WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R~GIONAL OU PACIFIQUE OCCIDENTAL
•
ORGANISATION MONDIALE DE LA SANTE
REGIONAL COMMITTEE Thirty-sixth session Manila 16-20 September 1985 Provisional agenda item 15
WPR/RC36/10 Add.! 29 July 1985 ORIGINAL: ENGLISH
GUIDELINES FOR PREPARING A REGIONAL PROGRAMME BUDGET POLICY Report by the Regional Director Addendum
The financial audit in policy and programme terms, which will in no way replace existing auditing practice, should identify how, on the basis of what policy, and by whom decisions on expenditures were planned and decided upon. It should also clarify when decisions were taken, for example, before the start of the programme budget biennium, in the courseof it, or towards the end. Moreover, it should trace the progress of programme implementation in relation to expenditures incurred. It should also determine what has been achieved when expenditures have been incurred, and how they relate to the national, regional and global strategies for health for aU. This document briefly describes the protocol that is being developed for monitoring the use of WHO's resources through financial audit in policy and programme terms, as part of WHO's managerial process, to ensure accountability to the Member States.
WPR/RC36/10 Add.l page 2
MONITORING THE USE OF WHO'S RESOURCES THROUGH FINANCIAL AUDIT IN POLICY AND PROGRAMME TERMS
A protocol is being developed for monitoring the use of WHO's resources through financial audit in policy and programme terms, as described in the Director-General's introduction to the Programme Budget. 1 The purpose of this audit is to ensure that the use of WHO's resources by Member States and the provision by WHO of technical cooperation to national health development in countries are in conformity with the Organization's policy, the national, regional and global strategies, the process as outlined in the "Managerial framework for optimal use of WHO's resources in direct support of Member States",2 the relevant regional programme budget policies as they develop, and the related resolutions and decisions of the WHO regional committees, the Executive Board and the World Health Assembly. In this context, the use of WHO's resources refers to all resources - human, technical, information, financial and material - from all sources at all levels of the Organization. The audit team will be a multidisciplinary one composed of staff from WHO Headquarters, the Regional Office, the WHO Programme Coordinator's Office and senior national counterpart(s). Initially, only a few selected countries will be involved. The audit team wilJ identify how, on the basis of what policy, and by whom decisions on expenditure of WHO's resources were planned and decided upon. The team wiH trace through and document the joint programme budgeting and decision-making process which actually took place. It will then match this with the actions undertaken and expenditures actually incurred, which are assessed in the light of the collectively agreed policies governing the use of WHO's resources, and the nationally defined priorities for health-for-all strategy development and implementation. The expected output or product of the audit is a report which: (a) briefly describes the programme budgeting and decision-making process actually being applied for the use of WHO's resources, as compared with the process collectively agreed by the Member States of WHO;
!Proposed programme budget for the financial period 1986-J 987 (WHO document PB/86-87), Geneva, 1984, pp. XXXVII- XXXVIII, paragraphs 61-62. 2wHO document DG0/83.1, Geneva, J 983.
WPR/RC36/10 Add.l page 3
(b)
analyses the substantive decisions and uses actually made of WHO's resources in terms of the collectively agreed policies and the relevant nationally defined priorities; assesses the resulting programme relevance and outputs in relation to national health-for-all strategy development and implementation; and draws conclusions and makes recommendations for future action to strengthen the process, and ensure optimal use of WHO resources.
(c)
(d)
The final audit report will be submitted on a confidential basis to the Director-General and the Regional Director, who wHI decide on the future use of the report for follow-up action. The Director-General, with the Regional Director, may decide to follow up with the national authorities and with the WHO secretariat staff at all levels in ord~~r to explain the findings, jointly determine the best solutions and initiate corrective action if this should be required. It is emphasized that, at all times during the audit and any follow-up action, the Organization recognizes the joint responsibility of WHO and the Member State concerned for the use of WHO's resources. The intention Is to give WHO and the Member State a better understanding of the flow of WHO's resources within the country and the effect these resources are having on the national health system, and to provide an opportunity fo.r optimizing the use of WHO's resources in the future.
WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU RlGIONAL OU PACIFIQUE OCCIDENTAL
•
ORGANISATION MONDIALE DE LA SANTE
REGIONAL COMMITTEE Thirty-sixth session Manila 16-20 September 1985 Provisional agenda item 15
WPR/RC36/10 23 July 1985 ORIGINAL: ENGLISH
GUIDELINES FOR PREPARING A REGIONAL PROGRAMME BUDGET POLICY Report by the Regional Director
Pursuant to resolutions EB75.R7 and WHA38.ll, regional committees are requested to prepare regional programme budget policies that will ensure optimal use of WHO's resources at both regional and country levels in order to give maximum effect to the Organization's collective policies. The Regional Committee is requested to initiate the preparation of the regional programme budget policy starting with the thirty-sixth session in 1985, to finalize it during its thirty-seventh session in 1986, to submit it for review by the Executive Board and the World Health Assembly in 1987, to prepare the regional 1988-1989 and subsequent programme budget proposals in accordance with it, and to monitor and evaluate its implementation with a view to ensuring that it is properly reflected in the Organization's activities in the Region. The attached guidelines {document DG0/85.1) have been prepared for use by the regional committees as a frame of reference within which to establish their regional programme budget policies. The document is presented in two parts: (i) an executive summary, which presents the main principles of the guidelines and should thus serve as the main focus for discussion, and (ij) the more detailed guidelines, which provide the supporting background information for the Regional Committee. The views of the Regional Committee on how it wishes to proceed with the development of the regional programme budget policy for the Western Pacific Region are requested.
WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE
DG0/85.1 14 March 1985
GUIDELINES FOR PREPARING A REGIONAL PROGRAMME BUDGET POLICY
These guidelines constitute a frame of reference for regional committees in establishing regional programme budget policies in accordance with resolutions EB75.R7 and WHA38.11, copies of which are reproduced on pages (i) and (ii) of this document.
Contents
EXECUTIVE SlJMMARY •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
INTRODUCTION ISSUES
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(iii)
1
3 3 6
Support to national strategies for health for all •••••••••••••••••••••••••••••••• Promotion of the national health strategy •••••••••••••••••••••••••••••••••••••••• Developing the health system through support to national health programmes ••••••• Strengthening national capacities to prepare and implement national health-for-all strategies and related programmes •••••••••••••••••••••••••••••••••••··········· Transfer of validated information and facilitation of its absorption ••••••••••••• Research and development for health for all •••••••••••••••••••••••••••••••••••••• Optimal use of resources .•.••••.•...••...•.••..••••.••••..••..••...........•.•.•.
7
10 11
Criteria for deciding on the form of WHO cooperation ••••••••••••••••••••••••••••• Intercountry and regional activities ••••••••••••••••••••••••••••••••••••••••••••• Training .•..............................•........................................ Use of and limitations on provision of supplies and equipment ••••••••••••••••••••• Use of consultants •...••.......•....•............................................
13 14 16 18 20 22 22 22
Meetings ••••••.••.•••••..•••••.•.•••.••••••.•.•.•••..••••.•.•••••••.•.••.......•.
PROCESS IN COUNTRIES REGIONAL OFFICE STAFFING POLICY
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23 24
MECHANISMS IN COUNTRIES
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25 26 27
BUDGETARY AND FINANCIAL IMPLICATIONS REGIONAL COMMITTEE TIMETABLE INDEX MONITORING AND EVALUATION
28 28
29 31
DG0/85,1 page (i) EB75.R7 REGIONAL PROGRAMME BUDGET POLICIES The Executive .Board , Recalling resolution WHA33.17 in which the Thirty-third World Health Assembly, inter alia~
-decided to concentrate the Organization's act1v1t1es over the coming decades on support to national, regional and global strateg~es for attaining health for all by the year 2000; - urged Member States to undertake a series of measures in the sp1r1t of the policies, principles and prograumes they have adopted collectively in WHO, including the tightening of their coordinating mechanisms so as to ensure the mutual relevance and support of their own health development strategy on the one hand and their technical cooperation with WHO and with other Member States of WHO on the other; - urged the regional committees to increase their monitoring, control and evaluation functions so as to ensure the proper reflection of national, regional and global health policies in regional programmes and the proper implementation of these prograumes, and to include in their progranunes of work the review of WHO's action 1n individual M,ember States within the regions; - requested the Executive Board to monitor on behalf of the Health Assembly the way the regional committees reflect the Assembly's policies in their work; Bearing in mind resolution WHA34.24 in which the Thirty-fourth World Health Assembly, inter alia~
reiterated that WHO's unique constitutional role in international health work comprises in essence the inseparable and mutually supportive functions of acting as . the directing and coordinating authority on international health work and ensuring technical cooperation between WHO and its Member States, essential for the attainment of health for all by the year 2000; urged Member States to act collectively in order to ensure the most effective fulfilment by WHO of its constitutional functions and the formulation by the Organization of appropriate international health policies, as well as principles and programmes to implement these policies, and to formulate their requests for technical cooperation with WHO in the spirit of the policies, principles and programmes they have adopted collectively in WHO; Anxious to ensure that optimal use is made of WHO's limited resources at all organizational levels and in particular of the funds allocated in the regi~~al programme budgets for cooperation with Member States;
1.
REQUESTS the regional committees: (1) to prepare regional programme budget policies that ensure optimal use of WHO's resources at both regional and country leveh in order to give maximum effect to the Organization's collective policies;
(2) to promote through such policies the further development of national strategies for health for all by the year 2000 and the self-sustaining growth of national health programmes that form essential part.s of such strategies; (3) to facilitate through such policies the preparation of country programme budgets and the rational use of all national and external resources in pursuance of national health development;
DG0/85.1 page (ii) (4) to submit such policies for review by the Executive Board and the Health Assembly and to prepare the regional 1988-1989 and subsequent programme budget proposals in accordance with them; (5) to monitor and evaluate the implementation of such policies with a view to ensuring that they are properly reflected in the Organization's activities in the region; 2. REQUESTS the Director-General: (1) to prepare, in consultation with the Regional Directors, guidelines so that the regional committees can have a frame of reference within which to establish their regional programme budget policies and a system for monitoring them; (2) to continue to promote the mobilization of national and external resources for the implementation of strategies for health for all;
(3) to report regularly to the Executive Board and the Health Assembly on the measures he has taken in connection with this resolution; 3. DECIDES that the Executive Board (1) shall~
monitor the preparation of the regional programme budget policies;
(2) monitor and evaluate on a regular basis the implementation of tnese policies and report thereon to the Health Assembly every two years in conjunction with the programme budget review; 4. RECOMMENDS to the Health Assembly that it actively support the adoption of regional programme budget policies and that it closely monitor and evaluate their implementation.
WHA38.11 The Thirty-eighth World Health Assembly, Recalling numerous Health Assembly resolutions concerning programme budget policy, WHO's international health work through coordination and technical cooperation, and the functions and related structures of WHO, and in particular resolutions WHA29.48, WHA30.23, WHA33.17 and WHA34.24; Having considered resolution EB75.R7 on regional programme budget policies; 1. STRONGLY SUPPORTS the preparation of such policies by the regional committees as requested by the Executive Board; 2. URGES Member States to assume their responsibilities for the preparation and implementation of such policies; 3. ENDORSES the Board's decision to monitor their preparation, as well as to monitor and evaluate their implementation in conjunction with the biennial budget reviews, and to report to the Health Assembly thereon; 4. DECIDES to monitor and evaluate their implementation in the light of the Executive Board's reports thereon;
5. REQUESTS the Director-General to provide full support to Member States and to the Health Assembly, regional committees and Executive Board, for the preparation, implementation, monitoring and evaluation of the regional programme budget policies.
DG0/85.1 page (iii) EXECUT.IVE SUMMARY
I. The aim of a regional programme budget policy is to enable Member States to make best possible use of WHO's resources for health development in their country, and in particular for their policy and strategy for health for all by the year 2000.
tb~
II. The mainstay of the programme budget policy is the process whereby countries make the most of WHO's resources- in the country, in other countries, in collaborating centres, at the regional level, in other regions and at the global level. The funds allocated in the regional programme budgets for cooperation with Member States are meant to ensure access to all of these as necessary. These resources have to be used to give rise to the self~sustaining growth of socially and economically relevant national 1 health strategies and related programmes managed by the countries themselves, and to lead to the mobilization and most rational use of national resources for health to that end, as well as, in developing countries, to the mobilization and most rational use of external resources to the same end. To be effective, these endeavours have to be consistent with the policies, strategies and related programmes that. Member States have decided upon collectively in WHO. Adherence to collective policy implies the kind of self-discipline required to focus the Organization's resources on activities that are vital for attaining the goal of health for all by the year 2000. III. To adapt collective international policy to individual national needs, and to define national policies, strategies and programmes accordingly, requires a process of research and development (R&D) and of exposure to the findings of others' R&D. WHO is uniquely placed by its Constitution to cooperate with its Member States in such R&D, and in ensuring this exchange of information and experience. I t can do so on condition that its Member States engage in the necessary communications with it. These R&D findings, like all endeavours in WHO, will only be of value if they, the process that gave rise to them and the results of their application are systematically monitored and evaluated and fearlessly reported on with a view to improving shortcomings and making up for deficiencies, as well as sharing experiences with other Member States. IV. By its Constitution, WHO is made up of all its Member States collectively, cooperating to promote and protect the health of all peoples. Cooperation among parts that make up the whole . i~plies a very intimate partnership between Member States and their Organization. Thus, cooperation that combines disciplined adherence to collective policy, experimentation in adaptively applying that policy to national circumstances, and free exchange of information andexperience throughout the Organization, is fundamental to the regional programnie budget policy. That policy will give visibility to Member States' loyalty to collective policies. As part of this loyalty they will understand that the Organization's resources are the collective property of its Member States and that in consequence the level of resources invested in a Member State in any biennium does not automatically become its everlasting right. V. There is nothing really "new" in the regional programme budget policy: it 1.s rather a systematic consolidation of policies that have been approved by WHO's governing bodies, such as the global and regional strategies for health for all by the year 2000, the Seventh General Programme of Work, resolutions of the governing bodies, and the global programme budget policy, together with the new managerial arrangements for ensuring optimal use of WHO's resources in direct support of Member States. VI. As part of their intimate partnership relations, WHO and its Member States will cooperate in developing and implementing national strategies for health for all along the lines described in the global and regional strategies. This will include the investment of resources in reviewing and in developing national health systems based on primary health care, incidentally strengthening national capacities to do so. It will also include the
1 Wherever the word "national" is used in these guidelines it implies the country level as opposed to the international level; it does not necessarily imply the central level within the country.
DG0/85.1 page (iv) transfer of validated information and the facilitation of its absorption including tra1n1ng, as well as the joint pursuit of R&D, and support in generating and mobilizing resources. WHO will provide international services as well as direct financial cooperation in conformity with defined criteria. Intercountry activities will also be jointly agreed upon in the light of defined criteria, as will the facilitation of technical cooperation among developing countries (TCDC). The monitoring and evaluating of national strategies as part of the managerial process for national health development will be prominent in WHO's cooperative activities with its Member States. VII. Resources will be invested in the promotion of national health strategies, including the formulation of well-articulated policy and strategy statements for the consideration of governments and socioeconomic planners, and the preparation of promotional material for the public, including the use of the mass media. Support will be given to the establishment of intersectoral mechanisms and the preparation of convincing inputs to national social and economic development plans as well as to major economic development projects. Measures will be taken to enlist professional health workers, citizens' groups and national nongovernmental organizations, including the possibility of providing appropriate incentives. VIII. Major emphasis will be given to developing national health systems through support to national health programmes. To define and implement their strategy and its component programmes, Member States will find it necessary to apply a systematic managerial process for national health development and WHO will invest heavily in supporting them in this. Both in considering national programme priorities and WHO's involvement in their formulation and execution, Member States will find it practical to make use of WHO's General Programme of Work, proceeding systematically through it as a "checklist" from which to select the main kinds of issues, targets and objectives, programmes and activities to implement the national strategy; priorities will certainly cover the essential elements of primary health care. WHO's involvement in the formulation and implementation of national health programmes will be decided on through joint government/WHO application of this scanning process, using defined criteria. Care will be taken to ensure a single infrastructure for the delivery of programmes, and to that end use will be made of the classes of programmes defined in the Seventh General Programme of Work - namely, direction, coordination and management; health system infrastructure; health science and technology; and programme support. In most countries, particular attention will have to be paid to the development and organization of a health system infrastructure based on primary health care. National science and technology programmes will be identified in which WHO's resources could be usefully invested. Support programmes too should not be forgotten, particularly health information support. The exchange of information between WHO and its Member States as well as among those Member States will always be kept in mind. IX. There will be no further independently managed "WHO projects" but only WHO cooperation in national programmes for whose execution the national authorities will be responsible. Existing WHO projects will be carefully reviewed with a view to phasing them out as quickly as possible, or, if appropriate, phasing them into national programmes. X. To strengthen national capacities to prepare and implement national strategies for health-for-all and related programmes, Member States will identify those national structures, institutions and individuals that are potentially capable of making a useful contribution and being strengthened in the process. Cooperative activities will then be undertaken that both further the strategies and programmes and at the same time strengthen the national capacities to do so. WHO will advocate, at top policy-making level, health development as an essential factor in socioeconomic development and will invest in strengthening as necessary ministries of health or equivalent health authorities. However, the Organization, by agreement with its Member States, will diversify its investments in countries by using where appropriate its constitutional right to have direct access to other relevant government departments and institutions, as well as nongovernmental organizations, strengthening them through the process of joint action. XI. WHO will transfer to its Member States the wide variety of validated information required by them on all aspects of health, and will facilitate the absorption of such information by them. To this end, it will allocate adequate resources to build up the
DG0/85.1 page (v) Organization's information systems and at the same time to support countries in building up their information systems so that they have the capacity both to absorb information from WHO and to contribute information to the Organization for exchange with other Member States. The use of appropriate information will be central to all cooperative ventures between WHO and its Member States. XII. There are too many variables and too many other unknown factors within these variables to have a universally applicable model of a health system. What is known has to be adapted to local circumstances, and what is not known has to be elucidated. In both cases the process of research and development (R&D) is required. In the course of applying the managerial process for national health development, as well as proceeding systematically through WHO's General Programme of Work, dialogues between Member States and WHO will give due consideration to defining the country's needs for health research and development and for joint government/WHO investment of resources in such R&D. Attention will be given to the prompt dissemination of useful research findings to all who need them, and to the identification of problems for which more extensive worldwide research is required. XIII. All the activities referred to above involve the investment of resources - knowledge, information, people, material, money. Optimal use has to be made of both national and international resources, since these are finite, and resources for health are usually scarce. WHO's resources have to. be invested primarily in spearheading development; they are much too limited to permit it to share national recurring expenditures. These must devolve on the government; less developed countries may be able to obtain the support of other external partners. It is the government's responsibility to induce these partners to support national health activities that are consistent both with the national health policy and strategy and with the interna~ional health policies and strategies decided upon collectively under the auspices of WHO. Such combined efforts of national and international action should r.esult in enlightened investment and use of resources. XIV. A systematic approach will have to be adopted to ensure the preferential allocation of resources to priority activities in the national health strategy, such as through programme budgeting and related cost-effectiveness and cost-efficiency estimates of alternative ways of reaching the same objective. Having defined resource needs, it is necessary to define realistic ways of financing them, first of all with the resources available or potentially available in the country, and only afterwards in the case of developing countries turning to external sources. This is a government responsibility, but WHO will cooperate in this endeavour with those Member States that so desire. However, before contemplating additional resources, it is wise to make sure that the most is being made of existing ones. Sustained financing of the health system, whether through existing or additional resources, can be achieved in a variety of ways, . and working out the optimal ways or combinations of them is another important R&D undertaking. XV. The use of all resources has to be accounted for, not only to demonstrate that they have been spent according to agreed financial regulations, but also that they have been spent for the purpose for which they were invested. This implies setting up national programme monitoring and evaluation processes which include national accounting control and auditing procedures. WHO too, in addition to existing auditing practices, is setting up a process of monitoring the use of its resources through financial audit in policy and programme terms, namely identifying precisely how expenditures were decided upon and what has actually been achieved once they have been incurred. XVI. The form WHO cooperation will take will be decided upon using defined criteria. From a financial accounting viewpoint, WHO involvement in national programmes will take the f~ of either the provision of international services or direct financial cooperation. In most instances in developing countries a combination of both forms will take place, the balance between the two depending on the country situation and the national capacity to handle a nd account for WHO's resources through direct financial cooperation. WHO will cooperate with Member States with a view to developing such capacities. International services will include the provision by WHO of the conventional kind of technical support services. Direct financial cooperation will involve the sharing between the government and WHO of budgetary costs for carefully designed national programme activities aimed at attaining defined health objectives, targets and outputs.
DG0/85.1 page (vi) XVII. Defined criteria will be used for the use of resources for intercountry and regional activities. WHO's intercountry activities have to be distinguished from technical . cooperation among developing countries (TCDC). WHO's role in TCDC will be mainly catalyt1c and supportive, financing being mainly the responsibility of the governments concerned. XVIII. Socially motivated and technically competent people are the most precious resource for health development. Heavy investments therefore have to be made in the training of health workers, and the pattern of that training will have to keep up with the changing pattern of the Organization's policies and the consequent relationships with its Member States. Particular emphasis will be given to the training of health workers in their own country in accordance with defined national health manpower policies and plans and in the light of critical needs that are part of defined national programmes. This will have the additional effect of strengthening national training institutions. The latter may also be effectively used for intercountry training which meets the criteria for intercountry and TCDC activities referred to above. WHO will provide its own training courses only in response to specific national needs emerging from joint government/WHO programme reviews. Similarly, WHO will set up intercountry training courses only on condition that they meet the criteria for intercountry activities referred to above. Fellowships will be granted in conformity with the policy on fellowships decided on by the Executive Board in resolution EB7l.R6. Once a fellowship has been determined as the most appropriate means of training, Member States will use an adequate selection mechanism and will consult WHO in the process of selection. The use of fellowships and other training activities will be monitored and evaluated periodically. XIX. WHO's resources for the provision of supplies and equipment will be highly selective and severely limited in accordance with defined criteria. Defined criteria will also be used with respect to the use of consultants. Greater use will be made of national staff of the country concerned in the execution of collaborative activities; and all consultants will have to be well versed in WHO's policies concerning the issues for consultation and will have to work together with the national health workers. All consultants will be carefully selected and adequately briefed. Clear criteria will also be adhered to with respect to meetings organized by WHO. XX. The process in countries for carrying out the above will follow that decided upon by the World Health Assembly in resolution WHA30.23 concerning the development of programme budgeting and management of WHO's resources at country level. Joint g 0 vernment/WHO review will identify the essential needs for the development of the national strategy for health for all by proceeding systematically through the global and regional strategies for health for all. National health programme support needs will be determined by proceeding systematically through the WHO General Programme of Work. For each area of collaboration the kinds of information needed by the country as well as the needs for international services and direct financial cooperation will be identified. Ongoing WHO-supported activities in the country will be monitored and evaluated jointly by the government and WHO. As part of the joint government/WHO review process, areas will be identified where national resources could profit from being rationalized and for which additional national resources would have to be mobilized, optimal ways of using these resources being defined. Care will be taken to apply the criteria for determining the organizational level for the implementation of programme activities. Opportunities for facilitating technical cooperation among countries will also be seized. XXI. Governments and WHO will thus engage in a continuing, joint process of programme budgeting. The regional committee will be provided with information on the proposed investment of WHO's resources in the country in terms of the programmes of the WHO General Programme of Work. Governments will also provide the regional committee with a succinct account of the use of WHO's resources in the country during the previous year or biennium. Moreover, they will explain why WHO's resources were not used for certain important parts of the national health strategy. --XXII. To carry out the above J01nt policy and programme reviews and programme budgeting process, an appropriate government/WHO coordinating mechanism will be established, the nature of which will depend on the situation in each country and the level of WHO resources being invested in it. Whatever the mechanism, wherever WHO programme coordinators exist they will
DG0/85.1 page (vii) exercise defined functions aimed at providing the government with information.and explanat1ons concern1ng the policies of the governing bo?ies of WHO; support1n~ the government in the planning and further management of nat1onal health progra~es,. collaborating with the government in identifying t~ose national programm~s 1n.wh1ch WHO could profitably have more specific functions; and help1ng the government to 1~ent1fy and. coordinate available or potentially available external resources for the ~mplementat1on.of approved national health programmes. An appropriate informatio~ system . w1ll be set up 1n WHO programme coordinators' offices to permit them to carry out the1r funct1ons properly. XXIII. Once the Regional Director has a~proved the programme budget proposals for the country, the question at the regional level will be~ these are to be provi~ed prompt~y, efficiently and effectively. To this end, an appropriate country support rev1ew mechan1sm will be established in the regional office to ensure a coordinated response from WHO to the total needs of each country. Its purposes will be to support the joint government/WHO mechanism; review programme proposals to the Regional Director; ensure a coherent response to countries' technical administrative and financial needs; help ensure that intercountry and regional activities' are relevant to countries in conformity with the defined criteria; and support the monitoring of the use of WHO's resources through financial audit in policy and programme terms. For such country support review mechanisms to be effective they will have to be managed by senior staff designated by the Regional Director, and supported by multidisciplinary teams. XXIV. The Regional Director will keep the organization of the regional office under review, ensuring a "best fit" of requirements to provide well-coordinated support to. national health strategies and programmes, to carry out the regional strategy for health for all and to implement the WHO General Programme of Work, always bringing to bear on countries the information and programme activities most appropriate to the situation. The information systems in the regional office will be updated or redesigned as necessary. The Regional Director will prepare the programme budget proposals for 1988-1989 and subsequent financial periods in accordance with the new programme budget policy. XXV. ~.
Staffing and recruiting polices in the region, along with staff profiles and training will be reviewed in the light of the new regional programme budget policy, and the necessary changes will be introduced as soon as possible. The budgetary and the financial implications of the new policy will also be considered, it being realized that these will relate not so much to the overall level of WHO budgetary and financial resources in the region as to how the resources are used within the region, as well as to their distribution among Member States. These implications will be reflected in the distributive allocation of resources in the regional programme budget proposals for 1988-1989 and future financial periods.
XXVI. As requested by the Executive Board in resolution EB75.R7, each regional committee will use these guidelines as a frame of reference in establishing the regional programme budget policy. It will monitor the further elaboration of the policy and will ensure that the 1988-1989 and subsequent regional programme budget proposals are prepared in line with it, establishing any necessary mechanisms to this end. In reviewing programme budget proposals, the Regional Committee, in compliance with resolution WHA33.17, will consider the proposals for each Member State in the region with a view to ensuring that they reflect the regional Irogramme budget policy. This will include the consideration of each Member State's account o the use or non-use of WHO's resources in the country during the preceding period. XXVII. The implementation of the regional programme budget policy will be monitored and evaluated, the main vehicle for doing so being the review of the programme budget proposals and of the use of WHO's resources in giving effect to these proposals once they have been approved by the Health Assembly. Monitoring and evaluation will be carried out successively b~ the Regional Committee, the Executive Board and the World Health Assembly. The D1rector-General and the Regional Directors will support them in doing so.
DG0/85oi page 1 · INTRODUCTION 1. The aim of a regional programme budget policy is to enable Member States to make . the best possible use of WHO's resources for health development in their country, and in . 1 2 particular for their policy and strategy for health for ali by the year 2000. •
2. The mainstay of the programme budget policy is the process whereby countries . do make the most o'f ·wh'a tever resources WHO has to offer - ' political, moral, human, technical, ;;;terial and financial, no ' matter ·where th·e se resources reside - in the country, in other countries ', in collaborating ce~tres, , at the regional level, in other regions and at the global level. The funds allocated in the regional programme budgets for cooperation with Member States are meant to ensure access to all of' these as necessary. These resources have to be used ·most effectively so that they do give rise to the self-sustaining growth of socially and economically relevant national health strategies and to related programmes managed by' the country itself· · and that they do lead to the mobilization and most rational use of national resources for health to that end,· as well ·as, in developing countries, to the mobilization and most rational use of external resources to the same end. These endeavours are most likely to bring nearer the goal. of health for all if they ~ consistent with the policies, strategies and related programmes ' that Member States have decided upon collectively in WHO, for in this way individual Member States derive benefit from the collective wiSdom and experience of all Member States. 3. All this is a far cr~ from b~reaucratic dispensation of funds, submission and app~ov~l . . of requests for isolated projects or unplanned equipment, supplies and ·fellowships, or ad hdc manifestations of magnanimity. It implies a process of constructive dialogue between Member States and their Organiz~tion in a spirit of democratic cooperation - but cooperation within a policy framework that has been ·agreed by Member States collectively. Adherence to collective policy implies discipline, which is often associated with sacrifice. In the event this is a' positi\te kind' df discipline that implies no sacrifice; ' on the contrary, it implies the beneficial acticin' ~f focu~ing ~ the Organization's resources on activities that are vital for the most daring enterprise WHO's Member States have ever undertaken- the attainment· of health for all by the year 2000, first and foremost through national strategies to that end. By corollary this ~eans eliminating activities that are not Vital to that end. 4. Are there uniform rules for achieving the above? No and yes. No, there are no universally applicable formulae that can be applied mechanically to reach the above goal. Yes, there are collectively agreed policies, strategies, programmes and principles ~hose application in specific national circumstances requires wise experimentation, learning not only from one's own doing but also from the experience of others. In short, to adapt collective international policy to individual national needs, and define national policies, strategies and programmes accordingly, requires a process of research and development (R&D) and of exposure to the findings of others' R&D. WHO is uniquely placed by its Constitution to cooperate with its Member States in such R&D, and in ensuring this exchange of information and experience. It can do that on condition that its Member States engage in the necessary communications with it. · These R&D findings will only be of real value if they, the process that gave rise to them and the results of their application are systematically monitoredand evaluated and fearlessly reported on with a view to improving shortcomings and making up for deficiencies, as well as sharing experiences with other Member States. Indeed, this applies to all endeavours undertaken by the Organization and its Member States. · . 5. The above manifests the kind of positive discipline that, if adhered to with open-mindedness and inquisitive probing as a joint enjoyable venture of WHO and its Member States, should go a long way. towards making it possible for each and every Member State less developed and more developed - to derlve greatest benefit from the Organization. -as .a ., whole. That whole, which is made up of all Member States collectively, was established for the purpose of cooperation among Member States to promote and protect . the health of ail peoples as the Constitution of the Organization clearly states. Cooperation among parts that make up the whole surely implies a very intimate partnership between Member States and their Organization - partnership in policy, in technical programmes, and in related financial
1 Resolution WHA30.43. Handbook of Resolutions and De-cisions, . Volume· -II . . ..( . 1973:;..19S4) . . .. '· Geneva, WHO, 1985, page 1. 2 Relevant regional committee resolution.
DG0/85.1 page 2 provisions. Moreover, national institutions and experts officially serving WHO are as much part of the Organization's system as are members of the Secretariat. Cooperation that combines disciplined adherence to collective policy, experimentation in adaptively applying that policy to national circumstances, and free exchange of information and experience throughout the Organization, is fundamental to the regional programme budget policy. Moreover, that policy will help Member States not only to use WHO as they have decided collectively, but also to give visibility to their loyalty to collective policies, particularly the policy and strategy of health for all by the year 2000 - no small matter in these days of growing criticism of international organizations. As part of this loyalty, they will understand that the Organization's resources are the collective property of its Member States and that in consequence the level of resources invested in a Member State in any biennium does not automatically become its everlasting right. 6. This having been said, there is nothing really "new" in the policy that follows. It is rather a bringing together in a systematic way of relevant policies that have been approved by WHO's governing bodies and appear in the globall and regional2 strategies for health for all by the year 2000, the Seventh General Programme of Work,3 and Health Assembly, Executive Board and regional committee resolutions, together with the new managerial arrangements for ensuring that WHO's cooperation with its Member States4 is as effective and efficient as is humanly possible. 7. It goes without saying that the global programme budget policy will have to be brought to bear on any regional programme budget policy. The objectives of the global programme budget for 1986-1987 have been defined as follows;5 (1) To strengthen national capacities to prepare and implement national strategies for health for all by the year 2000 with emphasis on sound health infrastructure development. (2) To focus technical cooperation on activities that support the mainstream of well-defined national strategies for health for all or on the development of such strategies where they do not exist. (3) To build up critical masses of health-for-all leaders in countries, in WHO, in bilateral and multilateral agencies, and in nongovernmental and voluntary organizations. (4) To promote the spectrum of research and development required for the further preparation and implementation of national strategies for health for all. (5) To ensure that valid information required to prepare and carry out national strategies for health for all is made available to all in need according to their need, and to facilitate its absorption by them. (6) To foster the coordinated and optimal use of resources by governments, bilateral and multilateral agencies and nongovernmental and voluntary organizations for the preparation and implementation of the national health-for-all strategies of developing countries. These objectives will therefore be borne in mind throughout the preparation of the regional programme budget policy.
1 Global Strategy for Health for All by the Year 2000. Geneva, WHO, 1981 ("Health for All" Series, No. 3). 2 Reference to the regional strategy for health for all by the year 2000.
in direct su ort of Member Document 5 Proposed programme budget for the financial period 1986-1987 (Document PB/86-87), Geneva, WHO, 1984, pp,XXV-XXVI.
DG0/85.1 page 3 8. The regional programme budget policy will specify the issues to be considered, the process in countries for addressing these issues, and the related mechanisms for applying the process. This will be followed by consideration of adaptations required in the functions and structures of the regional office, staffing policy in the region, budgetary and financial implications, and the role of the regional committee. The monitoring and evaluation of the policy will be outlined. Finally a timetable for preparation, implementation, monitoring and evaluation of the strategy will be included. 9. The proposed regional programme budget for the financial period 1988-1989 will be prepared in accordance with this regional programme budget policy, as will subsequent regional programme budget proposals. ISSUES 10. The regional programme budget policy will include the following issues; (1) (2) (3) Support to national strategies for health for all Promotion of the national health strategy Developing the health system through support to national health programmes
(4) Strengthening national capacities to prepare and implement national health-for-all strategies and related programmes (5) (6) (7) (8) (9) Transfer of validated information and facilitation of its absorption Research and development for health for all Optimal use of resources for health-for-all strategies and related programmes Criteria for deciding on WHO international services and direct financial cooperation Intercountry and regional activities
(10) Training (11) Use of and limitations on provision of supplies and equipment (12) Use of consultants (13) Meetings Support to national strategies for health for all 11. WHO's regional programme budget will be used extensively and intensively to support national strategies for health for all. To identify the main activities and corresponding resources required of WHO to do that, it is necessary to recapitulate the main policy bases and main thrusts of a national strategy for health for all for which resources are required. 12. The main policy bases are: (1) the recognition of health for all by the year 2000 as a priority social goal;
(2) equitable distribution of resources for health leading to universal accessibility to primary health care and its supporting services; (3) (4) (5) government responsibility for the health of its people; community involvement in health development; the use of health technology that is appropriate for the country concerned;
(6) the involvement in health development of all sectors concerned, and not only the health sector;
DG0/85.1 page 4 (7) the mutually supportive influence of health and socioeconomic development leading to genuine human development; (8) national, community and individual self-reliance in health matters.
13. Resources will be required for all or some of the main thrusts of a national strategy for health for all appearing in paragraphs 14-20 below, depending on each country's particularities.
14. Countries will review further their health systems with a view to reshaping them as necessary in order to; (1)
encompass the entire population; include appropriate components from the health and related sectors;
(2)
(3) provide the essential elements of primary health care at the first point of contact between individuals and the health system; (4) (5) ensure the support of the other levels of the system to primary health care; exercise central coordination of all parts of the system.
15.
To develop such systems countries will take further steps to: (1) identify and set in motion the activities required in the health and related sectors and make sure they are well coordinated;
(2) devise ways of involving people and communities 1n primary health care and plan accordingly; (3) (4) set up a referral system to support primary health care; organize a countrywide logistic system;
(5) plan, train and develop health manpower in response to people's needs as the backbone of the health infrastructure; (6) establish suitable health care facilities;
(7) select health technology that is technically, socially and economically appropriate for the country, and ensure that it is properly used; (8) foster control of the system in ways that are commensurate with the country's political, social and administrative practices.
16.
To promote and support the development of such health systems countries will take further steps to: (1)
ensure political commitment to the strategy of the government as a whole; ensure economic support to the strategy; make efforts to win over the health and related professions;
(2) (3)
(4) disseminate information to different groups of people in order to mobilize political, financial, managerial, technical and popular support; (5) establish and apply a managerial process for national health development, making use of health systems research; (6) focus biomedical, behavioural and health systems research on solving problems related to the strategy.
17. To carry out the strategy all available human, material and financial resources will be generated and/or mobilized.
DG0/85.1 page 5 18. Activities that could benefit from cooperation with other countries will be identified and the necessary action taken to ensure stich cooperation.
19. The strategy will be monitored and evaluated, using at least the twelve indicators agreed upon glob'a lly in WHo.l 20. The following specific lines of action will be undertaken in countries in conformity with the regional strategy for health for all~ (1) (2) (3)
(e.g., in the European Region the targets would be included here in a suitable manner, for instance by presenting the Region's 38 targets and annexing the document, or merely by referring to the targets with or without annexing the document.) 21. The regional programme budget - first and foremost through WHO's resources in each country, but also supplemented as necessary by intercountry and regional resources, calling on global and other resources as necessary - will support the above national action in the ways that follow. - Throughdialogue between each Member State and the Organization, agreement will be reached c:m ,.priorities ,for WHO.' s actual involvement in that country, as well as the nature and scope of such involvement, following the articulation of realistic plans and prospects for the national health strategy. 22. WHO's direct support to national strategies for health for all will bring the Organization into intimate partnership relationships with its Member States and will include the following;
(1) COoperation in the review of the country's health system with a view to reshaping it as necessary as outlined in paragraph 14 above (2) Cooperation in developing the health system as outlined 1.n paragraph 15 above and described in paragraphs 25-34 below (3) Cooperation in promoting the development of the health system as outlined in paragraph 16 above and described in paragraphs 23-24 below (4) Cooperation in strengthening national capacities to prepare and implement strategies, as described in paragraphs 37-40 below (5) Cooperation in transferring validated information and facilitating its absorption, as described in paragraphs 41-45 below (6)
Cooperation in R&D as described in paragraphs 46-49 below
(7) Cooperation in generating and/or mobilizing all available resources, as mentioned in paragraph 17 above and described in paragraphs 50-58 below
(8)
Cooperation in training as described in paragraphs 78-84 below
(9) Provision of international services as listed in paragraph 61 below, e.g., internationally recruited staff, consultants (see paragraphs 86-87 below), fellowships (see paragraphs 83-84 below), _ s upplies and equipment (see paragraph 85 below) and meetings abroad (se~ paragraph ' 88 below) (10) Direct financial c_ o operation in conformity with the criteria presented 1.n paragraphs 62-69 below
1 Global stra tegy for health for all by the year · 2000. All" Series, No. 3), PP• 74-76.
Geneva, WHO, 1981 ("Health for
DG0/85.1 page 6 (11) Cooperation in identifying activities that could benefit from intercountry collaboration under the auspices of WHO (as mentioned in paragraph 18 above), in conformity with the criteria presented in paragraph 70 below (12) Facilitating of technical cooperation among developing countries (TCDC) as well as among developed countries and between developing and developed countries as described in paragraphs 73-74 below (13) Cooperation in monitoring and evaluating the national strategy, with particular emphasis on strengthening the national capacity to do so.l Promotion of the national health strategy 23. Technical and managerial action alone, no matter how well carried out, will not ensure recognition for the national strategy for health for all. It has to be "sold"; and to do that requires the expenditure of resources. It has to be sold to different kinds of people representing different kinds of interest. First of all the government as a whole has to be convinced if it is to give its political blessing; without that the road to health for all will be even more uphill than it is. At the same time, economic planners have to be convinced that health is essential for development; otherwise the strategy will have no chance of competing with other demands on the national economy. The whole concept of health for all by the year 2000 has been misunderstood by large bodies of professional health workers; they have to be won over by getting them to understand what it is all about and to realize that they have a highly positive and important role to play. Last but not least, the public at large - as individuals, families, communities, and in different professional and social associations - have to be properly informed so that they are irt a position to become intelligently involved in the health-for-all movement and capable of ensuring the social control of the health system. 24. The following is an illustrative list of activ1.t1.es on which countries could beneficially spend resources to ensure the above and call on WHO to collaborate; (1) Submission of well-conceived and articulated policy statements to government to demonstrate the political popularity that can result from action aimed at attaining health for all citizens by the year 2000 (2) Presentation of a synopsis of the strategy for consideration and endorsement by the government (3) Presentation of promotional material to public bodies, such as political parties, religious groups, trade unions, nongovernmental organizations, as well as to influential individuals
(4) Use of the mass media to get across to the public the message of the strategy and their part in it (5) Establishment of mechanisms for joint action of the m1.n1.stry of health or equivalent body and other ministries, and provision of appropriate encouragement and support for such action (6) (7) Submission of convincing inputs to the national social and economic development plan Promulgation of legislation required to develop or implement the strategy
1 To this end, use will be made of Health programme evaluation: Guiding principles for its a lication in the mana erial rocess for national health develo ment, Geneva, WHO, 1981 Health for All Series, No. 6 ; Develo ment indicators for monitorin towards health for all by the year 2000, Geneva, WHO, 1 81 Health for All Ser1.es, No. 4); "Common framework and format for monitoring progress in implementing the strategies for health for all by the year 2000" (WHO document DG0/82.1, Geneva, 1982); "Evaluating the strategies for health for all by the year 2000 - Common framework and format" (WHO document DG0/84.1, Geneva, 1984). The two latter documents may be updated in the light of experience, in which case the latest version will be used.
DG0/85.1 page 7 (8) Presenting material to .economic planners to explain how health contributes to productivity, and involving these planners as economic advisers for the development of the strategy (9) Submitting proposals for health protection in major economic and for the health care of the communities involved developmen~
projects,
(10) Organizing gatherings of professional health workers, and in particular doctors and nurses, (for example through their professional organizations), to explain the policy of health for all and the strategy for giving effect to it, and the roles of leadership, education, guidance and supervision they ought to be assuming - using appropriate audiovisual material accompanied by informative brochures (11) Encouraging health workers to become involved in the practice of primary health care in communities, for example through appropriate remuneration and career structures (12) Preparing suitable learning material for schools of medicine, nursing, public health artd other h~alth sciences, and providing incentives to use that material (13) Motivating citizens' groups and national nongovernmental organizations to lend their support to the strategy. Developing the health system through support to national health programmes 25. A national strategy for health for all usually includes specific programmes, namely organized aggregates of activities directed towards the attainment of defined objectives and targets that are . consistent with those of the strategy. Each programme should set out clearly the requirements in health workers, physical facilities, technology, equipment and supplies, information and intercommunication, methods of monitoring and evaluatiotl, ways of ensuring correlation between its various elements and related programmes, a timetable of activities, and the expected costs as well as ways of covering them. 26. To define and implement their strategy and component programmes, Member States will find it necessary to apply a systematic managerial process for national health development.l Ideally such a process should include the following; (1) (2) (3) (4) (5) Formulating policies and defining priorities Translating policies into a strategy with clearly stated objectives and targets Preferential allocation of resources to implement the strategy A plan of action to implement the strategy Preparation of detailed programmes as outlined in paragraph 25 above
(6) Delivery of the programmes through the health infrastructure arid applying of sound day-to-day managerial procedures to this end (7) Monitoring and evaluating strategies and programmes, and introducing modifications to them in the light of the findings (8) Ensuring information support for all the above.
27. WHO will pay particular attention to the use of its resources for cooperation with Member States in establishing and applying such a managerial process. In considering both national programme priorities and WHO's involvement in their formulation and execution,
sup~ort
All
1 Managerial process for national health development: of strate~ies for health for all by the year 2000. Series, No. ).
Guiding principles for use in Geneva, WHO, 1981 ("Health for
DG0/85.1 page 8 Member States will find it practical to make use of WHO's General Programme of Work,l proceeding systematically through it as a "checklist" from which to select the main kinds of issues, targets and objectives, programmes and activities to implement the national strategy. The priority programmes that emerge from such a process will depend on the country situation, but they will certainly cover the essential elements of primary health care.2 Decisions concerning WHO's involvement in the formulation and implementation of national health programmes will be taken through joint government/WHO application of this scanning process. 28. The following set of criteria will be used to decide on WHO involvement in national programmes, it being understood that not all the criteria need apply simultaneously, but that a reasonable number of them should; (1) The problem is clearly defined.
(2) The underlying problem is of major importance to the country in view of its high social relevance in terms of its effect on people's health and particularly the health of underprivileged and high-risk groups; its incidence, prevalence, distribution and severity ; or its adverse social and economic implications. (3) The programme is an important part of the national strategy for health for all, having been identified as such through a systematic managerial process as described in paragraph 26 above. (4) (5) There is a demonstrable potential for solution. WHO's involvement has been clearly indicated in the national or regional strategy.
(6) WHO is better equipped than other external partners to support the country with respect to the issue, in view of its constitutional mandate and the knowledge and experience it can bring to bear. (7) WHO's involvement could have a significant impact on the promotion of health and improvement of the quality of life.
(8) WHO's involvement will promote the establishment and self-sustaining growth of the programme throughout the country. (9) The country will be able to maintain the programme in terms of financial resources and human resources that are either currently available or could become available if appropriate training was provided; (10) WHO's involvement will help developing countries to rationalize and mobilize their resources for health as well as to mobilize external resources and use them rationally. 29. The danger is always present of establishing separate infrastructures for each programme, or perpetuating those that already exist. To overcome this, in keeping with the strategy for health for all and in the interests of effectiveness, efficiency and economy, WHO's current General Programme of Work classifies programmes under four main headings: (1) (2) (3) (4) Direction, coordination and management [of WHO's policies and programmes] Health system infrastructure Health science and technology Programme support.
1 The current one will be found in Seventh General Pro ramme of Work coverin the period 1984-1989. Geneva, WHO, 1982 ("Health for All" Series, No. 8 • 2 Declaration of Alma-Ata, Article VII. See Alma-Ata 1978: Primary health care. Geneva, WHO, 1978 ("Health for All" Series, No. 1), p. 4.
DG0/85.1 page 9 30. Health systems infrastructure programmes aim at establishing comprehensive health based, on ,primary health care and the related political, administrat~ve and social adjustments, including a high degree of community involvement. They deal WLth: the establishment, progressive strengthening, organization and operational manage~ent of . hea~th system .iqfrastruc.t ures·, including the relevant manpower, through the systematLc applLcatLon of a well;.;.defined managerial process and related lieafth systems research, and on the basi.i of the most valid available information; the delivery of well-defined countrywide health programmes; the absorption and application ·of appropriate technologies that form p~rt.of those programmes; and social control of the health system and the technology used Ln 1t. sy~tems
31. H .e alth science and technology programmes, being an association of methods, techniques, equipment. an: d supplies (together with the research required to develop them)! constitute the content of a health system • .· Health science and technology programmes deal WLth: the identification of. technologies that are already appropriate for delivery by the health system infrastructure; the re~>earch required to adapt or deyelop technologies that are not yet appropri~te f().r deliv~·ry; the search for social and ·behavioural ~lternatives to technical mea~ures; an.d the. related aspects of social control of health scLence and technology.
'!'he joint government/WHO scanning of the General Programme .of Work, using the criteria in paragraph 28 above, will lead to identifying the national programmes in which WHO's r .esources ~ould be . usefully invested. In most countries it will be necessary to pay particular attention to the investment of resources in the development and organization of a health syst~m infrastructure based on. primary health care - either to establish or strengthen one or, in some ' countries, to put order into the multiplicity of institutions and convert them into a system. So it will be necessary to invest in assessing the health situation and trends, in setting up or reinforcing and applying the managerial process referred to above, in organizing the system so that it is capable of delivering health technology appropriate to the country, in ensuring the availability of socially and technically relevant health manpower and in inducing people's involvement through the right kind of information and education so .t hat they become competent to contribute to and control the country's health system. Essentia~ . to all. Qf this is .th. e establishment, continued. updating and constant use of a supportive national health information system. A glance at the criteria in paragraph 28 above will reveal how extensive WHO's involvement in these matters ought to be, and therefore how extensively its resources should be invested in them and used wisely and with discipline to ensure effectiveness and efficiency. 33. This does not mean neglecting the health science and technology programmes; these too have to pe dea.lt with in the perspective of the health and socioeconomic situation in each country • . As 131e.ntioned in the Introduction, there are no universally applicable rules but rather general principles whose adaptation to any particular set of circumstances has to be researched and developed. This applies to health infrastructure programmes too. Hence the importance of research promotion and development - the first health science and technology programme in the Seventh Gene.r al Programme of Work. Hence also the importance of health systems research in applying the managerial process for national health development. This kind of . rese~rch will .b e useful for assessing the appropriateness of any health technology for the country and for arriving at the optimal organization of the health system infrastructure for delivering programmes that use technology that is appropriate.
3i.
34: National. science and technology programmes in which WHO's resources would be usefully iny.e sted includ.e those concerned with health protection and promotion in general or of specific groups; promotion of mental and environmental health; diagnostic, therapeutic and rehabilitation technology; and disease prevention and control. Support programmes too should n.ot Qe forgotten, particularly health information support. Moreover, WHO's medium-term programmes should be scanned to identify relevant cooperative activities within programmes that the Organization might have to offer. 35. There will be no further independently managed "WHO projects" but only WHO cooperation in.na~iopal prog:ammes ~or whose execution ~he national authorities will be responsible. Any ex1st1.ng WHO proJeC~s W1ll be carefully rev1ewed with a view to phasing them out as quickly as possible .or, if appropriate, phasing. them into national programmes. If the government agreesl WHO w~ll make every effort to phase into national programmes those projects financed by other agencies for which it is executing agency, e.g., projects financed by UNDP UNEP or UNFPA. This will require negotiations both with the government and the other agenc; • concerned.
DG0/85.1 page 10 36. Cooperation in implementing WHO's General Programme of Work will include the highly important but sorely neglected function of exchange of information between WHO and its Member States and among Member States. This will be dealt with in paragraphs 41-45 below. Strengthening national capacities to prepare and implement national health-for-all strategies and related programmes 37. The importance of Member States managing their own health strategies and programmes has already been emphasized. Not all Member States have equal capacity to do this; that capacity has to be strengthened. In the era of WHO-managed projects in countries, reference was made to "national counterparts". The aim will now be to have the national structures, institutions and individuals responsible- WHO's structures, institutions, information systems and staff being the "counterparts"• Such counterparts will only be useful if they have resources that are deficient in the country - knowledge, information, know-how, experience, powers of persuasion, and to some extent financial resources. Some or all of these as necessary will be shared with Member States, the latter assuming not only formal responsibility for the activities concerned but also operational responsibility, and thus learning and gaining experience by doing. To that end, the necessary resources will have to be invested - both national and WHO. 38. Member States will identify those national structures, institutions and individuals that are potentially capable of contributing usefully to the national health strategy and programmes. (Some such institutions have been termed "national health development centres".) The list might include: (1)
The ministry or department of health, or equivalent authority Social security authorities or departments
(2)
(3) Ministries or departments of education, agriculture, planning or development, finance, environment, housing, public works, communications and the like (4) Interministerial mechanisms
(5) National consensus groups on various health matters, similar to WHO's expert committees at the international level (6) Universities, including schools or faculties of medicine, nursing; pharmacy or other health sciences, as well as schools and faculties of social, 'economic and behavioural sciences and postgraduate schools or faculties, for example of public or community health · (7) Other schools for professional or non-professional health workers
(8) Research and other academic institutions, for example for biomedical and health systems research, social and economic studies, and management (9) Nongovernmental and voluntary organizations active in the health and related fields
(10) Individuals, such as experts in relevant fields and educational, civic, social and religious leaders (11) Communities and their leaders, for example seen as community laboratories for self-determined patterns of primary health care. 39. WHO will use its powers of persuasion at top policy-making level to advocate health development as an essential factor in social and economic development. It wi~l.invest in strengthening, as necessary, ministries of health or equivalent health author1t1es so that they become the directing and coordinating authority on national health work as urged by the world Health Assembly. Ways of doing so are to be found in the Global Strategy fo~ Health for All, the Seventh General Programme of Work, and a number of regional documents. 1 Resolution WHA33.17, para. 2(1). See Handbook of Resolutions and Decisions, Volume II (1973-1984), Geneva, WHO, 1985, pages 48-50. 2 To be cited.
DG0/85.1 page_ 11 However, the Organization, by agreement with its Member States, will diversify its investments in countries by using where appropriate its constitutional right to have direct access to other relevant government departments, as well as to governmental and nongovernmental health organizations,! strengthening these through the process of joint action.
40. The following illustrates the kind of cooperative activities that will be engaged in with a view to developing and implementing the national health strategy and related programmes and at the same time strengthening the capacities of the national structures, organizations, institutions, and individuals involved: (1) Development and application of the managerial .process for national health development, including monitoring and evaluation of the national strategy for health for all
{2) (3)
Training Research and development Epidemiological studies Health situation and trend assessment Management studies Information collation, analysis, synthesis and dissemination Financial cooperation.
(4) (5) {6) (7) (8)
Transfer of validated information and facilitation of its absorption 41. One of the main functions of WHO is to provide information to its Member States on all aspects of health. For . this information to be useful it has to be assessed and validated, objective and balanced. The Organization generates, collates and disseminates a vast . amount of information, not all of it equally useful to all Member States, and much of it highly specific information that is required by different kinds of people in Member States. So the . identification of relevant information for the national health strategy and prog.rammes i .s a highly important activity that should permeate many other activities. Thus, during the application of the managerial process for national health development, it is necessary to identify and use information not only emanating from the country itself, but also available from WHO. The joint scanning of the General Programme of Work mentioned in paragraphs 27 and 32 above has therefore another important function - that of identifying information available to WHO that could be useful for the national strategy and its diverse programmes. Such information is a highly precious resource that has to be used more often. Even if additional involvement of WHO in the national programmes concerned is not required, .the provision of relevant, objective, validated information should be considered as a major contribution by the Organization. 42. The following kinds of information may be required by countries from WHO: (1) The Organization's policies and strategies, programmes and principles, managerial arrangements and procedures (2) Resolutions of its governing bodies and reports on their debates
(3) Regional and global reports by Member States on the monitoring and evaluation of the strategies for health for all
(4) Relevant, sensitive and consistent programme information relating to programme planning, implementation, monitoring and evaluation; the experience of other countries; scientific and technical information whether or not generated by WHO, including bibliographical references to the relevant world literature; technical and managerial guidelines 1 Constitution of the World Health Organization, Article 33.
DG0/85.1 page 12 (5) Expert committee, study group and scientific group reports, as well as other WHO scientific and technical publications and documents (6) (7) (8)
Findings of research and R&D Training and learning material Popularized information on health matters
(9) Lists of relevant collaborating institutions throughout the world and of other sources of information and expertise
(10) Potential sources of external technical cooperation and financing from the international community (11) Reports of Member States to the governing ' bodies (12) Reports of the Director-General to the Executive Board and Health Assembly (13) Reports of the Regional Directors to the regional committees (14) Regional and global programme budget information. 43. WHO will allocate adequate resources to build up information systems ·capable of making available to Member States the above kinds of information, and at the same time to support countries in building up their information systems so that they have the capacity both to absorb information from WHO and to contribute information to the Organization. Some, but not all, of the information will be held in the offices of the WHO programme coordinators; these offices will have reference to the source of information not held by them and will have access to these sources through the regional office. The regional office too will have references to the sources of information not stored by it and will have access to the information held at other regional offices and at the global level. The global level will take active measures to ensure that the regional level is informed about the availability of the information it holds and will selectively disseminate that information by mutual agreement. Moreover, the global level will have access to information held in the regions. All this is not for the glory of the Secretariat, but to ensure that Member States do in fact get the information they require and that none of the organizational levels is overloaded with information that it may need only rarely, or not at all. Indeed, a leading criterion for evaluating the work of WHO at all levels will be the relevance, response rate, and quality of the information it provides to Member States. 44. For information to be useful it has to be used. The use of appropriate information will thus be central to all cooperative ventures between WHO and its Member States. This means seeking all possible avenues for transferring the required information. They will include insistence on clarifying what is the most appropriate information for any joint activity and persistence in using it. This relates not only to joint planning and operational activities but also to workshops, seminars and other learning happenings. Moreover, it may be useful to appoint focal points or networks within countries to ensure that the information reaches the individuals, institutions and programmes that require it. It will be a highly legitimate use of WHO's human, material and financial resources to cooperate in setting up and sustaining such focal points and networks. 45. But the ultimate responsibility of Member States for WHO requires an information flow in the other direction too. So in the joint scanning of the General Programme of Work, information will be identified from the country's programmes and experience that might usefully be absorbed by WHO's information system for exchange with other Member States. Such information could include, for example, successful research and development in the country on the organization of health systems based on primary health care or on the delivery of a new technology for prevention and control of disease, which could be adapted to provide solutions in other countries. Thus the value of the relationship between WHO and any particular Member State is to be measured not only by what that country can get out of WHO, but also what the country can put into the cooperative system. ---
DG0/85.1 page 13 Research and development for health for all 46. As stated in thelntroducticm, there are no universally applicable models of a heal..~ system, even if the goal for which the system was set up is identical. There are too many variables - political, social, cultural, economic, epidemiological, managerial, scientific and technological - and too many unknown factors within those variables, for uniformity to be possible. What is known has to be adapted to local circumstances; what is not known has co be elucidated. In both cases the . process of research and development (R&D) is required; put simply, that: means generating knowledge and working out the most appropriate ways of applyi.ng it for a useful purpose.
47. When Meml>er States adopted the Global Strategy for Health for All, they undertook to revie'w the scope and content of their activities in the fields of biomedical, behavioural and health systems research with a view to focusing them on problems requiring solution as part of their own strategies for health for all. This implies developing an R&D strategy to support the national health strategy. To do that will require new attitudes and new ways of thinking on the part of national and international health workers, as well as their appropriate,training. ~est it be considered that research is a luxury of the affluent, it should be pointed out. that its successful pursuit and the application of its findings are often the source .of .a~fluence. Dialogues between Member States and WHO will therefore give due consideration to· defining the country's ne.eds in health research and development. In so doing, acc6unt will have to be taken of the potential applicability of the R&D findings to the country as a whole and not merely to that part of it under investigation. There are at least two .in_terconnected ways of defining .the R&D needs: one is in the course of applying the managerial process for national health development, and the other is in the course of proceeding systematically through WHO's General Programme of Work as mentioned above. 48. In both cases, as each issue arises, questions such as the following have to be asked: (1)
Is the problem clear?
If not, studies have to be undertaken in order to clarify it.
(2) Does the knowledge exist for solving the problem? If not, biomedical or social and behavioural research - or both - have to be pursued in order to generate that knowledge. (3) Does the technology exist for solving the problem? If not, developmental activities have to be undertaken to devise the technology.
(4) Is the technology appropriate for the country concerned or for different areas, communities and social groups in the country? To determine that, the technology has to be assessed in terms of its scientific soundness, its social and cultural acceptability cind its economlc feasibility. (5) Is the technology potentially appropriate but not effective, or not being adequately or properly used? In response to that, operational research to adapt the technology,or modify the health system infrastructure is required. (6) Are there social and behavioural alternatives or additions to the technical measures that would'solve the problem or contribute to its solution? To reply to this question req\lifes social and behavioural research.
(7) Are there social, cultural or economic obstacles to applying the technology? When .such obsta~les are suspected, socio-anthropological and economic research is indicated. (8) Are there adequate n1,1mbers ,of health workers for the work to be performed, and are they socially motivated for their responsibilities and technically capable of fulfilling them? Health manpower research and development will be required to respond to these q1,1estions and to introduce any necessary improvements in the situation.
programmes using appropriate technology and induce the social and behavioural llleasu'f.es required? Health systems research can help to answer that. (10) Wl1atar~ ehe most suitable waysof financing the health system? To answer that rationally, ~ili require econol!lic and social research in addition to political insight.
i9, dep.:ver
(9) . Is the health system infrastructure s1,1ffidently developed and adequately organized
DG0/85.1 page 14 49. In practice, various combinations of the above kinds of research are -required. It is clear that a mine of opportunities presents itself for potentially fruitful joint government/WHO investment of resources in R&D. The following illustrates the kinds of activity that will be considered for such investment; (1) Formulation of a health research strategy, including ways of determining priorities
(2) Establishment or strengthening of promotional, coordinative and supportive mechanisms for health research, such as health research councils or health research sections in general scientific research councils (3) Setting up of mechanisms to bring together health research workers, health planners and socioeconomic planners (4) Clinical research on issues of importance for the provision of medical care in the country, such as testing new diagnostic procedures or promising new drugs (5) Connnunity research, such as; epidemiological studies, intervention trials for new -_ drugs and vaccines, connnunicable disease control through primary l}ealth care_ , development of low-cost technology for drinking-~ater supply, investigation of the effect's of behaviour on feeling healthy, and prevention and control of coronary heart disease or of the chronic disorders prevalent in the country, to mention a few examples (6) Participation in global research activities, for example on human reproduction or on endemic tropical diseases (7) Training of young research workers by involving them in research
(8) Establishment of a career structure for health research workers and provision of incentives, particularly to those entering sorely needed but highly neglected areas, ensuring that a balance is maintained between research and service (9) Prompt dissemination of useful research findings to all who rieed them
(10) Identifying problems on which more extensive, possibly worldwide, research is required, such as to develop a new or more effective vaccine, pesticide or drug. Optimal use of resources 50. All the activities referred to above involve the investment of resources - knowledge, information, people, material, money. Since resources are finite, and resources for health usually scarce, optimal use has to be made of them. This applies to the country's ,resources, to WRO's, and to those of other partners outside the country. In many instances in the preceding sections no distinction has been made between the use of resources by countries on the one hand and by WHO on the other. This derives from WHO's international position as the intimate partner of Member States with respect to health development, from which it follows that its cooperation is so close that it is sometimes hard to distinguish qualitatively between WHO's share and that of the country concerned. It has to be realized, however, that such intimacy may touch on the raw nerves of the country's social and economic system and that it is therefore the government's prerogative to decide on its limits. 51. Quantitatively the situation is different. WHO's resources have to be invested primarily in spearheading development; they are much too limited to permit it to share the recurring expenditures of administering the health services, such as cost's of staff, maintenance of institutions, and provision of drugs. Such expenditure must devolve on the government; - · less developed countries may be able to obtain the support of other external partners, such as bilateral or multilateral agencies and nongovernmental and voluntary organization·s. It is the government's responsibility to induce these partners to support national health activities that are consistent both with the national health policy and strategy a·nd w'ith the international health policies and strategies decided upon collectively under the auspices of WHO. That is what is meant by "enlightened external support". Such support can provide valuable supplements to national health development efforts as well as to the current administration of the health system. WHO will cooperate with its Member States - the less affluent and the more affluent - in ensuring that such relationships between
DG0/85.1 page 15 countries in the field of health are indeed "enlightened". Combined national and international action will in this way result in enlightened investment and use of resources. 52. It is a truism to state that in order to implement strategies for health for all and related programmes it is necessary to identify, find and use the resources required. But the best ways of doing so are not obvious. Reference was made in paragraph 26 above, in connection with the managerial process for national health development, to the preferential allocation of resources to activities that form part of the national health strategy as well as to a plan of action to implement the strategy. How are these resource needs to be identified? A systematic approach to that task is called programme budgeting, which implies formulating priority programme activities to attain defined objectives and allocating budgets to those activities. To do that, it is first necessary _ to analyse the economic carrying capacity of the country and the distribution of resources between health and other competing concerns, as well as the distribution among the various concerns within the health system. It is also necessary to study the cost-effectiveness and cost-efficiency of alternative ways of reaching the same objective. Guiding principles for programme budgeting are to be found in a WHO document entitled "Programme budgeting as a part of the managerial process for national health development (MPNHD): Guiding principles".! 53. Having defined resource needs it is then necessary to define realistic ways of financing them, first of all with the resources available or potentially available in the country and only afterwards, in the case of developing countries, turning to external sources. This again is a government responsibility, but WHO will certainly cooperate in such an endeavour with those Member States that so desire. Before contemplating additional national resources it is wise to make sure that the most is being made of existing ones. This applies to countries at all levels of economic development; for those with the least resources it is the most urgent. Thus, making sure that the technology being used is really appropriate for the country and is being applied properly, ensuring coordinated action among the different components of the health system, and reducing slack to a minimum through improved management of the health system infrastructure and the programmes it is delivering, can all contribute to releasing resources for additional high priority activities. 54. Sustained financing of the health system, whether through existing or additional resources, can be achieved in a variety of ways. They include (to mention only the main ones) central, regional or local taxation, community contributions, social security systems, health insurance schemes, employers' contribution, fee-for-service, revolving funds, and other forms of cost sharing and cost recovery. The blend of costs and means of financing will vary between countries, and sometimes between different states or localities within a country. Working out the optimal ways or combinations of them is another ~mportant R&D undertaking. Guiding principles for financing health systems are to be found in a WHO publication entitled "Planning the finances of the health sector; A manual for developing countries".2 · 55. When the health authorities of developing countries decide to have recourse to external sources of funds for·health, they will first have to list and analyse the use of such funds as are already available in the country with a view to making optimal use of these. They will then have to identify those activities for which it can realistically be expected to attract additional external funds. To do so they will have to present to potential partners convincing justifications, demonstrating how these funds will be used to support essential components of the national health strategy that are consistent with international collective health policy. They will also have to demonstrate how they are using their own resources, and other external resources already available, for activities essential to the strategy. All this may be termed "country resource utilization review"; it is an inseparable part of a managerial process for national health development. 56. The use of all resources are no exception. This is an Introduction. However, it is according to agreed financial has to be accounted for; national and WHO resources for health essential part of the discipline first referred to in the not enough to demonstrate that resources have been spent regulations, it is necessary to show that they have been spent
1 WHO document MPNHD/84.2, Geneva, 1984. 2 Mach, E.P. & Abel-Smith, B. Planning the finances of the health sector: for developing countries. Geneva, WHO, 1983. A manual
DG0/85.1 page 16 for the purpose for which they were invested. This means that if countries are to ensure the optimal use of both internal and external resources, they will have to set u~ national programme monitoring and evaluation processes which include national account1ng contr~l and auditing procedures that provide sound evidence of internal and external resources be1ng effectively and efficiently used for the purpose intended. The demonstration of proper use of resources is the best guarantor of continued and increased availability of resources for health. 57. WHO too, in addition to its existing auditing practices, is setting up a process for monitoring the use of its resources through financial audit in policy and programme terms, namely: identifying precisely how expenditures were decided upon, what has actually been achieved once they have been incurred, and how they relate to the national, regional and global strategies for health for all. Thus, the process will clarify how, by whom, and on the basis of what policy decisions expenditures were planned and decided upon and when the decisions were taken. It will trace the progress of implementation in relation to expenditures incurred, and will assess the efficiency with which resources were used. The Organization will cooperate with its Member States in monitoring the use of WHO's resources in this way. Since WHO's resources will be intimately interwoven with those of its Member States, the existence of similar auditing processes within Member States will lighten the joint task. The setting up of such internal processes by Member States will therefore be useful not only for helping them to make optimal use of their own resources but also for monitoring the use of their Organization's resources. 58. While governments retain full responsibility for making optimal use of resources in their country, it is possible to sum up the ways in which WHO will cooperate with them in doing so. They include: (1) Analysis of national health resources situation and trends 1n the light of the country's economic carrying capacity
(2) Programme budgeting of national health resources to ensure preferential allocation to priority activities (3) Costing of health strategies and programmes, and related cost-effectiveness and cost-efficiency studies (4) R&D on optimal ways of financing the health system
(5) Country resource utilization reviews as part of the managerial process for national health development (6) Preparation of convincing proposals for attracting external funds for the national health strategies and programmes of developing countries (7) Ensuring that WHO's resources are used to spearhead developmental action for health
(8) Setting up national systems for financial monitoring and evaluation in policy and programme terms, including the assessment of both the effectiveness and efficiency of the use of resources (9) Cooperation in applying WHO's process of financial audit 1n policy and programme terms. Criteria for deciding on the form of WHO cooperation 59. Whatever the nature of WHO's direct cooperation with Member States, the regional programme budget policy calls for sufficient flexibility in WHO's internal programme budgeting procedures. These have to be consistent with standards of international accountability for the use of the contributions of Member States, and to permit maximum interface and minimum interference with properly designed national programme budgeting procedures, as part of the overall managerial process for national health development. From a financial accounting viewpoint, WHO involvement in national programmes can take two forms: (1) Provision of international services and related technical support to national programmes
(2)
Direct fi nanc ial cooperation in the national programmes .
DG0/85 .1
page 17 60. In most instances in developing countries a combination of both forms will take place, the balance .b etween the two depending on the country situation and the national capacity to handle and account for WHO's resources through direct financial cooperation. WHO will cooperate with Member States with a view to developing such capacity. However, where national fiscal policy precludes direct financial cooperation, the Organization will have to administer certain activities financially on behalf of the health authorities of the country concerned. International services include the prov1s1on by WHO of the conventional kind of technical support services - internationally recruited staff, consultants, meetings, equipment and supplies, training including fellowships, attendance at international meetings, etc., which can be accounted for by the Organization in the first instance. 61.
62. Direct financial cooperation involves the sharing between the government and WHO of the budgetary costs of carefully designed national programme activities aimed at attaining defined health objectives, targets and outputs. In accounting for such cooperation it is unnecessary to identify WHO's financial share with particular objects of expenditure, as under what have conventionally been called "local cost subsidies", for example paying for supplies and equipment bought locally or meeting part of the salary of national staff. "Direct financial cooperation" is an .expression of partnership with countries in that it implies WHO's cooperation in agreed national health programme activities. It is in no sense a "give away. " of money, since WHO and the government will share their vital interest in the progress and. performance of the specific activities agreed upon, in keeping with their intimate partnership relationship forged by disciplined adherence to collective policy. Moreover, accountability is required to show that the funds have been used for the intended national programme purpose, and, ultimately, that the programme can be monitored and evaluated in terms of performance. Cooperation will thus be accompanied by monitoring of the use of the money in terms of measurement of outputs and attainment of targets and objectives: for example, with respect to R&D an assessment of the outcomes and their usefulness for national health development programmes. To give other examples: Were immunization targets reached? Were the planned numbers of trainees actually trained and were they absorbed usefully into the health system? In view of the novelty of this approach, and in order to dissipate misunderstandings, it is worthwhile describing it in more detail. The following are some particularly relevant examples. 63.
64. Governments might ask for WHO support in policy promotion, in the form of information and the participation of staff in a consultative capacity. But to promote policy it would be useful to strengthen national institutions. An agreement would be worked out between the government and WHO on the form that cooperation for policy promotion should take, and the costs would shared. Most of the promotion would be undertaken by the country, but some would be undertaken by WHO both to facilitate the initiation of the effort and to attract additional resources to it from inside and outside the country.
be
65. Cooperation in the managerial process for national health development might be similar to the promotion of policy. It could involve the setting up or the strengthening of a national health dev.elopment centre or a network of centres, for example in planning, social and economic analysis and information system support. It could also involve training within the country - WHO providing training material, taking part in the training of trainers and ensuring direct financial cooperation for a few years to set the process in motion and make sure that it gets firmly established. 66. The transfer o.f technology and information is one of the weakest areas in WHO's programme. The Organization is producing a great deal of useful technology and information but in comparison is doing much less to ensure their penetration and absorption. Therefore, joint schemes could be established with countries to work out programmes of information transfer, incorporating libraries, information systems, workshops and training courses, WHO's contribution being the technology and information to be transferred and a share of the overall costs in the countries concerned. 67. R&D could take place jointly in a multiple variety of areas, involving government ministries, universities and other academic and research institutions, WHO providing expertise, methodology, the experience of other countries and o ther information, and participating in the overall costs. Examples have been given in paragraphs 46-49 above. In all c.ases the information and experience generated would be fed back to WHO's information system for use as required in other countries.
DG0/85.1 page 18 68. National training activities, as part of a national health manpower development strategy, lend themselves admirably to direct financial cooperation. Thus, training in national institutions (both academic and other), non-institutional or on-the-job training such as in primary health care in communities, and specific workshops decided on through joint government/WHO programme reviews, could all benefit from WHO support through provision of training and learning material, training of trainers, participation of staff and consultants in ongoing training and, in addition, direct financial cooperation until the activities become nationally self-sustaining and the related institutions firmly established. 69. Direct financial cooperation can be useful for launching national programmes, e.g., for launching primary health care on a countrywide basis, or starting in certain communities and progressively extending the experience gained by them to other communities and eventually to the whole country. By virtue of their involvement in applying WHO collective policy, such communities and the national programme they are implementing become part of the Organization's system. Also, a government might decide to initiate a number of primary health care elements jointly depending on the local situation, e.g., water and sanitation using locally appropriate technology, maternal and child health including family planning, iliiDunization, diarrhoeal disease control, and essential drugs. WHO, in addition to providing information required, and possibly collaborating in programme planning and in related R&D and training, could also cooperate financially by providing seed money. This could be provided on a diminishing scale over a period of years until the country can take over financially; or to initiate the programme in additional areas until the whole country is covered. Moreover, such seed money can act as an encouragement to bilateral and multilateral agencies to provide "enlightened" support for the further development of such programmes once they have been launched. Intercountry and regional activities 70. Thus far consideration has been given almost exclusively to the use of WHO's resources in individual Member States. But it may also be useful to use these resources for intercountry activities. To decide on that, the following criteria will be applied (compare with criteria for activities at the country level in paragraph 28 above): (1) Similar needs have been identified by a number of countries in the region following a rational process of programming or a common awareness of joint problems. (2) The activity will be useful for eventual application by countries.
(3) The pursuit of the activity as a cooperative effort of a number of countries in the same region is likely to contribute significantly to attaining the programme objective. (4) For reasons of economy the intercountry framework is useful for pooling selective national resources, for example for the provision of highly skilled technical services to countries. (5) Cooperating countries, whether developing countries cooperating among themselves (TCDC/ECDC), developed countries so doing, or developed countries cooperating with developing countries, have requested WHO to facilitate such cooperation. 71. The above criteria, taken from the Seventh General Programme of Work,l will be applied as part of the government/WHO dialogue concerning the use of WHO's resources in the country, and in particular when scanning jointly the General Programme of Work as described in previous sections. Also, WHO's medium-term programmes will be scanned to identify the precise intercountry activities that will be available if the need has become apparent for the participation in such activities of the country concerned. 72. The following kinds of issue lend themselves well to intercountry activities: (1) Advocacy of the policy and strategies for health for all and related leadership development (2) Training and sharing of training facilities
DG0/8.5.• 1, page 19
(3) R&D, for example for generating appropriate technology and identifying various useful ways of applying it through the health infrastructure, as well as for exchange of methodology (4) Exchange of information and experience
(5) Joint programme activities along common borders, for example for the control of malaria or onchocerciasis (6) Specific issues identified as priorities for intercountry action by the regional committee. 73. WHO's intercountry activities have to be distingui~hed from technical cooperation among developing countries (TCDC) although often the distinction has not been made. The characteristics of TCDC are that political cooperation among the countries concerned, or at least the absence of political antagonism, is a prerequisite. Cooperation results from voluntary agreements between governments and joint activities aim at strengthening the self-reliance of the countries or group of countries concerned with respect to the subjects of collaboration and in the interest of promoting active socioeconomic development. These might include, in addition to the issues mentioned above for intercountry activities, such matters as information on institutions in the countries concerned that are a:ble to provide the services required; transfer of technology; joint planning and purchasing of equipment and supplies, such as drugs; quality control of vaccines and drugs; and provision of specialized medical care. All this may apply equally to cooperation between developing and developed countries, as well as among developed countries. 74. WHO's role in TCDC will be mainly catalytic and supportive. The financing of TCDC will be mainly the responsibility of the governments concerned; otherwise there ~s a, risk of destroying the very self-reliance that TCDC aims at generating. Member States will be entitled, howeve,r, to m . a ke use of the WHO country allocation as seed money to plan and initiate the process, but the bulk of the funds will have to come from the countries themselves, with the possible support of bilateral and multilateral development agencies. WHO is ready to cooperate with governments that so wish to obtain such support, . i f the TCDC proposals seem promising. . 75. WHO also has resources at the regional level. These are meant to support Member States collectively through the work of the regional committee and its subcommittees and by ensuring appropriate cooperation with individual Member States in line with regional and global policy. The following criteria will apply for deciding on regional activities~ . (1) The activity directly supports the work of the regional committee or one of its subcommittees.
(2) (3) (4)
The activity encompasses regional planning, management, monitoring and evaluation. The activity ensures r~gional
coordination.
The activity facilitates TCDC.
(5) The activity supports direct cooperation between WHO and a Member State at the national level. (6) The activity supports approved intercountry activities.
(7) The activl.ty is an essential regional component of an interregional or glc;>bal activity.
(8) For reasons of economy the regional framework 1s useful for pooling highly selective international resources, for example for the provision of highly skilled technical services to countries. 76. Support from regional-level resources will include the (1) following~
Enlisting top-:-level political support for the national and regional strategies Supporting the implementation and monitoring of the strategies
(2)
DG0/85.1 page 20 (3) Promoting intersectoral and international action in the region
(4) Facilitating information exchange and technical cooperation among countries of the region (5) (6) (7) Supporting country and intercountry research and development Supporting country and intercountry training Coordinating multidisciplinary technical support to countries
(8) Identifying needs for, and possible sources of, external resources for health strategies in developing countries, with greatest attention to development of the health system infrastructure in accordance with the defined priorities articulated in the national policies and strategies for health for all (9) Setting up appropriate information systems to carry out the above.
77. The regional level will draw on the global level as necessary for global political support for health-for-all strategies, coordination of information and resources transfer, promotion of ideas and research, and specialized technical support, as well as financial cooperation in highly selective innovative activities from which useful experience might be gained for Member States throughout the world. Training 78. The most precious resources for health development are human beings, on condition that they are socially motivated and technically competent to carry out the tasks devolving on them. To satisfy that condition requires heavy investment. Training of health workers is one of WHO's time-honoured priority preoccupations, but the pattern of that training has to keep up with the changing pattern of the Organization's policies and consequent relationships with its Member States. In the past, overriding priority was given to fellowships abroad. This has resulted in the existence of tens of thousands of health workers throughout the world who were trained in this way. But what might have been highly relevant in the past is not necessarily so in the context of the Organization's latest policies and related functions. Now the emphasis must be on training that is highly relevant to each country's strategy for health for all and that at the same time strengthens the national capacity to generate itself the kinds of health workers it requires. Hence priority will now be given to training within the country itself whenever possible, and to the concomitant strengthening of the national training institutions concerned. 79. It also has to be remembered that fellowships abroad require the spending of WHO's hard currency outside the country of origin of the trainee, whereas training in the country implies the infusion of additional resources into the country. Moreover, the latter makes it possible to train more people in more relevant and cost-effective ways than by sending them abroad to study in systems, technologies and settings that may be quite inapplicable to their country. Where fellowships abroad are still indicated, care will be taken to ensure that they take place in a country whose conditions are comparable with those of the fellow's country, with the exception of a limited number of fellowships in highly specialized subjects.
80. Training in countries with WHO's involvement will take place selectively in accordance with defined national health manpower policies and plans and in the light of critical needs that are part of defined national programmes. In addition to, and also as part of, cooperation with Member States in formulating relevant national health manpower policies and plans, the following are some of the forms that such cooperation will take in the country: (1)
Cooperation in training leaders for health for all from diverse walks of life Cooperation in training trainers
(2)
(3) Cooperation in tra1n1ng all categories of health workers and of workers 1n related sectors in primary health care and community health in general (4) Cooperation in training non-professional primary health care workers on the job in the community
DG0/85.1 page 21 (5) Cooperation in training non-professional primary health care workers from other communities in communities with more experience (6) (7) (8) (9) Cooperation in other on-the-job training Cooperation in national seminars and workshops Cooperation in reshaping the curricula of training institutions Provision of health learning material and cooperation in adapting it to local needs
(10) Direct financial cooperation in training institutions (11) Making available information on training facilities. 81. National training institutions may also be effectively used for intercountry training which meets the criteria and purpose of intercountry and TCDC activities (indicated in paragraphs 70 and 73 above), taking into account the suitability and acceptability of the institutions to the other countries involved. WHO will help to identify and bring into contact such institutions, thus creating training networks. 82. In the past, WHO ran a considerable number of its own training courses. In the light of the new policy, the Organization may provide critically needed training courses in countries in response to specific national needs emerging from joint government/WHO programme reviews (see paragraph 27 above), particularly as a prelude to important developmental or operational activities, such as the introduction or updating of a managerial process for national health development, monitoring and evaluating strategies for health for all, and training of managers, for example for the national immunization, diarrhoeal disease control and essential drugs programmes. WHO may sometimes set up intercountry training courses on condition that they meet the criteria for intercountry activities (see paragraph 70 above) as well as the kind of criteria for national training courses mentioned in this paragraph. 83. Fellowships will. be granted in conformity with resolution EB7l.R61 of the Executive Board, entitled "Policy on fellowships". The following criteria will be adhered to: (1) A fellowship is the most relevant and cost-effective training option.
(2) A fellowship is the most appropriate means of contributing to the attainment of the objectives of the national health manpower policy and plan. (3) A fellowship is the most appropriate means of contributing to the attainment of the objective of a specific national health programme that forms an essential part of the health strategy. (4) The institution abroad is capable of providing training that is highly relevant to the conditions of the fellow's country. (5) Appropriate employment is assured to the fellow in the subject of study on return to the home country. 84. For the purpose of selecting WHO fellowship candidates once a fellowship has been determined as the most appropriate means of training, Member States will use an adequate selection mechanism, such as a properly constituted selection committee composed of representatives of the national health administration, the appropriate national body concerned with the education of health personnel, and the appropriate professional group (if applicable), and will consult WHO in the process of selection. The use of fellowships and other training activities will be monitored and evaluated periodically in terms of impact of health manpower development on national health development.2
1 Handbook of Resolutions and Decisions, Volume II (1973-1984), Geneva, WHO, 1985, page 72. 2 Resolution EB7l.R6 and any regional committee resolution on training policy, including fellowships.
DG0/85.1
page 22 Use of and limitations on provision of supplies and equipment WHO's role of technical cooperation rather than technical assistance implies a highly selective use of WHO's resources for the provision of supplies and equipment, and severe limitations on such use. The following criteria will be adhered to when contemplating the use of resources to this end; (1) The supplies or equipment are essential technical components for implementing a well-defined national programme in which WHO has become involved following a government/WHO dialogue in which the criteria appearing in paragraph 28 above have been applied, and the government concerned is itself committed to the purchase of supplies or equipment for the same programme. (2) The purchase by WHO is not a substitute in the long term for purchase by governments. (3) The purchase, if and when required, has been included in the joint planning of WHO's involvement in the national programme, and not added as an afterthought or as a way of using up unused funds towards the end of the biennial financial period. (4) Subsequent use of specifically planned supplies or equipment provided by WHO must be accounted for in terms of their essential nature for the development of the programme concerned. Use of consultants 86. WHO's international services include the prov~s~on of expert advice and on-the-job sharlng of information, experience and know-how through the use in countries of WHO staff in a consultative capacity and other consultants. Before considering the use of external consultants, optimal use will be made of national staff of the country concerned in the execution of collaborative activities, in order to ensure the relevance of technical contributions to such activities, and at the same time build up national capacity through learning-by-doing. If there is a need for external consultants the following criteria will apply to their use: (1) Consultants must be well versed in WHO's policies concerning the issues for consultation. (2) Consultants must work together with the national health workers concerned in reviewing, applying and adapting as necessary the knowledge, information and technology identified collectively in WHO as being potentially appropriate. (3) WHO staff in addition must have a proper understanding of WHO's overall policy framework and of the place the issues for consultation occupy within that framework.
85.
87. To meet the above criteria, consultants to countries- both external consultants and WHO staff acting in a consultative capacity - will be carefully selected and adequately briefed. Meetings 88. Meetings are a popular WHO activity. If well prepared and properly managed they can provide an efficient and effective means of bringing together expertise, exchanging information and experience, and reaching consensus decisions for health development work. If not, they can be a huge waste of time and money. The following criteria will be adhered to with respect to meetings:
(1) WHO's resources will be used for intercountry and regional meetings only if they meet the criteria for intercountry and regional activities indicated in paragraphs 70 and 75 above respectively. (2) Such meetings should form an essential part of a carefully thought out WHO medium-term programme. (3) To ensure optimal value, meetings will have clear purposes and expected outcomes, will be properly structured, and will be based on working documents that will lead to practical results.
DG0/85.1 page 23 (4) Participants will be nominated/selected who can contribute to the proceedings and related programme development; they should include those from sectors other than the health sector where relevant. (5) Detailed information and specific criteria for selection of part1c1pants in each meeting will be sent to countries at the beginning of each financial biennium. PROCESS IN COUNTRIES 89. Having described the issues addressed by the regional programme budget policy, it is useful to outline the process for carrying it out, beginning with country level. This is in accord with the agreed approach to the development of p+ogramme budgeting and management of WHO's resources at country leve1.1,2 90. Having considered the country's epidemiological, environmental and socioeconomic conditions, the first step is for government health officials and the WHO counterpart to review the essential needs for the development of the national strategy for health for all (paragraphs 11-24 above) by proceeding systematically through the WHO global and regional strategies for health for all. If there are areas of fundamental weakness, these will be areas for highest priority in terms of the resources of WHO. 91. With regard to individual national health programme needs (paragraphs 25-36 above) these should be determined by proceeding systematically through the WHO General Programme of Work, taking into account the essential criteria for health system infrastructure programmes, and science and technology programmes. 92. Priorities within the collaborative programme will result from careful analysis of countries' needs in support of their strategies for health for all, translating these needs into WHO's response under the WHO programmes concerned; such priorities will also result from careful selection of the approaches to be used, individually or in combination as appropriate, for each programme, with a view to ensuring that all programmes do in fact support the progressive development by countries of comprehensive health systems based on primary health care. 93. For each area of collaboration, it is necessary to identify the kinds of information needed by the country (paragraphs 41-45 above) as well as the needs for international services and direct financial cooperation (paragraphs 59-69 above). 94. In considering future directions for WHO collaboration, it is necessary for the government and WHO jointly to monitor and evaluate ongoing WHO-supported activities in the country in order to assess their relevance and effectiveness for national health-for-all strategy development and for the development of health programmes that form part of the strategy. Use will be made of the results of financial audit in policy and programme terms (paragraphs 56-57 above). This will also lead to the identification of activities in which WHO's involvement should come to an end, either because they are no more of relevance to the country or now have low priority, or they are too inefficient to warrant continuation and there is little hope of rendering them reasonably efficient. 95. As part of the joint government/WHO review process, areas will be identified for which national resources could profit from being rationalized and for which additional national resources would have to be mobilized (paragraphs 52-54 above). Optimal ways of using these resources will then be defined. This may be followed in developing countries by performing the same kind of diagnosis and remedial action with respect to external resources (paragraph 55 above). 96. Care will be taken to apply the criteria for determining the organizational level for implementation of programme activities, that is, at country level (paragraph 28), intercountry level (paragraph 70), or regional level (paragraph 75). Opportunities for facilitating technical cooperation among countries will also be seized (paragraphs 73-74 above).
1 Resolution WHA30.23. Handbook of Resolutions and Decisions, Volume II (1973-1984), Geneva, WHO, 1985, page 184. 2 Relevant regional committee resolution.
DG0/85.1
page 24 97. Governments and WHO will thus engage in a continuing, joint process of programme budgeting which: (a) takes into account the experience of the past biennium; (b) reviews and further elaborates the activities for the current operating period; and (c) outlines the broad programme actions and resources allocations for the next financial period. 98. Once the above has been carried out for the joint preparation of the WHO proposed programme budget for the coming biennial financial period, the regional committee will be provided with information on the proposed investment of WHO's resources in the country in terms of the programmes of the WHO General Programme of Work, rather than in the form of individual projects or detailed activities. Detailed plans of operations or work, and budgetary estimates for individual activities or groups of activities planned within defined national health programmes, will be develored at a later stage, closer to and as part of programme implementation at country level. 99. Technical cooperation programme proposals will be presented in the WHO regional draft programme budget in the form of narrative country programme statements, supported by budgetary tables in which the country planning figures are broken down by programme so as to facilitate a programme-oriented review by the regional committee.2 100. Governments will also provide the regional committee, through the regional office, with a succinct account of the use of WHO's resources in the country by programmes of the WHO General Programme of Work in the previous and/or current biennium or in the previous year, as decided by the regional committee. In addition to indicating how WHO's resources were used, these reports will show how these were integrated with or gave rise to otner activities in the country, and an attempt will be made to assess what results might be attributed to WHO's investments. Moreover, they will explain why WHO's resources were~ used for certain important parts of the national health strategy. The intimate relationship between Member States and WHO, and the principle of fearless reporting mentioned in the Introduction, should make this possible without embarrassment. All this will facilitate the monitoring and evaluation of the work of WHO in support of the national health-for-all strategies and health programmes of the countries of the region. As noted in paragraph 57 above, WHO will work jointly with countries to monitor the use of WHO's resources through financial audit in policy and programme terms. MECHANISMS IN COUNTRIES 101. To carry out the above J01nt policy and programme reviews and programme budgeting process, appropriate mechanisms will be needed in countries. It cannot be stressed sufficiently that the programme budget policy is not being formulated for the sake of the Secretariat. Its purpose is to enable Member States to make optimal use of WHO's resources, and this includes utilizing them to lead to the improved use by the country of its own resources for health as well as those of other external partners collaborating in the country. This fundamental principle should guide governments when deciding on the mechanism that is most appropriate for them. Depending on the situation in each country and the level of WHO resources being invested in it, these may include permanent high level government/WHO coordinating committees, joint policy and executive level coordinating forums meeting at fixed intervals, senior level offices in ministries of health dealing with cooperation with WHO and possibly with other international development agencies, joint planning and evaluation groups and the like. Whatever the mechanism, appropriate representation from relevant ministries and sectors other than health is to be encouraged. The regional programme budget policy will identify the range of mechanisms that seem to be most useful in the light of experience in the region. 102. The government/WHO coordinating mechanism provides a forum for discussing the main lines of collaborative action and the optimal use of WHO's resources in support of the country. The mechanism will guide the formulation of joint programmes and programme activities resulting from these discussions and the elaboration of the practical issues of programme implementation, monitoring, evaluation and reprogramming, including any further WHO involvement if desired. Under the auspices of the overall coordinating mechanism, i t may be desirable to establish specific working groups or programme development teams to pursue work 1 Resolution WHA30.23, paras. 1(1) and 1(3). Handbook of Resolutions and Decisions, Volume II (1973-1984) Geneva, WHO, 1985, pages 1842 Resolution WHA30.23, para. 1(2). Handbook of Resolutions and Decisions, Volume II (1973-1984) Geneva, WHO, 1985, page 185.
DG0/85.1 page 25 on certain health-for-all issues or health programmes that form part of the national strategy. In some countries it may be desirable to establish a continuing national resources coordinating coimnittee, involving the ministries of planning, finance, health and other sectors most closely involved in health work. This committee may need to convene periodically in a wider group, including external partners, for the coordination and mobilization of external resources in line with nationally defined priorities and programmes. An appropriate mechanism may have to be established for the monitoring of programme performance, including the use of financial audit in policy and programme terms. WHO and the government will · identify jointly th.e most suitable mechanisms for the country concerned, and the appropriate involvement and support required of WHO. 103. Whatever the mechanisms at country level, wherever WHO programme coordinators exist, whether international or national, their principal functions will be to: (1) provide the government with information and explanations concerning the policies of the governing bodies of the Organization, including the regional and global strategies for health for all and principles of the Seventh General Programme of Work, with a view to ensuring that . these policies will be taken fully into account in national policy and programme reviews; (2) support the government in the planning and further management of national health programmes, including the · setting up of appropriate supportive health information systems; (3) colla·b orate with the government in identifying those national programmes in which WHO could profitably have more specific functions, and in the planning and further management of joint activities for their implementation; and
(4) help the government to identify and coordinate available or potentially available external resource·s · for · the implementation of approved national health programmes. An appropriate. information sy-stem will be set up in WHO programme coordinators 1 offices to permit them to fulfil their functions. properly (see par·a graphs 41-45 above). REGIONAL OFFICE 104. The main functions of the regional level have been listed in paragraph 75 above. As regards. support to individual Member States, the regional programme budget policy, based as it is on the· recognition of the prime responsibility of the government itself for the use of WHO's resources in the country in conformity with collective WHO policy, means a profound change intheway support is provided from the regional office. WHO's resources at country level are understood to. be an integral part of the national health development programme and not extensions of regional progranmies- a further expression of the intimate cooperative nature of the relationship. between WHO and its Member States. There will thus be no imposition of vertical programmes on countries, because all programme proposals will have been screened at national level during the · joint programme reviews, and what is needed, in the way of technical, administrative and financial support, will have beenworked out through jo i nt policy and programme reviews. Once the Regional Director has approved the programme budget . .proposals for the country, based· on these needs, the question at the regional level will be~ these are to be provided promptly, efficiently and effectively. 105. An appropriate country support review mechanism will be established in the regional office to ensure a coordinated response from WHO to the total needs of each country, as identified by the joint government/WHO mechanism in the country. Thus, just as the WHO programme coordinator in the country holds dialogues with the government with a view to defining these needs, the country support review mechanism will hold dialogues with the joint government/WHO country mechanism to identify the most appropriate support from the regional level and from all other parts of the Organization. (In some regions, or in some countries in some regions where there are no WHO programme coordinators, the country's needs may be identified by a joint government/WHO mechanism whose WHO partner is stationed in the regional office - a sort of regional all-country or multi-country WHO programme coordinator.) The country support review mechanism will ensure that support is forthcoming from the same and other regions and from the global leve 1 as necessary. Its purposes will be :
DG0/85.1 page 26 (1) to support the joint government/WHO mechanisms;
(2) to review programme proposals to the Regional Director from governments or from any level of the Organization; (3) to ensure coordinated support to countries by providing a coherent response to their technical, administrative and financial needs; (4) to help ensure that intercountry and regional activities are relevant to countries in conformity with the criteria mentioned in paragraphs 70 and 75 above; (5) to support the monitoring of the use of WHO's resources through financial audit in policy and programme terms. 106. The country support review mechanism will engage in support to the government/WHO mechanism in the country in such matters as comprehensive reviews of the country's health situation and needs; policy analysis; formulation, implementation, monitoring and evaluation of strategies for health for all; development of the national health system, bringing science and technology to bear on health development through the health infrastructure; and cooperative planning of programmes in which WHO is involved and proper use of WHO's resources to this end. The mechanism will thus deal with the substance of WHO's cooperation in the light of each individual country's needs rather than of separate WHO programmes; to this end it will have to have access to the right kind of information. It goes without saying that any periodic review of support to countries will take place with the national health authorities and WHO programme coordinator of the country concerned. 107. For such country support review mechanisms to be effective they will have to be managed by senior staff designated by the Regional Director. They will have to be supported by multidisciplinary teams whose composition will vary in the light of the specific requirements of each country and the particular skills, technology or experience required in each case, including administration and finance as necessary. The Regional Director will decide on the form the country support review mechanism will take, its composition, the way it functions and involves the multidisciplinary teams, and its relationship with other regional mechanisms, making sure that it does not become a mere bureaucratic structure or clearing-house. 108. It follows that the Regional Director will keep the organization of the regional office under review, ensuring a "best fit" of requirements to provide well coordinated support to national health strategies and programmes, to carry out the regional strategy for health for all and to implement the WHO General Programme of Work, always bringing to bear on countries the information and programme activities most appropriate to the situation. The country, programme, managerial and administrative and finance information systems in the regional office will be updated or re-designed as necessary to permit the office to fulfil its functions properly. (Indicate specific regional developments or plans to this end.) 109. The Regional Director will prepare the programme budget proposals for 1988-1989 and subsequent financial periods in accordance with this new programme budget policy. In so doing, he will provide the regional committee with programmatic and budgetary analyses - by WHO programmes- of the proposed use of WHO's resources in each country, showing for example the types of activities and the resources being devoted to critical components of primary health care, such as nutrition, immunization or training of community health workers. He will also provide information on reasons for not using WHO's resources for certain important activities, based for example on the information provided by countries on this aspect, as mentioned in paragraph 100 above. STAFFING POLICY
110. The regional programme budget policy has obvious implications for WHO's human resources. First of all, the engagement of national health personnel in collaborative national health programme activities will be explored. 1 The extent to which this can be
1 Resolution WHA33.17, operative paragraph 6(3). Handbook of Resolutions and Decisions, Volume II (1973-1984), Geneva, WHO, 1985, pages 48-50.
DG0/85.1 page 27 carried out will be reviewed with each Member State concerned in the light of its circumstances. This policy will influence the types and numbers of internationally recruited field staff to be engaged in countries. Moreover, the profile of WHO programme coordinators will be reviewed in the light of their functions (see paragraph 103 above) and recruitment policy modified accordingly. 111. In a similar manner, the functions of the regional office resulting from the new programme budget policy will make it necessary to free technical staff from as much bureaucratic work as possible so that they can perform the newer functions devolving on them. The performance of these functions will require a shift in emphasis from the ability to transfer techniques and manage WHO projects to the ability to work in teams and deal with all components and specific problems encountered by countries, including the ability to provide them with all the relevant information WHO has to offer and absorb the information they have to offer for exchange with other countries. The staff of administration and finance will also have modified functions. They will be more active in providing services to countries, supporting them in administrative and financial matters, and taking part in the country support reviews and related multidisciplinary teams, including financial audit in policy and programme terms. The above implies close cooperation between technical programme staff and the staff of the administration and finance support services. Moreover, regional office staff will be allotting their time in accordance with countries' needs as defined through the country support review mechanism. Pools of experts or resource persons will be identified, drawing on national and WHO personnel who can be placed "on call" for prompt response to country needs, whether these be of a technical, administrative or financial nature. 112. Training requirements for WHO staff will be identified, to update their capacity to deal with the new programme budget policy. This requires an intensive grounding in health policy and strategy matters, national health development experience, the transfer of information, and the application of validated technology through the health system. Moreover, senior national and WHO staff in the region will be involved in health-for-all leadership development efforts. 113. Staffing and recruitment policies in the region, as well as staff profiles and training needs, will be reviewed in the light of all the above and the necessary changes introduced as soon as possible. BUDGETARY AND FINANCIAL IMPLICATIONS
114. The foregoing issues, procedures and mechanisms relating to the regional programme budget policy will have implications not so much for the overall level of WHO budgetary and financial resources of the region as for how the resources are used within the region, as well as for their distribution among Member States. 115. To recapitulate, WHO's resources will be used preferentially to strengthen national capacities for developing and implementing national health policies and strategies for health-for-all and related programmes. The Organization's resources in the region will be focused on technical cooperation activities that support the mainstream of well-defined national strategies, leading to the establishment or strengthening of health systems based on primary health care and delivering programmes that use technology which is appropriate for the country, with full governmental, intersectoral and community involvement. The resources will also be used to build up a critical mass of health-for-all leaders and managers in countries. They will ensure the transfer of appropriate technology and valid information, an«:! promote the spectrum of research and development required. And they will be used to mobilize and foster coordinated, optimal use of all resources for health development in the countries of the region and the region as a whole. 116. WHO's resources will be used mainly for catalytic, developmental act1v1t1es, as distinguished from routine, ongoing operational programmes in countries. Moreover, the input of a small amount of WHO resources may be used as seed money to attract much greater financing from internal and external sources. In considering investment of resources in national health development from different sources - national and international - assessments will be made of the best means of covering recurring costs through different forms of financing and cost-sharing or cost recovery.
DG0/85.1 page 28 117. The budgetary and financial implications of the regional programme budget policy will be assessed and reflected in the distributive allocation of resources in the regional programme budget proposals for 1988-1989 and future financial periods. REGIONAL COMMITTEE 118. The regional committee has been requested by the Executive Board in resolution EB75.R7 1 to prepare the regional programme budget policy, submit it for review by the Executive Board and World Health Assembly, prepare the regional 1988-1989 and subsequent budget proposals in accordance with it, and monitor and evaluate its implementation with a view to ensuring that it is properly reflected in the Organization's activities in the region. The committee will therefore review these guidelines and initiate the preparation of the regional programme budget policy in accordance with them as appropriate. It will monitor the further elaboration of the policy and will ensure that the 1988-1989 and subsequent regional programme budget proposals are prepared in line with it. It will establish and control any necessary mechanisms to carry out the atiove. In reviewing the 1988-1989 and subsequent programme budget proposals, the regional committee, in compliance with resolution WHA33.17, 2 will consider the proposals for each Member State in the region with a view to ensuring that they reflect the regional programme budget policy, which in turn is a reflection of the Organization's collective policy. As part of that, they will consider each Member State's account, mentioned in paragraph 100 above, of the use or non-useof WHO's resources in the country during the preceding period. MONITORING AND EVALUATION 119. The regional programme budget policy will be judged in the light of its implementation. This implies the need for monitoring and evaluation to ensure that the policy is indeed being carried out and is being carried out efficiently and effectively. The main vehicle for doing that will be the review of the programme budget proposals and of the use of WHO's resources in giving effect to these proposals once they have been approved by the Health Assembly. There is no shame in admitting that there are deficiencies and problems if this leads to attempts to make good the deficiencies and overcome the problems, and thus improve implementation. There is shame in hiding the truth; to do so will help nobody and will hurt most those whom the programme budget policy is being set up to help. 120. The regional committee will therefore initiate and start to monitor the preparation of the regional programme budget policy at its session in 1985, and will submit a progress report to the Executive Board. At its session in 1986, it will finalize the policy, submitting the policy document for review by the Board, and will consider concomitantly the 1988-1989 programme budget proposals that will have been prepared in conformity with the evolving policy. The programme budget proposals, once endorsed by the regional committee, will as usual be submitted to the Director-General before he makes final proposals to the Executive Board and World Health Assembly. 121. The processes and mechanisms in countries and in the regional office, as described earlier, will become progressively operational starting in 1985. This will include the monitoring of programme budget implementation through financial audit in policy and programme terms. 122. The Executive Board will inform the Health Assembly in 1985 about its decision concerning regional programme budget policy. In 1986 it will review the progress reports of the regional committees and will report thereon to the Health Assembly. In 1987 the Board will review the actual regional policies together with the related programme budget proposals for the financial period 1988-1989. It is expected that the Fortieth World Health Assembly will consider the Board's report on the regional policies in 1987 when it considers these programme budget proposals. 123. The regional committee will monitor and evaluate the implementation of the policy, starting in 1988 at the same time as it considers the regional programme budget proposals for 1990-1991. As part of this process, it will review the way Member States in the region have 1 Document EB75/1985/REC/l, p. 6. 2 Resolution WHA33.17, para. 3(8). Handbook of Resolutions and Decisions, Volume II (1973-1984), Geneva, WHO, 1985, pages 48-50.
DG0/85.1 page 29 used WHO's resources during the preceding period, in the light of the account presented to it by each Member State. Starting in 1989, the Executive Board and World Health Assembly will also monitor and evaluate implementation at the time they review the programme budget proposals for the coming financial period. 124. The Director-General and the Regional Directors will support the regional committees, the Executive Board and the World Health Assembly in monitoring progress in preparing the regional programme budget policies and in the subsequent monitoring and evaluation of their implementation. TIMETABLE 125. The timetable for the devela.pment, review,, adoption, implementation, monitoring and evaluation of the regional programme budget policy will be as follows: {1) (2)
Decision by Executive Board- Resoltition EB75.R7 ••••••••••••••••••• Consideration of Board's resolution by Global Programme Committee (GPC)l ••••••••••••••••••••••••••••••••• Preparation of draft guidelines by Director-General •••••••••••••••• Consideration of draft guidelines by Programme Development Working Group (PDWG)2 •••••••••••••••••••••••••••••••••••••••••••••
January 1985 January 1985 February 1985 March 1985
(3)
(4) (5)
Provision of information on regional programme budget policy to Thirty-eighth World Health Assembly by the Executive Board representative and Director-General •••••••••••••••
May 1985
(6) (7)
Consideration of draft guidelines by GPC ••••••••••••••••••••••••••• :~, May 1985 Finalization of guidelines. by Director-General ••••••••••••••••••••• Initiation of development of regional programme budget polic-y by regional c:ormnitte·e •. •-• .. •-• ..••.. ••-•-•• •., •..••.....•.• ., ......_ .....
June 1985 September/ Octobe.r 1985 throughout last quarter of 1985 and whole of 1986 January 1986 end January 1986 March 1986 May 1986 May 1986
(8)
(9)
Concomit.a:nlt p·reparation of 19'&&-19'8·9' programme budget proposals in-- the. reg·i on •.•...-* • •.•••• ., ••. .., .- ...., ••.••••~ . ....... . . . . . . . . . . . . . . . . . . . . .
(10)
Review of progress by Executive Board Consideration of implications of Executive Board's review by GPC Review by PDWG of problems encountered in using guidelines to prepare regional policy and related programme budget proposals Cons.iderari&n b:y Thirty-ninth World Health Assembly of progress report by Executive Board • • • • • • •. • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Review by GPC of problems encountered and suggestions for mid-stream· modific·ations • . . • • . • • . • • . • . • • • • . . • • • . • . • • . . . . • • . • . • . • . •
(11) (12) ( 13:):
04):
1 The GPC consists of the Director-General, the Deputy Director-General, the Assistant Directors-General and the Regional Directors. 2 The PDWG is a working group of the GPC. It consists of the Directors of Programme Management in the regional offices, the Chairman of the Headquarters Programme Committee and the Adviser on Health Policy in the Director-General's Office.
DG0/85.1 page 30 (15) Finalization of regional programme budget policy and review of r:lated 1988-1989 programme budget proposals by regional coiDin1 t tee •••••••••••••••••••••••••••••••••••••••••••••••••••••••••
September/ October 1986 January 1987 January 1987 May 1987 starting
(16)
Review of regional programme budget policies and related programme budget proposals for 1988-1989 by Executive Board Incorporation by Executive Board of regional programme budget policy in draft of Eighth General Programme of Work ••••••••••••••• Review by Fortieth World Health Assembly ••••••••••••••••••••••••••• Monitoring and evaluation of implementation by regional committee ••••••••••••••••••••••••••••••••••••••••••••••••
(17) (18) (19)
September 1988 (20) Monitoring and evaluation of implementation by Executive Board ••....•..•..••....•.•.•.•.•••.......•..............
starting January 1989 starting May 1989
(21)
Monitoring and evaluation of implementation by World Health Assembly ••.•••.....•.......•.•.........•.•••....•...
DG0 / 85.1 page 31
I NDE X Numbers refer to paragraphs of the text proper, unless otherwise specified (ES= Executive summary). The more important references are underlined.
Academic institutions, 24, 38, 67, 68 Accounting control, ES-XV, XVI; 56-58, 59-64 supplies and equipment, 85 Administration and finance staff, functions, 111 Appropriate health technology, see Technology, health Audiovisual material, 24 Audit (financial) in policy and programme terms, ES-XV; 56-57, 58, 94, 100, 102, 105, 111, ~ Auditing practices, ES-XV; 56, 57 Behavioural research, 16, 48 Bilateral agencies, 7, 51, 74 Biomedical research, 16, 48 Budget, see Programme budget ••• Budgetary and financial implications of regional programme budget policy, ES-XXV; 114-117 Citizen's groups, 24 Clinical research, 49 Collaborating institutions, 42 Collective policies, adherence to, ES-II, IV; 2, 3, 4, 5, 47, 62, 69 Community involvement, 12, 15, 23, 24, 32, 38, 68, 69 Community research, 38, 49 Consensus groups, 38 Consultants, ES-XIX; 10, 61, 64, 86-87 Coordinating mechanisms, country level, ES-XXII; 101-103, 121 regional support, 76, 77, 104-107, 121 Costing of health programmes, 58 Counterparts, 37 Country resource utilization review, 55, 58 Criteria for: consultants, 86 country activities, 28, 96 fellowships, 83 intercountry activities, 70-72, 96 meetings, 88 ----programme formulation, 25, 98 regional activities, 75-,-96 research and developm~t, 49 supplies and equipment, 85 training courses, 82 WHO cooperation, 28, 59-69
Direct financial cooperation by WHO and international services, ES-XVI; 10, 59, 60, 61, 62-69, 93 Director-General~ 120, 124, 125 Documentation, see footnotes to pages 2, 6, 7, 8, 15~8 Economic and social research, 48 Economic development projects, health protection, 24 Economic planning and health development, 23, 24, 39, 49 Epidemiological studies, 40, 49 Evaluation, see Monitoring and evaluation Executive Board, 42, 120, 122, 124, 125 Expert committees and similar groups, 42 Expertise, sources of, 38, 42, 70, 75, 86-87, 88, 111 External resources, 42, 51, ~. 58, 64, 76, 95, 101, 102, 103 Facilities for health care (physical), 15, 25 Fellowships, ES-XVIII; 61, 78-79, 83-84 Financial aspects, see Accounting ----control; Administration and finance staff; Auditing practices; Budgetary and financial implications; Direct financial cooperation by WHO; Financing of health systems Financial audit in policy and programme terms,~ Audit (financial) .. • Financing of health systems, ES-XIV; 48, 53-55, 116 Fiscal policies, national, 60 General Programme of Work, reference to, ES-XX, XXI; 32, 36, 41, 45, 47, 71, 91, 98, 100, 103, 108 classification, 29 use as check list, ES-VIII; 27 Global programme budget policy, 6, 7 Global Programme Committee, page 29footnote 1, 125 Health Assembly, 4 2, 119, 120, 122, 124, 125 "Health for All" Series, see Documentation --Health science and technology programmes, 29, l!. 33, 34
DG0/85 . 1 page 32 Health systems development, ES-VIII; 10, 14, 15, 16, 25-36, 46, 48, 76 Health systems infrastructure programmes, ES-VIII; 29, 30, 32, 33 Health systems research, 16, 33, 48 Information systems, ES-XI, XXIV; 26, 32, ~. 65, 67, 76, 108 Information transfer, ES-XI; 7, 10, 36, 41-45, 66, 72, 76, 77, 93, 115 dissemination, 16, 32, 40 focal points/networks, 44 kind of information required, 42 two-way flow, 45, 67 Intercountry and regional activities, ES-XVII; 10, 18, 70-77, 105 meetings, 88 ----training, ES-XVIII; 81, 82 International services, see Direct financial cooperation by WHO Intersectoral action, see Sectors other than health, involvement of Leaders, health-for-all, 7, 24, 72, 80, 112, 115 Learning material, 24, 42, 65 Legislation to implement strategies, 24 "Local cost subsidies", 62 Logistics, ~ Supplies and equipment Mass media, 24 Managerial process for national health development, ES-VI, VIII; 16, 26, 27' 32, 40, 41, 47, 55, 58, 59,65 Manpower, ES-XVIII; 15, 25, 32, 48, 110; see also Staffing policies; Training Medium-term programmes, scanning, 34, 71 Meetings, ES-XIX; 10, 61, 88 Ministries of health and other than health, ES- X; 38, 39, 101 interministerial mechanisms, 24, 38 see also Sectors other than health, involvement of Monitoring and evaluation, of health strategies, ES-VII, XV; 19, 22, 26, 40, 42, 58, 94, 100 of fellowships, ES-VIII; 84 of programme performance, 63, 102 of regional programme budget policy, ES-XXVII; 119-124 of research and development, 4 monitoring as related to a ccounting control, ES-XV; 56, 63, 121 see also Audit (financial) in policy and programme terms Multilateral agencies, 7, 51, 74 National health development centres/ networks, 38, 65 Nongovernmental organizations, 7, 24, 38, 39, 51 Non-health sectors, see Sectors other than health Organizational level for implementation of activities, ES-XX; 92 Political commitment/support, 16, 23, 76, 77 policy promotion vis-a-vis governments, 24, 42, 64 Preferential allocation of resources, ES-XIV; 26, 52, 58, 115; see also Priorities, definition of Primary health care, essential elements, ES-VIII; 14, 27, 69 promotion of interest in, 24 referral system, 15 support of other levels, 14 training in, 68, 80 Priorities, definition, of, 26, 27, 72, 92 Professional health workers, 16, 23, 24, 38 Programme audit, see Audit (financial) in policy and programme terms Programme budgeting approach, ES-XIV, XXI; ~. 58, 5~, 97 Programme budget policy, regional: aim, ES-I; 1 budgetary and financiai implications, ES-XXV; 114-117 issues addressed, 8, 10 mechanisms, 101-103 -monitoring, ES-XXVII; 119-124 policy base, ES-V; 6-8, 11-12, 104 process, ES-II, XX, XXVI;---2-,-89-100 relationship to global programme budget policy, 6, 7 resolutions governing,-pages (i), (ii) timetable for adoption, 125 Programme budget proposals, at country level, 104, 105, 109 regional, ES-XXIV, XXVI; 9, 21, 42, 98, 99, 109, 117, 125 global, 42, 98 review process, 118, 119-125 Programme Development Working Group, page 29 footnote 2, 125 Programme formulation, 25, 16, 98, 102 Promotional activities, 23-24, 64 Public information, 16, 23, 24, 32, 42 Referral system, 15 Regional activities, see Intercountry and regional activities Regional committee, ES- XXI, XXVI; 8, 72, 75, 98, 99, 100, 109, 118, 120, 122, 123, 124 --Regional director, ES-XXIV; 42, 104, 107-109, 124 Regional-level resources, 75, Zi Regional office, ES-XXIII, XXIV; 8, 43, 100, 104-109, 111, 121 Regional review mechanism, 105-107 Reports as source of information, 42 Research and development, ES-III, XII, XIV; 4, 7, 10, 33, 40, 42, 46-49, 67. 72, 76, 115 -on financing of health system, 58
DG0/85. 1 page 33 Research councils, 49 Research institutions, 38, 67 Resolutions governing regional programme budget policy, pages (i), (ii) Resource mobilization, ES-II; 2, 17, 50-58, 64; see also External resources Resource utilization, ES-II, XIII, XXI, XXV; 2, 7, 10, 27, 50-58, 95, 100, 101, 109, 114, 115-116, 118, llg:123; see also Regional-level resources Review processes, ES-XX, XXIII; 55, 58, 95, 104, 105-107, 108, 111, 119 Scanning process, ES-XX; 27, 32, 34, 41, 71 Schools of medicine, nursing, etc.,~ Academic institutions Sectors other than health, involvement of, 12, 14, 24, 76, 88, 101 Seed money, 69, 74, 116 Self-relianc~ 12, 74 Seminars, workshops, etc., 66, 80 Situation and trend assessment, 32, 40 of resources, 58 Social and economic research, 48 Social control, 15, 23, 30, 32 Social security authorities, 38 Socioeconomic development, see Economic planning and health development Staffing policies, ES-XXV; 24, 61, 62, 87, 107, 110-113 research workers, 49 Strategies for health for all, 47, 72 global, 6, 90 national, ES-II, VI, VII, X, XX; 2, 7, 10, 11-24, 25, 28, 37-40, 47, 58, 7 6 - regional, 6, 20, 28, 76, 90 Strengthening of national capacities, ES-X; 7, 10, 37-40, 64 Supplies and equipment, ES-XIX; 10, ~~. 25, 61, 62, 85-87 Support programmes, ES-VIII; 29, 34 see also Information systems TCDC/ECDC, ES-VI, XVII, XVIII; 70, 73-74, 75, 81, 96 Team work, 111 Technical publications, 42 Technology, health, 12, 15, 25, ~. 32, 33, 48, 72 transfer of, 66, 115 Timetable for adoption of regional programme budget policy, 120-123, 125 Training, ES-XVIII; 10, 40, 61, 65, 68, 72, 76, 78-84 courses, ES-XVIII; 66, 82 institutions, 78, 80, 81-,-83 research workers, 49 WHO staff, 112 see also Learning material Universities, etc., see Academic institutions Utilization of resources, see Resource utilization Voluntary organizations, 7, 38, .51 WHO as executing agency, 35 WHO cooperation, modalities, ES-IX, XVI; 28, 58, 59-69, 96 WHO international services, see Direct financial cooperation by WHO WHO programme coordinators (WPCs), ES-XXII; 43, 103, 105, 106, 110 "WHO projects", termination or phasing out, ES-IX; 35, 94 World Health Assembly, see Health Assembly