Keeping countries Strengthening country support in the WHO Regional Office for the Western Pacific Western Paci c Region at the centre Western Paci c Region
Keeping countries Strengthening country support in the WHO Regional Office for the Western Pacific at the centre WHO Library Cataloguing-in-Publication Data Keeping countries at the centre: strengthening country support in the WHO Regional Office for the Western Pacific 1. Country programmes. 2. Programme planning. 3. World Health Organization – organization and administration. I. World Health Organization Regional Office for the Western Pacific. ISBN 978 92 9061 661 0 (NLM Classification: WA 525) © World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). 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In no event shall the World Health Organization be liable for damages arising from its use. iiiKEEPING COUNTRIES AT THE CENTRE CONTENTS Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Section 1: The external review of country support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Approach and methodologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Key findings: Areas of good progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Key findings: The challenges remaining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Section 2: Opportunities from wider reforms in WHO . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Section 3: Framework for action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Theory of change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Action area 1: A transformative Regional initiative on Universal Health Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Action area 2: Streamlining administrative processes in the Regional and country offices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Action area 3: Empowering the Regional Office workforce . . . . . . . . . . . . . . . . . . . . 13 Action area 4: Improving Region-country teamwork . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Action area 5: Strengthening the technical support capacity of the Regional Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Action area 6: Making the change happen in the Regional Office . . . . . . . . . . . . . . 16 Section 4: Changing the way the Regional Office sees itself . . . . . . . . . . . . . . . . . . . . . 19 Annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Annex 1: Mock-up of change management project management tool . . . . . . . . . 20 Annex 2: Terms of reference and methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Annex 3: List of people interviewed during the external assessment . . . . . . . . . . . 23 Annex 4: Staffing analysis (selected charts) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Annex 5: Budget analysis (selected charts). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Annex 6: Meeting analysis (selected charts) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Annex 7: Staff survey (selected charts). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Annex 8: Bibliography and references . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 iv KEEPING COUNTRIES AT THE CENTRE ACKNOWLEDGEMENTS This publication and the assessment on which it is based were funded by the World Health Organization (WHO) Regional Office for the Western Pacific. However, the publication reflects the views of the assessment team and does not necessarily represent the decisions or policies of WHO. The assessment team was composed of Bob Fryatt, Consultant, Mott MacDonald Australia; Philippe Lamy, Consultant; former WHO Representative, Pan American Health Organization; Yunguo Liu, WHO Representative, Lao People’s Democratic Republic; and Steve Kadish, Senior Vice President and Chief Operating Officer, Northeastern University, Boston, United States of America. vKEEPING COUNTRIES AT THE CENTRE ACRONYMS AC Assessed Contributions CCS Country Cooperation Strategy DAF Division of Administration and Finance DCC Division of Combating Communicable Diseases DHS Division of Health Sector Development DHP Division of Building Healthy Communities and Populations DPM Division of Programme Management DPS Division of Pacific Technical Support DSE Division of Health Security and Emergencies GSM Global Management System PB Programme Budget PDO Programme Development Officer PIC Pacific Island Countries PMDS Performance Management and Development System RBM Result-Based Management RMNCH Reproductive, Maternal, Neonatal and Child Health VC Voluntary Contributions WHO World Health Organization vi KEEPING COUNTRIES AT THE CENTRE EXECUTIVE SUMMARY This is an external assessment of how the World Health Organization can improve its support of country offices, its efforts to improve health outcomes for individuals, families, communities and Member States in the Western Pacific Region. This work was requested by the Regional Director as a follow-up to a specific recommendation to evaluate the Regional Office’s ability to provide effective support to the country offices. Over the last five years, significant changes have been made to the organizational structure and performance. The results in terms of programmatic accomplishments as well as spending targets and key human resources goals met are impressive and whet the appetite for more. This report done in the last quarter of 2013 is structured in four major sections. Section 1 provides the overall context, background, and a summary of the key findings. Section 2 reviews the opportunities for synchronizing reforms in WHO. Section 3 focuses on recommended “action areas”. Section 4 provides concluding comments on how the WHO Regional Office for the Western Pacific might see itself in the future. After discussions and interviews with dozens of individuals at the Regional Office and country offices, we believe that significant action can be taken within the first 100 days of the Regional Director’s new term and that the remaining recommendations can be largely completed within 12–24 months. The aim is not to be prescriptive, and the details of projects, if accepted, will no doubt change as they are considered in greater depth. However, most of the ideas for projects build on existing concepts developed by the Regional Office staff members themselves, showing the broadly shared desire to continually improve on current ways of working. Recommendations for the first 100 days of the new term Establish the infrastructure to make change happen Launch a cross-programme approach to health systems strengthening Increase delegation of authority for WHO Representatives Expand annual Regional Office-country office strategic dialogue on country needs Assign country focal point responsibility to Regional Office directors Establish monthly dialogue between technical units and WHO Representatives/country offices Engage in a critical review of administrative procedures Streamline publication procedures Codify streamlined approach to emergency procedures Enhance targets for recruitment and selection Post Regional Office monthly travel by country Circulate bimonthly division updates Expand bimonthly Team Leaders’ meeting Establish minimum response times of technical teams to country office requests Establish mechanism for communicating dates for visits of country office staff across the Regional Office 1KEEPING COUNTRIES AT THE CENTRE INTRODUCTION This report is an external assessment of how the WHO Regional Office for the Western Pacific can improve its support of country offices in its efforts to improve health outcomes for individuals, families, communities and Member States in the Region. This work has been done at the request of the Regional Director as a direct follow-up to a specific recommendation to evaluate the Regional Office’s ability to provide effective support to the country offices. The openness, enthusiasm and energy demonstrated by everyone we spoke with regarding how to improve the Regional Office/Country Office effectiveness is a great asset and opportunity. We hope that this is a different kind of document—not just an assessment, but a blueprint for action and next steps. In fact, one of the key recommendations included in the report is a specific approach to “making change happen”. Given the strong foundation for change and improvement built over the Regional Director’s first term, we make a bold assertion. After discussions and interviews with dozens of individuals at the Regional Office and country offices, we believe that significant action can be taken within the first 100 days of the Regional Director’s new term and that the remaining recommendations can be largely completed within 12–24 months. Having made this assertion, we understand that the work of the Regional Office is not about change for change’s sake, but always has the goal of improving health outcomes, and has to be understood in the context of competing critical global, regional and national priorities. Nevertheless, all organizations with the intent to not just survive, but to thrive and improve, are always balancing competing priorities and the need to change for the better. The Regional Office is no different, and may in fact have the experience, determination and leadership to operate at this higher level. The recommended “action areas” are the heart of this report. It is here that we want to focus attention. It is the successful implementation of these action areas that we believe will bring the improvements not only to how the Regional Office supports the country offices, but also to how the Regional Office and country offices work together towards the health outcome goals established by WHO and each Member State. In fact, we believe that the start of a new term for the Regional Director and his leadership team offers a unique opportunity for action. With the groundwork of change already laid, the enthusiasm of staff and focused leadership, the first 100 days of the new term can be a moment to complete and launch a set of initiatives that will propel the Regional Office forward. We have made more than 40 specific recommendations for action. Of this total set, we believe that a third can be achieved in the first 100 days, setting the stage for further improvements. In Section 1 is the list of items that we recommend be tackled right away. More specific information about all the recommendations can be found in the annexes. It is important to note that these initial recommendations are “no cost” but will require some dedicated effort. It is here that we suggest the overall efforts begin. We look forward with great anticipation to what the Regional Office will accomplish. 2 KEEPING COUNTRIES AT THE CENTRE SECTION 1: THE EXTERNAL REVIEW OF COUNTRY SUPPORT Background 1. The Regional Office engagement in WHO reform: Since 2009, the Regional Office has been undertaking major reform.(1) This started with a wide consultation called “Fit for the Future” aimed at improving results at country level. This led to a reform strategy and detailed plans to strengthen the Regional Office’s focus on Member State needs, deliver value for money, convene and coordinate for better health, and improve strategic and technical communications. Additional “enabling” changes focused on human resources planning, resource mobilization and communications. In addition, the Regional Office has been a major player in the WHO reform effort(2) as illustrated by the Regional Director’s joint chairing of the Taskforce on the Roles and Functions of the Three Levels of WHO. These changes, and the Regional Director’s drive to improve the Region’s focus on results in countries, were given broader endorsement during the review. Many interviewees commented that the Regional Office is an enjoyable place to work, and for those rotated to the Region, possibly more so than other parts of WHO. 2. WHO’s performance at the country level in the Regional Office: The first external assessment was commissioned in 2012.(3) It noted the progress being made, in particular through the use of self-assessments by staff in country offices to enhance the reforms, and the use of joint strategic discussions between Regional Office and country offices to define WHO priorities in specific countries in the Region. The assessment focused on WHO’s work in three countries, Cambodia, Papua New Guinea and Solomon Islands. It concluded that there were both strengths and weaknesses in the Regional Office workforce, that the Regional Office was not being sufficiently strategic at country level, that WHO had to take a different role in different settings, that health systems support was not strong enough, and that WHO productivity was hampered by its own culture and systems. The review proposed seven action areas: y place the best people in the most demanding jobs; y make health systems the main focus in all country offices; y be strategic: make tough choices to achieve real impact; y assess whether the Regional Office is really country-focused; y focus on value for money; y beyond convening: be bolder in driving the policy dialogue; and y communicate with purpose. Approach and methodologies 3. Terms of reference and methodologies: This external assessment follows the recommendation of the 2012 review to “assess whether the Regional Office is really country-focused”. The terms of reference and proposed methodologies are attached in Annex 2. The work included: extensive desk reviews; an anonymous 3KEEPING COUNTRIES AT THE CENTRE online survey of WHO staff members both from the Regional Office and country offices and key informant interviews and focus group discussions with the Regional Director, division directors, WHO Representatives, technical officers and secretaries. Three interviews were external to WHO: with the Minister of Health of the Lao People’s Democratic Republic, health specialists at the Australian Agency for International Development and an independent consultant who helped lead the previous external assessment in 2012. 4. Approach taken by external assessment team: Given the work that had already gone into the internal reform drive, the team made particular efforts to build on and help implement previous recommendations. After an extensive desk review, the interviews and focus group discussions provided the opportunity to hear about progress and challenges as well as a large number of proposals for future change. These proposals were documented, prioritized and then reviewed with staff as part of the assessment. The previous reform effort had produced a large set of reports and various forms of documentation, so this assessment aimed to come up with specific and actionable recommendations. The team was also requested to produce an outline implementation plan with actions, responsibilities and time frames. 5. Specific recommendations: We heard and recognized that concepts alone would not be helpful. Specific recommendations, ways forward, and possible time frames would be needed to move from concept to reality. With this in mind, we maintained our focus on answering two questions: i) What is the specific recommendation to be made? and ii) What are the specific steps to be taken? This resulted in an outline implementation plan including measures to be taken, assignment of responsibilities and judgement of time frames as requested. Key findings: Areas of good progress 6. The Regional Office commitment to reforms to strengthen country support: As noted above, the Regional Office senior management has taken the current reform effort in WHO very seriously, with most of the focus on improving efficiency and delivering results in countries. The assessment of staff trends and budgets shows an increase in the total number and proportion of staff in country offices when compared to the Regional Office (see Figure 1), with a similar trend for the overall budget split. The willingness to have two external assessments of progress in strengthening country support is also a sign of how seriously the Regional Office takes the internal reforms and the need to change. Figure 1: Proportion of Staffing, Regional Office vs Country Offices 230 218 222 246 281 309 307 335 333 346 290 287 298 291 312 314 323 323 302 300 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 RO CO 4 KEEPING COUNTRIES AT THE CENTRE 7. Innovations and willingness to experiment with new approaches: There have been numerous examples of the Regional Office trialling new ways of working to improve impact in-country, through subregional initiatives. These include the cross-sectoral Mekong Healthy Borders work,(4) the Western Area Health Initiative in China,(5) the emergency response to artemisinin resistance in the Greater Mekong Subregion designed with the WHO headquarters and the Regional Office for South-East Asia,(6) new approaches to strategic planning and rewarding innovations aimed at improving WHO performance in countries. 8. Implementation of structural reforms within the Regional Office: The Region has also undergone recent structural reforms specifically aimed at strengthening country support including the establishment of the Division of Pacific Technical Support (DPS) in Fiji and the Country Support Unit in Manila under the Division of Programme Management (DPM); the latter was seen as a very positive change by the WHO Representatives interviewed. The strategic consultations between the Regional Office and country offices, aimed at linking country cooperation strategies (CCS) and routine planning, also received positive comments from country teams interviewed during the assessment. 9. Programmatic successes: The Regional Director’s Annual Report noted impressive gains in recent years, including all countries maintaining polio-free status; endemic measles interrupted in 32 countries; Hepatitis B seroprevalence reduced to fewer than 2% in 30 countries; 9 out of 10 malaria endemic countries changing programme goals from control to elimination; and progress in HIV, tuberculosis and neglected tropical diseases. The interim report on programme budget performance showed a good record of achievement with the Regional Office on track to perform well for the biennium.(7) As with the previous biennium, over 60% of expenditure on results was in country offices. There had also been a significant increase in spending under the category “health systems and services”, from US$ 24.2 million to US$ 29.8 million, from the comparable period in the previous biennium, with higher overall allocation in line with previous recommendations to increase this area of work to strengthen country support. The programme budget performance narrative gives a comprehensive and impressive overview of progress and provides open discussion on challenges such as Member States finding they are unable to yet comply with International Health Regulations, the problem of antimicrobial resistance in TB and malaria, and the lack of resources to adequately take forward the noncommunicable disease agenda. 10. Preparing for stronger support to health systems: The Regional Office has just undertaken an internal review of its work on health systems.(8) This was partly aimed at Member States in the Region, but also included a useful set of internal recommendations for the Regional Office Secretariat to consider. A number of weaknesses in its current approach were highlighted in the review, which recognizes that the Regional Office needs “whole-of-system” approaches and engagement with both state and non-state actors. The review also contains a section on building more effective technical partnerships. This review, and the arrival of new directors at the Regional Office, provide a firm basis for a renewal of the Regional Office’s approach to supporting the development of health systems in the Region. 11. Strengthening the quality of country cooperation strategies: The Regional Office recently reviewed the quality and utilization of CCSs undertaken in the Region.(9) As in this review, mixed opinions were revealed, generally much more positive at country level than at Regional level. It is clearly important for WHO to undertake 5KEEPING COUNTRIES AT THE CENTRE in-depth strategic reflection on its cooperation in relation to national policy and planning timetables, and the CCS serves this purpose well. It also provides a visible, strategic commitment between a Member State and WHO as a whole, as confirmed by the Minister of Health, Lao People’s Democratic Republic. However, the analysis made several recommendations for strengthening the CCS process in the Region, by improving in the following areas: documenting the process; being inclusive; distributing it widely within and outside the country; giving greater emphasis to in-depth situation analysis; ensuring quality, consistency and coherence through a “clearing house”, as well as peer and stakeholder review; reporting progress and lessons learnt periodically; involving staff at the Regional Office; and prioritizing the strategic agenda in a more selective way. In addition, resource allocation to country support in the programme budget does not seem to be influenced by the CCS. Health ministries do not refer sufficiently to it to prioritize their engagement with WHO; it does not define results but only a high-level strategic agenda covering almost everything. Some questioned whether a document that reads the same across the world is required, and suggested it should be replaced with a negotiated cooperation agreement that fits the country situation and available resources. 12. Review of WHO collaborating centres in the Western Pacific Region: The Regional Office is reviewing the role of WHO collaborating centres. There is still a strong demand to be associated with WHO, but informants reported mixed experience of the utility of Collaborating Centres with regard to support to other countries. Some provide an excellent service (for example the laboratory reference services) while others provide no support at all. Some demand very high fees for providing support to other countries. A quick review of the 177 collaborating centres in the Region shows that most centres (about 80%) are in three countries; Australia, China and Japan. An approximate breakdown shows a good spread across WHO technical areas (communicable diseases 18%, noncommunicable diseases 23%, health systems 26%, healthy communities 28%) but within this, some areas have high levels of collaboration (e.g. 15 of the 21 collaborating centres on drugs are focused on traditional medicines) while some areas of high demand in countries (e.g. health financing) have no collaborating centres. If considered as part of WHO support to countries, collaborating centres should be included in the regular planning processes of the Regional Office, including their own resources when appropriate. The Regional Office’s ongoing review of collaborating centres should continue and provides an opportunity to consider how the Region can benefit more from them. 13. Emergency response: The Western Pacific Region is prone to earthquakes, tsunamis, typhoons, floods, landslides and droughts; around 40% of worldwide disasters occur in the Region. Many result in enormous loss of life and serious damage to health infrastructure and health systems. The Emergency and Humanitarian Action programme, established in the Division of Health Security and Emergencies (DSE) in 2010, works with Member States and partners to minimize the health impact of emergencies and disasters. The present assessment of country support by the Regional Office was ongoing when Typhoon Haiyan, one of the most devastating storms in history, hit the Philippines on 8 November 2013. Based on the WHO Emergency Response Framework, the Regional Office declared a Grade 3 emergency, which allowed mobilization of experts and other resources, regionally and globally, to the Philippines. WHO has invested in more capacity in the Regional Office for such disasters. The Regional Office should run an external assessment in 2014 of WHO’s response to Haiyan and use the findings to strengthen the Regional Office preparedness and response capacity. 6 KEEPING COUNTRIES AT THE CENTRE Key findings: The challenges remaining 14. Missed opportunities from working in “silos”: While it is neither necessary nor desirable for WHO to always work as cross-cutting technical teams, the interviews with country teams and external parties did suggest that WHO was missing opportunities from not working in a more collaborative way. For example, the staff survey revealed a significant problem of senior technical staff in the Regional Office and country offices not planning their work together (see Figure 2). Previously, attempts had been made to impose more integration across programmes (for example a project on looking for synergies between health systems and disease control and a collaboration with the London School of Hygiene and Tropical Medicine and the Global Fund to Fight AIDS, Tuberculosis and Malaria on linkages among HIV; tuberculosis; malaria; the Expanded Programme on Immunization; reproductive, maternal, newborn and child health and health systems in Cambodia). The results from the latter project have never been published despite important conclusions related to contracting and integration that are very relevant in countries across the Region and beyond. These efforts should be revisited and the lessons built on. During this review, other areas were mentioned that could be explored, for example, linking the relatively strong regional HIV network with the currently weak platform for strengthening maternal and child health services in countries and using the relatively strong network of TB experts to help take forward some of the work on reducing tobacco consumption. Also, many technical units make recommendations to countries without considering cost implications; this issue could be addressed by routinely working with health economists (in WHO and World Bank). In the area of monitoring, surveillance and strengthening health information systems, country teams complained of fragmented support to countries, which reinforces existing tensions between weak central monitoring and evaluation (M&E) units and institutions and the various national priority programmes. 15. Expanding WHO cooperation to countries through partnerships: Countries are facing new and important challenges while needing to address existing issues. The guiding and convening role of WHO is recognized at national, regional and global levels. Nevertheless, WHO has not always played this role in an effective manner; the technical expertise, institutional capacity, or financial resources are often with other institutions. The WHO collaborating centres are one example, responding to a set of criteria, essentially based on scientific standards, and most of them are based in a few developed countries. The Regional Office, with the 53.97 27.63 75.00 9.21 31.75 7.89 3.17 0.00 55.3 11.1 25.0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% G staff P staff NPO Percentage of respondents St aff ca te go ry (n=143) Adequate Inadequate None Not Applicable Figure 2: Extent of the Regional Office staff consultation with country office in developing activity work plan 7KEEPING COUNTRIES AT THE CENTRE WHO South-East Asia Region, is exploring a new way of cooperating with countries through a new partnership, the Asia Pacific Observatory on Health Systems and Policies, which brings together governments, international organizations and research institutions in order to link scientific knowledge and decision-making processes. In emergencies, many organizations and institutions—local, national, or international; governmental and nongovernmental—are mobilized to respond to the health needs of the affected populations. In such circumstances, WHO is recognized as the lead of the so-called “health cluster”. In the Regional Office, there is a wealth of experience in establishing and coordinating different kinds of formal and informal partnerships in various technical areas. The Regional Office should capitalize on this rich universe of collaboration, ensuring formal and sustainable integration of its partners within its strategies, plans and programmes with countries. 16. Weak results-based management: Previous reviews, including by donor partners, have consistently noted that WHO is weak in results-based management. Our review showed that the WHO planning system, supported by the Global Management System (GSM), is focused on global goods and not on planning and delivering results agreed in individual countries following priorities agreed for country cooperation. Related to this was confusion over the role of the CCS, with staff in-country and others saying it is “central to what WHO does” while others found it a “dusty strategy—once completed, left on the shelf to gather dust and never referred to again.” This has been recognized as a weakness across WHO and is the subject of wider WHO reform to be discussed at the next Executive Board. 17. Insufficient investment in developing the Regional Office workforce: There has been good progress in some human resources reforms, but more could be done. Given the relatively small size of the office, its geographical spread and a tightening of budget, the level of resources and effort dedicated to ensuring a consistently strong staff workforce seemed limited. While some progress and improvements have been made, a common comment from staff was that more should be done. A lot of the meagre staff development and learning budget goes to travel for training. There has been progress in reducing the average times for selection and recruitment. There has also been very good progress with implementing a regional rotation and mobility policy, which will no doubt strengthen the Western Pacific Region over time, as more staff members are taken on according to different geographic and thematic responsibilities. However, there seems to be only a very limited induction process for new staff members, and key positions in country teams sometimes remain unfilled for long periods. 18. Administrative rules and procedures: While there was universal support for the work that the Division of Administration and Finance (DAF) team has undertaken and its accomplishments, virtually all those engaged in this review emphasized the problem of various administrative procedures with no apparent added value. Staff noted the presence of parallel processes performed both via GSM and paper or Microsoft Excel-based systems. While some changes have been made since the introduction of GSM, there does not seem to have been a comprehensive review of procedures, so existing old ones persist because it is “what we have always done”. WHO Representatives are now selected through a more rigorous process, focusing on more experienced managers, yet delegation of authority in a number of areas is limited. This was similar for many directors in the Regional Office, who are required to elicit often very time-consuming authorization for travel, for example. Many of these approval rules are in place because of previous (and sometimes ongoing) 8 KEEPING COUNTRIES AT THE CENTRE abuses, but alternative approaches such as spot audits or selective increased delegations awarded according to performance and adherence to rules should be considered, along with other solutions. Lastly, the information technology (IT) problems facing many country offices seem out of place for a modern organization. In some places, GSM is virtually unusable because the system interface is so slow, and basic standards of functionality for both GSM and video-conferencing are not being met, despite the large investments made in communications infrastructure. 19. Inadequate response to priority areas of technical support: There was agreement that the Regional Office provides generally high-quality technical support and dialogue. Some technical areas were, however, considered relatively weak, and efforts for further improvement are needed. These included support to engage in health systems dialogue, such as sector reform or strengthening primary health care in-country, drug regulation, health financing reforms, linking WHO technical strengths to strengthening services in countries, and in-country technical support to address noncommunicable disease crises. The duplication of effort and staff time in the development of regional action plans and regional advocacy events, despite the presence of a global action plan, had been commented on by Member States. 20. Insufficient learning and Regional Office-country office collaboration: The review of country mission reports was facilitated by a simple, accessible database, but there is no system for ensuring recommendations are followed up. Some commented on the lack of sharing of reports and recommendations across technical units, and insufficient focus on planning more collaborative approaches to country missions (e.g. joint missions, or one technical expert following up on recommendations in another technical area). However, the high demand for technical support from countries and the limited level of resources in the Regional Office, has led to some innovative approaches. Many of the technical units have effectively mobilized technical networks in the Region and created innovative alliances to expand the Regional Office’s response capacity and influence, sometimes with support from web-based tools (such as “TB Team” shown in Figure 3). There have been attempts to share these experiences across programmes, but it might be timely to revisit these past exchanges. Also, the experience of working with WHO collaborating centres seems mixed, with many selected because of history or internal and external lobbying on behalf of specific institutions rather than the strategic needs of the Regional Office and its Member States. 21. Inadequate internal communications compromise performance: WHO at both Regional and WHO headquarters levels has a strong need for information from countries, whether it be related to regular data or responses to ad hoc surveys. Information requests, which individually might seem reasonable, are administered in an uncoordinated way and together can place a major burden on country teams. A more coordinated approach would improve efficiency and provide opportunities for a common analysis of data and information obtained. Figure 3: TB Team: An example of an innovative web-based approach to strengthening technical support to countries 9KEEPING COUNTRIES AT THE CENTRE In-country, an uncoordinated approach to monitoring national programmes (e.g. HIV/Tuberculosis, Expanded programme on immunization, Maternal, child health and nutrition, Noncommunicable diseases, etc) may mean missing opportunities for strengthening national institutions responsible for monitoring and evaluation of health (e.g. statistical institutes and monitoring and evaluation departments in health ministries). 22. Previous recommendations for reform not all heeded: While the efforts to reform the Regional Office seem to have been widely appreciated by staff and external partners, not all were clear on the path of reform, or about how much progress has been made. The extensive list of reform activities in the “Moving Forward, Making a Difference” document is not linked to a systematic monitoring system, although the related donor support to reform does have some monitoring elements. Given their importance, these reforms should perhaps be more visible. This has been compounded by change in some senior staff positions in the Regional Office and the continual flow of ideas arising from the regular meetings of WHO country leads and Team Leaders, some of which require development or review of the Regional Office internal systems. 10 KEEPING COUNTRIES AT THE CENTRE SECTION 2: OPPORTUNITIES FROM WIDER REFORMS IN WHO 23. WHO’s “bottom-up” planning: The Regional Office should continue to explore how the wider reform effort underway in WHO could be used to strengthen country support. One example is the commitment to explore “bottom-up” planning, i.e. to start with defining the needs of Member States and then work up to a global agenda. This could be an opportunity for the Regional Office to take a “whole-of- the-health system” approach to engaging with Member States, in line with the previous recommendation to make health systems the main focus in all country offices. In the Western Pacific, the Regional Office and country offices should take into consideration national development plans and strategies, including national health and insurance plans, as well as the existing CCS (it can be an opportunity for reviewing its pertinence and identifying the need for any updates). Rather than awaiting precise guidance from the WHO headquarters, the Regional Office should be proactive in shaping a new approach to results-based planning in WHO. 24. GSM review: The external review team was also informed that the Global Management System (GSM) is being reviewed, again providing an opportunity to change the way it is used in WHO. The system should be amended around the business needs of the organization with country-specific results forming the basis for the Regional Office’s country support. The review should also explore adapting GSM so that it is functional in countries with limited IT infrastructure, for example through speeding up the interface by making its processes functional “offline” as happens in other organizations, where data entered during business hours are uploaded to the system at night. 25. Working with middle-income and developed countries: Many of our discussions focused on the changing economies and environments in the Region and the imperative for existing ways of meeting needs to be rethought. Middle-income countries’ needs are different and often more complex, with different expectations of WHO. In such situations, WHO’s normative role must be complemented by engagement in policy dialogue and being able to articulate policy options and their disadvantages and advantages. Global and regional commitments, agreed to by WHO and the Regional Office governing bodies, require actions in all countries to achieve the expected results. Good examples would be the implementation of the International Health Regulations or the Framework Convention on Tobacco Control. Achieving Universal Health Coverage or addressing the objectives of prevention and control of noncommunicable diseases will require the full, robust involvement of all countries of the Region. 11KEEPING COUNTRIES AT THE CENTRE SECTION 3: FRAMEWORK FOR ACTION Theory of Change 26. The reforms proposed for the WHO Regional Office for the Western Pacific add up to a substantive agenda of change for the Regional Office. To assist with this conceptualization of change, the external review team was asked to place their recommendations in a logical order; they have therefore been arranged into a “Theory of Change”. Once the final plan for the WHO Regional Office for the Western Pacific reforms is agreed, this can be revised and monitored to help strengthen the evidence on whether the required changes are taking place and leading to the desired results. 27. Timetable for action: Most of the recommendations are based on ideas and viewpoints expressed by the WHO Regional Office for the Western Pacific staff. Most of these recommendations can be actioned, and many completed, within a few months. Some may take one to two years to fully implement, but even these could be started soon. In particular, the first set of actions that we recommend, those that could be implemented in the first 100 days of the new term, are selected because they are feasible, clear, and have no direct financial cost although some dedicated time would be required. The benefits of these changes should be quickly evident. 28. Making successful changes and improvements: For these changes to be implemented, the WHO Regional Office for the Western Pacific needs to use its committed leadership to develop a common understanding of what changes are required, and then to agree on a plan with specific activities and initiatives, each with specific products and actions. The key changes have been summarized into six action areas. Figure 4: Strengthening the WHO Regional Office for the Western Pacific country support: Theory of Change Overarching goal: WHO reforms lead to improved health outcomes in Member States Indicators: MDGs, post-MDGs and WHO GPW the WHO Regional Office for the Western Pacific ‘change management’ work plan Assign responsibilities A transformative Regional initiative on Universal Health Coverage More empowered WHO Regional Office for the Western Pacific staff Streamlined administrative procedures Track change and review Impact of WPRO country support: progress towards Universal Health Coverage in Member States Indicators: UHC indicators / milestones agreed with individual countries MDG = Millennium Development Goal, GPW = general programme of work Expand the WHO Regional Office for the Western Pacific technical response capabilities Improve Regional Office/Country Office collaborations Make the change happen in the WHO Regional Office for the Western Pacific 12 KEEPING COUNTRIES AT THE CENTRE Action area 1: A transformative Regional initiative on Universal Health Coverage Why: To develop an initiative that takes a health systems approach to country support, promotes integration across technical programmes, and takes advantage of the wider WHO bottom-up planning due to start in 2014. Universal Health Coverage is a key theme of the post-Millennium Development Goal agenda. Specific actions: a. The four Regional Office technical directors will lead a shared approach to health systems strengthening, in a joint effort already underway that is to be finalized by early 2014. This should apply the concept of Universal Health Coverage that WHO is championing globally, and to which Member States have agreed. The WHO Regional Office for the Western Pacific could also utilize and strengthen the conceptual frameworks and indicators that are already being established.(10) b. To take this forward, the Programme Development and Operations Officer in the Regional Office should work closely with the Division of Health Sector Development and be fully aware of the Universal Health Coverage concept and assist with organizing a consultation on each Member State’s health system in early 2014 to start bottom-up biennial planning. The consultation could cover the current status of the health system and key gaps in achieving universal health coverage. The WHO Regional Office for the Western Pacific as a whole should then consider the short- and long-term opportunities for working more effectively with the Member States on both supporting needs identified in-country and enabling it to respond to global and regional commitments. The WHO Representative in the country would be responsible for setting the agenda and preparing any necessary background documentation. c. Each country consultation should end with an agreement with the WHO Representative on monthly calls between the Regional Office and each of the country offices to review ongoing operational priorities in the coming months. This would include the need for integrated joint missions to countries. The four directors would each take the lead on a group of countries and be responsible for setting up and publicizing a schedule of calls with the relevant WHO Representatives. d. The Regional Office technical directors should also set up a Strategic WHO Advice Team, coordinated by the DHS, consisting of a small number of senior, experienced technical staff members who can respond quickly to important cross-cutting policy events or bottlenecks in-country. e. Directors should agree on categories for grouping countries and themes. These could then be used by all technical units and country teams with the explicit aim of easing the exchange of knowledge across borders, and could feed into the work to develop category networks across WHO. f. Monitoring progress in countries will, in the future, rely on a monitoring and evaluation framework for Universal Health Coverage adapted to individual Member State needs. The WHO Regional Office for the Western Pacific should stay closely involved in the joint WHO–World Bank consultation launched recently in the Region.(11) 13KEEPING COUNTRIES AT THE CENTRE Action area 2: Streamlining administrative processes in the Regional and country offices Why: To free up staff time from procedures that do not add value and to adapt administrative systems so that they not only ensure adherence to WHO business rules but also build trust and efficiency. Specific actions: a. The Division of Programme Management and the Division of Administration and Finance should undertake a critical review of existing WHO Regional Office procedures and substantially reduce non-value-added approval signatures and memos. This would include, but not be restricted to: - sign-offs and paper processes that are duplicated in GSM; - streamlining procurement of services (e.g. pre-approved vendors, other appropriate delegations); - establishing a minimum technical budget allocation (e.g. US$ 10 000) to country offices to minimize non-strategic activities; and - streamlining the publication policy for general (non-technical) documents. b. There are existing “accelerated” administrative and financial procedures applied in order to respond effectively to emergencies. The WHO Regional Office for the Western Pacific should review such procedures, which could be expanded and applied as a regular standard in order to expedite and facilitate administrative support for country work. c. The Division of Administration and Finance should continue to set targets and monitor changes to improve human resources selection and recruitment (e.g. define separate targets for general service and professional staff, and report median days, not just averages), and consider introducing a system of automatic escalation to the Division of Programme Management or the Regional Director when delays breach a certain threshold. d. The Division of Administration and Finance should lead a review of GSM in the Region to inform the wider GSM review planned by WHO. This review should consider: - setting standards for functionality of in-country IT systems and GSM with plans and timelines to improve on the current situation; and - automatic GSM uploads in country offices during out-of-office hours, with daytime use of a quicker offline system. Action area 3: Empowering the WHO Regional Office for the Western Pacific workforce Why: To provide the WHO Regional Office for the Western Pacific staff with more opportunities to: develop new skills and competencies; streamline decision-making; and promote more collaborative ways of working. Specific actions: a. The Division of Administration and Finance and the Division of Programme Management should oversee the work of a small group, including general service 14 KEEPING COUNTRIES AT THE CENTRE and professional staff, in developing a broader staff development and learning plan for the WHO Regional Office for the Western Pacific. This work should include: - A comprehensive orientation programme for the first 90 days for each new employee, as well as follow-up sessions at 6 and 12 months. This should include basic WHO procedures, country support, the CCS and the roles and functions of the three levels of the Organization (global, regional and country); - Setting up three to four information/training sessions per year, including training on administrative matters to all staff, delivered in a variety of ways. - Identifying relevant staff training opportunities from free/low-cost courses on areas such as budgeting, use of Microsoft PowerPoint and Excel, planning, etc. b. The Regional Director should promulgate an updated Delegation of Authority for WHO Representatives and directors. These delegations would then be awarded according to the country office’s adherence to WHO administrative rules, ascertained through annual audits and spot checks. The suggested increases in delegations to WHO Representatives are outlined in Box 1. c. The WHO Regional Office for the Western Pacific should undertake a review of the profile of each country office following completion of its CCS, to align its capacity with its purpose and to help it adapt to changes in priorities. Action area 4: Improving Region-country teamwork Why: To improve teamwork between Regional Office and country office staff to build trust, ensure “cross-cover” of roles, and help build an understanding of what each staff member is doing and why. Specific actions: a. The WHO Regional Office for the Western Pacific should introduce changes to the way staff from the Regional Office and country offices interact and update each other. The following should be considered: - including priority technical areas on the agenda of WHO Representatives/ Country Liaison Officers consultations; Box 1: Proposed changes to delegations to the WHO Representative: I. approve use of WHO logo at country level II. approve donor agreements up to US$ 50 000 III. approve donor agreement extensions up to 1 year IV. approve contracts and expenditures up to US$ 50 000 (in place, but needs to be clearly communicated and practices established to make it operational) V. approve budget adjustments/reallocations up to US$ 50 000 VI. approve WHO Representative and country office staff domestic duty travel on GSM only, without additional paperwork and restriction to less than 10-day rule VII. approve Programme Management Officer contracts and extensions documenting that budget funds are available VIII. approve in-country professional and general service staff contract renewals documenting that budget funds are available IX. after position has been approved, WHO Representative has authority to fill a general staff position X. overall, delegations will be observed by all relevant WHO Regional Office for the Western Pacific parties. 15KEEPING COUNTRIES AT THE CENTRE - communicating the monthly travel report by country, not by individual, to improve coordination and promote joint programme work in countries, and circulating details of WHO Representatives’ Regional Office visits to directors in advance; - ensuring that bimonthly divisional updates are shared with country offices; - expanding the bimonthly Team Leaders’ meeting to include WHO Representatives from countries through tele- or video-conferencing, with minutes shared and circulated to all WHO Representatives after the meeting; and - establishing procedures to ensure that the country office is informed about communications to government counterparts before making contact/ communication with the government official. b. Time-bound projects specifically aimed at promoting collaboration should be defined and a more coordinated approach taken to cross-cutting technical priorities. Two areas are suggested: - a coordinated approach to providing country support for monitoring, evaluation and strengthening health information systems, to strengthen the role of national institutions charged with this responsibility; and - a coordinated approach to providing country support and Regional follow-up for addressing antimicrobial resistance through country office team members joining the existing WHO Regional Office for the Western Pacific taskforce to guide engagement with country partners. c. The regular review of staff performance (via the Performance Management and Development System) should be accompanied by an annual peer feedback mechanism between technical directors in the Regional Office and WHO Representatives. Both a simple 360° feedback mechanism and a formal scorecard mechanism were proposed, and each could be considered so that there are opportunities to acknowledge and encourage collaborative working. d. A mechanism should be established in the Regional Office to systematically alert country offices to opportunities for mobilizing resources, and assist in proposal preparation and cross-country applications and approvals. Action area 5: Strengthening the technical support capacity of the Regional Office Why: To ensure WHO technical support is of high quality, responsive to Member State needs and effective in bringing about change. Specific actions: a. The Regional Office technical directors should lead a short review of mechanisms across technical units for mobilizing technical expertise and promoting policy dialogue in-country in response to country demands. This review should consider: - Strengthening the Regional Office capacity for technical dialogue through establishing “accredited” technical institutions, collaborating centres, alliances and networks by building on existing experience. - Establishing pre-qualified lists of technical and emergency experts to enable more responsive and speedy access for Member States, and to ensure the quality of expertise and the products that they deliver. 16 KEEPING COUNTRIES AT THE CENTRE - Posting of Regional Office staff for a period ideally of two to four weeks in a country office to build stronger relationships with the country teams and their counterparts in government and partner agencies, and to follow up on priorities identified in that country. Terms of reference and timing would be agreed well in advance with WHO Representatives to ensure such visits add value to country work. - Establishing a mechanism for ensuring follow-up on the recommendations from country mission reports, such as an annual audit or scorecard by technical directors to assess compliance, and for reviewing the feasibility of recommendations made, for example on whether cost implications and capacity constraints have been sufficiently considered. First priority should be given to the recommendations of support and guidance directed to the Regional units. - Agreeing on a minimum response time (e.g. 48 hours) for technical units in the Regional Office to reply to requests for support from WHO Representatives, with monitoring of follow-up by directors. b. The Director, Building Health Communities and Populations should undertake a review of technical support capability for noncommunicable diseases in order to seek ways of increasing the responsiveness to demands for assistance from countries. This should include: - Focusing on global action plans and aiming to minimize any duplicative regional strategies and action plans over time, so that in future internal resources can be focused on follow-up with individual countries. - Establishing synergies with other technical units and institutions within the region to expand the Regional response through other programmes (e.g. tobacco and tuberculosis, noncommunicable disease and communicable disease surveillance) and regional United Nations and other institutions (e.g. obesity and education, public health legislation). - Building the understanding in country teams on how to action a “health in all policies” approach in-country through health and other ministries, parliament, the wider United Nations and non-state actors through the development of guidance and a system for mentoring of country staff. Action area 6: Making the change happen in the WHO Regional Office for the Western Pacific Why: To establish a simple, effective way of monitoring the required changes in the WHO Regional Office for the Western Pacific, to assign responsibilities and to monitor progress, making adjustments as necessary. Specific actions: a. The Regional Director and directors (including WHO Representatives) should meet at one of the regular Cabinet meetings in order to review the recommendations from this report as well as the suggestions and responses that it provokes. They might then determine 12–15 priority projects to strengthen the WHO Regional Office for the Western Pacific and its response to countries with regular, scheduled follow-up meetings (see Box 2). The Cabinet should be the forum for jointly monitoring progress, with a director and a WHO Representative assigned as joint 17KEEPING COUNTRIES AT THE CENTRE leads for each of the projects (which should be incorporated into their individual performance agreements). The joint leads would then: - assign responsibilities and tasks and set goals, make a timetable for deliverables and identify required resources (e.g. other staff time); - develop a small project team for each initiative involving wherever possible staff from across programme teams and across both the Regional Office and country offices; - develop measures of success and indicators for monitoring, with project leads providing regular reports on progress to the Regional Director through the regular Cabinet and Team Leaders’ meetings; and - designate clear responsibility for an individual/team within the Regional Director’s office to be given responsibility for overall tracking, support and monitoring of this set of initiatives with regular reporting to the Regional Director and his leadership team. Box 2: Implementing change management/key priorities initiatives: HOW Executive Leadership: Regional Director and senior leaders commit to biweekly meetings Designate lead within the Regional Director’s office to coordinate meetings and follow-up items. 90-minute meeting with clear agenda to: Review key priority initiatives and other change management items Raise and resolve specific project problems, bottlenecks, and resources Determine next steps Key priority initiatives scorecard Prepared and provided in advance with information from the respective Director/Project Leader Scorecard includes updates on project scope, budget, timelines, issues, recent achievements and upcoming activities Designated secretariat (Team leader, Country Support Unit/Executive Officer) for the key priority initiatives/change management Box 3: Recommendations for the first 100 days of the new term establish the infrastructure to make the change happen launch a cross-programme approach to health systems strengthening increase delegation of authority for WHO Representatives expand the annual Regional Office-country office strategic dialogue on country needs assign country focal point responsibility to Regional Office directors establish monthly dialogue between technical units and WHO Representatives/country offices engage in a critical review of administrative procedures streamline publication procedures codify streamlined approach to emergency procedures enhance targets for recruitment and selection post Regional Office monthly travel by country circulate bimonthly division updates expand bimonthly team leaders’ meeting establish minimum response times of Technical Teams to country office requests establish mechanism for communicating dates for visits of country office staff across the Regional Office 18 KEEPING COUNTRIES AT THE CENTRE b. Project monitoring systems with scorecards should be developed for each project along with a dashboard to monitor the progress of all projects. This would enable the multiple projects involved in change management to be monitored on a regular basis by senior management in the WHO Regional Office for the Western Pacific. A mock dashboard is provided in Annex 1. c. Significant action should be taken within the first 100 days of the Regional Director’s new term. The list of projects that could be included in this early action are summarized in Box 3. d. The Country Support Unit should consider taking on the role of developing, tracking and facilitating the changes suggested in this report, with a view to strengthening regional support to countries. The Country Support Unit should continue to strengthen its role in: promoting innovative and evidence-based best practices at country level; supporting intercountry, subregional and interregional initiatives; elaborating strategic information on countries; promoting and mobilizing partnerships for country cooperation; representing the WHO Regional Office for the Western Pacific in countries without country offices; contributing to resolve issues between global, regional and country levels; monitoring and assessing the recommendations of missions, visits and meetings related with country cooperation; and coordinating the training of WHO Representatives. In summary, the Country Support Unit has a key enabling role in supporting the WHO Regional Office for the Western Pacific Placing countries at the centre initiative, both at Regional and country levels, and will have an increasing responsibility in the implementation of the WHO Regional Office for the Western Pacific reforms. 19KEEPING COUNTRIES AT THE CENTRE SECTION 4: CHANGING THE WAY THE REGIONAL OFFICE SEES ITSELF 29. The interviews with staff and the review of the organigram suggest that the Regional Office and country offices do not act as one singular body; instead each acts on its own, with the Regional Office perceived as being the lead in defining the Regional agenda. This perception is changing, and the organigram and related communications need to change to reflect this. The external review team suggests a new way of seeing the WHO Regional Office for the Western Pacific (see Figure 5). In this model, the main business of the WHO Regional Office for the Western Pacific is achieved through technical units and country teams working closely together, accountable to the Regional Office senior management and Member States. The administration led by the Division of Administration and Finance provides the enabling environment for this to work. The WHO Regional Office for the Western Pacific should further develop this view of itself as an office of WHO and amend its organigram to reinforce its reform programme, and communicate this with Member States and partners in the Region. 30. The WHO Regional Office for the Western Pacific is pioneering impressive changes aimed at improving the performance of WHO in serving the needs of Member States in the Region. This review, however, concludes that there is much more that could be done to improve the Regional Office country support, even in the presence of the WHO headquarters-imposed systems that sometimes seem to undermine achieving country-specific results. WHO is yet to fully leverage its potential in the Region. However, the enthusiasm shown by the WHO Regional Office for the Western Pacific staff suggests that the office as a whole is in a good position to continue its reform effort and deliver more efficiently the results in countries that Member States require. RD DPM DAF Country Offices (WRs/CLOs) Technical Divisions Member States WHO WPRO Figure 5: Changing the way the WHO Regional Office for the Western Pacific sees itself WHO = World Health Organization, WPRO = Regional Office for the Western Pacific, RD = Regional Director, DPM = Division of Programme Management, WR = WHO Representative, CLO = Country Liaison Officer, DAF = Division of Administration and Finance 20 KEEPING COUNTRIES AT THE CENTRE ANNEXES ANNEX 1: MOCK-UP CHANGE MANAGEMENT PROJECT MANAGEMENT TOOL (SCORES FOR DEMONSTRATION PURPOSES ONLY) Draft for Discussion WPRO Change Management & Key Priority Initiatives Project No. Project Description Project Sponsor Project Lead Team Members Scope Health Services Development ACTIVE PROJECTS A1 Develop Change Management Implementation Work Plan Deliverables: • Determine key priority inititiatives, assign responsibility, project time to complete, etc. RD CSU, EO Directors YELLOW YELLOW A2 Establish New Delegation Authorities • Review existing delegations • Work group to review and amend original proposal to expand delegations DAF DAF staff Procurement HR WR from xx WR from xx GREEN GREEN A3 Regional Hub for the Emergency Response to Artimisinin Resistance in the Greater Mekong Subregion • Develop a strategic implementation approach • Hire lead and other key staff ??? ??? ??? RED TBD A4 Transformative Regional Strategy • Determine key priority inititiatives, assign responsibility, project time to complete, etc. TBD CSU Directors WR from xxx WR from xxx Key staff YELLOW GREEN A5 Transformative Regional Strategy • Determine key priority inititiatives, assign responsibility, project time to complete, etc. TBD HSD Directors WR from xxx WR from xxx Key staff YELLOW GREEN A6 Upgrade IT Performance for Video conference, teleconference and GSM DAF IT WR from xxx WR from xxx N/A N/A A7 Improve Admininistrative Processes and Staff Development Deliverables: • Determine key priority inititiatives, assign responsibility, project time to complete, etc. TBD TBD Directors YELLOW YELLOW A8 Improve Regional Office/Country Team Working Together • Determine key priority inititiatives, assign responsibility, project time to complete, etc. TBD TBD Directors WR from xxx WR from xxx Key staff YELLOW YELLOW A9 Innovative Technical Networks and Partnerships: • Determine key priority inititiatives, assign responsibility, project time to complete, etc. TBD TBD Directors WR from xxx WR from xxx Key staff YELLOW YELLOW A10 Develop Change Management Implementation Work Plan: • Determine key priority inititiatives, assign responsibility, project time to complete, etc. RD CSU, EO Directors YELLOW YELLOW Red - needs senior leader attention Yellow - issues identified to be discussed Green - on track 21KEEPING COUNTRIES AT THE CENTRE WPRO Change Management & Key Priority Initiatives HCP HSE CDC DAF Country Office Target End Date Overall Status Messages GREEN GREEN GREEN YELLOW N/A 15-Feb YELLOW 14/Nov/13: • Initial set of projects outlined • Specific project charters to be developed for next meeting • Outreach needed to xxx WHO Representatives GREEN GREEN GREEN GREEN GREEN 15-Feb GREEN 14/Nov/13: • Initial proposal reviewed, and a total of 12 new delegtions are being proposed • Specific implementation memos are being drafted YELLOW Late!! RED 14/Nov/13: • Project needs critical attention • Key sponsors are highly critical that a year has passed and that key staff are not yet in place YELLOW YELLOW GREEN YELLOW YELLOW 15-Feb YELLOW • 14/Nov/13: • Initial set of projects outlined • Specific project charters to be developed for next meeting • Outreach needed to xxx WHO Representatives YELLOW YELLOW GREEN YELLOW YELLOW 15-Feb YELLOW 14/Nov/13: • Initial set of projects outlined • Specific project charters to be developed for next meeting • Outreach needed to xxx WHO Representatives N/A N/A N/A YELLOW YELLOW 1-Apr YELLOW 14/Nov/13: • Initial set of projects outlined • Specific project charters to be developed for next meeting • Outreach needed to xxx WHO Representatives GREEN GREEN GREEN YELLOW N/A 15-Feb YELLOW 14/Nov/13: • Initial set of projects outlined • Specific project charters to be developed for next meeting • Outreach needed to xxx WHO Representatives GREEN GREEN GREEN YELLOW N/A 15-Feb YELLOW 14/Nov/13: • Initial set of projects outlined • Specific project charters to be developed for next meeting • Outreach needed to xxx WHO Representatives GREEN GREEN GREEN YELLOW N/A 15-Feb YELLOW 14/Nov/13: • Initial set of projects outlined • Specific project charters to be developed for next meeting • Outreach needed to xxx WHO Representatives GREEN GREEN GREEN YELLOW N/A 15-Feb YELLOW 14/Nov/13: • Initial set of projects outlined • Specific project charters to be developed for next meeting • Outreach needed to xxx WHO Representatives Annex 1 (continued) 22 KEEPING COUNTRIES AT THE CENTRE ANNEX 2: TERMS OF REFERENCE AND METHODOLOGY (ABRIDGED) Objectives: The overarching aim of the assessment is to determine how the Regional Office could strengthen its contribution to improving WHO performance at the country level. Although this is an external assessment, the approach should give emphasis to staff involvement and the possibility for learning and reflection related to their work. y Review the current situation including the attitudes and practices of the Regional Office in providing country support. y Analyse and identify lessons learnt, including what works and what does not work. y Identify the factors that constrain or facilitate a country-focused Regional Office. y Identify key issues and make recommendations on further improvements for more effective country support. y Provide direction for future WHO, and WHO Regional Office for the Western Pacific, reforms. Methodology: y Interviews with key informants y Online questionnaire survey y Focus group discussions y Desk review: Analysis of: { documentation { budget { intercountry meetings { collaborating centres { mission reports { case study of the WHO Regional Office for the Western Pacific support to the Philippines [cancelled due to typhoon emergency] y Validation of findings Review questions: Used in interviews and adapted for Focus Group Discussion: Is the WHO Regional Office for the Western Pacific being strategic in its approaches and ways of working with countries? Are the administrative and management systems adapted to country needs? How is senior management assessing and responding to the performance of WHO at country level? Are programme planning and programme management in the WHO Regional Office for the Western Pacific conducive for effective support of Member States? Is the WHO Regional Office for the Western Pacific providing country-focused, appropriate high-quality technical and policy support? How effective is the WHO Regional Office for the Western Pacific as a knowledge hub for health in Asia? 23KEEPING COUNTRIES AT THE CENTRE ANNEX 3: LIST OF PEOPLE INTERVIEWED DURING THE EXTERNAL ASSESSMENT Division Names Title / Position RDO Dr Shin Young-soo Regional Director RDO Dr Corinne Capuano Executive Officer RDO Dr Charuni Senanayake Technical Officer RDO Mrs Marie Sarah Villemin- Partow Publications Officer RDO Miss Maria Victoria Castillo Administrative Assistant DPM Dr Han Tieru Director, Programme Management DPM Mr Wu Guogao Administrative Officer, Programme Development and Operations DPM Dr Kidong Park Team Leader, Country Support Unit DPM Mr Bernard Tomas Technical Officer, Global Health Partnerships, Country Support Unit DPM Dr Kunhee Park Technical Officer, Community Health Care, Country Support Unit DPM Mrs Perseveranda Mappatao Administrative Assistant DPM Mrs Ma. Teresa De La Cruz Administrative Assistant DPM Mrs Elvira Javier Assistant, Meeting and Courses DAF Mr Jeffery Kobza Director, Administration and Finance DAF Mr Sambasivan Easwar Budget and Finance Officer DAF Mr Eric de Coninck Regional Human Resources Manager DAF Mr Ahmad Partow Administrative Officer (Information Technology and Administration) DAF Mr Reginald Malapit Administrative Assistant, Personnel DAF Mrs Jennifer Chia Administrative Assistant, Finance DCC Dr Mark Jacobs Director, Combating Communicable Diseases DCC Dr Ying-ru Lo Team Leader, HIV/AIDS and STI DCC Dr Eva Christophel Team Leader, Malaria, Other Vectorborne and Parasitic Diseases DCC Dr Najibulah Habib Programme Management Officer DCC Dr A.B.M. Tauhidul Islam Medical Officer DCC Dr Pengfei Zhao Technical Officer DCC Dr Jorge Mendoza Aldana Technical Officer, Expanded Programme on Immunization DCC Dr Lasse Vestergaard Medical Officer (Therapeutic Efficacy Studies & Operational Research) DCC Dr Walter William Schluter Medical Officer DCC Mrs Edenor Gongora Administrative Assistant (Programme) DCC Mrs Cherry Garcia Administrative Assistant, Expanded Programme on Immunization DCC Mrs Remis Caspillan Administrative Assistant, Stop Tuberculosis DHP Dr Susan Mercado Director, Division of Building Healthy Communities and Population DHP Dr Howard Sobel Team Leader, Maternal, Child Health and Nutrition DHP Dr Katrin Engelhardt Technical Officer (Nutrition) DHS Dr Vivian Lin Director, Health Sector Development DHS Mr Mark Landry Team Leader, Health Information, Evidence and Research DHS Dr Narantuya Samdan Regional Adviser, Traditional Medicine DHS Ms Laura Hawken Technical Officer, Health Services Development DHS Dr Annie Chu Health Economist DHS Dr Ayesha De Lorenzo Technical Officer (Health Systems Strengthening) DHS Mrs Mary Ann Gamilla Administrative Assistant (Team Support), Health Services Development APO Dr Dale Huntington Director, Asia Pacific Observatory on Health Systems and Policies DSE Dr Ailan Li Director, Health Security and Emergencies 24 KEEPING COUNTRIES AT THE CENTRE Division Names Title / Position DSE Dr Chin-Kei Lee Team Leader, Emerging Disease Surveillance and Response DSE Mrs Maria Carmela Dichoso Administrative Assistant (Programme) DSE Dr Norikazu Isoda Technical Officer (Emerging Infectious Disease) DSE Mrs Maria Carolina Rebullida Secretary, Emergency and Humanitarian Action DSE Mrs November Corazon Palang Secretary, Emerging Disease Surveillance and Response DSE Mrs June Pearl Orbe Secretary, Food Safety DPS Dr Dong Il Ahn WHO Representative in the South Pacific/ Director, Pacific Technical Support DPS Dr Temo Waqanivalu Coordinator (NCD/HPR) DPS Dr Ezekiel Nukuro Technical Officer (Human Resources and Health Systems) DPS Ms Gaik Gui Ong Senior Programme Management Officer DPS Ms Jane Wallace Technical Officer (Health Adviser) DPS Dr Madeline Salva Medical Officer, HIV/AIDS and STI WHO Philippines Dr Julie Hall WHO Representative in the Philippines WHO Philippines Dr Florence Tienzo NPO (Programme Management Officer), WR/PHL WHO Malaysia Dr Graham Harrison WHO Representative in Malaysia, Brunei Darussalam and Singapore WHO Malaysia Dr Chun Paul Soo Programme Officer WHO China Dr Bernhard Schwartlander WHO Representative in the People’s Republic of China WHO China Dr Mukundan Pillay Senior Health Adviser WHO China Dr Fabio Scano Medical Officer, Tuberculosis WHO China Dr Sirenda Vong Medical Officer (Emerging Infectious Diseases) WHO China Mr Murray Singer Administrative Officer WHO China Mr Martin Taylor Team Leader, Health Services Development WHO China Dr Jaana Marianna Trias Senior Programme Management Officer WHO Viet Nam Dr Takeshi Kasai WHO Representative in Viet Nam WHO Viet Nam Dr Ornella Lincetto Medical Officer (Family and Community Health) WHO Cambodia Dr Pieter van Maaren WHO Representative in Cambodia WHO Cambodia Dr Momoe Takeuchi Senior Programme Management Officer WHO Cambodia Dr Rasul Baghirov Health Systems Development Advisor WHO Cambodia Dr Masami Fujita Medical Officer, HIV/AIDS and STI WHO Cambodia Dr Daravuth Yel National Professional Officer (Tobacco Free Initiative) WHO Mongolia Dr Soe Nyunt-U WHO Representative in Mongolia WHO Mongolia Dr Salik Govind Public Health Specialist WHO Mongolia Dr Tsogzalmaa Bayandorj National Professional Officer (Noncommunicable Diseases) WHO Mongolia Dr Sodbayar Demberelsuren National Professional Officer WHO Samoa Mrs Caroline Bollars Technical Officer, Health System and Noncommunicable Diseases WHO Lao People’s Democratic Republic Mr Jun Gao Senior Programme Management Officer WHO Papua New Guinea Dr Paulinus Lingani Ncube Sikosana Technical Officer WHO Solomon Mr Sherif Y. Younan Technical Officer Outside WHO His Excellency Dr Eksavang Vongchivit Minister of Health, Lao People’s Democratic Republic Outside WHO Dr Jim Tulloch Independent Consultant, Team Leader of Papua New Guinea country assessment in 2012 Outside WHO Dr Ben Rolfe Lead Sector Specialist, Health, Pacific Division, Department of Foreign Affairs and Trade, Australia Outside WHO Ms Beth Slatyer Health Adviser, Department of Foreign Affairs and Trade, Australia Annex 3 (continued) 25KEEPING COUNTRIES AT THE CENTRE ANNEX 4: STAFFING ANALYSIS (SELECTED CHARTS) 230 218 222 246 281 308 308 335 333 346 290 287 298 291 312 314 323 323 302 300 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Proportion of staffing Regional Office (RO) vs Country Office (CO) RO CO Total Country Office National Professional Officer staff by Division from 2004 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 DSE DHS DHP DCC DAF DPM TOTAL 0 10 20 30 40 50 60 70 80 0 1 1 11 17 35 43 48 66 74 3 4 9 11 14 17 14 2 3 8 11 11 17 18 3 7 14 14 14 18 24 1 1 1 1 2 2 3 6 6 2 2 2 5 6 8 12 1 1 1 1 1 1 1 39 39 47 47 56 60 66 43 45 44 11 11 9 14 15 21 26 24 27 3614 16 13 20 21 22 20 24 25 27 27 26 26 33 36 43 38 52 51 42 20 18 22 91 92 95 115 129 147 151 164 167 172 0 20 40 60 80 100 120 140 160 180 200 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Total number of country office Professional Staff by Division DSE DPM DHS DHP DCC DAF TOTAL 26 KEEPING COUNTRIES AT THE CENTRE ANNEX 5: BUDGET ANALYSIS (SELECTED CHARTS) 40 573 000 42 283 025 41 293 185 44 983 646 29 219 622 47 198 913 39 232 586 76 790 034 116 573 052 78 166 052 - 20 000 000 40 000 000 60 000 000 80 000 000 100 000 000 120 000 000 140 000 000 160 000 000 180 000 000 2004–2005 2006–2007 2008–2009 2010–2011 2012–2013 Assessed Contributions (AC)/Voluntary Contributions (VC) Funds implementation in country offices from 2004–2005 to 2012–2013 VC AC AC /V C C on tr ib ut io ns (U S$ ) 44 973 296 64 127 495 48 628 170 18 437 050 26 241 580 14 971 211 23 585 520 30 776 436 20 435 497 4 924 777 8 708 461 6 130 187 8 727 379 6 974 720 3 655 822 - 20 000 000 40 000 000 60 000 000 80 000 000 100 000 000 120 000 000 140 000 000 160 000 000 180 000 000 2008–2009 2010–2011 2012–2013 Proportion of implementation by expenditure type in country offices from 2008–2009 to 2012–2013 Others General Operating Costs Medical Supplies & Literature Travel Direct Financial Cooperation Contractual Services Sta Costs Im pl em en ta tio n by e xp en di tu re ty pe in Co un tr y O ffi ce s ( US $) 50 778 641 54 017 913 40 841 537 11 673 162 10 020 064 9 025 536 2 644 509 2 127 037 1 754 172 16 908 025 15 010 202 9 334 719 1 054 559 2 776 095 932 485 3 966 237 3 340 119 2 694 095 7 619 014 7 917 460 2 915 156 - 10 000 000 20 000 000 30 000 000 40 000 000 50 000 000 60 000 000 70 000 000 80 000 000 90 000 000 100 000 000 2008–2009 2010–2011 2012–2013 Proportion of implementation by expenditure type in the Regional Office from 2008–2009 to 2012–2013 Others General Operating Costs Medical Supplies & Literature Travel Direct Financial Cooperation Contractual Services Sta Costs Im pl em en ta tio n by e xp en di tu re ty pe in R eg io na l O ffi ce (U S$ ) 27KEEPING COUNTRIES AT THE CENTRE ANNEX 6: MEETING ANALYSIS (SELECTED CHARTS) 0 5 10 15 20 25 30 Le ad er sh ip Re se ar ch No rm s/ St an da rd s Po lic y Te ch Su pp or t M on ito rin g Division of meetings by WHO’s six core functions, 2008–2011 (%) % DSE 11% DHS 23% DHP 21% DCC 35% Other 10% Division percentage of meetings by division, 2010–2011 (%) 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 2008 2009 2010 2011 Location of meetings (% of total meetings) Asia ex-Philippines Philippines Paci c Outside of Region 28 KEEPING COUNTRIES AT THE CENTRE ANNEX 7: STAFF SURVEY (SELECTED CHARTS) Characteristics of Respondents I. GENERAL INFORMATION 28% 18% 15% 14% 9% 9% 7% DAF DCD DHS DNH DPM RDO DSE Distribution of respondents, per division of the WHO Regional O ce for the Western Paci c division (n=169) CHARACTERISTICS OF RESPONDENTS 19.75 17.28 17.28 15.43 8.02 6.79 6.17 5.56 3.70 Distribution of country office staff survey respondents (n= 162) Cambodia Viet Nam China Philippines Papua New Guinea Mongolia Malaysia Lao People’s Democratic Republic Pacific island countries (with WHO presence) 29KEEPING COUNTRIES AT THE CENTRE 57% 39% 4% General Services staff Professional staff National Professional Officer staff Distribution of respondents, the WHO Regional Office for the Western Pacific staff category (n=169) G staff 40% P staff 32% NPO staff 28% Distribution of respondents, per country office staff category (n=162) Annex 7 (continued) 30 KEEPING COUNTRIES AT THE CENTRE 24.68 58.33 87.30 64.00 75.00 67.44 1.3 14.58 3 36.00 0.00 16.28 11.69 6.25 1.6 4.65 62.34 20.83 7.9 25.00 11.63 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage Planning duty travel to countries Adequate Inadequate None Not Applicable Country office National Professional Officer Regional Office National Professional Officer St aff ca te go ry Regional Office General Services staff Country office General Services staff Regional Office Professional staff Country office Professional staff 24.68 56.25 66.67 46 75.00 48.84 1.30 10.42 14.29 46 0.00 34.88 11.69 6.25 3.17 8 4.65 62.34 27.08 15.87 0 25.00 11.63 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage Planning Regional meetings Adequate Inadequate None Not Applicable Country office National Professional Officer Regional Office National Professional Officer St aff ca te go ry Regional Office General Services staff Country office General Services staff Regional Office Professional staff Country office Professional staff Annex 7 (continued) 31KEEPING COUNTRIES AT THE CENTRE 27.63 9 53.97 30 75.00 53.49 9.21 3 31.75 52 0.00 30.23 7.89 18 3.17 12 4.65 55.3 11.1 6 25.0 11.63 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage Developing activity work plan Adequate Inadequate None Not Applicable Country office National Professional Officer Regional Office National Professional Officer St aff ca te go ry Regional Office General Services staff Country office General Services staff Regional Office Professional staff Country office Professional staff 12.20 35.29 61.90 36 25.00 44.19 12.20 29.41 22.22 46 0.00 34.86 0 3.92 0 12 9.3 60.98 27.45 12.70 4 75.00 11.63 14.63 3.92 3.17 2 0.00 0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage Recent country visit initiation Country office National Professional Officer Regional Office National Professional Officer St aff ca te go ry Regional Office General Services staff Country office General Services staff Regional Office Professional staff Country office Professional staff requested and intiated by the country office based on their needs intiated by the Regional Office based on a country need identified by the Regional Office initiated by WHO headquarters; Regional Office participated in the visit to support the WHO headquarters mission Not applicable Others Annex 7 (continued) 32 KEEPING COUNTRIES AT THE CENTRE 18.29 31.37 63.49 40 25.00 53.49 10.98 39.22 23.81 50 34.88 1.96 6 2.33 70.73 27.45 12.70 4 75.00 9.30 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage Visit's fulfillment of identified country needs Yes, completely Yes, partly No Not applicable Country office National Professional Officer Regional Office National Professional Officer St aff ca te go ry Regional Office General Services staff Country office General Services staff Regional Office Professional staff Country office Professional staff 28.75 64 85.71 74 25 79.07 3.75 12 6.35 18 6.98 2.5 4 2 65 20 7.94 6 75 14.0 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage Communication regarding the work prior to travel Adequate Inadequate None Not Applicable Country office National Professional Officer Regional Office National Professional Officer St aff ca te go ry Regional Office General Services staff Country office General Services staff Regional Office Professional staff Country office Professional staff Annex 7 (continued) 33KEEPING COUNTRIES AT THE CENTRE 16.67 56.25 73.02 70 25 74.42 7.69 12.50 17.46 20 0 11.63 5.13 10.42 0 4 0 70.51 20.83 9.52 6 75 13.95 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage Opportunities/arrangements to allow in- country discussions Adequate Inadequate None Not Applicable Country office National Professional Officer Regional Office National Professional Officer St aff ca te go ry Regional Office General Services staff Country office General Services staff Regional Office Professional staff Country office Professional staff 16.88 58.33 60.32 58 25 69.77 7.79 10.42 14.29 24 0 13.95 3.90 8.33 3.17 2 0 71.43 22.92 22.22 16 75 16.28 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage Feedback from country office on the mission recommendations Adequate Inadequate None Not Applicable 147 Country office National Professional Officer Regional Office National Professional Officer St aff ca te go ry Regional Office General Services staff Country office General Services staff Country office Professional staff Regional Office Professional staff Annex 7 (continued) 34 KEEPING COUNTRIES AT THE CENTRE Areas facilitating effective delivery of country support, responded by Regional Office staff Area P staff (n=56) NPO (n= 3) G staff (n= 64 ) All respondents n=(123) rank % rank % rank % rank % Knowledge of country priorities and setting 1 22.02 2 22.22 1-2 19.27 1 20.60 Structured regular communication between the Regional Office and the country office 4-5 11.90 3-6 11.11 1-2 19.27 3 15.72 Flexible funding from the Regional Office for country needs 6 9.52 0.00 7-8 6.77 6 7.86 Reduced workload from administrative tasks in the Regional Office 7 8.93 0.00 7-8 6.77 7 7.59 Joint country support plan between Regional Office and country office 3 12.50 3-6 11.11 5 11.46 5 11.92 Support and motivation by the Regional Office management 8 4.17 3-6 11.11 6 7.29 5.96 Adequate and regular consultation by Regional Office with country offices on needs 2 17.86 1 33.33 4 14.06 2 16.26 Timely and adequate consultation by country offices on Regional Office support 4-5 11.90 3-6 11.11 3 14.58 4 13.28 Others 9 1.19 0.00 0.52 8 0.81 Areas P staff (n=50) NPO (n=42) G staff (n=49) Total (n=141) rank % rank % rank % rank % Knowledge of country priorities and setting 1 18.67 1 19.84 2 17.69 1 18.68 Structured regular communication between Regional Office and country office 3 14.67 4-5 15.08 1 19.73 2 16.55 Flexible funding from the Regional Office for country needs 2 16.67 2 19.05 4 12.93 3 16.08 Reduced workload from administrative tasks in the Regional Office 6-8 8.67 8 3.17 8 4.76 8 5.67 Joint country support plan between Regional Office and country office 6-8 8.67 4-5 15.08 7 9.52 5 10.87 Support and motivation by the Regional Office management 6-8 8.00 7 3.97 6 10.20 7 7.57 Adequate and regular consultation by Regional Office with country offices on needs 4-5 10.67 3 16.67 3 13.61 4 13.48 Timely and adequate consultation by country offices on Regional Office support 4-5 10.67 6 7.14 5 10.88 6 9.69 Others 9 3.33 0.00 9 0.68 9 1.42 Areas facilitating effective delivery of country support, responded by country offices staff Annex 7 (continued) 35KEEPING COUNTRIES AT THE CENTRE ANNEX 8: BIBLIOGRAPHY AND REFERENCES References 1. 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40 KEEPING COUNTRIES AT THE CENTRE Keeping countries Strengthening country support in the WHO Regional Office for the Western Pacific Western Paci c Region at the centre Western Paci c Region