Concerns over reform plan, South stresses on "development"

31 Jan 2011

Geneva, 28 Jan (K. M. Gopakumar and Sangeeta Shashikant) -- Developing countries highlighted a number of concerns over the reform agenda on "The Future of Financing for WHO" that was unveiled by the Director-General of the World Health Organization (WHO) at the 128th session of the organization's Executive Board held from 17-25 January.

Several developing countries pointed out amongst others that health cannot be de-linked from socio-economic development, and voiced strong support for the WHO's role in development and its leadership on global health issues. There was also a call for a transparent process to discuss the reform.

While the reform agenda was initially instigated by the need to ensure more predictable and sustainable financing for WHO, proposals for reform that are contained in Director-General Dr Margaret Chan's report (DG's report) suggest a much more far-reaching agenda that could lead to significant changes in the role of WHO on matters of public health at the global level.

The reform plan contained in the DG's report to the Executive Board (EB128/21) itself acknowledges that: "Over the course of 2010, a discussion that started by looking at the future of financing has broadened into an important discussion on the role of WHO in global health and the changes required in the Organization to fulfill that role more effectively."

The DG's report outlines the reform agenda in six key areas, namely, "global health governance", "programme priorities", "results-based planning, budgeting and evaluation", "organisational design", "human resource policy and practice" and "financing for WHO: mobilizing and allocating resources".

Broadly, some of the more contentious reform plans contained in the DG's report include: questioning WHO's role in the field of development and proposing that WHO play a peripheral role (rather than set the agenda) in global health governance; WHO focusing on facilitating technical assistance from other sources rather than providing assistance; implementing a corporate approach to mainstream cross-cutting issues, such as health promotion, gender, human rights and social determinants, substituting the current arrangement of separate departments for each of these themes; distributing certain WHO functions to regional and sub-regional locations; and outsourcing or leaving certain WHO activities for other actors.

On the core issue of financing for WHO, the reform plan surprisingly appears to be short on ideas, as it largely proposes more of the same. The reform plan recognises that "closer alignment between agreed objectives and resources allocation depends on a significant increase in the proportion of flexible, un-earmarked funding".

To solve the problem of financing, the report urges Member States to give "serious consideration to the issue of increasing assessed contributions and, where appropriate, revisiting national policies that restrict their growth". It stresses on the need to attract new donors and explore new sources of funding, in particular targeting Member States with emerging economies, foundations and the private and commercial sector. It further proposes the introduction of a "corporate approach to resource mobilisation" that will include improving the effectiveness of existing resource mobilisation efforts, expanding the donor base of the organisation, and establishing an enabling environment.

The far-reaching implications of the reform plan created much unease, particularly among developing countries and civil society groups.

Several developing countries including Bangladesh, India, Brazil and China raised a number of concerns. In particular, these countries pointed out that health cannot be de-linked from socioeconomic development and WHO reduced to being a mere technical agency. They also expressed strong support for WHO's role in development and its leadership in global health issues.

The importance attached to the reform process can be easily discerned from the opening statement of the Director-General to the 128th Session of the Board (EB128/2). Dr Chan stated that: "WHO needs to change at the administrative, budgetary and programmatic levels. We do not need to change the Constitution, but we do need to undergo some far-reaching reforms".

Executive Board documents EB128/21 and EB128/INF. DOC./2 provide glimpses of the WHO reform agenda. EB128/INF. DOC./2 contains a summary of an informal consultation convened by the Director-General on 12-13 January 2010 (attend by 27 member states), responses of a web-based consultation held between April-October 2010 and discussions of regional committees on this matter in 2010. [Full report of the informal consultation is available at]

Dr Chan's report to the Executive Board (EB128/21) spells out the background, broad content and process of WHO reform.

The report identifies three fundamental problems that drive the need for WHO's reform: (i) clarity regarding WHO's role in global health governance in order to define the role of WHO in relation to other actors in international health; (ii) the over-extension of WHO results in the compromise of effectiveness and efficiency; (iii) the failure of WHO to act with sufficient speed and agility while facing new challenges and a rapidly challenging environment.

It further recognises that the current financial crisis also increases the urgency of reform. It notes that the purpose of reform is to ensure that "WHO is fit for [its] purpose".

"Achieving this objective requires consolidation rather than expansion," the report adds, stating that "Improvements in the quality of financing are more important than ever-higher budgets". "The reform process requires the engagement of Member States, but can move ahead without changes in WHO's Constitution," the report further notes.

The report also identifies four activities of WHO as its "core business": (i) coordinating rapid response to public health emergencies like outbreak of epidemics, natural disasters etc.; (ii) "international norms and standards, as for the safety of food, water, urban air and industrial chemicals, or global strategies and legal instruments for addressing universally-shared problems, such as those posed by tobacco use, the marketing of breast-milk substitutes, or substandard/spurious/falsely-labelled/falsified/counterfeit medical products"; (iii) evidence-based guidance on financing of health services, provisioning of high quality health care and expert advice on the management of individual diseases; and (iv) bringing to the attention of Member States information regarding neglected problems, alerting Member States on alarming trends, assessing the progress of internationally-agreed goals, and encouraging the accountability of Member States, donors and partners.

The report goes on to outline the reform agenda. The reform agenda consists of reforms in six areas -- global health governance, programme priority, results-based planning, budgeting and evaluation, organisational design, human resource policy and practice, and financing for WHO.

The report reaffirms WHO's role in global health governance in two areas -- health security (particularly, outbreak surveillance and response) and humanitarian action, adding that WHO has well-established mechanisms for developing international guidelines, norms, and standards, and these make a clear contribution to global health governance.

Controversially, the report states that the role of WHO in the field of development is "much less clear". It notes that recently, "... development has attracted growing political attention, increasing resources, and a proliferation of global health initiatives", and consequently, it "has attracted an increasingly crowded array of actors with little, if any, effective institutional architecture at the global level".

The report recognizes that "development for health urgently needs greater coordination and coherence", but states that "reform is not the sole responsibility of WHO". It does not see WHO playing a leading role at the global level, stating that "at the global level, however, real progress depends on actions by others". It then goes on to stress the role that "donor countries" can play in becoming more effective and reducing duplication. It further states that "Global health policy is shaped by a wide range of stakeholders from the public, private and voluntary sectors", adding that "it is of growing importance that these voices are also heard in WHO".

It further sees WHO as bringing together actors that can influence global health policy rather than WHO taking the lead to set the agenda on global health policy. In this regard, it informs that "To supplement existing bodies, WHO is introducing a new forum that will bring together Member States, global health funds, development banks, partnerships, non-governmental organizations, civil society organizations, and the private sector to address issues critical to global health."

Under the section on "programme priority", the report notes that given the breadth of WHO's core business, setting specific priorities is a challenge. It further notes that even though priority-setting starts with disease burden and country demand, this does not "always mean that budget allocation should match the scale of the health problem or size of the health burden". Budgetary allocations should reflect the capacity of WHO, executing its core functions, the report says, adding that for some problems, advocacy by WHO is important, but work done by others will have the greatest impact within countries. It cautions that "increasing requests from Member States to add new items for debate or new areas of work can distort the process of responsible priority settings".

The report says that the continuing difficulties with priority-setting will be: (i) given that more than 60% of WHO's income takes the form of highly-specified funding, an area of work that attracts significantly more, earmarked, voluntary funding than another becomes de facto a priority in the absence of sufficiently flexible funding to reduce the imbalance; and (ii) prioritisation cannot be carried out by terminating one or more programs due to the breadth of WHO's core business.

The report notes that progress in the short-term in refining priorities has been based on a review of programs to protect key areas of core business, cost drivers to protect those costs that directly benefit countries and the core functions, thus ensuring that WHO's activities are adjusted to expected levels of income in the current biennium.

It concludes by stating: "Developing a more systematic approach to priority setting is central to the reform agenda" although "experience to date suggests that priority setting cannot be tackled in isolation from how WHO is financed and from other aspects of organizational reform".

According to the report, reform on "results-based planning, budgeting and evaluation" seeks to address two problems. First, the current process of preparing plans and budgets is not always realistic, it states, adding that biennial budgets are aspirational and insufficiently grounded in implementation capacity or the availability of funds to finance the range of activities included. Secondly, much greater precision is needed in defining the results for which WHO itself, at each level of the Organization, is held accountable.

The report says that the objective of the reform process will be to design a more effective system of planning and budgeting, linking strategic, technical and managerial inputs, before embarking on the next General Programme of Work and Medium-Term Strategic Plan. The reform process will also assess the potential for the greater use of independent evaluation in order to better understand WHO's strengths and weaknesses and to inform future priority setting, the report adds.

Reform proposals on "organisational design" involve some drastic changes, and on this, the report suggests: (i) possibility of closure of country offices in certain countries, which no longer need a WHO office; (ii) shifting of emphasis to quality rather than number of personnel in country offices; (iii) changing WHO's current style of working at country level, i. e. shifting from exclusively working with government agencies to working more closely with non-governmental organisations, civil society organisations and the private sector; (iv) that WHO would not remain the exclusive provider of technical assistance but act as facilitator for technical assistance from other sources; (v) to implement a corporate approach to mainstream cross-cutting issues, such as health promotion, gender, human rights and social determinants, instead of the current arrangement of separate departments for these themes; (vi) distribution of functions of WHO between regional and sub-regional locations; (vii) outsourcing or leaving out of certain activities of WHO for other actors.

The report concludes by stating that a "broader set of structural questions will be addressed as part of the reform process", including "developing clear criteria for what WHO should do itself (in terms of both technical work and support functions) and what it should contract out, commission or leave to others". It adds that "WHO will review functions in relation to their location, particularly from the perspective of using low-cost locations for essential services."

On human resource policy and practice, the report attributes WHO's inability to develop and maintain a workforce either with new skills or with an ability to respond to new challenges to WHO's financing model, which is highly specified, not long-term, predictable or flexible.

The report thus proposes a review of the overall staffing model: to achieve consolidation, while allowing for limited growth in others followed by adapting the Staff Rules and Regulation with the aim of ensuring that the most appropriate contract framework is in place and managed to meet changing demands. It adds that the measures will be backed by ongoing work on performance management to promote greater accountability, to increase mobility within the Organization, both in terms of location and job, and to emphasize competency assessment without compromising the evaluation of technical expertise. All reforms will be undertaken in consultation with staff and their representatives, the report further states.

On the issue of "financing for WHO: mobilizing and allocating resources", the report says that "closer alignment between agreed objectives and resources allocation depends on a significant increase in the proportion of flexible, un-earmarked funding". It goes on to identify flexible financing as the "essential ingredient of [the] reform agenda", as "it will enable WHO to respond effectively to new health challenges and a changing environment."

The report goes on to say that "In reality, many voluntary contributions will continue to be specified", but this "arrangement need not be a problem, provided that there are other sources of flexible and predictable funds to ensure alignment of resources across the programme as a whole". It urges Member States to give serious consideration to the issue of increasing assessed contributions and, where appropriate, revisiting national policies that restrict their growth.

It further recognizes that WHO's traditional donors may face their own budgetary pressures and therefore it needs to attract new donors and explore new sources of funding. With regard to the latter option, the report states that the aim will be to widen WHO's resource base, for example, by drawing on Member States with emerging economies, foundations and the private and commercial sector, without compromising independence or adding to organizational fragmentation. WHO will also examine the advantages of a replenishment model for attracting more predictable voluntary contributions.

Dr Chan's report also sees the introduction of a "corporate approach to resource mobilisation" as a central piece of reform, adding that the resource mobilisation strategy is to be anchored on three pillars, viz. improving the effectiveness of existing resource mobilisation efforts, expanding the donor base of the organisation, and establishing an enabling environment.

In terms of "Next Steps", the report only states that subject to the view of the Executive Board, the Director-General will lead the reform process, seeking assistance from external experts where required and soliciting the advice and support of Member States. A more fully developed plan for the reform of WHO will then be submitted to the World Health Assembly in May 2011.

In presenting her report on the reform agenda, the Director-General also implied that certain parts of the reform plan were already being implemented. For instance, Dr Chan informed Member States that WHO will be holding its first multi-stakeholder Global Health Forum in May 2012 in Geneva. Dr Chan also reiterated that WHO should remain a technical organisation based on science.

She also provided more detail on the "Next Steps" right up to the World Health Assembly in May 2011, saying that her office will host a team of staff to look at the managerial reform and a group of experts would be appointed to prepare the details of the various reform proposals, such as on global health governance, including the concept of global health forum, development of framework for priority-setting etc. The report would be made available to Member States in mid-April.

A number of concerns were highlighted by developing countries on the Director-General's reform plan before taking note of her report on the matter.

China said that health is increasingly linked to socioeconomic development. It stressed that WHO should not define itself as a technical support agency, but should be an international organisation with all its functions. It further said that it did not agree to WHO being reduced to a technical agency, adding that it supported WHO's role in the area of "Development". It pointed to WHO's Constitution that has mandated WHO with directing and coordinating international health work.

China also highlighted the need for an international instrument to address the elimination of poverty and socioeconomic inequity. It further urged WHO to not limit its coordination activities to public health emergencies but to also coordinate to provide support in the provision of basic health care.

India said that the lack of funds should not be the reason for closing down WHO country offices. It suggested that the Secretariat firm up a new plan for resource mobilisation before the 64th World Health Assembly in May 2011, adding that the plan should state clearly the role of WHO in providing leadership in global health issues, as well as how to reverse the financial situation. It further suggested developing a mechanism to ensure that voluntary or donor contributions are not channelled for specific programs, but are available for the overall promotion of WHO's goals, which would be determined collectively by Member States.

India noted with apprehension the Secretariat's proposal to tap new sources of finance from foundations and the private sector, since those funds would be conditional. It advocated a code of conduct for voluntary contributions to prevent conflict of interest between donor partners and WHO.

Brazil said that WHO should focus on its primary objective, namely, the attainment by all peoples of the highest possible level of health. It added that WHO should contribute to the strengthening of health systems and not merely services, as mentioned in the (Director-General's) report, and provide guidance and expert advice for the achievement of universal, equitable, integral and high-quality health care.

The role of WHO as the coordinator agency on international health issues calls for initiatives to address the social determinants of health, it said, adding that integrated responses through coherent and equitative social and economic public policies to overcome inequities and advance development and sustainability are critical to improve health outcomes. The recognized inter-linkages among the Millennium Development Goals and the efforts to achieve them have highlighted the importance of addressing the social determinants and the root cause problems of inequitable health conditions, it further said.

Brazil pointed out that in order to achieve these objectives, WHO must undertake the responsibility of coordinating the global health architecture at the international, regional and national levels, and should actively participate in the harmonization of international cooperation and work in a close multi-sectoral relationship with other relevant organizations and actors, guiding global actions and reorienting public funding disparities across and within countries.

In this respect, said Brazil, the international community, in particular Member States and UN agencies, should consider the merging of initiatives so as to reduce the current fragmentation and distortion in the global health architecture, rendering health solidarity more equitable and effective.

It added that in the debate on the future of financing for WHO, its utmost concern was to strengthen WHO and to allow the Organization to carry out its core activities, established by its Constitution. Brazil also pressed for a transparent process of reform to discuss the issue.

Bangladesh said that the core functions of WHO should be as set out in Article 2 of the Constitution, adding that the reform agenda must factor in these functions. It observed that the reform plan in the Director-General's report seeks to dilute some of WHO's core functions.

It also stressed the role of WHO in development, saying that global public health is an integral part of the global discourse on development. It also wondered whether it might be the time to consider a "Development Agenda" for WHO.

Mozambique, on behalf of the African group, stated that reform of the organisation should maintain WHO's leadership position in international health, adding that any debate on financial aspects deserves a wider discussion.

Sri Lanka said that certain terminologies used in the (Director-General's) report like "global health governance" and "health security" need to be defined in the context of WHO's role in the last 64 years.

It also said that foundations or private entities can only supplement and not substitute the work of WHO. It further suggested that WHO should be strengthened by increasing voluntary un-earmarked funding. Sri Lanka also mentioned that WHO should prioritise the needs of the most vulnerable population in developing countries.

Thailand proposed that the reform process be comprehensive and not limited to finance. It also suggested sustainable financing methods, e. g. financing through taxing of international financial transactions, alcohol, tobacco etc.

Hungary, on behalf of the European Union, said that it mandated the Director-General for WHO reform, adding that the Constitution should be the base for reform.

The United States said that the role of WHO in "Development" is not clear. It also expressed concern over the exclusive advocacy role of WHO in certain areas, as proposed in the report.

Several civil society groups expressed concern over the "mainstreaming" of "cross-cutting issues", reducing WHO to a technical body. They also cautioned that public health should not take a back seat to market-led initiatives.

The Peoples Health Movement voiced concern "that the mainstreaming' of cross-cutting issues' will lead to the neglect of such issues." It further said that "WHO must accept the responsibility of engaging in the politics of health as well as advising on technical issues".

In its intervention on the agenda item of non-communicable diseases, Consumers International (through International Baby Food Action Network - IBFAN) raised concerns over the proposed multi-stakeholder forum for health.

It said that the proposal (for the forum for health) seems to amount to a restructuring of global health governance.

The notion of actors with commercial interest sharing policy-making and governance platforms is worrying, it said, warning also that past experience shows that it is hard to ensure that strong policies to protect public health do not take a back seat to market-led initiatives that mainly benefit industry.

Published in SUNS #7077 dated 31 January 2011
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