When Dr. Tedros Adhanom Ghebreyesus took the helm of the World Health Organization in July 2017, his first speech at the headquarters in Geneva landed on a hopeful audience. WHO staff had seen a recent string of new bosses, each with a plan to reinvigorate and shake up the organization. The leaders’ reforms often involved bringing in management consultants, such as McKinsey, one of the world’s most influential and secretive firms. But every attempt had ultimately failed to solve the WHO’s most vexing — and decades-old — challenges, like the agency’s problematic financing structure and related chronic funding shortfalls.

Tedros, as he’s known, suggested things would be different this time. He seemed to sense the staff’s reform fatigue and their leeriness of external consultants, reassuring his rank and file: “Any enduring change at WHO will come from the staff outwards. I do not believe in perpetual reform, and I think WHO staff are reformed out.”

But Tedros appears to have embraced change, of a sort. Halfway through his five-year term, his reform — known as “the transformation” — is still in progress. And while he has offered WHO staff opportunities to engage in the process, the agency is also crawling with outside consultants, current and former WHO staffers told Vox.

“The one thing that WHO staff didn’t want,” said a senior official who was involved in the reform process, “is a McKinsey type of reform,” using the well-known firm as a shorthand for what they’ve seen consultants bring to WHO and other health agencies over the years: “musical chairs,” “cost cutting,” and “debunked management fads.”

In addition to McKinsey, the WHO confirmed they’ve worked with five other consultancies during the transformation: BCG, Deloitte, Preva Group, Seek Development, and most recently, Delivery Associates, which has a multi-year contract worth $3.85 million. The total value of the consultant contracts is about $12 million, at least a quarter of which has been paid for directly by the Bill and Melinda Gates Foundation, one of the most powerful players in global health.

Though the WHO is a public institution, the details of these engagements, and Gates’s involvement, aren’t available in the WHO’s budgets or financial statements. The information that is disclosed on the WHO’s website is incomplete. The WHO has a portal with data on contracts the agency processes — but it excludes those paid for directly by donors like Gates. It’s also missing information on what, exactly, consultants have been hired to do.

For example, the portal shows the WHO’s headquarters awarded McKinsey with $4.19 million in contracts between 2017 and 2018 — but not whether those were reform-related. (The WHO declined to specify.)

Even agency staff — including officials who have reported directly to Tedros — say they’ve been left in the dark.

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. Another told Vox: “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.” A third said: “It’s now been two years [the reform] has been going on. I have no idea what is happening.”

How consultants are shaping global health

Global health, a field dedicated to improving the health and wellbeing of the poor and most vulnerable, has quietly developed a penchant for highly-paid management consultants and their business world tools.

According to an internal 2016 McKinsey PowerPoint presentation obtained by Vox, the firm has been involved in the 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, the Vaccine Alliance — a global public–private partnership focused on expanding access to immunizations in poor countries — from its earliest days, helping develop their vaccine financing strategies. Ditto, the Global Fund (another public-private partnership that invests in treatment and prevention for infectious diseases like HIV/AIDs, TB, and malaria), UNITAID, the Gates Foundation, the global health nonprofit Partners in Health, and the WHO.

The 80-plus global health leaders and staff, current and former consultants at multiple firms, researchers, health care professionals, and NGO workers we spoke to for this story described the consultants as “pervasive” and “ubiquitous.” And many have become wary of consultants’ involvement in the sector.

But how these secretive businesses, which mostly profit from serving corporate interests, are shaping global public health is an open question — and one that’s hard to answer. An additional mystery: How much money — designated by foundations and governments for improving the health of the poorest — is being spent on them?

These and other uncertainties concern global health workers and analysts, many of whom would only speak on the condition of anonymity for fear of compromising their professional prospects.

While some believe management consultants can help institutions become more effective, others are dubious, particularly after they’ve seen the consultants’ interventions fail to help — and in some cases even damage — institutions. And they’ve begun questioning whether precious resources, especially money designated to helping save and cure the poorest people in the world, should be flowing to the highest-paid consultants in the world — who simultaneously advise industries that are exacerbating public health problems.

“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, a global health pioneer who led the UK’s first HIV/AIDS program, and has worked with consultants from multiple firms over the decades.

Madhu Pai, who directs McGill University’s global health program, recently wrote of an African colleague who has had to face “‘kids’ with little or no experience [coming] all the time to ‘advise’ her government on what to do about health.” Pai now calls this “global health consulting malpractice.”

Do you have a tip about consultants in global health or the reforms at the WHO? Contact reporter Julia Belluz at julia.belluz@vox.com, on Twitter @JuliaofToronto, or via Signal.

The opaque nature of the consulting business means it’s difficult to know which firms are most influential. While Dalberg, PwC, Accenture, Bain, and others came up, McKinsey and BCG seem to have an outsized impact on the global health sector. One measure of that: The two firms have consistently been among the top five professional services’ contractors at the Gates Foundation, according to the foundation’s tax returns, even after the organization vowed to, and did, curtail spending on consultants beginning in 2015.

A WHO spokesperson said the agency welcomed the use of consultants. “The [consulting] companies have supported WHO in areas where we lack in-house expertise or want to tap the current best-in-class standards,” the person told Vox. “These are not unreasonable expenditures for an organization of our size, with a biennial budget of around $6 billion and more than 8,000 staff in almost every country around the world.”

“Since 2017, we have committed $11.509 million to support WHO transformation efforts,” a Gates Foundation spokesperson said. “WHO sought these funds to help it implement reforms that had been requested by its member states.”

BCG declined to comment. A McKinsey spokesperson said, “We are proud of our work on global public health.”

The latter firm has been in the news lately for advising the Trump administration to cut spending on food and medical supplies for migrants, manipulating statistics at Rikers Island prison, and declining to disclose the client details of Democratic presidential candidate and former McKinsey staffer Pete Buttigieg’s work, until the lack of transparency became an issue in the Democratic primary.

In global health, critics are also demanding more transparency from the firms themselves, and from the organizations that keep hiring consultants — beginning with the Gates Foundation.

“The rise of the Gates Foundation has resulted in more space being created for management consultancies to solve global health’s problems,” said Devi Sridhar, chair in global public health at the University of Edinburgh. “The challenge is trying to follow the money, and figure out the relationships between funders like Gates, consultancy firms, and the WHO.”

Indeed, the philanthropic juggernaut changed the face of global health. It also quietly played an instrumental role in launching the field’s consulting era.

How we got here: The Gates Foundation believes in consultants

In the early part of the 21st century, “international health” was an often-forgotten, under-funded, public sector or NGO-supported enterprise, focused on understanding and fighting the diseases affecting mainly developing countries. As recently as the 1990s, the WHO was one of a few key funding sources, alongside other multilateral organizations (like the World Bank), health-related UN agencies (like UNAIDS), and national governments (like the UK).

Around the turn of the 21st century, that changed. In 2000, the UN set its Millennium Development Goals around health-related targets, which the organization’s 191 member countries agreed to work toward by 2015, according to a report on the “golden age” of global health funding. The same year, Group of Eight (G8) countries called for a reduction in infectious diseases — HIV/AIDS, TB, and malaria — that “threaten to reverse decades of development.”

In parallel, the US government and American NGOs ramped up their spending on global health — so did American philanthropists, most notably Bill and Melinda Gates and Warren Buffett. Together, the trio formed the Gates Foundation, based on the belief that improvements in health (as well as education and development) could happen in low- and middle-income countries, with the help of science and technology. Since its inception in 2000, the foundation has given out more than $50 billion.

Between 1990 and 2018, investments in development assistance for health grew more than five-fold, according to the Institute for Health Metrics and Evaluation, from $7.7 billion to $38.9 billion.

Over this period, “international health” became known as “global health,” and with Gates’s help, the sector gained an unprecedented degree of visibility. The foundation’s funding helped set up public-private partnerships like Gavi, which has boosted immunization rates around the world. The foundation distributed billions of dollars to fight crippling infectious diseases such as polio, HIV/AIDS, tuberculosis, and malaria. They also fund media organizations to report more frequently on global health.

“Gates changed the whole complexion of global health,” said Don de Savigny, a professor of health systems at the Swiss Tropical and Public Health Institute, and adviser to the WHO. These investments have unquestionably had a profound impact.

“[Gates funding] has brought remarkable innovation, creativity, and new ways of organizing and delivering global health,” said Gavin Yamey, a professor of global health and public policy at Duke University and a Gates Foundation grantee. “The foundation helped to support the launch of highly innovative, new forms of global health cooperation that have had a documented impact.” For example, Yamey said, the foundation contributed $750 million to launch Gavi, which now estimates that it has averted 13 million deaths.

The foundation also introduced a new way of doing things, said Linsey McGoey, a University of Essex professor and author of the book No Such Thing As a Free Gift, about the foundation. The three trustees, Bill and Melinda Gates, and Warren Buffett — two of them titans of corporate America — wanted to borrow from and work with the private sector. They pursued a results-based, data-driven approach to health and development — the exact method consultancies like McKinsey and BCG excel at.

“At times, the most effective way to achieve our mission is to work with consultants who have deep expertise relevant to the problems we’re trying to solve,” the Gates Foundation told Vox in a statement.

For instance, Gates engaged McKinsey to work with the Nigerian government and Global Polio Eradication Initiative partners on establishing emergency operations centers. BCG, according to Gates, helped “organize the multi-partner effort that led to the development and launch of a safe and effective vaccine to protect against meningitis A, the first vaccine to be developed specifically for Africa.”

At the WHO, Tedros affirmed that consultants provide the kind of expertise his organization needs. “If I am building a house,” he told Vox in a statement, “I will have a vision of what I want it to look like and how I want it to function, but I won’t attempt to build it myself, I will employ an architect or an engineer. The same is true of WHO.”

A WHO spokesperson said all relationships with philanthropic foundations are governed by the WHO’s code of conduct for the agency’s engagement with non-state actors. Established in 2016, it’s meant to protect the WHO from “conflicts of interest, reputational risks and undue influence.”

But critics like McGoey wonder how much autonomy recipients of Gates’s money, like the WHO, really have. The WHO has always been funded by two types of contributions: “assessed” and “voluntary.” Its member countries have to pay dues to the agency each year — the assessed contributions — and WHO staff can direct funding to areas they think should be prioritized.

With assessed contributions, McGoey said, “the WHO typically has more freedom to spend the money on the most pressing health concerns, rather than on pet projects specified by a charitable donor.” With voluntary funding — the type Gates gives — the donations are overwhelmingly specified for a particular purpose by the donor. In 2018, Gates was again one of the top three contributors of voluntary funds to the WHO’s general fund.

“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.”

Those strings can involve hiring consultants, an ex-McKinsey consultant who worked on global health projects, said. 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.”

Why McKinsey elbowed its way into global health, according to its internal documents

The rise of consultants in the global health sector wasn’t just driven by powerful foundations embracing them. The field of global public health has also been a boon for McKinsey — for new business, talent recruitment and retention, and public relations.

McKinsey saw an opportunity in the Gates Foundation’s growing influence — and the “private sector involvement” that came with that — when the firm was contemplating expanding its global health work, according to internal planning documents obtained by Vox.

“We are witnessing a transformation in the way the world goes about solving its toughest and most urgent problems,” read one 2006 document, which was prepared for McKinsey’s Shareholders Council — the firm’s ultimate decision-making body, equivalent to a board of directors. The document singled out “the rise of the global philanthropists” in rationalizing a global health focus:

In the US alone, individuals will donate $5.5 to $7.4 trillion to charitable causes between 1998 and 2017. Globally-focused institutions like the Gates Foundation are leading a sea change in philanthropic giving: Their founders are actively involved, they distribute far greater sums far more quickly, they demand measurable results and are pioneering innovative solutions, on a national and global scale.

McKinsey was interested in more than just pursuing profits. In the document, McKinsey said it saw itself as “ideally suited” for tackling cross-cutting problems, such as the HIV epidemic.

“We solve tough problems for a living. We operate fluidly across geographies and sectors of society. We are objective and fact-based. We are credible with world leaders and have ‘convening power’ within the private sector.” The firm could also “‘raise our game’ in tackling important societal problems” while also having an impact and “delivering inspiring leadership opportunities for our people,” according to a McKinsey Shareholders Council meeting presentation in September 2006.

To increase its global health influence, McKinsey had to invest time and resources. Consultants had to “publish actively, co-host major conferences and reach [a] level of recognition that we are invited to present/moderate at all within these areas of expertise.” They had to develop “long-term partnerships” with “sector leaders” such as the Gates Foundation, Gavi, the WHO, and the health-focused Clinton Foundation. The internal documents suggested the firm undertake a mixture of pro bono and discounted fee work.

During 2005-2006, global health activities at McKinsey consisted of 10 to 15 projects per year, according to the documents, and McKinsey hoped this would turn into 30 projects annually by 2009. Today, the firm’s “social sector” practice, however, includes among others, the Global Public Health group, focused on advising “foundations, governments, bilateral and multilateral agencies, and healthcare companies” with projects in 35 countries.

Consultants told us pro bono contracts often turn into paid work. Or as author Duff McDonald wrote in his history of McKinsey, The Firm: “Once [consultants] get the wedge end of a relationship into a company in the form of one engagement, they usually manage to hammer in the rest. ... To wit: They never leave.”

The firm declined to comment on the internal documents or provide details of its current revenues, but an internally published history shared with Vox estimated the social sector practice made up less than 5 percent of McKinsey’s overall work in 2009. Today, global public health work represents less than 1 percent of the firm’s work globally.

Given that McKinsey’s revenue is now $10 billion, the ex-McKinsey consultant, who worked on global health projects, estimated the firm likely generates at least $100 million in annual revenue from all social sector projects.

Even so, McKinsey’s history says social sector projects have had a “disproportionate impact on the Firm’s external image and internal sense of purpose.” They’re also a powerful recruiting tool, particularly in an era when McKinsey is facing tougher questions from a new generation of job candidates, more energized by the idea of fighting an Ebola outbreak than helping pharmaceutical companies profit.

Behind closed doors, however, another former McKinsey consultant, who recently left the firm, explained that getting on these projects is a competitive slog that requires lobbying. They’re also not as well remunerated as other positions.

“Externally, they want to put their best face forward — the most inspiring work,” the consultant said. “Internally, those projects are super hard to get on. They are in high demand. And when you’re working on social sector projects, you get paid 75 percent of your full compensation for the duration of the project. So I think it sends a clear message about how the work is valued.”

McKinsey would not comment on the details of its global health employees’ compensation. A person familiar with the firm’s recent compensation structure confirmed the discounted rate but said it may vary depending on a staffer’s role.

“McKinsey began working on global public health issues three decades ago because a group of colleagues was passionate about public health and believed they could make a positive difference,” a firm spokesperson said in a statement. “This has included helping to end preventable child deaths, control and eradicate infectious diseases, and enhance emergency response capabilities, among other important initiatives.”

Global health’s consulting dilemmas

The contributions of McKinsey and other consulting groups to global health are now being questioned, and they’re part of a larger conversation, mainstreamed by ex-McKinsey consultant and author Anand Giridharadas, about doing right by the world’s poor, trying to reduce wealth disparities, and saving lives efficiently and effectively. In conversations with more than 80 people who’ve worked in global health, including a dozen current and former consultants, these questions and concerns came up again and again:

How much is spent on consultants, who is paying, and what evidence do we have that it’s money well invested?

First and foremost, there’s the money question: How much flows to consultants in global health and who is paying their bills? The answers speak directly to concerns over transparency and power. You can’t understand who is influencing global health agendas, and by how much, if you don’t know who is carrying out the work and how they’re being paid.

Yet it’s impossible to get the full picture. The firms, citing client privacy, don’t disclose the contract details of their relationships, 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. There’s also no information about consulting contracts paid for through in-kind donations, like the consultants’ work on reform paid for by Gates.

“A lot of the information is not public or transparent”

Foundations like Gates’s disclose spending on various consultants in their tax returns, but 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.

This murkiness has frustrated the University of Edinburgh’s Sridhar, who has been trying to track the investments in management consultants for global health by international and philanthropic organizations.

“It’s an open secret in global health that all of this is happening,” she said. “[But] a lot of the information is not public or transparent. And it matters for accountability, transparency, and to ensure we can follow that the money is going to where it’s most needed.”

The fragments of public data we do have suggest it’s a staggering amount. In total, the Gates Foundation spent more than $300 million on McKinsey and BCG between 2006 and 2017, according to the foundation’s tax returns. 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.

Many people we spoke to questioned whether the dollars could have had more of an impact if they were spent elsewhere. “If you could add up the amount of money [global health] foundations spent on consultants, they could have funded research and developed a new drug or vaccine,” said one senior global health official, who has worked directly with consultants on public health projects.

An ex-consultant, who quit a major firm over a public health project she thought the firm handled badly, stated, “The harm is you’re taking scarce research and development resources you could have put into better things.”

Others wondered what evidence supported the investment in consultants. Global health is a field that’s supposed to be evidence-based, said Anthony Costello, the former director of the Department of Maternal, Newborn, Child and Adolescent Health at the WHO. But after looking for high-quality randomized trials on the impact of consultants for his book The Social Edge, and finding none, he wrote: “One would think company boards sanctioning huge payments to management gurus would seek evidence of effectiveness. ... The lack of hard evidence on the impact of management methods raises multi-billion dollar questions.”

From that exercise, he told Vox he came away “astonished” about global health’s reliance on consultants, and “a skeptic of the amount of funding that goes into [them].”

Since Costello searched for evidence, the only systematic evaluation of the impact of management consultants on the public sector — a study of the UK’s National Health Service — found no increase in efficiency from their services. “The theory [is] if you spend money on consultants, even if only for strategic advice, it would have some impact on your efficiency. You’d expect some gain,” said the study’s author, Ian Kirkpatrick, a professor at the University of York in the UK, who studies management consultants. “We actually find there is no gain.”

When consultants’ advice flops in global public health, who is accountable?

The hundreds of millions spent on consultants, and lack of systematic evidence to support hiring them, is more concerning when you consider one feature that makes global health different from other areas: When consultants’ advice fails, it’s the lives of the poor and marginalized on the line. Or, in the case of McKinsey’s work with UNITAID, an organization funded mainly by public money, it was a high-profile fundraising initiative for tuberculosis, HIV/AIDS, and malaria in developing countries that failed.

When UNITAID was created in 2006, it was hailed for establishing a new funding model through a small tax on airline tickets in some countries. But by 2007, bringing new countries with significant airline markets on board was proving difficult. So UNITAID’s chair at the time, Philippe Douste-Blazy, along with some of his close allies in the tourism business, came up with an idea: Why not work with the travel industry directly and offer travelers the possibility of making micro-donations every time they purchase an airline ticket?

The agency turned to McKinsey to get advice on the idea because, “That was just the way things worked,” Douste-Blazy wrote in his 2010 book, Power in Numbers. UNITAID was also funded by the Gates Foundation, which, from day one, paid for McKinsey’s consulting work, according to UNITAID’s publicly available 2006 board minutes. UNITAID’s board suggested a feasibility study be done before launching the new fundraising program, known as “MassiveGood.” Since McKinsey was already working there thanks to Gates, the firm was the obvious choice.

Consultants at the firm proposed a four-month study for $1 million. In April 2008, McKinsey presented its analysis to the UNITAID board. They didn’t find any fault in UNITAID’s plan; instead, the consultants endorsed it as a “great idea,” Douste-Blazy wrote. McKinsey’s study projected that the new fundraising strategy could raise $1 billion annually from private donors, a doubling of UNITAID’s budget. So the board moved ahead with the plan, allocating a provisional budget of $10 million for the first year, and $12 million for the second year.

MassiveGood launched with a splash at the United Nations in New York in 2010. Then-UN Secretary General Ban Ki-moon, Bill Clinton, and director Spike Lee announced the campaign. Backed by the Gates Foundation, the scheme was hailed as an innovation in health care financing by major media outlets.

But McKinsey’s projections were wrong. Travelers did not want to donate even meager sums to the organization. By July 2010, the foundation had only raised $14,000 from the new initiative — a sum far less than 1 percent of the $1 billion McKinsey projected. It didn’t even offset the $11 million UNITAID wound up paying out for consulting fees, advertising, and legal expenses.

Several members of the board expressed “concerns that UNITAID had invested such a large amount of funds with very little return,” and recommended the initiative be independently assessed. To do so, UNITAID hired yet another consulting firm, Dalberg. Its study, the costs of which were not made public, was damning and pointed at flaws in the assumptions and initial revenue modeling produced by McKinsey.

The foundation raised $14,000 — far less than 1 percent of the $1 billion McKinsey projected

By December 2011, UNITAID’s chair reported that the MassiveGood project had failed to reach its objectives, and that its board had passed a resolution to dissolve it. So MassiveGood — and the millions of US dollars invested in the project, as well as its proceeds aimed at fighting HIV/AIDS, malaria, and tuberculosis — were gone. (UNITAID and McKinsey declined to comment.)

Former UNITAID staff and board members voiced frustration over the resources that were sucked into what turned out to be a dead-end for the organization in interviews with Vox. Instead of sending UNITAID in the right direction with a successful campaign, the exercise risked discrediting the organization, one ex-staffer said. “Everyone was so embarrassed by its failure — all these national governments.” The exercise also raised questions about who is publicly accountable when consultants’ advice fails at organizations funded, wholly or in part, by public money. “There [was] no accountability,” the ex-staffer said, “about how McKinsey got it wrong.”

Is it ethical to hire Western consultants if they supplant locals in developing countries and give out-of-context health advice?

The growing reliance on what are often US consulting firms, Vox learned, is a symptom of a larger problem at global health organizations: The work is still done by people in wealthy countries for people in developing countries, too often without their participation.

“It’s frustrating in 2019 that the flows [of money and knowledge] are entirely from north to south,” said McGill’s Pai. “It’s understandable this happened 50, 100 years ago — but why this happens today is an important question to ask.”

Before Pai moved to Canada from India, he saw firsthand how this imbalance manifests: External consultants were overwhelmingly favored over hiring locals with deep expertise on local health problems.

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,” he said. “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.”

Anand Giridharadas, the ex-McKinsey consultant and author, has likened this phenomenon to a new form of colonization in his recent book, Winners Take All. “The situation was no longer British colonizers helping themselves to your country,” he writes. “It was well-suited people with laptops offering to solve social problems, often pro bono, without needing to know much.”

The well-suited outsiders too often give advice that lacks context — like pushing high-tech solutions in low-resource places, Sandro Galea, dean of the Boston University School of Public Health, said. In the mid-aughts, he recalls management consultants advising government officials in Liberia to create a system for electronic medical records for the whole population. For Galea, who was doing research in Liberia at the time, it seemed like a no brainer: it wouldn’t work.

“I am thinking, there isn’t electricity here for 23 of 24 hours a day,” Galea said. “Consultants are drawn to flashy technology, but that technology requires infrastructure, like electricity, that was non-existent.”

In global health consulting, it’s also sometimes knowledge of health, or public sector and multilateral organizations, that’s lacking.

One former consultant told Vox about quitting a major consulting firm in 2016 over a public health project gone awry. The ex-consultant, who has graduate degrees in public health, had been assigned by the firm to a team where the other members had no health expertise. Together, they were tasked with making a recommendation about female contraceptives in West Africa.

“The consultants could not understand our humanitarian business”

The team’s leader insisted on pushing a form of birth control the ex-consultant had warned would never be accepted in the country. “It’s really hard to learn all the nuances of development quickly, especially if you’re not humble,” the ex-consultant said. “And I don’t think many consultants are humble.”

Instead of humility, what’s favored is fast advice and measurable results, or as BCG describes them, “private-sector approaches.” These approaches have become “the essential toolkit for solving anything” in “our age of market supremacy,” Giridharadas writes. But even though they can sometimes be helpful inside public institutions, they aren’t always a good fit in global health.

When Mukesh Kapila worked as undersecretary general for the International Federation of Red Cross and Red Crescent Societies from 2010 to 2012, he and his team hired consultants to develop a new business strategy for the organization. “The consultants could not understand our humanitarian business and their recommendations were completely irrelevant,” he recalls. “It was a complete failure … a complete and utter waste.” He wound up ignoring the firm’s advice.

Former WHO executives, with decades of experience at the agency, told Vox they felt the consultants did not fundamentally understand the organization and provided business solutions that didn’t make sense. “Consultants have often found it difficult to ... appreciate decision-making processes at a multilateral international agency,” one said. “The private sector models have not been particularly helpful.”

Another ex-official said, “A lot of the recommendations made over the decades with different consultants coming in and trying to help reform the WHO — my guess is the majority of the recommendations have not been implemented and it would be more sensible to find out why the recommendations were not implemented instead of just repeating or iterating them.”

Can consultants take credit for solving global health problems while also working for the industries that exacerbate them?

There’s an even deeper conflict between consultants’ private sector experiences and their public sector global health work: Their advice has been linked to some of the most urgent health crises of the last half-century.

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. “Our historical work for clients in this industry was designed to support the legal prescription and use of our clients’ products,” McKinsey told Vox in a statement. “However, opioids have had a devastating impact on our communities, and we are no longer advising any clients on any opioid-specific business.”

McKinsey has also recently egged on another deadly industry — coal. In 2015, their analysis of Poland’s economy encouraged the country to boost the efficiency and productivity of coal mining in order to help the Central European country become one of the “world’s most advanced economies.”

In the report, McKinsey consultants suggested one key way to achieve “double-digit productivity improvement” in coal mining would be to “eliminate those regulatory barriers that increase effective costs and decrease labor productivity without improving safety or work conditions.”

For years, the environmental health dangers of Poland’s coal industry have been documented: Poland’s coal mining industry plays a large role in the country’s pollution crisis. A 2014 air quality report from the European Environment Agency, singled out Poland and coal burning as leading contributors to air pollution in Europe. The same year, the WHO warned that air pollution is “the single biggest environmental health risk.” Now, 33 of the 50 most polluted cities and towns in the European Union are in Poland, according to the WHO, earning the country the moniker the “continent’s capital of smog.”

“[McKinsey’s] advice is completely wrong and anachronistic, even in 2015,” said Zoltán Massay-Kosubek, policy manager at the European Public Health Alliance, a public health advocacy NGO based in Brussels. “The air wasn’t cleaner five years ago.”

In 2018, the EU’s highest court even charged Poland with “persistently” exceeding air pollution limits, endangering human health. That’s why a WHO bulletin advised doing exactly the opposite of what the McKinsey report suggested: using tougher regulations on coal to increase the cost and encourage the shift to cleaner energy sources. (More recently, McKinsey has done analyses of how the industrial sector and cities can reduce carbon emissions.)

Meanwhile, consultancies have helped grow the market around the world for processed foods and beverages, including soda, which has been heavily linked to the global obesity and diabetes pandemics.

In a 2015 report from BCG — co-developed with the Confederation of Indian Industries, including the then chair and CEO of PepsiCo India — the firm looked at how to increase India’s market for “Fast-Moving Consumer Goods,” including sugary drinks. The report came out well after discussions about reducing sugary drinks consumption, and even taxing the products, to curb disease — something the WHO supports — gained prominence. (BCG declined to comment.)

“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 and other global health agencies “should be avoiding any management company that has linkages with the food, health care, or tobacco sectors,” said University of North Carolina Gillings School of Global Public Health obesity expert Barry Popkin. He pointed out that Bloomberg Philanthropies has longstanding guidelines around not hiring any company, including management consulting firms, with ties to industries that undermine their public health work. The philanthropy has not worked with McKinsey or BCG in at least the past five years.

Adam Kamradt-Scott, a professor in global health at the University of Sydney who studies the WHO, applauded its conflict-of-interest policies around tobacco. But he said despite “calls for the WHO to take a similar tough stand on the alcohol and sugar industries, we haven’t seen much progress in that yet.” He added, “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.)

These conflicts are more apparent in a time when there’s greater scrutiny of how the winners of global capitalism are taking credit for reputedly solving the problems of the losers.

“The social and humanitarian sectors have been conquered by the idea that business people and business methods are specially capable of reforming them and improving people’s lives,” Giridharadas, the ex-consultant and author, told Vox. “The problem with the winner-take-all approach to solving public problems is that the winners, McKinsey among them, get to shape what change is and ignore their role in perpetuating the very problems they claim to be solving.”

In a phone interview, Giridharadas imagined another world, where consultants took an approach that was truly considerate of health instead of just maximizing profits. “Imagine if McKinsey advised its pharma clients not to cling to patents in developing countries that make it so hard to fight HIV/AIDS. Imagine if it advised food and beverage behemoths to stop selling the products that cause obesity and heart disease. Imagine if it actually persuaded its clients to pay their taxes instead of avoiding them so that national health organizations and organizations like WHO would have adequate resources.”

For now, McGill’s Madhu Pai said, consultants and their business strategies remain extremely influential. “The corporate way of thinking has become the way global health organizations think.”

Do you have a story to share about consultants in global health or the reforms at the WHO? Contact Vox reporter Julia Belluz on email at julia.belluz@vox.com, Twitter @JuliaofToronto, or via Signal.

Marine Buissonniere is an independent researcher and adviser on humanitarian issues and global health.

Clarification: The article has been updated to clarify that the New York Times and ProPublica stories about McKinsey’s advice to two companies on how to increase sales of prescription opioids cited allegations from lawsuits.