conversation has been edited for length and clarity.

Take me back to the time when you arrived at the Africa regional office two years ago. What was it like?

First of all, to emphasize, I’ve worked in the regional office before. I was away for quite a few months, almost a year, from my position as deputy director. So I had a good idea of the work of WHO in the region.

Of course, I came in when the Ebola outbreak was at its peak. A lot of the staff were out, deployed. There was a huge sense of, I would say, a global panic. It was a time when there were a very large number of cases, and the number of beds in the treatment centers was a big challenge in the countries [affected]. The partners as well as the governments involved with WHO were trying their best to expand the treatment centers. I remember being struck by one partner’s intention to build a treatment center in a country and feeling a sense of, “OK, if it’s going to be bricks and mortar, by the time it’s up, what will have happened to the number of people who cannot find beds?”

[I started at] that time, when the situation was very acute, the rate of increase of cases was still going up, and the pace at which our capacity to manage both at the treatment side to save people’s lives and on the prevention side — to stop health care workers, family members and community members getting infected — was really a challenge.

The Ebola outbreak and WHO’s response led member states to call for a review and reform of the WHO. What reforms have you initiated at your office and in the continent since you came?

It was with regard to the Ebola outbreak itself. I restructured the department that deals with outbreaks and emergencies. I brought together the people dealing with outbreaks and humanitarian crises; they used to be two different departments. I created a new cluster, understanding that we needed to have this work linked. As it turned out, this is the way in which the global department has been restarted in WHO.

And then after that, the reforms that I instituted were very much aimed at improving WHO’s functioning, effectiveness, and results focus in the region, so that we would be better able to handle not only preparedness for outbreaks and support to outbreak response, but that in general the work that we do, especially on building health systems in countries, would be more effective at the country level. We understood very well that part of the reason why [the Ebola] outbreak was able to get out of control relatively quickly was that it started in remote areas where the health system was extremely weak.

There’s outbreak preparedness work, health systems work, and also [work] to help countries to do better in relation to some of the older programs that we have been managing, including childhood diseases, immunization and maternal mortality.

One of the first things that we did was to work on revising the structure of the regional office so as to make it more fit for purpose in relation to the objectives and priorities that we were slightly resetting, including reorganizing our health systems work. We have emerged with a structure that is better suited. I’m particularly pleased that the reorganization of our health system work were focused on an integrated approach. We understand that both ourselves and WHO in countries [need] to model on what WHO is doing and recommending. We need to be more efficient in using resources and to better link different elements of service delivery systems — such as procurement and supply, data for monitoring human resources distribution — so that we can help countries to expand the reach of their services. [That will also allow] progress toward universal health coverage, ensuring that people are able to get basic health care access throughout the country.

We did that with a view toward aligning better with the [broader WHO] objectives, and we have since also introduced programmatic key performance indicators. We developed an accountability framework. At WHO, one of the areas in which we really do need to reform our work and have not yet managed to, is to prioritize better and have a more manageable range of areas in which we work. We work in a very broad span of program areas, and this is a challenge to the resources and capacities of the organization.

Within all the programs, we’ve identified some of the key performance indicators, meaning we absolutely have to try and achieve these across all our 47 country offices, and we expect them to deliver on this. We’re going to monitor these key performance indicators, which are also linked to the performance management of staff who play a key role in [each of the] programmatic areas.

I hope [these measures] will help us to manage for results, so that every day when we are deciding who’ll do what, or if a supervisor has to approve and say, “yes, it’s fine you can do that,” he can be checking that what is being agreed is going to contribute to a key result, and therefore make a difference in our support to countries.

Secondly, we’ve paid a lot of attention to our management. Clearly we need to have a management system that is helping us to deliver programs well. In the areas of procurement, travel — we travel a lot to countries to provide technical experts, but we also convene a lot of meetings, policy and technical, for different purposes — we need to get more efficient in terms of cost and being able to get things done appropriately.

We put in place managerial key performance indicators, which are now rolled out across the region in all our country offices. We really noticed an increasing improvement in several areas of our management, [such as] how we deal with advances to countries.

For example, one of the ways in which we support countries is to advance funds to ministers of health for carrying out some activities, primarily trainings or meetings, which is part of our convening and capacity building role. In the past we’ve had a lot of challenges with getting budget reports so that we are able, in turn, to account to our governing bodies for the way we have utilized the money entrusted to us. In the past we’ve had lots of delays and, frankly, challenges in the validity of some of the reporting about the use of WHO money. It’s now one of the key performance indicators in which we have seen a big improvement.

We developed a handbook and briefed ministry of health officials, so that they are aware that we’re going to have a more stringent regime now for ensuring the correct use of this money and improving reporting. I’m really pleased to see that has improved a lot.

We’ve also paid attention in terms of how we implement audit recommendations, and one of the best indicators of improvement is that, in the last year, all of our audits carried out in the region were either satisfactory or nearly satisfactory. We’ve improved quite a lot on the management side in terms of how we deal with money and advances. Reporting to donors has improved. Procurement is improving.

But one of the areas in which we need to see more improvement is travel, in terms of timeliness of organizing travel and therefore reducing costs of travel.

There are also other areas that we’re trying to reform. I’m very keen on the human resources side, trying to achieve a better balance in our staffing in relation to gender equity, and in relation to diversity of the staff in the region. We tend to have a very middle-aged staff, because we recruit experts who’ve had fairly established careers. But we recognize that we need to recruit young people, so they can see a career path in the organization. We therefore need to open up the range of grades and also ages to attract young professionals in the organization.

We’re starting more and more to recruit younger people, more women. I insist, when I’m being sent recruitment files, to seeing the number of women applying and how the final selection and recommendations get made as far as any women candidates that were shortlisted. I’m glad to see we’ve seen an increase in the proportion of women who are being recruited now. If you look, I think you’ll find talented women who are available to be recruited. You just have to look and make sure we’re not recycling people who are already … middle-aged males. We’re really putting a lot of effort into this. Also, we’re recruiting more and more people coming from diverse regions. Of course we want to recruit excellent African expertise, but we also want to combine it with people with other experiences, as I think it can make our work better.

How do you make sure these human resource efforts are institutionalized?

Through our governing bodies — it’s one of the indicators they look at in the human resources. From that point of view, it’s something that a regional director would always need to confront, report on and show progress on. It is institutionalized in that sense. And we need to be working toward this better gender balance as required by our governing bodies.

I think a leader has no choice but to pay attention to this. It just so happens that this is part of my own inclination, [but] we need to do more. We need to go looking for good women. So you can advertise, and you can be fortunate some good women will apply, but I think we need to have a combination of both.

We tend to get a preponderance of male applicants and a smaller proportion of women applicants. I think that goes beyond the recruiting process, to training women, encouraging women to look for careers in the sector.

One of the challenges I believe in an international organization is the fact that, especially younger women, are involved in having families. Therefore if it is the woman who is taking a first step of seeking a job, it brings out the whole issue about family responsibility.

I still have women candidates who apply for the job and at the moment of deciding to take the position, family issues come up. So it really does mean that we need to be aware of this and go simply beyond looking to get women who are qualified but think about whether we have an environment in the workplace that encourages women to take up positions.

How has staff responded to the performance tracking?

I think being tracked is a very good inspiration for people to pay attention, so it helps. I mean we have had many discussions. We have a system of developing the plan, then periodically we review how we’re doing, how are we progressing and implementing activities — are we achieving our results. We always have a difficulty answering the question: Are we delivering on our results? It’s easy to describe how we have organized these activities, but sometimes it’s difficult to see the connection between the organized activity and the results to which they’re supposed to be leading, and even difficult to see the link with money that is being spent.

I find that when people see themselves scrutinized, compared to others, it’s a massive stimulation and inspiration for them to pay attention and do better. I hope it will work in that way.

Can you talk briefly about the new reforms you are initiating?

We’ve been at this for two years, and to make change happen in a big institution — we’ve got 47 country offices, a big regional office, and several intercountry teams — for these reforms to take hold and be integrated requires some consolidation of the work that is being done.

We have just carried out an independent evaluation of this reform program, which has been very encouraging. It showed that most staff members agree with what is being done. But you know instituting change is not easy; you need people to accept it.

We’re moving into a second phase now, and we’re just looking at this report to see what has progressed well. There have been some challenges, one of which has been communicating adequately with staff. So keeping people engaged and informed of every step of the way of this reform program and also informing our member states in more detail, so they understand and they can comment and help us improve what we’re doing.

We’re going to go very much into a consolidation phase, institutionalization as we call it. It started off as a special project. We put together a small team who are tracking, who are ensuring that things happen now. We would like this to be an integral part of the programs of the different clusters and country offices, this different way of doing business; this way of using indicators.

It was a very broad, and very ambitious reform program, and we’re going to look again and see what we can prioritize to do in the next couple of years and really deliver the key results that we want.

How confident are you that the Africa office won’t once again face the same criticism it did during the Ebola outbreak in West Africa?

I am confident in the way we’ve reorganized the work of our outbreaks and emergencies group, not only in the regional office but globally. You’ll be aware that there was a special session of the executive board in 2015 that asked WHO to reform our work on outbreaks. This reform has been ongoing for the last couple of years. We work on outbreaks now in a very different way, in a very joined-up way between the three levels. We organize the whole process quite differently.

We have a small fund, which enables us to put people out in the field very quickly, within 24 hours, within 48 hours. So we’ve set quite clear indicators of each of the steps that would follow this process. I think the way that we have structured the work, structured the program, holds out a lot of promise.

The challenge, and here I think is a challenge for the member states as well, is that the type of staffing which is needed for a more effective preparedness and response has not really been forthcoming from the member states. The recruitment that was supposed to happen to fill up positions in this newly-designed program is moving very slowly, because the resources are not available. If there’s anything that would be a threat, it’s the capacity.

One thing that I’m very happy about, though, is the way the work has been reshaped and reorganized. At the moment, we’re handling about 49 events — outbreaks — small, medium and severe in the African region. Our capacity is quite overstretched, but we have a way of working on these which is leveraging our internal capacity and working with partners. What we need to do more is mobilize regional experts who we’ll be able to deploy.

The way we’ve organized the work has changed radically, and I believe we’re very much in shape to be effective. What needs to happen though is that the capacity needs to increase, and there we still have challenges, because the funding has not been made available.

How big of a game changer will a new director-general from Africa be?

I think it’s going to be extremely interesting to have a director-general who knows the region well — that would be an advantage for us. But I think this is also a director-general who knows global health extremely well, who has good networks all over the world, so I think it will be good for Africa and globally.

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