EXECUTIVE BOARD Special session on WHO reform Provisional agenda item 3.1
EBSS/2/INF.DOC./7 25 October 2011
WHO reform
The Director-General has the honour to transmit to the Executive Board the report provided on behalf of the Regional Committee for the Eastern Mediterranean, in line with operative paragraph 4 of decision EB129(8). The report is provided in the annex.
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ANNEX REPORT OF THE REGIONAL COMMITTEE FOR THE EASTERN MEDITERRANEAN
WHO reform for a healthy future Dr Abdulla Assaedi, Deputy Regional Director, presented the agenda item on WHO reform for a healthy future. He said that discussions on WHO reform had begun with a consultation on the future of financing for WHO in early 2010. Following discussion by the Executive Board, an agenda for reform, proposed by the Director-General, was endorsed by the World Health Assembly in May 2011. The 129th Executive Board had called for a transparent, Member-State driven and inclusive consultative process on WHO reform, based on existing mechanisms, and requested regional committees to engage in strategic discussions regarding the WHO reform process, summaries of which would be reported to the Special Session of the Executive Board in November 2011. The reform was expected to focus core business to address the 21st century health challenges, reform the financing and management of WHO and transform governance to strengthen public health. WHO would focus the scope of its work on what it did best, working on priority issues identified by Member States, with adequate financing for these areas of focus. The 64th World Health Assembly had endorsed five areas of core business for WHO: health systems and institutions; health and development; health security; evidence on health trends and determinants; and convening for better health. The next task was to identify: the priorities in each area of core business, the expected outputs and outcomes and the proposed measurements of performance. Dr Assaedi then described the proposal for WHO financing and managerial reforms, focusing on: organizational effectiveness and alignment; results-based management and accountability; financing, resource mobilization and strategic communication; and the human resources framework. Finally, he said, reform would look at governance of the organization. This would involve transforming at governance of WHO itself, including a mechanism for priority-setting, the work of the governing bodies, engagement of Member States, and oversight. It would also involve global health governance and measures to enhance the leadership role of WHO. Discussions H.E. the Minister of Health of Qatar noted that the reform process was twofold. Internal reform was the role of the Secretariat and external reform was the role of the Member States. He also said that elements of success must be looked at from all perspectives; in terms of the political, economic, social, legal and environmental aspects. They should all be encompassed by the reform. He suggested that priority-setting must start with the most simple problems and build up to the most difficult. These priorities should be tackled accordingly. Success stories must be publicized. He enquired as to whether there was a projection for self-financing, through investments and whether or not this was allowed in the Organization. He also enquired about voluntary employment opportunities; either at country or regional level, pointing out that this should cut down the financial costs to the organization and ensure the participation of proactive elements in implementing the Organization’s activities.
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The Representative of the Islamic Republic of Iran said that, in general, Member States agreed with the concepts in the paper on reform – priority setting, efficiency, effectiveness, transparency, accountability, and results-based planning – but wondered whether the suggested proposals were conducive to these goals. He said that considering the intergovernmental nature of WHO a priority-setting mechanism was needed to improve the effectiveness of the Organization. The Organization’s financing did not always match well with its priorities and plans. One of the most important issues was the relationship between short- and long-term objectives and Member States needed oversight and direction in this. He felt that some of the Organization’s ways of working were outdated. Instead of the term “results-based planning”, he preferred “results-based management”, as programme activities only started with planning but moved through a whole process involving budgeting, implementation, monitoring, evaluation and feedback to keep the Organization effective. He urged WHO to learn from the experiences and lessons of other agencies. He expressed the need for better alignment between WHO’s global and regional governing bodies. He expressed his concern that financing on WHO did not match always with its priorities. He made reference to the World Health Assembly (WHA) resolution WHA64.2 which requested the Director General, in consultation with Member States to develop an approach to independent evaluation and to present a first report on the independent evaluation of the work of WHO to the 65th WHA in May 2012. He expressed concern about the ability of Member States to establish a consortium group to do this within such a short time frame. The Representative of Lebanon noted that one of the reasons for initiating the process of reform was the difficulty faced by the Organization in carrying out a large number of tasks with limited resources. This necessitated that only essential work be conducted and priorities set. He enquired about tasks or priorities that WHO will not focus on anymore and who would do its job. He asked if a new agency or fund would be established to undertake additional tasks. Governance required that the Organization be more transparent, accountable and effective and to avoid ambiguous terms. He also noted that for the process of evaluating country progress, an advanced information system needed to be created, although recognized that this was not feasible for a number of countries in the Region. He said that the Organization, within the framework of global governance, needed to play a leading role in international health efforts, as mandated by the WHO Constitution, but questioned the willingness of other agencies to “allow” it to do so, with the number of global health organizations increasing. He added that financing needed to be sustainable and predictable and suggested that either assessed contributions be increased or to change the way that resources are managed. The Representative of Iraq highlighted the importance of quality management standards and indicators for the planning, implementation, monitoring and evaluation process of all WHO activities. There was a need to enhance the mechanisms of governance to follow-up on these activities and to ensure the best utilization of available resources and the use of health economics, especially in terms of the administrative expenses of the Organization. Effective partnerships needed to be built with countries for the planning, implementation, monitoring and evaluation of joint programmes, especially for prudent financial control. It was important for countries to review WHO financial reports, at the country level, and integrate primary health care programmes to ensure the best utilization of resources. He called for effective partnership between international organizations and nongovernmental organizations in respect of implementation of joint programmes. An ongoing regular review of the reform process was important in order to address any identified problems.
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H.E. the Minister of Health of Sudan emphasized the importance of setting practical objectives which could be implemented with existing resources. The leadership role of the Organization in international health needed to be emphasized, not by excluding other agencies, but by distributing roles through proper coordination to achieve what was needed. The relationship between WHO programmes and the role of the private sector in all fields needed clarification, such that maximum benefit would be realized, while maintaining the technical independence of the Organization. He called for greater involvement of countries by organizing meetings and gatherings in these countries with other health partners. He stressed the importance of using simple and understandable language in WHO publications and documents and in the training courses organized for country trainees to ensure maximum benefit. The Representative of Yemen said that focusing on areas that WHO can do best is contradicting to the role of WHO to support the needs of member states. He added that the experience of this Region with reform was a serious endeavour and an ongoing process. He pointed out that the reform process ought to ensure the best utilization of resources in accordance with typical criteria and standards. He criticised the ambiguity of terms related to governance which required further clarification and more details. He added that there was a need to identify new resources, and utilize the services of WHO former and current experts. He questioned who would undertake areas of work dropped by the Organization. He stressed the importance of ensuring full coordination with the agencies and institutions that would be entrusted with such work. He also stressed the need to provide clarification and explanation on the phases of reform and clarification on the role of both the Secretariat and the Member States. The Representative of Bahrain noted that the holding of annual meetings by WHO with civil society organizations and relevant partners would enable the Organization to become properly involved with civil society, in accordance with the paper on reform and its proposed directions. She added that consulting with those organizations on the control of noncommunicable diseases was a step in the right direction. The setting of urgent global and regional priorities was a practice of good governance. Moreover, redirecting resources according to these priorities and based on surveys and evidence enabled decision- makers to make informed decisions. She highlighted the importance of developing clear performance indicators for evaluation and follow up. She also stressed the need for proper coordination and partnership with United Nations organizations in order to avoid duplication and fragmented efforts. She indicated agreement with the proposed managerial reform steps. The Representative of Egypt said that the WHO budget for Member States was allocated for specific activities and moving funds from one programme to another was not supported. That rendered countries unable to determine funding priorities. Funding was sometimes duplicated by WHO and other organizations, with the same programmatic activities divided between several donors. He pointed out that WHO had a prominent role in capacity-building in the field of public health in all countries of the Region. He questioned why WHO no longer supported the training of students of epidemiology, public health and vital statistics. The Representative of Morocco stressed the need for WHO to be more resilient in addressing the needs of different countries and regions by enriching national health policies and activating a new strategic priority-setting mechanism taking into consideration regional particularities. He added that there was a need to develop an institutionalized approach to resource mobilization, ensuring sustainability and resilience, as well as the development of a global health information system. He
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requested that as Member States of the Region would be chairing the Executive Board the opportunity should be exploited to make the important reform initiative a success through extending the necessary efforts and support. He praised the efforts of WHO in structuring the reform process and ensuring its implementation according to the defined schedule. He requested that the Regional Director make his own evaluation of the process from the perspective of his long and rich experience. The Representative of the Syrian Arab Republic suggested that a meeting be convened between representatives of countries of the Eastern Mediterranean Region on the Executive Board with members of the Regional Office leading the process of reform to discuss the reform and make the necessary arrangements for coordination and consultation to develop a unified working paper representing the views of the Region on the reform process. This paper would be presented to the forthcoming regular meeting of the Executive Board, to be held in January 2012. H.E. the Minister of Health of Public Health of Afghanistan said that from a country perspective they welcomed the proposal suggested as part of WHO reform of working more closely with civil society groups and the private sector. She said that investment in WHO national staff was needed to improve technical capacity at the country level. Changes were needed in regard to local contracts. WHO Afghanistan, specifically, had lost its reputation for recruiting the best people and that “good” people were discouraged from coming to the country. WHO was requested to introduce more incentives to attract more competent and qualified staff to work for WHO at country level. The Representative of the United Arab Emirates emphasized the importance of WHO reform, particularly as the Region anticipated new challenges, in addition to the current challenges, such as noncommunicable diseases. He stressed the importance of developing a roadmap, which set goals to confront those challenges. He expressed his appreciation of public–private partnerships and the importance of selecting relevant partners. He suggested that an open seminar be held to which experts from the Region and other WHO regions would be invited to hear their views in this connection. The Director-General began by commending H.R.H. Prince Abdulaziz Ahmad Al-Saud for his tireless work in the prevention and control of blindness. She informed delegates that Dr Abdulla Assa’edi, WHO Deputy Regional Director for the Eastern Mediterranean, was one of the members nominated by the Regional Director to input the views of staff in the reform process. The starting point for reform had been 2010 when dialogue was initiated with the 193 Member States, now 194, on the process of reform. Member States were the most important stakeholders of the Organization despite the perceptions of some who perceived WHO as the secretariat. WHO was managed by the secretariat, under delegatory authority, but for a successful reform process both Member States and the secretariat were needed with clearly defined roles for each. Reform would be a continuous process. Dr Chan made reference to competing priorities that were overwhelming ministries of health and agreed that there were many “unfinished” priorities. Global mechanisms, such as the International Health Regulations (IHR 2005), the Framework Convention on Tobacco Control (FCTC) and the Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases, had been created, in agreement with Member States, to address priority public health problems.
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She said that WHO was not proposing increases in assessed contributions in the short term, and if 80% of voluntary contributions could be matched to priorities this represented an achievement. Member States were setting public health priorities, such as tobacco control and vaccine pricing, but implementation of the Framework Convention on Tobacco Control and Prequalification of Medicines Programme were being funded by external funds, such as Bloomberg Foundation. Priorities needed to be country-driven, bottom-up and demand-driven. Country Cooperation Strategies represented a mechanism or blueprint for countries to specify their priorities and expectations; Member States maintained the supremacy of decision-making. WHO was the only UN agency with a decentralized mechanism but needed to adjust at country level. There was plenty of scope for reform. WHO would propose a new mechanism to mobilize resources and would accept voluntary contributions based on the priorities set by Member States. In addressing the interventions of Member States she said that highlighting success stories for evidence-based decision-making was an important element in successful programmatic planning. Responding to the question of priority setting she noted that it had not been sufficiently strategic and Member States were presenting between 25 and 28 resolutions to the World Health Assembly every year for which financing was not available. If ministries of finance were not providing the funds why was so much time spent on so many resolutions in the World Health Assembly, especially as resolutions were not always aligned in terms of priorities and timing; it was time to go back to basics. Discipline was needed and in terms of over-commitment in WHO’s five core areas of work the challenge lay in identifying which areas of work to cut. WHO, as a 64-year-old agency, needed to evolve. Its Constitution required Member States to coordinate health activities but engagement was needed from all countries. There needed to be a better division of labour and capacity-building at the country level. While the World Health Forum, open to a range of partners, including the private sector, would explore ways in which the major actors in health could work more effectively together – globally and at country level – countries did not want the private sector making decisions; WHO would be uncompromising in exposing conflicts of interest. Dr Chan said that future human resource models would influence WHO contracts, particularly in relation to the contracts of national professional officers. WHO had been criticized for taking the best staff from country offices, who then never returned to serve their own countries and this needed to change. Responding to the comments on coordination, she said that WHO had separate governance structures from health partners. Some partnerships were good initially but then partners had left after taking advantage of Member States’ generosity in hosting them. WHO had hosted several partnerships but greater regulation was needed in these partnerships. The Director-General said that the leadership of Member States in global health was a responsibility. Some countries were sitting on the boards of agencies whose agenda and global initiatives differed from WHO and this was creating problems, not only at country level but at the level of headquarters and the regions. The Regional Director said that priority setting was discussed with Member States and put into the Joint Programme Planning and Review Mission (JPRMs) documents, sometimes with instructions from the World Health Assembly that were fed into the JPRMs. He said that in terms of assessed contributions, he strongly believed that those Member States who were not in favour
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of increasing assessed contributions had brought WHO to the unfavourable position that it was in today. Over the last few decades the percentage of assessed contributions had fallen from 80% to 19.8%, with voluntary contributions now forming over 80% of the budget. With voluntary contributions came fixed conditions and no flexibility. Core voluntary contributions were more flexible but it was impossible to determine when or how much might be received. They were sometimes received 3 or 4 months before the end of a biennium and could not be implemented. The Region was receiving 3% to 4% of the total of assessed contributions; some countries were only paying US$10 000. If the percentage of assessed contributions was increased incrementally this would help WHO to return to its former position. It was necessary to discuss the money that WHO was expecting to receive, or had received, because for years the Executive Board of the World Health Assembly had only been discussing the 20% and ignoring the 80%, and without addressing this issue both Member States as stakeholders and WHO as the secretariat would always be experiencing difficulties. Finally, the Regional Director said that capacity-building was a priority. The Representative of the Gulf Federation for Cancer Control thanked the Regional Director for his keenness to have nongovernmental organizations join this important gathering. He stressed the need for nongovernmental organizations to play a significant role within the public health system. He added that they give an example of the best utilization of resources by adopting health education work. He wished for international organizations to have a special section to evaluate the work of nongovernmental organizations, so that they could build partnership with them to undertake a part of the international organizations’ tasks. The Representative of the International Federation of Medical Students’ Associations, welcomed the proposed reform for a transparent, efficient and accountable WHO and the suggested World Health Forum. He said that the Federation looked forward to taking an active part in the forum in order to advance the agenda of sustainable and healthy societies. He expressed concern at the consequences if there was a heavy influence of the private sector in the proposed forum. He recalled resolution WHA64.28 Youth and health risks, and hoped that the Member States and WHO would follow up on this, as well as include young people in the WHO reform process.
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