When it Comes to ‘Global Health’, Corporate Consultancies Rule the Roost

New Delhi: Thanks to the Bill and Melinda Gates Foundation—which sets the agenda for what has come to be known as “global health” or the disproportionately large involvement of private sector in the public health of Third World countries—the World Health Organisation (WHO) is now dominated by “big-business style strategies” management consultancy, McKinsey, one of the world’s most secretive consultancies, and others like it.

A recent story by Vox reveals how the WHO, which was already hiring highly paid management consultants over the past few years, has intensified its reliance on corporate consultants and worked with four other consultancies besides McKinsey since the so-called “transformation” period ushered in by Dr. Tedros Adhanom Ghebreyesus from Ethiopia in 2017. These other consultancies are BCG, Deloitte, Preva Group, Seek Development, and Delivery Associates. 

The Gates Foundation or BMGF has not only encouraged WHO’s reliance on external intervention from management consultancies for internal matters over the years, it has also paid directly for at least a quarter of these $12 million-worth total contracts, reports Vox.

However, the details of these engagements/transactions as well as Gates’ involvement are not available in WHO’s budgets or financial statements, says Vox, while the information on WHO’s website is incomplete. For instance, the website shows the WHO’s headquarters awarded McKinsey with $4.19 million in contracts between 2017 and 2018, but does not specify whether these contracts were reform-related.

Not only is there any publicly accessible information regarding what these consultants have been hired to do. Even the WHO staff apparently have no idea.

 “One senior official, who worked at the WHO when Tedros’s overhaul started, said the consultants subjected the official to a barrage of questions, on everything from staff mobility to the WHO’s “hierarchies and silos.” The official said they were never told how the information they shared would ultimately be used.”

Vox quoted another staffer as saying, “It was like a beehive on the seventh and eighth floors. There were many people [in] suits. But they don’t talk to us directly”, and another as saying, “It’s now been two years [Tedros’s reform] has been going on. I have no idea what is happening.” 

Article authors Julia Belluz and Marine Buissonniere interviewed “more than 80 global health leaders and staff, current and former consultants at multiple firms, researchers, healthcare professionals, and NGO workers, many of whom said that consultants’ presence in the field had become “pervasive” and “ubiquitous.””

Citing an internal 2016 McKinsey PowerPoint presentation, Vox said the firm has been “involved in response to the biggest international disease outbreaks of recent years, from Mers in Saudi Arabia to Zika in Brazil. During the 2014-2016 Ebola epidemic in West Africa, both BCG and McKinsey sent staff to West Africa, to advise the WHO and the countries affected.” 

These firms worked at GAVI—Global Alliance for Vaccines and Immunization—a global public-private partnership (PPP) founded in 2000 with an initial contribution of $750 million from the BMGF, focussed ostensibly on expanding access to immunisations in poor countries of the Global South.

However, as this Newsclick article elaborates (the Vox article does not mention this), GAVI is basically used to secure the monopoly of certain pharmaceutical giants and to channelise the flow of enormous subsidies into private projects of these pharma companies.

“Millions of dollars, not only of private philanthropic grants but also public money, have been transferred through this PPP to some of the largest corporations associated with the foundation.

The extent of public money flowing through this PPP is evident in the fact that 80% of GAVI’s finances are paid by donor states. Only the remaining 20% are coughed up by private donors - mostly the BMGF, which holds a permanent seat on the board of the alliance, along with UNICEF, WHO and the World Bank. 

The WHO is funded by two types of contributions—“assessed” and “voluntary.”

As Linsey McGoey, professor at University of Essex and author of No Such Thing As a Free Gift about BMGF, told Vox, the WHO has more freedom to spend the money from the assessed contributions “on the most pressing health concerns, rather than on pet projects specified by a charitable donor”.  

But, with voluntary funding—which is the category that funding by BMGF etc. falls under—the donations are overwhelmingly specified for a particular purpose by the donor. 

The BMGF, which has Warren Buffet as trustee besides foundation owner and software magnate, Bill Gates, and his wife Melinda, pursues a “results-based, data-driven approach to health and development — the exact method consultancies like McKinsey and BCG excel at.” 

“WHO is faced with budget constraints,” McGoey said. “They’re under-resourced, and they need financing from somewhere. But they may have been a little naive in accepting a lot of Gates money, because it does come with strings attached.” 

As an ex-McKinsey consultant who worked on global health projects told Vox, those strings include hiring consultants. 

“As Gates began regularly paying for consultants on behalf of institutions like the WHO, it created a “reliance” on the firms. Then, the person said, “it became more of the norm to pull these same consultants in for strategy.”” 

In fact, as the Gates Foundation’s influence in global health agenda-setting grew and it pushed “private sector involvement” in an unprecedented manner, McKinsey saw and grabbed the opportunity at a time “when the firm was contemplating expanding its global health work, according to internal planning documents obtained by Vox.” 

But as many experts and insiders told Vox, these management consultancies do more harm than help — as these consultants typically not only lack local context of the countries where they’re executing a project (for example, pushing high-tech solutions in low-resource places), they also lack expertise in health as well as knowledge about public sector and multilateral organisations. 

And yet these corporate consultants are “overwhelmingly favoured over hiring locals with deep expertise on local health problems.” 

However, as Madhu Pai, who directs McGill University’s global health programme, told Vox, these consultants “are able to talk the language that’s understood by corporate philanthropies and the private sector — they are comfortable with that way of thinking but many of them aren’t anywhere close to the ground.”

“The amount of money you’d pay for McKinsey, BCG, or Deloitte [consultants] — you could probably hire several deeply experienced country experts. But unfortunately, the national expertise is undervalued,” Pai added.  

What’s more, the consultants fundamentally misunderstand the “humanitarian” nature of the work that an organisation like WHO is supposed to do and push “business solutions that didn’t make sense”, coming as they do from the corporate set-up focussed on “private-sector approaches” like measurable results and not to mention profit maximisation.

Mukesh Kapila, who worked as undersecretary general for the International Federation of Red Cross and Red Crescent Societies in 2010-2012, said his team had hired consultants to develop a new business strategy. He told Vox, “The consultants could not understand our humanitarian business and their recommendations were completely irrelevant.” 

“Consultants have often found it difficult to ... appreciate decision-making processes at a multilateral international agency,” a former WHO executive was quoted, adding that the private sector models were unhelpful. 

“After 30 years of work at many institutions, nothing done by management consultants comes to my mind as having been brilliant, and a lot has been inappropriate and wasteful of time and resources,” said Mukesh Kapila, who led the United Kingdom’s first HIV/AIDS programme. Writing on “global health consulting malpractice,” Madhu Pai talked of an African colleague who has had to deal with “‘kids’ with little or no experience [coming] all the time to ‘advise’ her government on what to do about health.” 

There is also a fundamental conflict of interest—as these consultancies work for industries and companies that are categorically antithetical to the public good and public health. 

“Consider McKinsey’s role in the opioid epidemic, which has taken the lives of nearly a million Americans since 1999. Court documents that surfaced in litigation included allegations that McKinsey advised two companies on how to increase sales of prescription opioids, from the early 2000s until at least 2014 — when the overdose epidemic was already well-known. One lawsuit alleged that McKinsey advised Johnson & Johnson to “get more patients on higher doses of opioids” and study techniques “for keeping patients on opioids longer,” the New York Times reported.” 

“Another lawsuit alleged that McKinsey also worked with OxyContin-maker Purdue Pharma, coming up with strategies to “counter the emotional messages” of mothers whose children had overdosed and to overcome “patient pushback” so hesitant doctors could prescribe more opioids, according to ProPublica.” 

These consultancies have also helped to expand the market for processed foods and beverages, including soda, which is majorly linked to the global obesity and diabetes pandemics.

For example, one of the top consultancy firms, BCG, in a 2015 report—“co-developed with the Confederation of Indian Industries, including the then chair and CEO of PepsiCo India”—the firm considered how to expand India’s market for FMCG, or Fast-Moving Consumer Goods, including sugary drinks. 

Adam Kamradt-Scott, a professor in global health at the University of Sydney, said, “There is an inherent tension and conflict of interest if WHO is engaging consultancy firms that also work with companies whose products harm health outcomes.” The WHO declined to comment, says Vox.

The Question of Money

So, how much money flows to these management consultancies? Vox says it is impossible to get “the full picture” and as these firms, citing privacy concerns of clients, do not reveal any details of their contracts, “and even publicly funded organizations that hire consultants aren’t fully transparent about their spending.” 

“At the WHO, there’s no budget line disclosing the details of the agency’s management consultant expenses in its financial statements,” says Vox. 

“There’s also no information about consulting contracts paid for through in-kind donations, like the consultants’ work on reform paid for by Gates.”

And while philanthropic foundations like BMGF do disclose in their tax returns the expenditure on consultants, “they are only required to report total annual amounts, not details about specific contracts or which organizations received donations in the form of consulting engagements.” 

Between 2006 and 2017, BMGF spent a staggering $300 million on McKinsey and BCG, as per the Foundations’ tax returns, says Vox.

“That’s more than the domestic health budget for an entire low-income country, like Haiti. It’s also roughly half of what the US government spent on McKinsey and BCG in the last decade.” 

Citing data from the Institute for Health Metrics and Evaluation, Vox says that “investments in development assistance for health grew more than five-fold”—between 1990 and 2018—from $7.7 billion to $38.9 billion. These spending this money include US philanthropic organisations like Gates Foundation, American NGOs, World Bank and even the US government.

Moreover, “global health” being a field that’s supposed to be evidence-based, many that Vox spoke to were wondering what evidence supported the astounding “investment” in management consultancies. 

And whatever little evidence does exist, it lends no credence to the old argument of private sector boosting efficiency. 

Anthony Costello, former director of the Department of Maternal, Newborn, Child and Adolescent Health at the WHO, searched for high-quality randomized trials on the impact of consultancies—but found non—for his book The Social Edge.

In fact, a study on the UK’s National Health Service carried out by University of York professor Ian Kirkpatrick—which, says Vox, is the “only systematic evaluation of the impact of management consultants on the public sector”—found no increase in efficiency from services of private consultants. 

“One would think company boards sanctioning huge payments to management gurus would seek evidence of effectiveness,” Costello told Vox. “The lack of hard evidence on the impact of management methods raises multi-billion-dollar questions.”