WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
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REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R£GIONAl DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Twenty-ninth session Manila 21 to 25 August 1978 Provisional agenda item 12
WPR/RC29/18 8 August 1978
ORIGINAL:
ENGLISH
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STUDY OF WHO'S STRUcrURES IN THE LIGHT OF ITS FUNCTIONS Attached for the co~stderation of ~he Regional Committee is a document prepared by the Director·General as a bac~ground paper ~or the study of WHO's structures in toe light of its functions, which the Thirty-first World Health ~ssembly. ~n operative paragraph 6(3) of resolution WHA3l.27 requested him to undertake. Since the Regional C~ittees are to perform •. major role in carrying out the study, the proposal is made in the document (see the schedule for the study, pages 20 and 21) that an appropriate sub-committee should be established, the members of which would make the necessary country visits for consultation with governments and would prepare a report to, in the case of the Western Pacific Region, the thirtieth session of the Regional Committee. In the Western Pacific Region we already have the Sub-Committee on the General Programme of Work. It is suggested therefore that the Committee might wish to expand tbe te~ of reference of the Sub-Committee on the General Programme of Work to enable it to carry out the tasks involved in the study of WHO's structures in the light of its functions, to include the following: (1)
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to conduct the study in the Region together with the Regional Director on behalf of the Regional Committee; I
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to ensure adequate consultations with all governments of the Region on the basis of the Director-General's background paper, including selected visits to countries as necessary; to monitor the progress of the study in the Region, making sure in particular that the necessary dialogues take place between governments and WHO;
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WPR/RC29/18 page 2
(4) (5)
to prepare a repprt to the 1979 session of the Regional Committee based on the country consultations; and to prepare a final regional report based on the discussion in the 1979 session of the Regional Committee so as to permit the Director-General to prepare his global repor~ for submission to the Execut~ve Board in January 1980.
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WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE
DGo/78.1
STU D Y
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WHO' S S T R U C T U RES 0
I NTH E L I G H T
FIT S
FUN C T ION S
Background paper prepared by the
Director-General
CONTENTS INTRODUCTION . . • . . . . . . POLITICAL, SOCIAL AND ECONOMIC CONTEXT THE EXECUTIVE BOARD ORGANIZATIONAL STUDY ON WHO'S ROLE AT THE COUNTRY LEVEL, PARTICULARLY THE ROLE OF THE WHO REPRESENTATIVES • WHO'S FUNCTIONS PROBLEMS CONCERNING WHO'S STRUCTURES THE MEANING OF TECHNICAL COOPERATION THE NATURE OF GLOBAL PROGRAMMES REVIEW OF THE ORGANIZATION'S STRUCTURES THE INTERACTION AND INTERDEPENDENCE OF ALL ORGANS AT ALL OPERATIONAL LEVELS AS ILLUSTRATED BY THE MANAGEMENT OF WHO'S RESEARCH ACTIVITIES SCHEDULE FOR THE STUDY . . . . . • . . . 2 2
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Geneva, July 1978
DGO/78.1 page 2 INTRODUCTION 1. The Thirty-first World £ealth Assembly, in resolution WHA31.27, having considered the Executive Board's Organizational Study on WHO's role at the country level, particularly the role of the WHO representatives, requested the Director-General inter alia to re-examine the Organization's structures in the light of its functions, as recommended in the Study, with a view to ensuring that activities at all operational levels promote integrated action, and to report thereon to the sixty-fifth session of the Executive Board to be held in January 1980. The document that follows is intended as a background paper for this re-examination.
POLITICAL, SOCIAL AND ECONOMIC CONTEXT 2. Before embarking on the Study of WHO's structures in the "light of its functions, it is necessary to analyse the political, social and economic context in which the Organization will function in the future, particularly within the United Nations system. This can be characterized by a rapid socializing tendency within Member States, particularly in developing countries, and the political determination of these countries to increase their soc~al and economic productivity, among other ways by overcoming the burden of disease. International changes in this direction are expected to be even more rapid. Multisectoral effort for development is a historical imperative both nationally and internationally. 3. The aspirations of developing countries to improve the lot of their people were articulated in the Declaration of the New International Economic Order, to which health has an important contribution to make. Well coordinated social, economic and political action could convert this Economic Order into a genuine international development Order. WHO's functions will be heavily influenced by the contribution that health can make to this New Development Order. If health is important for development, and if WHO consists of Member States" cooperating among themselves in the spirit of the Constitution to attain an acceptable level of health for their people, it follows that WHO is equally important both for health and for development. The crucial question that has to be asked is in which way and to what extent governments want WHO and what kind of WHO they want. 4. The future of WHO cannot but be affected by current trends in the Organization. Guided by the principle of social justice, WHO's recently adopted policies reflect a growing concern for the social purpose of health development and for the role of health in promoting social and economic development. To reduce the gap between the health level of the developed and the developing countries a policy was adopted aiming at reorienting the work of the Organization to ensure greatly increased technical cooperation with countries. This policy is in full accord with the Organization's constitutional functions. The strategy for giving effect to this policy is based on the formulation and vigorous implementation of socially relevant technical cooperation programmes, directed towards defined national health goals, that foster national self-reliance in health matters and contribute directly and significantly to the improvement of the health status of the populations concerned. However, justice in the distribution of health resources cannot be achieved through technical cooperation between WHO and its Member States alone. Technical cooperation among countries, and particularly among developing countries, is even more important. Recent policy has emphasized WHO's duty to complement technical cooperation among countries as part of broader cooperative socioeconomic schemes whenever indicated, making full use of the capacities and potentialities of developing countries, including manpower, training and research facilities a~d exchange of technical information. This concept is implicit in the Organization's regional structure. 5. Encouraged by one major stride in the direction of international health justice, the Organization quickly took another when it decided that the main social target of governments and WHO in the coming decades should be the attainment by all the citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. A blueprint has been formulated that aims at attaining this target. An essential feature of this blueprint is the preferential allocation of health resources to the
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DGO/78.l page 3 social periphery both within and among countries. To attain the target, priority programmes have been identified and the mechanisms required for health development described, a beginning has been made in assessing the resources needed, and the political support that is essential for success has been highlighted.
THE EXECUTIVE BOARD ORGANIZATIONAL STUDY ON WHO'S ROLE AT THE COUNTRY LEVEL, PARTICULARLY THE ROLE OF THE WHO REPRESENTATIVES 6. Fundamental to the evolution of WHO's policies is the recent emphasis on action in countries, including intersectoral collaboration for development. The Executive Board presented to the Thirty-first World Health Assembly its Organizational Study on WHO's role at the country level, particularly the role of the WHO representatives. Below is a complete list of the conclusions and recommendations of the Executive Board Study. As mentioned in the Introduction above, it was the last recommendation that led the Thirty-first World Health Assembly to request the Director-General to undertake the present Study. (a) The donor to recipient "assistance" approach should be abandoned and replaced by real cooperation between the Member States and WHO as equal partners. (b) The ultimate aim of any collaboration should be the country's self-reliance; this implies a gradual change in the mode of collaboration so as to adapt it, at each moment, to the country's real needs. (c) One of the essential functions of the Organization is to collaborate with countries in planning, management and evaluation of their own health programmes; this type of collaboration should enable the countries to select the activities they should undertake in order to solve their priority problems, and to determine the fields of application of collaboration with WHO and other cooperating agencies. (d) Programming at country level will place WHO in a better position to develop its programmes at the regional and global levels. (e) In order to fulfil its role at country level, the Organization should actively seek all means of facilitating dialogue with nationals at country level, and at other echelons of the Organization. (f) The dialogue between WHO and governments should lead to increased participation of national authorities in, and responsibility for, the work of WHO. (g) WHO should contribute to a more equitable distribution of health resources, both between and within countries. (h) The new methods of collaboration imply a better utilization of all the resources which WHO can mobilize, whatever their origin. (i) Development of the WHO representatives' role should be continued by strengthening their technical functions and reducing their representative functions. (j) The function of liaison between WHO and the governments, hitherto performed by WHO representatives, could benefit from new approaches that would make greater use of national skills and resources. (k) Further experimentation should take place with the use of national personnel as WHO representatives and project managers. (1) ~here is a need for continuing evaluation of different approaches to cooperation and coordination at the country level with particular reference to the roles of WHO representatives, national coordinators and other mechanisms, such as national coordinating committees.
DGo/78.l page 4 In the light of their functions as defined in the report, the title of WHO representative (m) should be changed to that of "WHO coordinator", and where national personnel fill this function their title should be "WHO national coordinator". (n) New methods for WHO action at country level together with reorientation of the WHO representatives' functions require a new type of public health training in which the Organization should play the role of pioneer in conjunction with appropriate educational bodies. (0) The training referred to in section (n) above should emphasize health management; the training should take place as far as possible in the regions themselves, should be geared to practical national problems in health management, should be based on national institutions· and should be organized jointly for national and international health personnel.
(p) The change in the type of relationship between Member States and WHO requires a re-examination of the Organization's structures in the light of its functions. 7. The Executive Board Study mentioned above took a step further the theme developed in a former Executive Board Organizational Study on the interrelationships between the central technical services of WHO and programmes of direct assistance to Member States. When the Twenty-eighth World Health Assembly reviewed that study it defined the need for an integrated approach to the development of the Organization's programmes, all programme activities at all levels being mutually supportive and parts of a whole. It also stressed the importance of programme planning being viewed as a joint endeavour in which national authorities, WHO representatives, Regional Committees, Regional Offices, the Executive Board, the World Health Assembly and WHO Headquarters should all be involved; and it urged that the Organization's mechanism for the allocation and re-allocation of resources should comply with the principle of responding to integrated programme planning (resolution WHA28.30).
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WHO'S FUNCTIONS 8. WHO's farsighted Constitution clearly indicates the Organization's functions. They can be summarized as its constitutional roles of the directing and coordinating authority on international health work and of technical cooperation with Member States. Its coordinating role includes the exchange of valid information among Member States, and the fostering of technical cooperation among them. The use by Member States of WHO as a neutral platform for the exchange of valid information and the application of this information in all national health programmes and in technical cooperation with WHO and with other countries, can only lead to strengthening national self-reliance. All these functions have to be fulfilled in such a way as to provide an integrated response to the needs of Member States. 9. The Constitution is as relevant today as when it was first adopted. The present Study is therefore based on the premise that no changes are required in the Constitution. The programmes based on the Constitution naturally vary in the light of the changing world health situation, but this in no way implies any need to modify the Constitution as such.
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PROBLEMS CONCERNING WHO'S STRUCTURES 10. If the Organizaton's functions are clear, what about its structures? WHO has a complex structure, constitutionally based on three organs - the World Health Assembly, the Executive Board and the Secretariat. The functions of each and the relationships between them are clearly defined in the Constitution. At the same time, there are regional arrangements with six regional organizations, each consisting of a Regional Committee and a Regional Office. The functions of the Regional Committees and of the Regional Offices were also clearly defined in the Constitution. There are rather flexible relationships between the regional organizations and the three constitutional organs of WHO.
DGO/78.l page 5 11. This Study will therefore have to deal with the structures in countries for dealing with the political and technical interface between the national authorities and WHO; the Regional Committees; the Regional Offices; Headquarters, or as it will be called in this Study, "the Global Office"; the Executive Board; and the World Health Assembly. 12. What problems, then, exist in the structure of WHO that have to be resolved in order to permit the Organization to fulfil its functions effectively and efficiently? To deal with the widely different needs of Member States, the regional arrangements have been strengthened. This has led to regional solidarity, but the solidarity of each region has carried with it the seeds of global fragility. Global policy has become too far withdrawn from national reality, and globally determined action often has not adequately responded to local needs, Similarly, local activities often have not adequately reflected global policies. These contradictions between global guidance and national execution have often led to a less than optimal use of WHO's resources in countries.· Moreover, different aspects of the same programme, provided on the one hand by Headquarters and on the other hand by the Regions, have become divorced from It is one another, whereas in order to be effective they should be closely interrelated. necessary to ensure that the right relationships exist between WHO staff in countries and the national authorities concerned; between the Regional Offices and the Regional Committees; among the Regional Offices themselves; and between the Regional Offices, the Global Office, the Executive Board and the World Health Assembly. Decentralization of management should strengthen unity of effort rather than lead to fragmentation of effort. The regional arrangements have to foster this unity and this can only be achieved through true interregional cooperation, since regional self-reliance does not imply regional self-sufficiency. The managerial and technical strengths of the regional structure have to be made to match its undoubted political advantages. 13. While there is much talk of an integrated approach to the Organization's programmes, in fact there is duplication of effort at the different operational levels. This is detrimental to the effective functioning of the Organization within countries. It is necessary to spell out what is meant by an integrated approach both in principle and in practice so that its application will give rise to concrete results. Inadequate communications within the Secretariat have often been blamed for weaknesses in providing an integrated response to countries' needs, but inadequate communications between the Secretariat and Member States are of even greater importance. Responsibility for improving these communications devolves on all sides. Member States vary widely in their perception of the functions of the Organization. The roles of international coordination on health matters and of technical cooperation are not always accepted as such, or are interpreted differently by different Member States. Some Member States even ignore the Organization's constitutional role as a technical agency, merely requesting equipment and supplies. Yet all Member States have repeatedly expressed their interest in cooperating with one another, and it is WHO's fundamental constitutional role to foster this cooperation in every possible way.
THE MEANING OF TECHNICAL COOPERATION 14. It is also necessary to clarify the real significance of technical cooperation. In the new programme budget policy and strategy it has been defined as activities that have a high degree of social relevance for Member States in the sense that they are directed towards defined national health goals and that they will contribute directly and significantly to the improvement of the health status of their populations through methods that they can apply now and at a cost they can afford now. While this definition has been accepted in principle, its meaning in practice is less clear. On no account can the concept be allowed to be considered as a new name for technical assistance. In providing technical assistance in the past WHO has either agreed passively to government requests, or has imposed its own vertical type of programme on countries. In both cases, the process has led in most instances to fragmented WHO projects that have had little real influence on the improvement of the.national health situation, and that have not promoted the self-sustaining growth of the relevant programme in the country after WHO's departure. The reason for such relatively low impact of WHO's assistance lies mainly in the inadequate interest shown by governments in using WHO in a more effective way and their lack of commitment to programmes they themselves had adopted in Regional Committees and the World Health Assembly.
DGO/78.l page 6 15. Technical cooperation, on the other hand, implies that no matter at what operational level programme doctrines have been generated or programme activities implemented, the programmes have to be concerned with solving specific priority national health problems. The development of technical cooperation programmes implies the identification of needs in countries £y these countries, as well as the identification or generation of appropriate methods for meeting these needs. It is necessary to develop technical methods that take full account of the social and economic context in which they are to be applied. These social and economic factors emanate from the countries. Suitable methods can also emanate from the countries, and it is WHO's duty to spot these methods, to analyse them and to transfer the appropriate information to all countries which require them. It is also WHO's duty to generate appropriate technical methods that take account of the social and economic factors involved in their application, if existing methods are inadequate or non-existent. The development of these methods has to be arrived at through cooperation among countries, WHO acting as a stimulator, catalyst and coordinator. Thus, the most suitable technical cooperation programmes are likely to be arrived at through a process of mutual influencing of socioeconomic and technical factors, the former deriving mainly from the countries, the latter often deriving from WHO through the coordination of activities in countries for the development of the technical methods concerned. This is one way in which the exercise by WHO of its coordinating role should lead to relevant programmes of technical cooperation. 16. Programmes of technical cooperation in and among countries can also be made more effective through support from various regional mechanisms. These include, for example, regional multidisciplinary panels of experts; Regional Advisory Committees on biomedical and health services research, which bring individual expertise from various countries to bear on research requirements and questions of research policy in each region; and national centres that are recognized as regional centres for operational research, development and training in specific programme areas, where countries work together to solve common problems and to build up cadres of national personnel trained for self-reliance in developing the programme concerned in their country. 17. The more general application of technical cooperation programmes at all operational levels should result from discussions in the Regional Committees that give rise to the realization of the need for inter-country cooperation. The proper manifestation of such cooperation should also be through national rather than Secretariat mechanisms. In like manner, global technical cooperation programmes should result from the realization of the worldwide nature of the problem and the need to solve it through cooperation among countries that transcends the boundaries of individual regions. The evolution of technical cooperation programmes in such a way is the best guarantee that the real needs of Member States will be reflected in their demands on WHO, and that their specific requests for technical cooperation will conform to the policies they have adopted in the resolutions of the Health Assembly and other deliberating organs.
THE NATURE OF GLOBAL PROGRAMMES 18. The Assembly resolutions mentioned in paragraphs 1 and 7 above imply the formulation of global programmes as a result of integrated programme planning. It is necessary to clarify what is meant by integrated programme planning. At the Thirty-first World Health Assembly, it was made clear that two distinct yet closely interlinked processes are at work, the one a process for national health development and the other a process fO.r the development of WHO's programme in response to national health development. The national health development process consists of country health programming, national health programme budgeting, national health programme evaluation and national health information systems support. The WHO programme development process consists of WHO medium-term programming, programme budgeting, health programme evaluation and information systems support. Ideally, integrated programme planning will result from the proper application of the national process for programme development in all WHO's Member States, and the corresponding response of the WHO process for programme development. In practice, there are multiple entry points to each of these processes.
DGO/78 .. 1 page 7 19. It is not possible to wait until all Member States have introduced country health programming. In addition to making most use of' the multiple entry points into the managerL:!l processes for programme development, accouht also had to be taken of political processes. Whatever the mixture of political andmariagerial processes for arriving at global programmes, there should be no separate Headquarters' programmes, but rather global promotion and coordination of regional programmes that reflect countries' real needs.
REVIEW OF THE ORGANIZATION'S STRUCTURES 20. In this Study, the term "structures" includes processes for improving the effectiveness and efficiency of the Organization. ln order to re-assess the Organization's structures in the light of what has preceded, it is pertinent to raise a number of questions. For each of these questions answers are provided for review. 21. What are the best ways of ensuring that governments apply in their own countries the policies adopted by them in the World Health Assembly and Regional Committees, and that their requests for technical cooperation with WHO comply with these poliCies and conform to the definition of technical cooperation appearing in the new programme budget policy and strategy?
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22. Member States have to understand their responsibilities towards the Organization if they are to assume their proper role of guiding its policies, applying them to their own health development and requesting technical cooperation from WHO in conformity with these policies. A major effort therefore has to be made to make countries aware of their responsibilities and of the benefits that can accrue to them by fulfilling these responsibilities. Once countries are convinced, they will exert the necessary pressures on the Organization in all its organs at all levels. It is therefore necessary to emphasize the mutually supportive nature of WHO's coordinating and technical cooperation roles. As part of its coordinating role the Organization has to make valid technical information available to all its Member States, and as part of its technical cooperation role it has to collaborate with Member States on request in ensuring that this information is properly absorbed and utilized. When this is properly understood Member States will be in a better pOSition to correlate country activities with World Health Assembly resolutions, and to grasp the significance of the regular budget being used mainly to support nationwide programmes rather than for isolated projects, or fellowships, supplies and equipment that do not form part of a well defined programme. Member States will also be in a better position to channel massive extrabudgetary funds into the implementation of priority national programmes. It is stressed that developed countries have the same rights and obligations as developing countries, although their technical cooperation with WHO will obviously assume different forms, for example the participation of collaborating centres in programme activities that are highly relevant to their health problems; such as the control of cardiovascular disease and cancer, mental health and the care of the aged. 23. For a better understanding of WHO's policies, national authorities might well study again such documents as the Sixth General Programme of Work, the policy and strategy for the 1 development of technical cooperation that was adopted by the Thirtieth World Health Assembly and the resolutions of the World Health Assembly and Regional Committees. To this end use can be made as required of whatever mechanism exists to ensure the political and technical interface with WHO in the country. The Secretariat should prepare any additional material required by countries to clarify policies. A careful analysis has to be made of the meaning of technical cooperation, for example as outlined in this paper.
1 See WHO Official Records No. 238,
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DGO/78.l l-'age 8 24. The establishment and maintenance on a continuing basis of the national health development process as mentioned in paragraph 18 above would help countries to define their priority health problems as well as the most appropriate ways of solving them. In so doing they might well put into practice the public health doctrines evolved by them in WHO by defining national health policies and programmes for giving effect to these doctrines. Such a process will lead to country-wide programmes to cover the total population rather than isolated projects which cannot possibly have any real effect in improving the national health situation. At the same time the process should help to identify activities for cooperation with other countries, including external funding on a real partnership basis. This could help to channel bilateral and multilateral support into the country's priority programmes and could include those activities for which WHO's cooperation is particularly appropriate. To this end the new system of programme budgeting and management of WHO's resources at the The main effect of this new system should be to develop the country level should be useful. l WHO programme budget in countries in terms of broad health programmes responding to nationally defined needs and priorities and to defer detailed programme planning until nearer the operational period, so that it can be brought into closer harmony with the national health programming process. Governments ought to be ready to give up money from WHO's regular budget for the implementation of isolated projects in order to invest it both in the national health development process and in the broad programmes that result from this process. WHO's funds at the country level could be put to better use to improve national capacities for absorbing and using valid information. The national centres for research, development and training mentioned in paragraph 16 above could well be used for this purpose. In making their requests to WHO, governments might well use the components of the definition of technical cooperation mentioned in paragraph 14 above as criteria for assessing the validity of their proposals. These criteria may also be useful for joint programming of the resources of WHO, UNDP and other United Nations agencies in the country, an effort which has just started and which should be given full encouragement and at least a fair try. 25. To ensure the proper appli~ation of the national health development process, Ministries of Health will have to be strengthened politically and technically in most countries, if necessary at the expense of their administrative functions. Under the present power structures, Ministries of Health often have little influence, real powers of development being vested in Prime Ministers' Offices or in Ministries of Economic Affairs and Planning. One of WHO's main tasks is to help strengthen Ministries of Health, particularly now that many Heads of States have realized the importance of health for social and economic development. It is necessary to capitalize on this new political reality and to build up Ministries of Health that will assume a central role in promoting health as part of social and economic development in close relationship with other sectors. 26. An additional way to ensure that ,countrie$ , ~equeats for technical cooperation with WHO comply with the Organization's policies is to establish national health advisory councils. Such councils can bring together expertise and personalities representing a wide range of interests in health and in political, economic and social affairs, including the health service consumer, to explore health matters as they related to social and economic development in general, as well as political, social and economic matters as they relate to health. These councils could be used in a continuous advisory capacity to WHO, thus strengthening the joint formulation of technical cooperation programmes in the country. A further way is to strengthen existing institutions or establish new institutions as national centres for research, development and training in specific programmes of the type mentioned in paragraph 16 above, that are recognized and used both within the country concerned and by other countries as part of technical cooperation among them. These centres would maintain close contacts with WHO, and, either independently or within the framework of WHO, among themselves.
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IDocument WPR/RC27/4.
DGO/78.l page 9 27. Finally, to ensure continuity and consistency in their relationships with WHO, governments should either send the same representative both to the Regional Committee and to the World Health Assembly or should ensure proper coordination between the different representatives. In a broader context, if governments are to derive the most from the United Nations system as a whole, they would do well to coordinate the views expressed by their representatives in the various United Nations fora. 28. What further practical steps arereguired to promote technical cooperation among developing countries (TCDC) and between developed and developing countries? What structural changes are requ~ired in Regional Offices to strengthen their role as active coordinating centres for TCDC?
29. The first step is for governments to study the. real implications of technical cooperation among themselves - politically, economically and technically. This understanding should be fostered in the Regional Committees which should help to arrange agreements between governments for technical coope.ration on health matters. A subcommittee of the Regional Committee might well be set up specifically for this purpose. The national centres referred to in paragraph 26 above should be encouraged to cooperate with similar. centres in other countries. When formulating programme budget proposals, those components that could well benefit from being implemented through TCDC should be identified. The financing of TCDC activities in cash and in kind is. largely the responsibility of the countries themselves, but WHO will have to cover the indispensable overhead technical and administrative costs. Information on priority health needs of countries and sources of meeting these needs has to be gathered. The information has to be distilled, analysed and then synthesized for proper dissemination among the countries of the region. It is important to collect relevant information from other sectors involved in social and economic development as well as from the health sector. Within the Secretariat, the Regional Office will have to create mechanisms for ensuring timely and appropriate exchanges of information among countries interested in the possibility of technical cooperation among themselves. The Regional Offices will also have to maintain relationships with the Regional Economic Commissions for this purpose. At the same time they have the duty of informing one another of information relevant to TCDC. Proper contacts have to be maintained with the UNDP Information Referral System for Technical Cooperation among Developing Countries (TCDC/INRES). 30. As for technical cooperation among developed and developing countries, as mentioned in paragraph 24 above in connexion with the national health development process, the identification of priority programmes and activities for which there are inadequate resources in the developing countries should help to channel the cooperative efforts of the more developed countries into the most productive forms of. cooperation. Also, twinning of institutions might be instituted, whereby an institution in one country cooperates closely with a similar institution in the other country. Both developing and developed countries require specific mechanisms for arriving at this type of cooperation, WHO. having essentially a catalytic and coordinating role.
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31. Regional Offices will no doubt have to create bureaux to coordinate TCDC. These bureaux will have to ensure that all programme activities take into account the possibility of TCDC. They will have to maintain contacts with other s.ectors at the regional level and to be closely involved in the information service mentioned above. They may also have to deal with commercial matters related to TCDC, including legal matters such as support to countries who so wish in reaching agreements and signing contracts. The bureaux will also have to provide support to any subcommittee of the Regional Committee set up for TCDC. These activities have obvious implications for the type of staff required for such bureaux. They will probably be quite different from the categories of staff employed in Regional Offices until now.
DOO/7B.I page 10 32. How can the Regional Committees be further strengthened?
33. The Regional Committees are crucial for involving Member States deeply in the work of the Organization, as part of the growing trend for the governing bodies to playa more active role in the Organization's affairs. This implies that these Committees should be strengthened so that they become a sort of parliamentary forum for the review and control of all regional activities, including the supervision of the activities of the Regional Offices in accordance with Article 50 of the Constitution. 34. The constitutional functions of the Regional Committees relate to policy, control, regional cooperation with other organizations and programme budget matters. To fulfil these functions the Committees have to display a high degree of leadership and determination. This has strong political implications, because, in order to gain acceptance of the application of the Organization's new policies, and to ensure the implementation of its new strategies, the full political support of all Member States will be required. Ways therefore have to be sought of creating greater awareness of policy issues within the Regional Committees so that these issues can be dealt with at the regional level and so that health administrators will be in a better position to deal with them in their own countries. 35. Among the policy issues with which Regional Committees will increasingly have to deal are intersectoral and inter-agency social and economic development activities in countries and at regional level; the introduction of new concepts of health services and health manpower which are likely to arouse the opposition of the established health professions; opposition from professional and commercial sources to the adoption of drug policies aimed at providing essential drugs for all and at establishing drug industries in developing countries; agreement on criteria for the selection of countries for vaccine production as part of the policy of reaching regional self-reliance in matters of vaccine supply; political and commercial arbitration in relation to the development and application of appropriate technology for health; and the resolution of any problems resulting from commercial interests or questions of prestige when attempts are made to put technical cooperation among developing countries into practice. 36. As for the programme budget aspects of the work of the Regional Committees, the new arrangements for the development of programme budgeting and management of WHO's resources at the country level offer an excellent opportunity to hold fundamental discussions with countries on the nature and extent of programmes for technical cooperation with WHO. On the basis of these discussions, the Regional Committees can now hold reviews of broad programme proposals, instead of the former practice of reviewing detailed project proposals. These broad reviews should include not only country programmes, but also common problems for which inter-country cooperation within the framework of WHO is indicated, as well as any global support required. They should help to ensure that the Organization's programmes are based as far as possible on countries' real needs based on first hand information rather than on second hand assumptions concerning the nature of these needs. They should also attempt to select programmes to be given priority in general and for the attraction of extrabudgetary funds in particular. 37. The Regional Committees are assuming an increasingly important role in guiding the direction of health research through the review of the proposals of the Regional Advisory Committees on Medical Research. This should lead to radical re-thinking of the vital role of socially relevant research in health promotion and thereby in technical cooperation for health development. The Regional Committees will have to pay particular attention to the strengthening of countries' research capacities, which can best be achieved through participating in the planning and conduct of research that is relevant to the health deve10pmerrt of their own people. 38. Additional ways of involving the Regional Committees more deeply in the work of the Organization that are being progressively put into practice are: the establishment of a Programme Committee with functions similar to those of the Programme Committee of the Executive Board; the creation of subcommittees to foster technical cooperation among countries; the establishment of subcommittees or ad hoc groups for reviewing national proposals for technical
DGO/78.l page 11 cooperation with WHO; the close involvement of the Committees in the development of regional mechanisms for programme development, such as multidisciplinary panels of experts and the recognition of certain national centres of the type mentioned in paragraph 16 above as regional centres for programme development; the designation of individuals to represent the Organization at relevant meetings of regional economic commissions or other regional organizations and to report thereon to the Regional Committees; special studies by working groups, including country visits. 39. To strengthen Regional Committees and make it possible for them to fulfil their leadership role it is necessary to ensure the highest possible level of national representation. National representatives should have the power to make decisions on behalf of their governments. 40. How can the work of the Executive Board be further strengthened?
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41. The Executive Board is playing an increasingly active role in giving effect to the decisions and policies of the Health Assembly and in acting as the Executive Organ of the Assembly and adviser to it. Its membership has been enlarged in proportion to the increased membership of the Organization. Its deliberations are becoming increasingly frank and open and its candid dialogues deal with crucial policy issues and programme priorities. To this end it is setting up working groups and committees of which the Programme Committee is a striking example. Other illustrative examples are the ad hoc committees on malaria and on drug policies and the ad hoc committee on cancer which gave rise to the establishment of the Director-Generalis Coordinating Committee on Cancer. The Board will no doubt wish to establish other groups to deal with priority issues from time to time. 42. The Board is also playing a more decisive role with respect to the Assembly, at which its representatives are active in introducing programme and budget matters and in responding to the comments of delegates. Yet the potentials for strengthening the work of the Board are far from having been exhausted, particularly with respect to the relationships between the Organization and the rest of the United Nations system in connexion with the mutually supportive effects of health and development and the establishment of the New International Economic Order. 43. How can the work of the World Health Assembly be improved?
44. The work of the Assembly too is being greatly intensified particularly in determining the policies of the Organization. The growing awareness of the need for global political action for health will no doubt engage the priority attention of the Assembly in the coming years. It will be called upon to a greater extent than ever before to give its full support to global efforts for health and through health for development and peace. It is also in a unique position to encourage harmonious relationships between Member States at all levels of development and of all shades of political ideology. 45. Some of the resolutions of recent years - such as resolution WHA29.48 on programme budget policy which requested the Director-General to reorient the work of the Organization towards greatly increased technical cooperation; resolution WHA30.43 on technical cooperation which decided on the main social target of governments and WHO in the coming decades, popularly known as "health for all by the year 2000"; and resolution WHA31.27 which requested the Director-General to undertake the present Study - will have a profound influence on world health development and on the work of WHO for many years to come. At the same time, the Assembly, the Board and the Regional Committees would do well to devote more of their time to analysing the implications of existing resolutions for the work of the Organization and for action within Member States, as well as to monitoring the implementation of these resolutions, rather than concentrating on additional resolutions which may add little to those previously adopted. 46. Constant efforts are being made to improve the methods of work of the Assembly and this should continue. Article 13 of the Constitution states that liThe Health Assembly shall meet in regular annual session". In the light of the present Study, the World Health Assembly
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DGO/78.l page 12 will, if it so wishes, be in a better position to discuss whether to hold biennial instead of annual Assemblies, a matter which was raised by the President of the Thirty-fiTst World Health Assembly. 47. In which way can relationships between the Regional Committees, the Executive Board and the World Health Assembly be improved?
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48. To strengthen the political unity of the Organization and to promote the process of formulating global programmes starting from countries, there is a need for closer interrelationships between the Regional Committees, the Board and the Assembly. While the Regional Committees have been increasingly active in fulfilling the function described in Article 50(a) of the Constitution "to formulate policies governing matters of an exclusively regional character", they have been less active in fulfilling Article 50(e) "to tender advice, through the Director-General, to the Organization on international health matters which have wider than regional significance". Moreover, Article 50(g), which gives the Regional Committees "such other functions as may be delegated to the Regional Committee by the Health Assembly, the Board or the Director-General", has been applied consistently only with regard to the review of the regional programme budgets, which form part of the global programme budget later reviewed by the Executive Board and the World Health Assembly. 49. Apart from these reviews by the Regional Committees and the occasional discussion of certain matters which the Director-General wishes them to consider prior to submission to the Executive Board, the sessions of these Committees tend to be considered as coming at the end of the yearly cycle of meetings of the main organs of the Organization. It is now necessary to adopt a forward-looking approach that would better synchronize the work of the Regional Committees with that of the Board and the Assembly, rather than the Regional Committees merely being informed of decisions taken by these bodies. One way of achieving this synchronization is to correlate the agenda of the Executive Board and the Regional Committees. Thus, the preparation of a draft provisional agenda for any session of the Executive Board well in advance would make it possible to include certain items in the agenda of the Regional Committees so that they could have preliminary discussions of the subject matter and make recommendations through the Director-General to the Executive Board. In this way the deliberations of the Regional Committees would have an important influence on the totality of the Organization's activities. Similar action could be taken with respect to Executive Board Organizational Studies, the subject matter of which could be discussed by the Regional Committees, whose reports would then be submitted to the Executive Board. In these ways, the work of the Executive Board and Assembly would be greatly influenced by the work of the Regional Committees. In like manner, more extensive analyses in the Regional Committees of the regional implications of World Health Assembly and Executive Board resolutions should help to strengthen the impact of these resolutions on national health policies. 51. The Director-General is already taking measures to ensure the correlation of the agenda of the Regional Committees and the Executive Board. 52. How can relationships between the Secretariat and Member States at all operational levels be improved?
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53. To ensure the right relationships between staff and national authorities, all concerned must understand and accept the truly international nature of the Organization. Supranationalism has no place in WHO. Field staff, to the extent that they will be engaged at all in the future in the light of the increasing employment of national personnel, and the execution of WHO supported programmes and projects by the government concerned, will have to identify themselves with the national programme in which they are working and to feel part of the national health personnel. At all levels, the emphasis should be on the mobilization of national resources, including national participation in meetings dealing with programme development. Staff have a crucial role in providing sound information to the Regional Committees, Executive Board and World Health Assembly so as to enhance the ability of these bodies to take rational policy decisions. To enable them to do so, further measures will
DGO/78.1 page 13 have to be taken to strengthen the capacity of staff to identify with the Organization's policies and to participate in translating them into action. 54. In which way can and should the WHO Programme Coordinators' (WPC) offices be strengthened to permit them to fulfil the tasks devolving on them in the light of the latest Executive Board Study?
55. The strengthening of the functions of WHO Programme Coordinators, and particularly their technical functions, in accordance with the Executive Board Study, makes it necessary to review the structure of their offices. In addition to coordinating the WHO Programme in a country and acting as Chief of the WHO team participating in that programme, the function of liaison between WHO and the government authorities devolves on the WHO Programme Coordinators. The Coordinators have to maintain close links not only with the Ministry of Health, but also, depending on the pattern of organization and on the desire of the government concerned, with other ministries whose activities are related to health and with the representatives of the United Nations and other international agencies concerned. The WPCs also have to be vigilant in ensuring that governments agree to execute health projects in which WHO is collaborating. 56. It would therefore seem reasonable to transfer further technical, administrative and financial responsibilities from the Regional Offices to the offices of the WHO Programme Coordinators. These responsibilities would be discharged under the guidance and control of the Regional Office. To permit the WHO Programme Coordinators to assume these additional responsibilities their offices may have to be strengthened with appropriate technical and administrative staff. It has to be realized however that this could carry the danger of creating small WHO units within countries, which would be counter to the principle of mobilizing national action and resources as much as possible. 57. Taking account of the greater emphasis being given to the participation of governments in the work of WHO, should there be a gradual phasing out of WPCs' offices accompanied by a phasing in of new direct relationships between the Regional Offices and governments?
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58. National self-reliance in health matters makes it inevitable that governments should consider alternative ways of ensuring the political and technical interface with WHO in the country. Quite apart from the employment of national health personnel as WHO Programme Coordinators, other solutions are being found. A growing number of countries have established units in the Ministry of Health which constitute the link between their country and the Organization and which are responsible for the coordination of WHO's activities in the country. Other solutions are international relations offices within Health Ministries; and international cooperation committees, either within Ministries of Health or within the framework of an interministerial structure. These solutions conform to resolution WHA29.48, which aims at a better use of the technical and administrative resources available in countries, and particularly in the developing countries. 59. How will the strengthening of the WPCs' offices and the presence of increasing numbers of national experts in countries (partly as a result of WHO Fellowships), affect the internal organization and staffing pattern of the Regional Offices? What will be the effect of establishing direct relationships between Regional Offices and governments if WPC's offices are phased out?
60. The strengthening of the WPCs' offices or the establishment of direct relationships between Regional Offices and governments are likely to have similar effects on the internal organization and staffing pattern of the Regional Offices. At present these Offices are mainly staffed on the technical side by Regional Advisers who often maintain direct contacts with their technical counterparts in country projects. The emphasis on broad programmes and on the coordinating role of the WPC will eliminate this arrangement. 61. The functions of WHO regional officers are already being reoriented towards the formulation and management of regional programmes and towards technical support for activities in the country at the request of the WHO Programme Coordinator or at the direct request of the government concerned. Regional Office staff will also be engaged to an increasing extent in
DGO/78.1
page 14 the servicing of the work of multidisciplinary panels of experts, such as the Regional Advisory Committee on Medical Research, in providing the kind of information that will make it easier for the Regional Committees to arrive at decisions and in acting as a clearing house for TCDC. Administrative and financial officers in the Regional Office will have to provide increased support to the management of resources assigned to countries, as prescribed by the WHO Programme Coordinator. They will also have an increasingly important role to play with respect to newer arrangements for providing fellowships and supplies and arranging for exchange of personnel as part of technical cooperation among developing countries. 62. The creation of special bureaux to permit the Regional Office to act as a clearing house for TCDC has already been referred to in paragraph 31. As mentioned in paragraph 29, an efficient information service for TCDC will have to be developed. 63. As part of the new policy of decentralization, certain functions and activities hitherto the responsibility of the Organization's Headquarters, will be transferred to the regional level, for example, many research responsibilities and the management of interregional projects. Regional Offices are also being made responsible for the worldwide coordination of certain global programmes. In order to put these new functions into practice, a further review of management systems at Regional Office level may be required, as well as the strengthening of practical collaboration among the regions on matters of common interest. 64. All the above will have profound consequences for the staffing of the Regional Offices. There will be a need for more generalists who are capable of synthesizing national expertise and experience into regional programmes and of distilling essential information from detailed data in a number of fields for dissemination to countries. This information will also be used to prepare documents that will help the Regional Committee to make rational decisions based on political, social and economic factors in addition to technical factors. Regional Office staff will often have to work in multidisciplinary programme teams aimed at attaining objectives through a wide variety of political, social, economic and technical measures, or at dealing with the totality of a country's health problems. The staff of the Regional Office will no doubt have to include a limited number of experts in social and economic affairs. Most of the technical expertise in the various fields of health will be obtained from national personnel, either through national or regional centres for specific programme areas or through staff working in the Regional Offices for comparatively short periods of time. 65. As the Regional Directors assume a stronger political role, outside the health sector too, e.g. for the promotion of "health for all by the year 2000", and act to an increasing extent as the Director-General's alter ego for global matters in their region, what will be the implications, if any, for the structure of the Regional Offices?
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66. Increasing political responsibilities, such as meetings with Heads of State and Ministers of Health, fighting the cause of health as part of social and economic development at regional political organizations, and appearing before Regional Economic Commissions, will make it necessary for Regional Directors to delegate programme responsibilities to an increasing degree to a second in command. At the same time, they will have to keep a close control on the use of funds in their development programme so that these are used for genuine high priority technical cooperation programmes whose implementation will have effects beyond the immediate use of the money invested in them. To fulfil their political role adequately, Regional Directors may require political advisers, and if they do, it would be wise to select them on a rotational basis from Member States, possibly with a coordinator in the Regional Office. Regional Directors are elected politically and are therefore vulnerable to political pressures and counter pressures. To protect the Organization and the Regional Directors personally, it may be useful to form around them a small group of national representatives on a rotational basis to provide a measure of collective political protection and power. This group could consist of individuals nominated by the Regional Committee on the proposal of the Regional Director. 67. In turn, how will changes in the structure of the Regional Offices, such as those implied above, as well as additional changes in their functions, such as cheir deep involvement in research management, and consequent additional changes in their structure, affect the functions and structure of the global level of the Secretariat?
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DCO/78.l page 15 68. The activities of the Global Office of the Secretariat have gradually changed as the management of the Organization's activities have become increasingly decentralized, and this trend is bound to continue. As mentioned in paragraph 12 above, central activities tended to become aloof from the expressed needs of Member States. Research in particular became a Headquarters' prerogative, divorced from nationally expressed needs. It was all too often dictated by needs as perceived by Headquarters staff. Interregional projects proliferated that had not been. requested by the regions and that had not resulted from the identification of similar needs in a number of regions following a rational process of programming. Much of the time of Headquarters' staff was devoted to managing these projects. 69. All this is rapidly changing. The global level now has to function with greater awareness of the fundamental importance of the impact of the WHO programme in countries, and its work therefore has to be more clearly oriented towards the practical solution of countries' problems. Direct technical cooperation activities devolve on the regions but the Global Office must be ready to support these efforts by providing valid information on health development and health technology. Greater attention will therefore have to be paid to the international transfer of valid information on health matters, the Global Office having prime responsibility for absorbing, distilling, synthesizing and disseminating information that has practical value for countries in solving their health problems. In this way WHO will be better able to provide the world with an objective assessment of what is really valuable for health development, and to identify those health problems for which there is as yet no suitable answer. It is the Organization's responsibility to ensure not only that the most valid health information is collated, analysed and adequately disseminated but also that this information is properly absorbed by those who require to use it. This last activity is the responsibility of the national and regional levels, but the global level has to support them. An additional information function that is of extreme importance is the provision of the right kind of information to the Executive Board and World Health Assembly to help these bodies make rational policy and programme decisions. This information will be a blend of political, social, economic, scientific, technological and managerial elements. 70. The global level has greater access than any other level to the multiple sources of political power and bilateral and multilateral funds, yet on the other hand the regional level has greater access. to the sources of information concerning the real health needs of Member States. This highlights the importance of close collaboration between these levels. The global level has the responsibility of promoting global progra~es that have been arrived at by the processes outlined in paragraphs 14 to 19 above, ensuring interregional coordination and supporting the regions. An increasingly important function at this level is to direct the worldwide political struggle for health and to maintain adequate contacts for this purpose with the world's leaders, with various political, social and economic bodies, and with the United Nations and the other specialized agencies of the United Nations system. 71. When Headquarters was dealing mainly with highly technical programmes as separate entities, the divisional structure was suitable. The present challenge of channelling expertise from various sources and disciplines to converge on attaining specific programme objectives in countries makes this bureaucratic divisional structure inappropriate. Recent experience with the creation of functional programmes for this purpose is showing promise. Another mechanism for this purpose that has given encouraging results is the interdivisional programme team. It is realized that the reorganization of the structure at Headquarters according to programmes and the increased use of interdivisional programme team will create managerial problems at the executive level, but these are problems that will have to be resolved. 72. To increase programme effectiveness while reducing WHO's staff establishment and the expenditure of the Organization's resources, greater use will have to be made of nongovernmental organizations in many fields of health. This should help to ensure worldwide involvement in the programmes concerned. In some areas, particularly in research and in the development of technology, whole programme areas may have to be contracted out to WHO collaborating centres. More testing of newer programme concepts, for example in the areas of primary health care and rural development, will have to be carried out by countries themselves, rather than institutionalized at Headquarters or in Regional Offices.
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DCO/78.l page 16 73. The new functions and structures of the Global Office have clear implications for its staffing. Greater reliance will have to be placed on national experts for specific scientific and technical issues. There will undoubtedly be a greater need within the Office for generalists, who, irrespective of their basic discipline, are capable of taking a global view of broad health problems, of synthesizing the information required to help resolve them, of dealing with global policy issues concerning a wide variety of health and related socioeconomic matters, of promoting and coordinating complex efforts on a worldwide scale, and of mobilizing the world's health and scientific community for international deliberation and action as individuals as representatives of their government and as members of nongovernmental organizations. 74. The question of the location of the Global Office was raised during the sixty-first session of the Executive Board. In accordance with Article 43 of the Constitution "the location of the Headquarters of the Organization shall be determined by the Health Assembly after consultation with the United Nations". The new functions and consequent structure of the Global Office that emerge from this Study may help the Assembly to decide whether it wishes to deal with this matter or not.
75.
What additional structural changes, if any, are required to strengthen the Organization's role in relation to the restructuring of the United Nations system, and to enhance its contribution to the establishment and realization of the New International Economic Order? Will it be necessary and possible to modify the regional affiliation of certain countries, as well as the number and boundaries of regions, in order to conform with the proposal to have identical regional structures for the whole United Nations system?
76. All United Nations agencies will eventually be affected by any restructuring of the United Nations system, and in particular by measures to concentrate efforts for development. The extent to which the United Nations system will be able to make a significant contribution to the establishment and maintenance of the New International Economic Order will depend to a high degree on its ability to work intersectorally. WHO has pledged itself to such jOint endeavours. Yet, gnawing doubts exist as to the real determination of governments to introduce the New International Economic Order and to convert it into a genuine international development order. If this determination does not exist, can WHO afford to take the risk of involving itself deeply in joint inter-agency efforts for development, possibly at the expense of some of its other activities? The answer to this question is particularly important in view of the limitations of the Organization's resources, which make it imperative to invest them in order to derive the greatest benefit from them to world health and to avoid as far as possible any waste of effort. On the other hand, can WHO, which has been a pioneer in advocating intersectoral collaboration for development and in demonstrating the interdependence of health and development, take the risk of not throwing its full weight into United Nations efforts for the New International Economic Order? It should be added that WHO has consistently emphasized intersectoral and inter-agency collaboration first and foremost at the country level, building up to regional and subsequently global action. 77. It would seem that the Organization must make greater efforts than ever before, both within and outside rhe United Nations system, in whichever bodies it may have an influence, to struggle for health as part of social and economic development. At all times and in all fora it should continue to insist on action first and foremost in countries. It may have to channel the energies of a small number of health generalists into these efforts, to convert a small number of existing posts to posts in the political and economic sciences, and to create a panel of experts in these disciplines from both developing and developed countries, as it does in relation to any other programme area. At the beginning, this effort may have to be concentrated in the Director-General's office, but as progress is made it will no doubt be necessary to decentralize it to the regional level. 78. As for the regional affiliation of countries and the number and boundaries of regions, in accordance with Article 44 of the Constitution these are matters on which the Health Assembly will have to decide.
DGO!78.1 page 17 79. Will any structural changes be required in the light of a hopefully positive response to the Director-General's appeal to the political leaders of the world, in his address to the Thirty-first World H~!:ilth Assembly, to adopt "health for all by the year 2000" as the world social goal for the end of the twentieth century, and to use health as a lever for social and economic development and as a platform for pea~.
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80. A positive response to the Director-General's appeal to the world's leaders will place heavy additional responsibilities on the Organization in working in various political arenas for health, development and peace. This may entail the creation of a small support group in the Director-General's office, perhaps identical with the one mentioned above in relation to the New International Economic Order. In addition, the Director-General is elected politically and is exposed to national, regional and global political pressures. At the same time, he is directing the political struggle for health on behalf of the Organization, which reinforces the political pressur'es on him. His latest appeal to the world's leaders can only increase his political responsibility. To protect the Organization as a whole, and the Director-General personally,it may be useful to form around him a small group of members of the Executive Board, or indiv~duals who are nominated by the E:l{ecutive Board on the proposal of the Director-General. Such a group, together with the Director-General, should help to provide a measure of global political protection and power to the Organization. 81. How can the interrelationships between the various operational levels within the Secretariat be improved?
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82. Wide staff participation at all operational levels in the development and implementation of the Organization's programmes is the best way of ensuring fruitful interrelationships within the Secretariat. Both formal mechanisms and informal consultations have to be strengthened to this end. New dimensions have been given to the Organization's managerial structure by the creation of Regional Programme Committees in Regional Offices, the Headquarters Programme Committee and the Global Programme Committee. Regional Programme Committees deal mainly with the review and monitoring of the implementation of regional programme activities; the Headquarters Programme Committee advises and assists in the development and implementation of the Organization's programme on the basis of the policies and strategies evolved by the World Health Assembly and Executive Board; the Global Programme Committee, consisting of the Director-General, Deputy Director-General, Regional Directors and Assistant Directors-General, coordinates the management of the Organization's programme on a global scale. It is now necessary to establish closer relationships between these Committees in order to reach greater cohesion at all operational levels. This could be achieved by discussing common issues in each of the Committees and by ensuring adequate intercommunications in order to create a better understanding of one another's problems. This implies the rationalization of the information flow in all directions. The Organization's information system will have to be used more purposefully to this end. Regional Programme Committees and the Headquarters Programme Committee each have the responsibility of ensuring the widest possible involvement of staff in their respective offices in the issues under review, and their subsequent enlightenment concerning the outcomes of the deliberations. 83. Crucial to the improvement of the efficiency of the Secretariat as a whole in responding to countries' needs is a more systematic coordination of the review of programme budget proposals in the regions and in the Global Office. In so doing it has to be realized that there are infinite variations in countries' needs, but that at the same time there are usually common global themes as increasingly articulated in the General Programmes of Work for a Specific Period, and that in all cases there is a need for an integrated response to countries' needs at whatever level the response takes place. Problems of timing exist, but these will have to be analysed thoroughly and overcome. When medium-term programming by programming groups representing all operational levels and with strong national involvement encompasses all programmes, and updating of the medium-term programme becomes a continuing process, a major step forward will have been taken in ensuring a high degree of coordination of activities across the world. The problem of timing for the programme budget review should then be less acute, but nevertheless a specific process will still have to be set in motion for the formulation of the biennial programme budget.
DGO/78.1 page 18 84. When the above processes take root, along with the consistent application by countries of the national health development process mentioned in paragraph 18 above, WHO will have gone far in implementing resolution WHA28.30, according to which the Organization's mechanism for the allocation and reallocation of resources should comply with the principle of responding to integrated programme planning.
THE INTERACTION AND INTERDEPENDENCE OF ALL ORGANS AT ALL OPERATIONAL LEVELS AS ILLUSTRATED BY THE MANAGEMENT OF WHO'S RESEARCH ACTIVITIES 85. Whatever the degree of fruitfulness of the interrelationships between the various operational levels of the Secretariat, it cannot be sufficiently stressed that the key to the success of WHO's activities lies in cooperation among Member States. The Secretariat has to service the best interests of such cooperation. Maximum involvement of Member States, their institutions and their personnel in the work of the Organization is therefore essential. Nowhere are the above principles more apparent than in the new mechanism for the management of the Organization's research activities which are about to be introduced for a trial period of two years. This mechanism illustrates well how the Organization's structures are being reorganized in the light of its functions. It is therefore presented in some detail below. 86. The new plan for the management of WHO's research activities is based on the following main principles: - research activities should form an integral part of programmes and should therefore be managed in the same way as all other programme activities; - emphasis must be laid on the development of national research capabilities, on national determination of research priorities in the light of social health policy and on. national implementation of research activities. These prinCiples apply to research at whatever operational level it is planned and conducted. From the perspective of Member States there can be only one integrated WHO managerial system. 87. In the plan, two vital issues are closely interlinked, namely the development of research capabilities in Member States, in particular in developing countries, and the conduct of research for the immediate solution of health problems. Impatience for immediate results could lead to imposing research activities on countries before they are ready for them, or to attempts at solving problems for countries instead of with them. At the same time, the best way for countries to develop research capabilities is to participate in the planning and conduct of research. 88. Additional complexifying factors are the need for managerial consistency coupled with scientific cohesion and effectiveness at all operational levels, and this in an area in which there are all too few people with the necessary research and research management knowledge and experience. Yet, it is just such competence that is so important not only for research as such, but also for the improvement of health management in the broadest sense. 89. The plan is based on a number of fundamental concepts and guiding principles. The new policy laying primary emphasis on technical cooperation with and among Member States, and the strategy being evolved for its implementation, have profound repercussions on WHO's research activities. Research in WHO is now more intimately identified with health development in general, and responsibility for its planning and execution spread over the national, regional and global levels of the Organization. The promotion of national self-reliance in health research is fundamental. Countries have to develop their own health research capabilities and to cooperate among themselves for the benefit of the less privileged. Since WHO's research activities should be an intrinsic element of health development, they have to be undertaken in relation to socially relevant health goals, and not for their own sake.
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DGO/78.1 page 19 90. The research component of the WHO programme has to be conceived, planned and managed as one mosaic, with well-coordinated national, regional and global components. Activities have to be evolved in response to country needs and have to take root where such needs are most directly felt, namely in the countries themselves. The research component of the programme, however, cannot be a mere aggregate of national fragments. The mosaic has to follow a pattern, and it is the role of the Organization to set that pattern on a regional and global basis. The criteria for determining at which operational level a research activity should take place are those that appear in the Sixth General Programme of Work and that apply to programme activities in general. The correct allocation of activities to the appropriate operational level should form the basis of the allocation of funds for research from both the regular budget and extrabudgetary resources. 91. Health research activities in countries should ideally address problems for whose solution research is necessary, that have been identified in the course of the country health programming process. These activities may bear on scientific substance, on the development of national research capability or on research management. In addition, the country may participate in research that has been fostered by WHO as part of its regional or global research activities and that is of relevance to the country concerned.' WHO's research activities at the regional level have to be based on needs emanating directly from countries, as well as on adaptations of global research policies and priorities to national requirements. In like manner, global research activities have to be based on a synthesis of global needs emanating from regional research activities on the one hand, and the research requirements of global health poliCies and programmes on the other. 92. Research management functions also have to be distributed rationally among the various operational levels in keeping with the respective roles of these levels in the planning and implementation of the programme in general. The Director-General therefore maintains full authority over research activities in WHO and is solely accountable for them to the Executive Board and the World Health Assembly. He delegates responsibility for some of these activities. Major responsibility is delegated to the Regional Directors for activities conducted in countries or at the regional level, and, as the alter ego of the Director-General and on behalf of the Secretariat asa whole, for all matters of a global nature in the Region. The Regional Directors are accountable to the Director-General, as well as to the Regional Committees as far as regional research activities are concerned. 93. The management of research in WHO has to be based on the greatest possible involvement and contribution of the world scientific and health community. WHO staff members too have to be involved, it being self-evident that they function as part of the Secretariat as a whole, whatever their operational level of assignment and the administrative framework in which they normally work. They, together with representatives of the world scientific and health community, have to form for each major programme an Organization-wide programme team whose function it is to guarantee the SCientific, technical and managerial cohesion of the research activities undertaken at every operational level. A senior technical officer will be designated to ensure the scientific and technical coordination of that team. He will be accountable in the final analysis to the Director-General, as well as to the Regional Directors for all aspects of research for which they have been made responsible. These research coordinators will have no executive responsibilities other than those attached to the post they normally hold. The location of this post may be in the Organization's Global Office or in one of the Regional Offices, depending on the focal point for the research concerned. 94. The mechanisms and resources for research management will be based on the above fundamental concepts and guiding principles. It is of primordial importance to develop suitable research management mechanisms in countries. At other levels, the Regional Committees, the Executive Board and the World Health Assembly are becoming involved to an increasing extent in the planning and management of WHO's entire programme, including its research component. The Advisory Committees on Medical Research at the global and regional levels ,are acquiring ever-growing importance, and will have to continue to develop closer working relationships among themselves and with the Organization's constitutional organs, including the Secretariat. 1 -
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DGO/78.1 page 20 95. The principal means of implementing specific research activities is a contractual technical service agreement. The preparation, negotiation, conclusion and execution of such an agreement will devolve upon that level of the Secretariat which has technical and financial responsibility for the research to which the agreement relates. Contractual technical service agreements will normally be signed by the Regional Director or staff designated by him. Contractual technical service agreements managed at the global level will be signed on behalf of the Director-General by staff designated by him. 96. The selection of experts relating to research will be the responsibility of the Regional Directors, who will act in close consultation with the research coordinator mentioned in paragraph 93 above. Regional Directors' proposals for appointment of experts will be submitted for the approval of the Director-General, who has to report on all appointments to the Executive Board. 97. The network of WHO collaborating centres will serve the Organization as a whole, being used for national, regional or global research support, training or reference according to uniform management criteria. The selection of institutions and the procedure of designation will be the responsibility of the Regional Directors, whose proposals will be submitted for the approval of the Director-General. The decision to recognize national centres will be taken by the Regional Directors. The major responsibility for research training will also devolve upon the Regional Directors. Use will be made of national research training institutions for training both national and international staff. 98. While all concerned will participate in the evaluation of the plan, its implementation will also be monitored and ultimately evaluated by the Global Advisory Committee on Medical Research in cooperation with the Regional Advisory Committees on Medical Research. To this end, the Chairman of the Global ACMR, together with the Chairmen of two of the Regional ACMRs, will fulfil a function similar to that of external audit, and will be provided with full information on progress and on problems. Governments too will be kept fully informed of research taking place in their country and the Regional Committees and Executive Board will be kept fully in the picture. 99. It is realized that two major events may well modify the plan outlined above, namely the results of the Executive Board's Organizational Study on "the role of WHO expert advisory panels and committees and collaborating centres in meeting the needs of WHO regarding expert advice and in carrying out technical activities of WHO"; and the present Study of the Organization's structure in the light of its functions. Nevertheless, the plan as envisaged complies with the needs expressed inresolutionsWHA28.30 and WHA31.27 for integrated action throughout the Organization; for programme planning to be viewed as a joint endeavour in which national authorities in their own countries and in the Regional Committees, Executive Board and World Health Assembly, as well as all operational levels of the Secretariat, are all involved; and for WHO to foster national self-reliance in health matters, in particular through technical cooperation with countries in the planning, programming, implementation and evaluation of their health programmes.
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SCHEDULE FOR THE STUDY 100. The following schedule is proposed for the Study: (1)
Discussion in Global Programme Committee • Introduction of proposed Study in Regional Committees and setting up of appropriate ad hoc groups or subcommittees of the Regional Committees to carry out the Study in the Regions . . • . • . • . • . • . . • • . . . .. Consultations with governments (not only Ministries of Health) . . • . . • . . • . ••••..••
May 1978
(2)
September 1978 November 1978 July 1979 January 1979
(3)
(4)
Review of progress in Global Programme Committee . . . • . . . . . . .
DGO/78.1 page 21 (5)
Review by Regional Committees of reports of ad hoc groups or subcommittees based on country consultations . • . . • • • • • . • • . . • • . Consideration of the matter in the Regional Programme Committees and Headquarters Programme Committee . • Review by Global Programme Committee of recommendations and proposals of Regional Committees, Regional Programme Committees and Headquarters Programme Committee . . . • • • • . • . . • • Preparation of the Director-General's Report to the Executive Board • • . . • • . . . • . . . . • Review of Director-General's Report by Executive Board Review of Executive Board's Report by World Health Assembly
September 1979 June 1978 June 1979
(6)
(7)
Date to be decided at fourth session of GPC in January 1979 October • November 1979 January 1980 May 1980
(8)
( 9) ( 10)
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11
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1
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II