SEA/RC60/11 - Membership of the South-East Asia region on the executive board

REGIONAL COMMITTEE Sixtieth session Thimphu, Bhutan 31 August – 3 September 2007

Provisional Agenda item 13 SEA/RC60/11 24 August 2007

MEMBERSHIP OF THE SOUTH-EAST ASIA REGION ON THE EXECUTIVE BOARD The issue of expansion of membership of the South-East Asia (SEA) Region on the Executive Board was discussed at the High-Level Consultation (HLC) with SEAR Member Countries on WHO Programme Development and Management held in New Delhi, in May 2007. There was agreement at the HLC that with its high disease burden and large population base, the SEA Region should strive to have a larger number of seats on the Executive Board. The HLC recommended that the Regional Office should constitute a group of experts from both Member countries and WHO, to agree on a formula that most clearly represents their position and to report to the Sixtieth session of the Regional Committee on the progress. The Joint Meeting of Health Secretaries and the Consultative Committee on Programme Development and Management, which met from 2 to 6 July 2007 in the Regional Office, New Delhi, endorsed this recommendation. In order to take forward the action points recommended by the HLC, a Regional Expert Group Meeting on the Representation of South-East Asia Region on the WHO Executive Board was organized, on 12-13 August 2007 in Bangkok. The objectives were to present, review and elaborate options and scenarios on health metrics related to the regional membership on the WHO Executive Board and to recommend the most appropriate approach and method to use in support of the proposal to increase the membership from countries of the SEA Region on the Executive Board. The meeting included experts from Member Countries and the WHO Secretariat from the Regional Office. The recommendations that emanated from this meeting are now presented to the Sixtieth session of the Regional Committee for its consideration.

Contents Page Background .................................................................................................................................1 Existing situation .............................................................................................................................................. 1 Need for review............................................................................................................................................... 2

Guiding principles for various scenarios .......................................................................................3 Main discussion points.................................................................................................................3 Recommendations.......................................................................................................................4 Option A ......................................................................................................................................................... 4 Option B ......................................................................................................................................................... 5

SEA/RC60/11

Background Existing situation 1. The Executive Board of WHO currently has 34 seats that are distributed to various regions to ensure regional representation (Table 1). The numbers of seats allocated to regions are fixed and countries are nominated for a three-year period from their respective regions. 2. Votes in the WHO Executive Board set-up are important as they provide opportunity to choose the governance and set the agenda. Whether resolutions are passed in the Executive Board through voting or not, the recommendations and agreed text of resolutions can have a bearing on the actions taken by WHO. Adequate representation from all regions is necessary to achieve a fair balance. WHO works for all Member countries and must continue to be perceived as such, as witnessed by its action and rules of governance. 3. The principle currently followed for regional representation is stated as “take into account an equitable geographical distribution” in Article 24 of the Constitution. This is assumed to imply representation in proportion of the number of countries in the region. Accordingly, maximum seats are allocated to the European Region with 53 countries and the minimum are allocated to the SEA Region with 11 countries. Countries of the SEA Region will have even less representation according to this criterion but the existing rules stipulate at least three seats for each region. The minimum of three seats is pursuant to the World Health Assembly resolution WHA28.22 requesting the Director–General to propose an amendment in the next Health Assembly for a marginal increase in seats of the Executive Board so that each region could designate at least one new member each year. Thus the representation in proportion of the number of countries has ceased to be the sole criterion. 4. Figure 1 shows the size of Executive Boards, Councils or Bodies of UN Organizations, which ranges from 31 (World Trade Organization) to 82 (World Intellectual Property Organization). The size if the Executive Board of WHO is on the lowest side among the UN organizations. Figure 1: UN Organization by the size of Executive Board 90 80 Number of EB Members/councils/bodies 70 60 50 40 30 20 10 UNESCO

0 WIPO ILO

UNIDO

UNICEF

WMO

WHO

ICAO

UN agencies

WTO

UPU

IMO

IAEA

FAO

ITU

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Need for review 5. Under the present regime, while assessing the equitable geographical distribution, parameters such as population are ignored. For example, the Western Pacific Region comprises 27% of world’s population but its representation on the Executive Board is only 15% (Table 1). Other relevant parameters such as burden of disease and health needs are also not considered. Three seats allocated to the SEA Region are extremely low for providing a voice to approximately one fourth of the world’s population, and to that section of people who are in desperate need of all kinds of health inputs ─ expertise, infrastructure and operational guidance. In May 2007, the High Level Consultation (HLC) with SEAR Member Countries on WHO Programme Development and Management decided to convene an expert group to analyze various options for enhanced representation of the Region on the Executive Board. A document was prepared for the HLC1. The expert group meeting intends to take this effort one step further. Table 1: Geographical distribution and Executive Board representation WHO Region AFR AMR EMR EUR SEAR WPR Total a b

Present members Number 7 6 5 8 3 5 34 Percent 21 18 15 24 9 15 100b

Countries Number 46 35 21 53 11 27 193 Percent 24 18 11 27 6 14 100

Population Billiona 0.718 0.885 0.539 0.881 1.662 1.758 6.442 Percent 11 14 8 14 26 27 100

Source: the SEA Region communication; for the year 2005 Sum is different from 100 due to rounding-off

6. In particular, the present review explores the possibility of making adjustments in the present system of regional representation on the Executive Board and examines health metrics that could be possibly considered for developing such a model. Alternative models for determining the representation are suggested that do not compromise the existing principles. The objective is to find a formula, which is equitable and convincing. The formula should have sufficient support for acceptance in the World Health Assembly. The first attempt is to retain the principle of equitable geographical distribution as enshrined and the second attempt looks for relevant parameters in addition to geography for equitable distribution. Scenarios are presented that would protect the existing representation from the regions.

1 Background Document for Discussion on Increasing the Representation of South-East Asia Region on the WHO Executive Board. SEA/HLC-PDM Meet/3, 26 April 2007.

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Guiding principles for various scenarios • • • •

Simple and understandable scenarios; Scenarios based on equitable distribution and expressing “health needs’; Scenarios based on scientific analysis and evidence, and Protection of current representation of all WHO regions (marginal increase is inevitable).

Main discussion points 7. (The Expert Group reviewed and discussed various scenarios, as presented in the working paper provided as information document.) •

With the above as guiding principles, the Group considered at length various parameters that should constitute the model. The present stipulation in Article 24 is to “take into account an equitable geographical distribution”. So far this has been implied to mean the number of countries in various regions. The Group was of the firm opinion that geographical distribution cannot be restricted to the number of countries alone ─ area and human inhabitants are essential ingredients of geography. In the context of health, a large barren area with practically no human habitation has no relevance. Inhabitants imply population, and cannot be ignored while considering geographical distribution. At present, the SEA Region has three seats (<10% of the size of the board) for approximately one-fourth of the population of the world living in this Region. This is a matter of concern and its fairness is questionable, particularly when population has been recognized as one of the parameters for increasing representation for a region (Western Pacific Region) previously. Furthermore, the whole concern regarding health is valid only in the context of people. The Expert Group was of the opinion that parameters considered for this model should be acceptable widely, and relevant to the objectives of WHO, with values being available for all regions, and with data being verifiable. Other than geographic-based indicators, viz., number of countries, area and population, other relevant parameters which were identified were disability-adjusted life years (DALYs) lost as a measure for health gap (burden of disease), human poverty index (HPI) of United Nations Development Programme as a measure for all-inclusive poverty (in place of restricting to economic poverty), and complement of human development index (1 − HDI) as a measure of development gap. These three are indicators accepted widely. According to the WHO Director-General, the ‘greatest concern of WHO must always rest with the disadvantaged and the vulnerable groups’2. Thus the above three parameters are very relevant to the functioning of WHO. The inclusion of these as criteria for determining the representation on the Board would demonstrate that WHO practices what it professes.

•

2

Working for Health: An Introduction to the Word Health Organization, 2007: p.1

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•

The Group also realized that the financial contribution made by the respective regions cannot be ignored. Those who contribute more may perceive their legitimate rights for greater representation, notwithstanding the fact contribution are made explicitly to meet the objectives of WHO and not for an increased role in its administration. Since the assessed component of financial contribution is fairly stable, this was considered as a candidate parameter for inclusion in the model.

8. Among many options considered were various combinations and permutations of the above-mentioned parameters – one at a time, two at a time, etc., including average of all. Equal and differential weights to different parameters were tried. Seat-allocation scenarios obtained by trying out all these different combinations were considered. Most scenarios were found to be impractical and unconvincing. Since the Expert Group felt that some indicators which had been collected regularly to monitor progress in achieving the Millennium Development Goals (MDGs) could also be considered, an attempt to use (i) under-five mortality; (ii) deliveries attended by skilled birth attendants; (iii) measles coverage, and (iv) HIV prevalence in the 15-49 year-agegroup was made.

Recommendations 9. After reviewing various scenarios as per the working paper (Information Document) the Expert Group recommended the following two options (based on health metrics) for regional membership of the WHO Executive Board.

Option A 10. This option exploits the present premise of a minimum of three seats to each region. This can be considered as the flooring option. Addition to the minimum number can be based on the number of countries in the region plus any other parameters which define the health needs. The parameters of DALYs lost was preferred because it is the most comprehensive indicator of health needs. Since the minimum number for countries in any region is 11 in the SEA Region this fraction can be used as a coefficient. Thus the formula arrived at was the following: Seats = 3 + 1 11

C + (Total DALYs lost in billions).

11. In this formula, since population is not incorporated, the total DALYs lost have been considered as they implicitly contain population. Since the DALYs are in billions, the number may not change for quite some time. The formula ‘reserves’ 18 seats (three per region) due to flooring, allocates ( 1 11

×193 =) 17.5 seats on the basis of number of countries, and only about

1.5 seats on the basis of DALYs.

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Table 2: Allocation of seats as per Option A Region AFR AMR EMR EUR SEAR WPR Total Present seats 7 6 5 8 3 5 34 Seats as per Option A 8 6 5 8 4 6 37

12. This formula allocates one additional seat each to the African, South-East Asia, and Western Pacific Region (Table 2). Also, this does not impose the restriction of 34 seats on the size of the Executive Board and does not require adjustment to protect the current seats. Seats are automatically protected under this formula. If implemented, the total size of the Board under this formula would be 37 seats. 13. The assessed component of the financial contribution was also included in calculations under this Option. The formula used was as follows: 14. Number of seats = 3 + 1/11 (Countries) + Average (DALYs in proportion + Population in proportion + Assessed Contribution in proportion) 15. This option which includes the parameter of financial contribution also leads to a marginal increase in the number of seats to SEA, Western Pacific and African regions (calculation is provided in the Annex). 16. Similar results were obtained when DALYs were replaced by selected MDG indicators (under-five mortality, deliveries attended by skilled birth attendants, measles coverage and HIV prevalence) for which data are collected routinely and are widely available (Annex 1).

Option B 17. A model based on the number of countries, population, DALYs per 1000 population, and financial contribution: When equal weights are assigned according to their proportion in the region out of the world’s total, the formula reads as follows:

Seats =

(

C ∑C

+

P ∑P

+ 4

D ∑D

+

F ∑F

) × 34,

where C = Number of countries in the region; P = Population of the region; D = DALYs lost in the region per 1000 population (same as per person because of the denominator); F = Financial contribution (assessed)–total number of countries in the region.

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18. If accepted, this formula gives one extra seat to SEA and the Western Pacific regions (Table 3). Two other regions (African and Eastern Mediterranean) lose but one of the guiding principles indicates that no region should have reduced representation. Thus, these Regions will maintain their present strength. This would imply an increase of two in the size of EB from the present 34 seats to 36 seats. Table 3: Executive Board representation under Option B Region AFR AMR EMR EUR SEAR WPR Total a

Present seats 7 6 5 8 3 5 34

Seats as per Option B 6 6 3 8 4 6 33a

When present seats are protected 7 6 5 8 4 6 36

Calculations are based on 34 seats but the total is different due to rounding-off

19. The positive features of this formula are that the number of countries continues to be a determinant, while the facts of financial contribution is considered. At the same time, health needs in terms of population and DALYs lost per 1000 population also get due recognition. Thus, all four parameters are assigned equal weights under this formula. That is, nearly 9 seats are allocated on the basis of number of countries, nine on the basis of population count, nine on the basis of DALYs lost per unit of population, and 9 on the basis of financial contribution. 20. The Expert Group found equal merit in the two options. 21. In recommending these options, the primary concern of the Expert Group was wide acceptability, scientific validity and easy understandability, as laid out earlier. However, it is also recommended that before making a formal proposal, countries of the SEA Region should proactively try and get support from Member States in other regions for expanding the membership of the SEA Region on the Executive Board. 22. The recommendations of the Expert Group meeting are now submitted to the Sixtieth session of the Regional Committee for its consideration.

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Annex – Calculations for the proposed Option ‘A’ based on health metrics for regional membership of the WHO Executive Board EB seats at present 7 6 5 8 3 5 34 Average achievement on MDG indicators 0.575 0.818 0.786 0.809 0.588 0.808 4.38 MDG Shortfall (1-Avg) 0.425 0.182 0.214 0.191 0.412 0.192 1.62 Number of member countries 46 35 21 53 11 27 193 Financial contribution in proportion 0.0058 0.3068 0.0158 0.4181 0.0073 0.2461 0.9999 DALYs DALYs per 100,000 population 50,445 16,665 26,075 16,953 24,804 14,739 149,681 Proportion 0.337017 0.111337 0.174204 0.113261 0.165712 0.098469 1.00 Population Total population 718,107,000 884,811,000 538,555,000 880,661,000 1,661,719,000 1,758,067,000 6,441,920,000 Proportion 0.111474 0.137352 0.083602 0.136708 0.257954 0.272910 1.00 Formula A (see below) 7.333248 6.366981 5.000293 8.040871 4.143655 5.660372 36.55 Formula B (see below) 7.308575 6.367410 4.986367 8.042515 4.173401 5.667153 36.55

Region

Proportion

AFR AMR EMR EUR SEAR WPR Total

0.262995 0.112624 0.132426 0.118193 0.254950 0.118812 1.00

Formula A: Seats = 3 + 1/11(Countries) + AVG(DALYs in proportion + Population in proportion + Contribution in proportion) Formula B: 3 + 1/11(Countries) + AVG(MDGs Shortfall in proportion + Population in proportion + Contribution in proportion) Observations Both formulae (A and B) require an increase in EB size Both give marginal increase in seats to SEAR and WPR and AFR

SEA/RC60/11 Page 7



REGIONAL COMMITTEE Sixtieth session Thimphu, Bhutan 31 August − 3 September 2007

Provisional Agenda item 13 SEA/RC60/11 Inf. Doc. 24 August 2007

MEMBERSHIP OF THE SOUTH-EAST ASIA REGION ON THE EXECUTIVE BOARD Regional Representation on the WHO Executive Board Based on Health Metrics In May 2007, at the High Level Consultation (HLC) with SEAR Countries it was agreed that with its high disease burden and large population base, the South-East Asia (SEA) Region should strive to have a larger number of seats on the WHO Executive Board. In order to take forward the action points recommended by the HLC, a Regional Expert Group Meeting on the Representation of South-East Asia Region on the WHO Executive Board was organized on 1213 August 2007 in Bangkok. This information document was prepared as a background paper for the meeting and describes the options and scenarios which were discussed, reviewed and considered at the meeting. Representation of the SEA Region on the Executive Board is not equitable at present. It neither takes into account the population, nor the health gap, nor the deprivation, nor development gap, nor even the contribution to the regional budget. There is a strong case to make representation more equitable by considering other factors in addition to the number of members from each region. These factors provide compelling evidence for increasing representation from some regions, particularly the SEA Region. WHO may adopt a procedure under which the present allocation of seats is not reduced for any region, while increased representation is allowed to deserving regions by increasing the size of the Executive Board. The proposed change will need strong and sustained diplomacy, consultation and consensus within the governing framework of WHO and without violating Article 24 of the Constitution.

Contents Page Background .................................................................................................................................1 Existing Executive Board in WHO .................................................................................................... 1 Need for review............................................................................................................................... 1 Pattern in other UN organizations .................................................................................................... 3

The present concept of equitable geographical distribution..........................................................4 Population is an essential ingredient of geographical distribution ...................................................... 5 Number of countries and population................................................................................................ 7

Approaches for enhanced regional representation .......................................................................8 Increasing the size of the Executive Board marginally........................................................................ 9 Available options for modeling ....................................................................................................... 10

Other Objective Criteria ............................................................................................................11 Parameters considered earlier ........................................................................................................ 12 Selection of parameters.................................................................................................................. 12 A simple solution ........................................................................................................................... 14

Needs........................................................................................................................................15 Equitable representation of the regions according to the health gap ................................................ 15 Equitable representation to the deprived ........................................................................................ 17 Equitable representation to poor nations ........................................................................................ 19 Equitable representation according to the gap in development ....................................................... 21

Various contributions as criteria .................................................................................................22 Equitable representation according to the funds contributed to the budget of WHO ...................... 23 Equitable representation based on achievements............................................................................ 24 Equitable representation through simultaneous consideration of several criteria ............................. 24

Conclusion ................................................................................................................................26

SEA/RC60/11 Inf. Doc.

Background 1. The Executive Board is the apex body of the World Health Organization (WHO) that gives effect to the decisions and policies of the World Health Assembly, provides advice and facilitates its work.

Existing Executive Board in WHO 2. The Executive Board of WHO currently has 34 seats that are distributed to various regions to ensure regional representation (Table 1). The seats allocated to regions are fixed although countries representating these seats are elected for a three year period from their respective regions. 3. Votes in any democratic set-up are important as they provide an opportunity to choose the governance and set the agenda. Whether resolutions are passed in the Executive Board through voting or not, the recommendations and the agreed text of resolutions can have a bearing on the actions taken by WHO. Adequate representation from all regions is necessary to achieve a fair balance. WHO works for all Member countries and must continue to be perceived as such, witnessed by its actions and rules of governance. 4. The principle currently being followed for regional representation is stated as “take into account an equitable geographical distribution” in Article 24 of the Constitution. This is assumed to imply representation in proportion of the number of countries in the region. Accordingly, maximum seats (8) are allocated to the European Region with 53 countries and the minimum (3) are allocated to the SEA Region with 11 countries. Countries of the SEA Region will have even less representation according to this criterion but the existing rules stipulate at least three seats for each region. The minimum of three seats is pursuant to the World Health Assembly resolution WHA28.22 requesting the Director–General to propose an amendment in the next Health Assembly for a marginal increase in seats of the Executive Board so that each region could designate at least one new member each year. Thus the representation in proportion of the number of countries has ceased to be the sole criterion.

Need for review 5. Under the present regime, while assessing the equitable geographical distribution, parameters such as population are ignored. For example, the Western Pacific Region comprises 27% of world’s population but its representation on Executive Board is only 15% (Table 1). Other relevant parameters such as burden of disease and health needs are also not considered. Three seats allocated to the SEA Region are extremely low for providing a voice to nearly one fourth of the world’s population, and to that section of people who are in desperate need of all kinds of health inputs ─ expertise, infrastructure and operational guidance. Fifty-ninth session of the Regional Committee for South-East Asia (2006) decided to convene a working group of

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interested Member countries of the Region to analyze various options for enhanced representation of the SEA Region on the Executive Board. A report was earlier prepared for this purpose1. This review intends to take this effort one step further. Table 1: Geographical distribution and Executive Board representation WHO Region AFR AMR EMR EUR SEA R WPR Total a b

Present members Number 7 6 5 8 3 5 34 Percent 21 18 15 24 9 15 100b

Countries Number 46 35 21 53 11 27 193 Percent 24 18 11 27 6 14 100

Population Billiona 0.718 0.885 0.539 0.881 1.662 1.758 6.442 Percent 11 14 8 14 26 27 100

Source: The SEA Region communication; for the year 2005 Sum is different from 100 due to rounding-off

6. In particular, the present review explores the possibility of making adjustments in the present system of regional representation on the Executive Board and examines health metrics that could be possibly considered for developing a model. Alternative models for determining the representation are suggested that do not compromise the existing principles. The objective is to find a formula, which is equitable and convincing. The formula should have sufficient support for acceptance in the World Health Assembly. The first attempt is to retain the principle of equitable geographical distribution as enshrined, and the second attempt looks for relevant parameters in addition to geography for equitable distribution. Scenarios are presented that would protect the existing representation from the regions. Guiding Principles for the Present Review • • • Protect the present regional representation; Modeling that stands to reason and scientific scrutiny, and Robust models that do not easily change the regional representation once established unless the model itself is revised.

Background Document for Discussion on Increasing the Representation of the South-East Asia Region on the WHO Executive Board. SEA/HLC-PDM Meet/3, 26 April 2007.

1

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7. Although the purpose is to look for a formula that helps increase representation of the SEA Region, the attempt is not to make this document SEA Region-centric. Needs and aspirations of other regions are also addressed. Also, although not explicitly stated, it will be meaningless to attempt this exercise without considering that the bargaining power of the SEA Region is increased. More seats to SEA R just to participate in Executive Board meetings more frequently will not achieve the ultimate goal, besides being a bone of contention for regions that have more countries than the SEA Region. The formula should be such as to enhance the size of relative membership justified of the SEA Region on justified grounds.

Pattern in other UN organizations 8. WHO is part of the UN system of organizations, and cannot possibly take unilateral decisions that are not in line with the other such organizations. Perhaps the organizations most intimately related to WHO’s activities are the Food and Agricultural Organization (FAO), the World Bank and the United Nations Children’s Fund (UNICEF). The present regional representation with regard to their respective executive bodies is given in Table 2. Table 2: Present regional representation with regard to executive bodies of some UN organizations FAO Councila Region Africa Asia Europe Latin America and the Caribbean Near East Northern America South West Pacific Total a b

IBRD Executive Directorsb Region Africa Asia Europe Americas Appointed Members 1 8 6 4 5

UNICEF Executive Board Region Africa Asia Eastern Europe Latin America and the Caribbean Western Europe and others (Including USA and Japan) Total Members 8 7 4 5 12

Members 12 9 10 9 6 2 1 49 Total

24

36

Source: www.fao.org/unfao/govbodies/membernations_reg_en.asp Source: web.worldbank.org/WEBSITE/EXTERNAL/EXTABOUTUS/ORGANIZATION/BODEXT/.. c Source: www.unicef.org/about/execboard/index_13225.html

9. The executive organ of FAO is the Council. This has 49 members divided into 7 regions (although there are only 5 regional offices), and meets at least 4 times between regular sessions. Sixteen members are elected in the first and second years, while 17 are elected every third year. The FAO’s general body is called Conference which meets once in two years whereas the World Health Assembly meets every year. That is hardly related to the size of governing bodies, which seem to be meeting with same frequency in different organizations.

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10. The World Bank is a group of several organizations such as the International Bank for Reconstruction and Development (IBRD) and the International Finance Corporation (IFC). Each has a separate Board of Directors. The IBRD body parallel to the Executive Board in WHO is the Board of Executive Directors. The present strength of this Board is 24. Five members with the largest number of shares are appointed. Currently these are the United States of America, Japan, Germany, France and the United Kingdom. The remaining 19 are elected every two years. The Bank applies electoral rules to achieve a balanced and diversified representation for the Executive Directors. Nonetheless, the bigger and/or richer countries have a larger share of votes. The elected Executive Directors can be divided into four regions. These regions are not fixed. More than 20 countries from Africa have only one representative. Thus, the number of countries in a region is not a consideration, although financial contribution is an important consideration in the case of the World Bank. 11. UNICEF has 36 members on its Executive Board, allocated to 5 regions. All are elected for a three-year term. In the year 2007, the Executive Board will hold three sessions. European countries have a large representation. However, the way these numbers have been decided upon is not clear. 12. It is clear though that different UN organizations follow different patterns. They do not have to toe each other line in this regard. Thus WHO too can evolve its own pattern for regional representation on Executive Board.

The present concept of equitable geographical distribution 13. The present principle of equitable geographical distribution is indeed appealing and may continue to be the guiding principle for any new formula. However, equating geographical distribution to only the number of countries in a region, as is being done presently, implies that if a country disintegrates into many smaller countries, as happened with the erstwhile Soviet Union, the representation increases. Such increase has actually happened in the past. This formula gives equal weightage to all countries and disregards any other consideration whatsoever. It is fortuitous for the smallest country to expect the same privileges as provided to the largest country. In a way, equating geographical distribution to the number of countries encourages smaller countries and penalizes bigger countries. Thus this aspect requires a fresh look. 14. The SEA Region has two countries (India and Indonesia) that are among the five most populous countries in the world and three (Bangladesh, India and Indonesia) among the 10 most populous. In terms of area and population, some states, provinces and districts of these countries are larger than many Member States of WHO. 15. One simple alternative is equal representation to regions. This would mean 6 members from each region and a total size of 36 of the Executive Board. This is given as Option A in Table 3. This would imply 6 members for 11 countries in the SEA Region, which may look like an over-representation. If the rotation principle is considered, 6 seats for 11 countries would mean that each country would be on the Executive Board once in two elections. Against this, 6 seats for 53 countries in the European Region could mean each country to be on the Executive Board once in nine elections. Along, wait is frequently cited as a source of frustration in some

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regions. This potential criticism should nevertheless be considered in the light of the arrangements in some regions for a ‘semi-permanent’ seat on Executive Board already existing de facto with respect to five permanent members of the Security Council (China, England, France, Russia, and the Unites States). They are regularly elected for a three-year term interspersed with only one-year absence from the Board1. In addition, Japan is currently serving its fifth three-year term over the past 20 years on the Executive Board from the Western Pacific Region1. 16. Six seats may be justified for SEA Region on the population of equitable geographical distribution as it inhabits more than one-fourth of the world’s population. Thus 6 members out of a total of 36 would only be one-sixth. From the viewpoint of population, the Region would still be under-represented. In this regard the following may be considered.

Population is an essential ingredient of geographical distribution 17. The review of the concept of equitable geographical distribution may open up opportunity for new processes. Literally speaking, geography has spatial overtones. It includes spaces and space occupants. Although environment has an important implication, the major concern in the area of health is with human inhabitants. Human geography is considered an integral component of geography2. Thus, in the context of health, population is an essential ingredient of ‘geographical’ distribution. This can be considered as a criterion without in any way compromising the present provisions of Article 24. 18. The World Health Assembly resolution WHA38.14 accepted the size of population as one of the criteria when the Western Pacific Region was allocated one more seat in the year 1986. Again, one more seat was allocated to the Western Pacific Region in the last revision in the year 1998 where large population was cited as partial justification. The major justification, of course, was increase in the number of countries.1 Figure 1: Glaring inequalities in number of members on the WHO-Executive Board from regions, per billion population 10 Number of EB members per billion population 8 6 4 2 0 AFR AMR EMR EUR SEAR WPR

2

en.wikipedia.org/wiki/Geography

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19. From the political angle also, democracy is the hallmark of modern civilization. A democratic framework requires full consideration of the population counts. A member on the Executive Board should represent nearly the same number of people as another. At present, a member from the Eastern Mediterranean Region represents nearly 100 million people while that from the SEA Region represents more than 500 million people. The inequalities are glaring (Figure 1). Depending on the perception, this can be viewed as unfair, inequitable—even discriminatory. Not just the concept of equality, the fulfillment of human rights also requires democracy that is inclusive. This is built on the principle that political power is dispersed and shared so that participation of those deprived is ensured and they also feel counted. This is especially true in the case of the deprived: perception is as important as the action. 20. Despite the persuasive arguments just mentioned, history suggests that population alone cannot possibly be the sole determinant. If it was the representation of various regions in Executive Board would be as given under Option B1 in Table 3. Although the calculations are based on absolute population figures, the results are the same if the relative proportion out of a total of 1 is used. This proportion is likely to remain stable at least for a few decades unless a large-scale calamity takes place. 21. Incidentally option meets the current requirement of at least three members from each region. As expected, such population-based geographical distribution gives higher representation to the SEA Region (due to large populations in Bangladesh India and Indonesia) and the Western Pacific Region (due to China’s large population). If the total size of the Executive Board membership remains same, this criterion will obviously reduce the representation of all other regions. While increasing the representation is relatively easy, reducing in may be resisted. Thus, this option is also worked out such that while representation from other regions is not reduced, regions with large populations get adequate representation, depending upon the size of their respective populations. 22. In the context of population, logarithm transformation is commonly advocated so that countries with large population do not get unfair advantage. This is not applicable here since the issue under review is regional representation and not country representation. However the regions do not differ from one another (with regard to total population-Table 1) to an extent that would justify logarithm transformation. For any logarithmic transformation, the ratio of the lowest and highest values must be a minimum of 1:10. In this case, it is only 1:3 for a region of WHO. 23. Just as the World Bank has permanent seats for highest shareholders, it may not be out of place for WHO to consider permanent seats on Executive Board for the largest stake-holders. In the context of health, this cannot be assessed in terms of financial stakes but in terms of the gap in health of the masses. If this argument is accepted, at least India and China can be considered to have a permanent seat in Executive Board of WHO. A system of semi-permanence already exists de facto with respect to five permanent members of the Security Council as already stated.

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Table 3: Equitable representation on the Executive Board under: (A) Equal representation and (B). In proportion to population B1. In proportion to populationa 1. If present the EB size 4 5 3 5 9 9 35b May NOT be acceptable 2. If size of the EB is increasedc 7 6 5 8 9 9 44 May NOT be acceptable B2. Based on number of countries and the populationa 1. If present size of the EB is maintained 6 6 5 7 5 6 35b May NOT be acceptable 2. If size of the EB is increasedc 7 6 5 8 5 6 37 MAY BE ACCEPTABLE

WHO Region

Present members

A. Equal representation

AFR AMR EMR EUR SEAR WPR Total

7 6 5 8 3 5 34 PRESENT

6 6 6 6 6 6 36 MAY BE ACCEPTABLE

a

Population as in Table 1 Although the calculation is based on 34 seats the sum is different due to rounding-off c To maintain the present regional representation b

Number of countries and population 24. Countries, howsoever small, deserve the opportunity to be on the Executive Board. Thus the number of countries in a region cannot and should not be ignored. This must continue to be one of the determinants. The number of countries and population can be considered together as criteria to provide a guideline for allocation of seats to regions. 25. According to the present stipulation, region will have less than three members. Such flooring is an important safeguard against an adverse formula that might give an extremely low representation to a particular region. This safeguard in a way reserves 18 seats. If the number of countries and population are considered as criteria to determine the addition to the flooring, the following simple formula provides representation that is similar to the one: B2. The Executive Boards seats for a region =3+ 1 20

(Number of countries in the region)

+ Population in billion in the region =3+ 1 x1 20

+ x2

in terms of notations. Note how the minimum number of three for each region is ensured by this formula. This gives the numbers as shown in Table 3. The coefficient 1/20 (number of countries)

SEA/RC60/11 Inf. Doc. Page 8

gives an advantage of more than two seats to the European Region (54 countries) over the SEA Region (only 11 countries). 26. A critical look at formula B2 reveals that this formula fixes 18 seats by virtue of allocating a minimum of three seats to each region, and another nearly 10 seats (1/20 of 193) in addition are allocated on the basis of number of countries. Only a few seats remain that are considered dependent on a criterion such as population in this case. This is the general feature of many scenarios presented in this note.

Approaches for enhanced regional representation 27. Four major approaches are available for enhanced representation of a region on the Board: •

Redistribute the countries between the Western Pacific and SEA regions so that the number of countries in the SEA Region increases substantially. This can be done by assigning DPR Korea to the Western Pacific Region because of physical proximity, and Malaysia, Singapore, Brunei Darussalam, Cambodia, Lao PDR, Papua New Guinea, Philippines and Viet Nam to the SEA Region. In that case, the SEA Region will have 18 countries and the Western Pacific Region 20 countries. The existing formula will raise the Executive Board seats for the SEA Region to four and reduce the Western Pacific Region’s seats to four. Reallocate the current number of seats among regions. This implies that if some regions get better representation, some other regions would lose automatically. The procedure for reallocation is relatively simple as only a World Health Assembly resolution is required. But the concerned region would strongly resist any reduction in the number of its representatives. Increase the number of seats on the Executive Board to allow for better representation to some regions on the basis of some agreed criteria. Any formula that would give enhanced representation to a region such as the SEA Region may correspondingly increase the representation of other regions as well, making the total size of the Board enormously large. Also, this approach would not provide a better say to a region in the Executive Board because other regions would also get enhanced representation. The whole idea of the present exercise is not to increase representation of the SEA Region in the absolute sense but in a relative sense so that it has better bargaining capacity. A combination of the two approaches above. This would mean a marginal increase in the size of the Executive Board by allocating seats to a region differently.

•

•

•

28. This review tries to take a middle course as enunciated in the third bullet. This would require an amendment of Articles 24 and 25 of the Constitution. The Health Assembly may take a couple of years in making the amendment. History suggests that it may take a further six to eight years for such an alteration or amendment to take place.

SEA/RC60/11 Inf. Doc. Page 9

Increasing the size of the Executive Board marginally 29. The scenarios presented in Table 3 and subsequent tables for equitable representation under various criteria also include a column that mentions number of members from various regions that satisfy the criterion of representation for those under-represented but, at the same time, do not decrease the seats allocated to other regions. This kind of alteration may be more readily acceptable because no region loses out—only that some regions gain. Historically also, there has been no occasion when representation for any region was reduced. However, enhanced regional representation could take effect only if the size of the Executive Board is increased from the present 34 members to accommodate equitable representation from regions that are currently not adequately represented. 30. Increasing the size of the Board to accommodate equitable representation from deserving regions is not difficult. Articles 24 and 25 of the Constitution have been repeatedly amended to increase the size of the Board (Table 4). These adjustments were made when certain regions became “under-represented”. This could be initiated again on the proposal of a Member State or by the Executive Board or the Health Assembly. Table 4: Increased size of the Executive Board from time to time1 Change in Executive Board size 18 to 24 members 24 to 30 members 30 to 31 members 31 to 32 members 32 to 34 members Adoption by the Assembly WHA12.43 in May 1959 WHA20.36 in May 1967 WHA29.38 in May 1976 WHA39.6 in May 1986 WHA51.23 in May 1998 Entry into force 25 October 1960 21 May 1975 20 January 1984 11 July 1994 15 September 2005

31. The initial increase was to increase in the membership of WHO but subsequent increases were primarily because of increase in the number of countries due to break-up of the erstwhile Soviet Union and Yugoslavia. The last increase in the size of the Executive Board to 34 members was based on allocation of the Board membership to reflect (i) the minimum of these seats accorded to each of the regions, and (ii) an allocation of the remaining seats to reflect the proportional membership of each region in excess of the membership of the smallest region. With three seats guaranteed to each region irrespective of its size, 18 seats on the Executive Board are constitutionally ‘protected’. According to the formula considered at that time, these three represented the region with the smallest number of countries, which was the SEA Region with 10 Member States at that time. At the rate of 3 members per 10 countries, 18 members represented 60 countries. At this rate, the size of the Executive Board membership should be 58, representing 193 countries. In fact, though, the other (34-18=) 16 seats were allocated in proportion to the remaining number of countries in the region1. This formula can be stated as follows:

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Number of the Executive Board seats for a region =3+ Total seats − 18 (Number of countries in the region − 10) Total countries − 60

32. The total number of seats was 34 while the number of Member States at that time was 191. The actual number of seats allocated does not exactly follow this formula. For example, this formula allocates 3+ 16 (22 − 10) = 4.47 ≈ four seats to the Eastern Mediterranean Region. 131

But it actually has five seats. Two features of this formula are: (i) the actual criteria continued to be the number of countries despite reference to the size of population; and (ii) three seats was the number for “flooring”. 33. A concern often cited against increasing the size of the Executive Board is the increased cost, cumbersome proceedings, and reduced efficiency. However, there is not much evidence that increasing the size from the initial 18 seats to the present 34 has caused many problems. Nevertheless, the demand for a sizeable increase could be counter-productive too. A marginal increase is relatively easy and would increase the relative representation. 34. The size of the Executive Board of WHO can be viewed against the situation obtaining in other international organizations. The Food and Agricultural Organization (FAO) has a Council comprises 49 members, UNICEF has a Board of 36 members and the World Bank has a Board of Executive Directors numbering 24. Thus the Board of WHO is just about average in size and is not on the larger side to serve as a disincentive. 35. Considering the various aspects just enumerated, a marginal increase in the size of the Executive Board to accommodate equitable representation from deserving regions can be actively considered.

Available options for modeling 36. Various criteria are discussed at length in this review on which possibly some consensus can be developed. The options available according to these criteria are: • • •

All seats allocated in proportion to the indicators or a set of indicators agreed as relevant for this purpose. Some seats fixed in proportion to the number of countries in regions and others allocated in proportion to the other agreed criteria. Flooring is fixed for each region to ensure minimal representation; some seats in proportion to the total number of seats, and the remaining seats in proportion to the agreed criteria.

37. This is not an exhaustive list. One can think of assessed contribution to the budget of WHO as an essential criterion, or population as an essential criterion. Other permutations can also be considered.

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38. The easiest way could be by increasing the “flooring” from the current three to four seats: this would increase the seats only for the SEA Region by one and not affect any other region. The size of the Executive Board then would become 35. This approach avoids trying to find a precise formula that takes into account other factors. It broadly reflects the thinking behind the initial establishment of a three seat minimum, but it would imply that one-seat increase at that time was insufficient to adequately take into account other relevant factors such as population. This approach constitutionally allocates 24 seats (four per Region) and leaves very little for any other criterion to play any significant role. If 4 seats are considered to represent 11 countries, other regions with large number of countries may also demand an increase in seats. If the total size of the Executive Board is presumed to be 50 seats after such enhanced allocation, perhaps 3 out of 34 seats is a better bargain than 4 out 50 seats. 39. If 4 seats are considered as “flooring” and other seats allocated in proportion to the number of countries in excess of 11, the formula would be 4+

34 − 24 (Number of countries − 11); 193 − 66

this gives one seat less to the European Region. Thus, it might resist this approach strongly. However, if the total size of the Executive Board is considered to be 35 instead of the present 34, the same formula allocates the same number of seats to all regions as per present situation but enhances the number of seats to the SEA Region from three to four. Thus this could be a very promising approaching to pursue. Population and not number of countries can be cited as the reason for “flooring” at four seats. The difficulty however is that this approach could be perceived as arbitrary, and could get an adverse reaction if it was perceived to help one particular region. Thus there is a need to look for other criteria that are convincing and dependable. Determining representations based on acceptable criteria is less arbitrary than simply adding a seat to the regional minimum. But it also presents a challenge of establishing a consensus on the criteria to be used for this purpose.

Other Objective Criteria 40. While the principle of equitable geographical distribution is laudable in itself, it is soft towards the very purpose of WHO. According to the present Director-General of WHO, the “greatest concern (of WHO) must always rest with the disadvantaged and vulnerable groups”3. This concern should be visible in the pathways adopted by various decision-making bodies—if necessary by affirmative action. Less developed countries and countries with larger health needs should have a better voice, and need at least an equal participation. The present formula that provides regional representation on the basis of number of countries seems to be working in the inverse direction. For example, most European countries have relatively lower health needs but have the highest representation. This occurs because these countries are small and too much in number. An organization must foster what it professes. Thus it is imperative for WHO that other parameters are also considered for determining representation on the Executive Board. When this is done, one can argue that this would require an amendment to Article 24. This Article 3

Working for Health: An Introduction to the World Health Organization, 2007: p.1

SEA/RC60/11 Inf. Doc. Page 12

merely says “take into account” rather than be “based on” an equitable geographical distribution. Thus this does not preclude other criteria. In any case, the scenarios presented in this note incorporate ‘number of countries’ as an important ingredient.

Parameters considered earlier 41. The report of the fifty-ninth session of the Regional Committee reveals that during the discussion on this item, it was suggested that the criteria for representation of regions on the Executive Board should include population and burden of diseases1. Presumably it was intended that these criteria should be in addition to the criterion of the number of Member States in a region, and that they should be included in the formula for determining directly the allocation, rather than simply adding one or more seats to the region's existing allocation as described in the preceding section. 42. Although such an approach might arguably be less arbitrary to implement than the approach of adding one or two seats, agreeing on a suitable formula may be more difficult. In fact, even some fairly basic considerations could be the source of debate. For example, in the case of burden of diseases, it would be necessary to agree on whether a high or a low rate of disease in a region should be the basis for increased representation. It could be argued either way: (i) regions with high disease rates need greater representation (e.g. so that the Organization will properly addresses their needs), or that (ii) those with low disease rates—those who have had greater success in solving their health problems—should be the ones having a greater representation (e.g. so that the Organization will have the benefit of their positive experience in its governance). 43. It could also be argued that if the formula is based on the number of Member States, population and disease burden, it would result in an unbalanced governance structure whereby the Member States paying the largest portion of the finances of Organization would not necessarily have an adequate opportunity to be represented on the Executive Board. Consequently, following this line of argument, it might be advisable to take cognizance of the contribution of Member States. This possible argument underscores the point made earlier that finding a formula that is acceptable to all, while not rendering the Board unmanageably large in the process could prove to be a challenge. Nevertheless, the following features may prove to be adequate for selecting the relevant parameters.

Selection of parameters 44. Regional representation on the Executive Board is an extremely important and sensitive issue. The model determining the representation must have a sound basis—it should be scientifically valid and be perceived as appealing. Thus the model and its constituents must be chosen carefully. The parameters of the model should be relevant and internationally acceptable. Also, corresponding values must be available for WHO regions, and they must be verifiable.

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Criteria for selection of parameters

• • • •

Relevant to the objectives of WHO; Internationally acceptable; Recent data available for the Regions of WHO (or can be computed), and Verifiable data.

45. Considering these criteria, the following indicators can be considered as parameters for inclusion in the model: (1) (2) (3) (4) (5) (6) (7) (8) Number of countries (x1); Population (x2); Burden of disease measured by disability-adjusted life years (DALYs) lost as a surrogate for health gap (x3); Human poverty index as a surrogate for deprivation (x4); Gap in development measured by (1 – HDI) as a surrogate for need for development (x5); Financial contribution of countries to the budget of WHO, as a measure of authority that donor countries may like to have over the funds they donate. (x6); Geographical area (x7), and Budget expenditure (x8);

46. These can be considered individually as well as collectively two at a time, three at a time, etc. The total number of such configurations is 28 = 256, when the square or such other terms are not considered. The first two criteria are already considered, individually as well as together. Some models based on these parameters that seem more relevant than others are explained in the next section onwards. 47. All these indicators can be standardized as follows:

x − xmin xmax − xmin 48. This would provide the relative index. This exercise is good for comparing the relative position of one region with the other but offers no advantage here. The results are still going to be nearly the same; thus this complexity can be avoided. 49. For allocating seats in proportion to the value of these indicators, an index can be proposed as follows:

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Index of Equitable Representation = Total size of EB × K, Sum of values for all Re gions

where K is a suitable constant such as 1 million. The denominator will change according to the indicator. The regional value is multiplied with this index to get the seats for the region. This is illustrated for area and budget in Table 5. Table 5: Area and Executive Board representation In proportion of area WHO Region Present members Area (million sq km) 23.5 40.2 13.5 27.9 6.9 21.6 133.7 0.2543 Budget (million US$) 1. If present the EB size 6 10 3 7 2 5 33c 2. If size of the EB is increasedd 7 10 5 8 3 5 38 In proportion of budget 1. If present size of the EB is maintained 11 4 5 3 6 4 33c 2. If size of the EB is increasedd 11 6 5 8 6 5 41

AFR AMR EMR EUR SEA R WPR Total Index c d

7 6 5 8 3 5 34

203.6 77.8 87.5 58.2 99.3 76.5 602.8 0.0564

Although the calculation is based on 34 seats the total is different due to rounding-off To maintain the present regional representation

A simple solution 50. Population size, disease burden and contribution to the budget of WHO can be incorporated in the following manner: Five most populous countries (China, India, the United States, Indonesia and Brazil) Five countries with the highest disease burden— choice may be based on deaths or DALYs per 100000 population Five countries contributing most to the funds of WHO If any country fulfills two criteria, select the next country for the subsequent selection based on the priority given above. Three Member States from each region other than suggested above 51. This makes a total of 33 Member States. This arrangement will ensure that the SEA Region will have 5 seats in a 33-member Executive Board. The Western Pacific Region will also have

SEA/RC60/11 Inf. Doc. Page 15

five seats (China, Japan and three others from the Region) and the African Region will possibly have seven or eight seats (four or five countries with the highest disease burden and three others from the Region). The Region for the Americas will be assured of five seats (the United States, Brazil and three others). The Eastern Mediterranean Region will perhaps have three or four seats (three from the Region and a country with the highest disease burden) and the European Region will be assured of six seats (three from countries with the highest contribution and three others from the Region) but may have an extra seat if the United States is eliminated based on the contribution as it will anyway get in on the basis of population size. 52. This formula will, in a sense, create a sort of permanent membership. For example, the five most populous countries will remain as such for a considerable period of time. If China and India remain intact and do not disintegrate, they will probably be virtual members of the Executive Board. Likewise, the five countries which contribute the most to WHO budget may also remain on the Executive Board for a long period of time. However, this may encourage other countries to contribute more in order to serve on the Executive Board of WHO. It is unlikely that countries with the highest disease burden will want to remain as such just to serve on the Executive Board. 53. As a variation, since the relative population will not change in a short period of time, the five most populous countries may be elected for a 5-year period by rotation. Countries contributing the most to WHO budget and countries having the highest disease burden may be elected every two years. Countries from a region may be elected for a three-year term. This will ensure a shorter interval to serve on the Executive Board for countries in regions with a large number of Member States. The advantage that the SEA Region has in this respect with only 11 Member States cannot be corrected. 54. Several other variations can be considered.

Needs 55. The needs of people, particularly in the context of health, have many dimensions. The health gap is measured by DALYs lost, deprivation is measured by human poverty index and development gap can be measured by (1 − HDI). All these parameters generally satisfy the criteria set forth in the previous section for considering partial determinants.

Equitable representation of the regions according to the health gap 56. The health gap is defined as the difference between actual health and what it should be. For practical purposes, a limit is set on longevity. The concept of DALYs lost considers a life table similar to a country with the highest expectation of life in the world for calculation of the years of life lost. DALYs is a comprehensive metric and includes incidence of various diseases, duration of sickness, severity of affliction, and age affected, etc. This single metric simultaneously measures many dimensions of gaps in health. 57. Arguably, populations with a bigger health gap should be able to influence WHO policies and actions in at least equal measure so that their interest in reducing this gap is served well.

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Thus, health gap, with DALYs lost as a surrogate, is a good candidate to serve as a criterion for determining representation on the Executive Board. The fifty-ninth session of the Regional Committee for South-East Asia also suggested this as one of the criteria1. When total DALYs lost alone are considered, representation on the Executive Board would be as shown under Option C1 in Table 6. By this criterion also, the SEA and WP regions gain, while other regions lose out. However, an adjustment can be made as before so that the regions continue to maintain their present strength. This would raise the size of the Executive Board from the present 34 to 43 members (Table 6). Such a big rise may not be acceptable. 58. The total DALYs lost are self-weighted for the population size, and there is no need to consider population size along with the DALYs lost. However, the number of countries in a region must continue to be an essential determinant. The present “flooring” of at least three members for each region with no ceiling also looks reasonable. The formula that does not significantly alter the total size of the Executive Board and achieves representation according to the health gap is given here under. Such a formula is general for all regions and may not be branded as the one trying to help one particular region. Support from countries of other regions is crucial for carrying such an amendment through, and thus the formula should have a wider appeal. Table 6: Equitable EB representation with lost DALYs as the criterion Total DALYs lost (2005) (billion)a x3 0.362 0.147 0.140 0.149 0.412 0.259 1.471 C1. In proportion of total DALYs lost 1. If present the EB size 8 3 3 3 9 6 32b May NOT be acceptable 2. If size of the EB is increasedc 8 6 5 8 9 6 42 May NOT be acceptable C2. Based on number of countries and DALYs lost 1. If present size of the EB is maintained 7 5 5 6 5 5 33b May NOT be acceptable 2. If size of the EB is increasedc 7 6 5 8 5 5 36 MAY BE ACCEPTABLE

WHO Region

Present members

AFR AMR EMR EUR SEA R WPR Total

7 6 5 8 3 5 34 PRESENT

a

Projected. Source: www.who.int/healthinfo/statistics/bod_dalybyRegion.xls Although the calculation is based on 34 seats the sum is different due to rounding-off c To maintain regional representation b

C2.

Executive Board seats for a region =3+ 1 20

(Number of countries in the region)

SEA/RC60/11 Inf. Doc. Page 17

+ 4 (Billion DALYs lost in the region) =3+ 1 x1 20

+ 4x3.

59. The coefficient 4 of DALYs is chosen such that the total is nearly 34. This formula provides nearly uniform representation to each region as shown in Table 6. 60. Formula C2 has many positive features: (1) (2) (3) A minimum of three members from each region are ensured. The number of countries in a region gets explicit consideration. The health gap measured by DALYs lost is also considered but it is not the only criterion. The formula provides equitable representation considering the health needs of various regions. The total size of the Executive Board does not need much alteration. Despite all these considerations, the number of members from various regions do not differ much. Thus this may have a wider appeal. The formula is simple and requires to consider of only two criteria—number of countries and DALYs lost. Population is not considered directly so that sensitivities against population as a criterion do not crop up. The formula meets the initial stipulation of the Regional Committee.

(4) (5) (6) (7) (8)

61. These calculations are based on the 2005 projections of the DALYs lost. When the estimates are available and substituted, the numbers in Table 6 will still remain unaltered as the estimates may not be very different. Thus the formula is robust too and can be used for a substantial period of time without affecting the actual representation.

Equitable representation to the deprived 62. There is concern all around the world regarding uplifting at the deprived, and providing them with equal representation. This is visible in WHO’s six-point agenda4 that emphasizes priority to the poor and the underserved. Participation is the corner-stone for empowering the deprived. Thus deprivation is also a valid criterion to determine representation on the Executive Board. 63. ‘Deprivation’ is a multidimensional entity that includes income poverty, diseases and early mortality, illiteracy, social exclusion and lack of infrastructure, etc. In a way this also defines health need. Various dimensions of diseases and mortality are adequately captured by DALYs as already discussed. For others, although the overlap is substantial, the most comprehensive and popular measure is the Human Poverty Index (HPI) of UNDP.

4

WHO Agenda: www.who.int/about/agenda/en/index.html - accessed June 28, 2007

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64. As opposed to income poverty, human poverty is defined by impoverishment in multiple dimensions—deprivation in terms long and healthy life, knowledge, decent standard of living and participation5. The HPI is calculated by methods which are different for developing and industrialized countries in view of their differential needs. For the present exercise, such differentials can be ignored, and both HPIs accepted on face value by placing them on the same pedestal. Such as, HPI is available only for 119 countries out of 193. Its availability is better for countries of the African Region but particularly countries of the European and Western Pacific regions. 65. Whereas DALYs are available for WHO regions, HPIs are not. Computing regional averages of HPI is a challenge in view of its multi-dimensional content. Population-weighted averages are given in Table 7. Since HPI is not computed for some countries due to lack of data or otherwise, these regional averages are based on countries in the region for which HPI is available. If the present representation of all regions is to be maintained, the total size of the Executive Board may have to be raised to 43 members to accommodate representation of some regions by this criterion (Table 7). However, such a big increase (from 34 to 43) in the size of the Board may not be acceptable. Table 7: Human Poverty Index and Executive Board representation D1. In proportion to HPI WHO Region Present members HPIa x4 1. If present the EB size 10 3 7 3 7 3 33b May NOT be acceptable 2. If size of the EB is increasedc 10 6 7 8 7 5 43 May NOT be acceptable D2. Based on number of countries and HPI 1. If present size of the EB is maintained 7 5 5 6 5 5 33b May NOT be acceptable 2. If size of the EB is increasedc 7 6 5 8 5 5 36 MAY BE ACCEPTABLE

AFR AMR EMR EUR SEAR WPR Total

7 6 5 8 3 5 34 PRESENT

0.415 0.116 0.276 0.137 0.294 0.125

a

Population-weighted regional average. Country wise population and HPI taken from HDR 20064 – out of 1.0 Although the calculation is based on 34 seats, the total is different due to rounding-off c To maintain the present regional representation b

66. However, the following formula that gives apparently reasonable representation shown for D2 in Table 7 can be considered. 5

Human Development Report 2000: pp.17, 292-300

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D2.

Executive Board seats for a region =3+ 1 20

(Number of countries in the region)

+ 5 (Average HPI in the region) =3+ 1 x1 20

+ 5x4.

67. Besides HPI, there are other dimensions of deprivation. The most important of these in the context of health is the lack of health resources such as gaps in sanitation coverage, inadequate availability of health manpower and health centres, incomplete coverage of immunization, and child deliveries without skilled attendants. These dimensions are far too many for an exercise like this, and it does not seem appropriate to consider such indicators individually. The best linear combination of these that explains the highest variation can be obtained by running the statistical method of principal component analysis. However, this is feasible only when the average situation for each region is obtained for each indicator. This is an even bigger challenge since different indicators have different denominators. For example, for immunization coverage by measles vaccine of one-year-old children, the denominator is the number of one-year-old children; for skilled birth attendance, the denominator is the number of births; and for sanitation coverage, it is the population. The relevant denominator for each country in each region can perhaps be obtained or estimated but this complex exercise may not yield substantially different results from what are obtained by using HPI. In addition, the exercise of obtaining the principal components is not conclusive. For example, if the first principal component accounts for 68% of variation, the remaining 32% remains residual. For these reasons, this kind of exercise was not considered useful for the present review.

Equitable representation to poor nations 68. Going a step further, economic poverty of Member States would be a consideration instead of human poverty. Given the importance now placed on poverty reduction and the role of improvement of health of the poor in reducing poverty, it is hardly a point for debate whether to include pro-poor strategies in representation or not. Improvement of health of the population in poor nations in general and of the poor in particular is perhaps one of the most difficult challenges presently facing WHO. One of the ways to tackle this challenge would be to have the voices of the poor heard in forums like the Executive Board of WHO. Thus, it is timely that appropriate formulas are developed and used in calculating the number of Executive Board members such that voices of the poor/poor nations are adequately represented. 69. Table 8 clearly depicts the lack of adequate representation of voices of the poor in the current Executive Board as reflected by the proportion of low-income (as per World Bank categorization) countries in the Board. It can be seen that the African Region has been seriously underrepresented, followed by the SEA Region if one applies the equity lens in terms of categorization of economies on the basis of per capita income of the country and number of members on the Executive Board.

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Table 8: Percentage of low-income (World Bank definition) countries in WHO regions and percentage of members on the Executive Board from various regions WHO Region AFR AMR EMR EUR SEAR WPR Total Percentage of low-income countries (rounded to zero decimal) 59 2 11 6 11 11 100 Percentage of members on the EB 21 17 15 23 9 15 100 Deviation from equity (percentage point) −38 15 4 17 −2 4 0 Comment Under-represented Over-represented Over-represented Over-represented Under-represented Over-represented

70. One of the ways to factor-in equitable representation of low-income countries is to allocate number of seats to a region on the basis of the number of low-income countries it hosts. This can be done by distributing members among regions in proportion to the number of low-income countries in the respective regions. 71. Table 9 presents the expected number of members from various regions under various scenarios by taking into consideration the proportion of low-income countries in regions. It can be seen in column 3 that the distribution of members obtained by strictly applying the proportion of low-income countries in Regions will result in a serious disruption of the current membership. Table 9: Expected number of members from various regions under different pro-poor distribution strategies Current Proportion numbers of lowof EB income members countries (2) 7 6 5 8 3 5 34 (3) .593 .019 .111 .056 .111 .111 .278 Members based on proportion of low-income countries* (4)=(3)×34 20.162 0.646 3.774 1.904 3.774 3.774 34.034 Imposing a Imposing a Imposing a minimum of 4 minimum of 3 minimum of 4 as in members from members from column (5) and not each region and each region and reducing distributing the distributing the rest membership for any rest by applying by applying (3)** region*** (3)** (5)= 3+(3)×16 3+9.488=12.488 3+0.256=3.256 3+1.776=4.776 3+0.896=3.896 3+1.776=4.776 3+1.776=4.776 33.968 (6)=(3)× 10 4+5.93=9.93 4+0.19=4.19 4+1.11=5.11 4+0.56=4.56 4+1.11=5.11 4+1.11=5.11 34.01 (7) 10 6 5 8 5 5 39

WHO Region

(1) AFR AMR EMR EUR SEA R WPR Total

* This will seriously disrupt the current membership ** This will also moderately disrupt the current membership *** Will not reduce the number of members for any region; however, it will increase the total to 39.

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72. In order to minimize the disruption in the current membership from various regions, it may be strategic to have a pre-determined minimum number from each region. Estimates in column 4 and column 5 of Table 9 are in fact based on three and four as the minimum number respectively of membership and the distribution of the remaining members (16 and 10) as per the proportion of low-income countries in regions. Both the strategies will disrupt the current status of membership; estimates in column 5 are less disruptive than estimates in column 4. The principle applied in column 5, however, was a compromise with the minimum number of members being set as four per region and distribution of the rest of the members (10 in number) in a similar manner as in column (4) plus no reduction from the existing number of membership for any region. However, this increases the total membership of the Executive Board to 39 from the current number of 34 members. Of the five additional members, three will come from the African Region and two from the SEA Region, thereby ensuring greater participation from regions hosting the most and the second most poor nations respectively. 73. A similar indicator is percentage of the population below the poverty line.

Equitable representation according to the gap in development 74. The extent of gap in development can also be considered for providing a say in a body such as the Executive Board of WHO. The Human Development Index (HDI) is an internationally accepted indicator. It measures the different dimensions of available opportunities that define development. However this is a positive indicator in the sense that a higher value indicates better state of affairs. The focus in this note is on the needs of various regions to be on the Executive Board. For this reason, negative indicators (a higher value indicates poor health) are being considered. The HDI can be converted to a 0 -1 scale. Thus the scale (1 – HDI) measures development gap can be considered. Such decimal values are more convenient for the present calculations. 75. Regional averages can be calculated using country-population as the weight. Such averages are given in Table 10. These are based on countries of different regions for which HDI is available. It is not available for 18 of the 193 countries. Table 10: HDI and Executive Board representation HDI gap WHO Region Present members (1 – HDI)a x5 AFR AMR EMR EUR 7 6 5 8 0.539 0.151 0.363 0.143 E1. In proportion to HDI gap 1. If present the EB size 10 3 7 3 2. If size of the EB is increasedc 10 6 7 8 E2. Based on number of countries and HDI gap 1. If present size of the EB is maintained 7 5 6 6 2. If size of the EB is increasedc 7 6 6 8

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HDI gap WHO Region Present members (1 – HDI)a x5 SEA R WPR Total 3 5 34 PRESENT a

E1. In proportion to HDI gap 1. If present the EB size 7 4 34 May NOT be acceptable 2. If size of the EB is increasedc 7 5 43 May NOT be acceptable

E2. Based on number of countries and HDI gap 1. If present size of the EB is maintained 5 5 34 May NOT be acceptable 2. If size of the EB is increasedc 5 5 37 MAY BE ACCEPTABLE

0.376 0.217

Population-weighted regional average. Country wise population and HDI taken from HDR 20064 – out of 1.0 Although the calculation is based on 34 seats, the total is different due to rounding-off c To maintain the present regional representation b

76. As in the previous case, scenario E1 depicts is the allocation of seats based on HDI alone and E2 considers number of countries as well: E2. Executive Board seats for a region =3+ 1 20

(Number of countries in the region)

+ 4 (Average (1 – HDI) in the region) =3+ 1 x1 20

+ 4x5.

Various contributions as criteria 77. Several other considerations can be cited as possible criteria. Among these are efficient performance and absorption capacity of regions. However, these are more suitable for the resource allocation exercise than for regional representation. When opportunity is adequate, perhaps all regions can do equally well with regard to membership on the Executive Board. 78. Another factor is the stewardship. This is a very relevant criterion for becoming a member of a body such as the Executive Board. This may already be getting reflected in the election process. Given an equal opportunity, perhaps all countries have the ability to produce people who can take any organization higher. 79. Undeniably, developed countries can claim better representation because of their achievements and because they contribute most to the funds of WHO.

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Equitable representation according to the funds contributed to the budget of WHO 80. Countries or regions contributing more to the WHO budget may like to have a greater say in governance and claim increased representation. Industrial countries are indeed major financiers of international organizations, but it is expressly to serve the agenda of these organizations. Thus their dominance in the decision-making bodies may not have many takers in the present-day context. However, financial contribution cannot be missed either. Regional contribution of funds to WHO’s budget is shown in Table 11. Representation in proportion to contribution provides extreme results (Table 11). Table 11: Assessed financial contribution and Executive Board representation Assessed contributio n x6 AFR AMR EMR EUR SEAR WPR Total 7 6 5 8 3 5 34 PRESENT a

WHO Region

Present members

F1. In proportion to contribution 1. If present the EB size 0 10 1 14 0 8 33b May NOT be acceptable 2. If size of the EB is increasedc 7 10 5 14 3 8 47 May NOT be acceptable

F2. Based on number of countries and contribution 1. If present size of the EB is maintained 5 6 4 8 4 6 33b May NOT be acceptable 2. If size of the EB is increasedc 7 6 5 8 4 6 36 MAY BE ACCEPTABLE

0.0046 0.2440 0.0126 0.3325 0.0058 0.1957 0.7952

Source: Financial Report and Audited Financial Statements for the Period 1 January 2002 – 31 December 2002 (Certified 30 march 2004). Fifty-seventh World Health Assembly, A57/20, 19 April 2004 b Although the calculation is based on 34 seats, the total is different due to rounding-off c To maintain the present regional representation

81. The effect of financial contribution is considerably attenuated when the number of countries in a region is also considered as per the following formula: F2. Executive Board seats for a region =3+ 1 20

(Number of countries in the region)

+ 7 {US $ (in billion) contributed by the region} =3+ 1 x1 20

+ 7x6.

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82. Note in this case that the coefficient of ‘contribution’ is 7. This was necessary to keep the total seats to 34. This formula is most favorable to the European Region because it has the largest number of countries which also are the largest contributors. The formula is most adverse to the SEA Region yet it provides the Region with four seats because of the flooring at 3 seats.

Equitable representation based on achievements 83. The claim of developed countries in a better position to run an organization such as WHO by being on the Executive Board in large numbers in view of their ability to achieve better health (as demonstrated over previous few decades) needs to be examined in detail and counterchallenged. In this era of affirmative action and all kinds of encouragement to the underprivileged, this argument may not get much support. 84. If the index of achievement is to be considered, then it has to be realized that achievement too is a multi-faceted term and can include several indicators. One that immediately comes to mind is the HDI itself instead of the development gap considered earlier. The others could be as follows: • • • •

Absolute decline in mortality (crude death rate; infant mortality rate, and under-five mortality rate, etc.) over the previous, say, quarter of a century; The rate of decline per year or percentage decline in mortality; Increase in expectation of life—in absolute terms or as a percentage, and Healthy life expectancy.

85. No matter which indicators are used individually or in combination, the formula will provide four seats to the SEA Region so long as “flooring” at three is admitted.

Equitable representation through simultaneous consideration of several criteria 86. Scenarios presented so far consider two situations: (a) one indicator at a time, and (b) the indicator plus the number of countries. The number of countries in a region has been especially considered, as this is the existing criterion. In the case of (b), the minimum of three members from each region has also been considered. 87. As stated already, a large number of models can be proposed depending upon whether one or many indicators are considered. Also, the coefficients can be varied to obtain almost an infinite number of models. This note presents a simplified version that is easy to understand, and yet is appealing. However, this exercise would be incomplete if all the indicators are not considered together. 88. As remarked earlier, the total DALYs lost automatically consider the size of the population. The total DALYs are for the population as a whole. If population is also to be considered, the DALYs lost should be computed per person. All other indicators can be considered as such without modification. The scenarios presented in Table 12 are based on the simple sum of these

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indicators, including the financial contribution. The constants K1 and K2 in equations G1 and G2 are chosen such that the total Executive Boards seats are 34. Table 12: Sum of various indicators and the Executive Boards representation G1. In proportion to the sum WHO Region Present members Suma 1. If present the EB size 6 4 4 5 7 7 34 May NOT be acceptable 2. If size of the EB is increasedc 7 6 5 8 7 7 40 May NOT be acceptable G2. Based on number of countries and sum 1. If present size of the EB is maintained 6 5 5 6 5 6 34 May NOT be acceptable 2. If size of the EB is increasedc 7 6 5 8 5 6 37 MAY BE ACCEPTABLE

AFR AMR EMR EUR SEA R WPR Total

7 6 5 8 3 5 34 PRESENT

2.181 1.562 1.451 1.663 2.586 2.443

a b

Sum of five indicators as in formula G1 To maintain the present regional representation

G1. Executive Board seats for a region = K1 [Population (in billion) + DALYs lost (per person) + Av HPI + Av HDI Gap + Budget Contribution (US $- in billion)] = K1(x2+ x3p + x4 + x5 + x6), where x3p is now DALYs lost per person. G2. Executive Board seats for a region = K2[3 + 1 20

(Number of countries in the region)

+ Population (in billion) + DALYs lost (per person) + Av HPI + Av HDI Gap + Budget Contribution (US $- in billion)] = K2(3 + 1 x1 20

+ x2+ x3p + x4 + x5 + x6).

Parameters and calculations used in various scenarios/options on health metrics for regional membership of the WHO Executive Board are in Annex.

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Conclusion 89. The present regional representation on the Executive Board of WHO is not equitable. It matches neither the population, nor the health gap, nor the deprivation, nor development gap, nor even the budget contribution (Figure 2). There is a strong case for more equitable representation that considers other factors as well, in addition to the number of members from various regions. These factors provide compelling evidence for increased representation to some regions, particularly to the SEA Region. WHO may adopt a procedure whereby the present allocation remains unchanged, while increased representation is allowed to deserving regions by increasing the size of the Executive Board membership. Figure 2: Present representation of regions on the Executive Board and the imbalance with different indicators 0% AFR Number of countries Population DALYs lost HPI HDI Gap Fund contribution

20% AMR

40% EMR

60% EUR

80% SEAR

100% WPR

Present members

90. For reasons mentioned earlier, the formulae considering the number of countries as an essential component plus one or more of the other criteria, with three as “flooring”, seem convincing. Also, the present representation should not be adversely affected. This would imply a marginal increase in the size of the Executive Board. The comparison of seats obtained by applying various criteria under these principles is shown in Table 13.

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Table 13: Regional representation, which may be acceptablea B2 WHO Region Present members Equal Countries +Population 7 6 5 8 5 6 37 C2 Countries +DALYs 7 6 5 8 5 5 36 D2 Countries +HPI 7 6 5 8 5 5 36 E2 Countries +HDI gap 7 6 6 8 5 5 37 F2 Countries+ Contribution 7 6 5 8 4 6 36 G2 Countries+ Sumb 7 6 5 8 5 6 37

AFR AMR EMR EUR SEA R WPR Total a b

7 6 5 8 3 5 34

6 6 6 6 6 6 36

Keeps regional representation at least as much as at present Sum of population in billion, DALYs lost in billion, average HPI, average gap in HDI and budget contribution US $ (billion)

91. The proposed changes will need a lot of diplomacy, consultation and consensus for these implementation within the governing framework of WHO and without violating Article 24 of the Constitution. Amendment to this Article will require even greater efforts. However, notwithstanding the success of these efforts, it may be ensured that countries or members on the Executive Board articulate the problems and strengths of their respective regions as a whole and not restrict their concern to individual countries.

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Annex Parameters and calculations used in various scenarios/options on health metrics for regional membership of the WHO Executive Board Indicator value Region EB Actual No. of countries x1 AFR AMR EMR EUR SEAR WPR Total *Source: SEARO Communication **Source: WHO website ***Source: Financial Report EB Representation B2.Countries +Pop 6.018 5.635 4.589 6.531 5.212 6.108 34.09 C1. DALYs 8.229 3.349 3.190 3.391 9.362 5.886 33.41 C2. Countries+DALYs 6.749 5.340 4.612 6.247 5.199 5.387 33.53 D1. HPI 10.352 2.894 6.885 3.417 7.334 3.118 34.00 D2. Countries+HPI 7.375 5.330 5.430 6.335 5.020 4.975 34.47 E1. (1-HDI) 10.244 2.870 6.899 2.718 7.146 4.124 34.00 Countries+ (1-HDI) 7.456 5.354 5.502 6.222 5.054 5.218 34.81 F2. Countries+ Contr 5.332 6.458 4.138 7.978 3.591 5.720 33.22 G2. Countries+ sum 6.414 5.412 4.716 6.269 5.260 5.824 33.89 7 6 5 8 3 5 34 46 35 21 53 11 27 193 718107 884811 538555 880661 1661719 1758067 6441920 Pop in '000* Pop (billion) x2 0.7181 0.8848 0.5386 0.8807 1.6617 1.7581 6.4419 8.856 8.947 8.731 8.945 9.221 9.245 0.204 0.078 0.087 0.058 0.099 0.076 0.602 log popn Budget (billion)* DALYs lost (billions)** x3a 0.362 0.147 0.14 0.149 0.412 0.259 1.471 DALYs per person x3b 0.50445 0.16665 0.26075 0.16953 0.24804 0.14739 1.496818 Average HPI x4 0.415 0.116 0.276 0.137 0.294 0.125 1.363 Average (1-HDI) x5 0.539 0.151 0.363 0.143 0.376 0.217 1.789 Contribution (billion $)*** x6 0.0046 0.2440 0.0126 0.3325 0.0058 0.1957 0.7952

Region AFR AMR EMR EUR SEAR WPR Total

B1. Pop 3.790 4.670 2.842 4.648 8.770 9.279 34.00

F1. Contr 0.197 10.433 0.539 14.217 0.248 8.367 34.00

G1. SUM 6.239 4.469 4.150 4.756 7.396 6.989 34.00

Parameters and calculations used in various scenarios/options on health metrics for regional membership of the WHO Executive Board (Contd…) Proportions/Ratios No. of countries x1 46 35 21 53 11 27 193 x1-p 0.2383 0.1813 0.1088 0.2746 0.0570 0.1399 1.0000 Pop in '000* x2 718107 884811 538555 880661 1661719 1758067 6441920 x2-p 0.1115 0.1374 0.0836 0.1367 0.2580 0.2729 1.0000 DALYs lost (billions)** x3 0.362252 0.147454 0.14043 0.149296 0.412171 0.259129 1.4707 x3-p 0.2463 0.1003 0.0955 0.1015 0.2802 0.1762 1.0000 DALYs per person x3a 0.50445 0.16665 0.26075 0.16953 0.24804 0.14739 1.4968 x3a-p 0.3370 0.1113 0.1742 0.1133 0.1657 0.0985 1.0000 Average HPI x4 0.415 0.116 0.276 0.137 0.294 0.125 1.3630 x4-p 0.3045 0.0851 0.2025 0.1005 0.2157 0.0917 1.0000 Average (1-HDI) x5 0.539 0.151 0.363 0.143 0.376 0.217 1.7890 x5-p 0.3013 0.0844 0.2029 0.0799 0.2102 0.1213 1.0000 Contribution (billion $) x6 0.0046 0.2440 0.0126 0.3325 0.0058 0.1957 0.7952 x6-p 0.0058 0.3068 0.0158 0.4181 0.0073 0.2461 1.0000

Region

EB Actual 7 6 5 8 3 5 34

Pop (billion) 0.718107 0.884811 0.538555 0.880661 1.661719 1.758067 6.4419

Budget (billion)* 0.204 0.078 0.087 0.058 0.099 0.076 0.602

AFR AMR EMR EUR SEAR WPR Total

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Parameters and calculations used in various scenarios/options on health metrics for regional membership of the WHO Executive Board (Contd…) EB size = 34 Region AFR AMR EMR EUR SEAR WPR Total Region AFR AMR EMR EUR SEAR WPR Total Number of states 46 35 21 53 11 27 193 By(A+C+D) 6.5922 6.7478 3.3854 9.1676 2.6063 5.5006 34 Proportion of WHO members (A) 0.238341969 0.18134715 0.10880829 0.274611399 0.056994819 0.139896373 1 Region 7 AFR 7 AMR 3 EMR 9 EUR 3 SEAR 5 WPR 34 Total Population per region 718107 884811 538555 880661 1661719 1758067 6441919 Proportion per region (B) 0.1115 0.1374 0.0836 0.1367 0.2580 0.2729 1 By (A+B+C+D) 5.89 6.23 3.25 8.04 4.15 6.45 34.00 6 6 3 8 4 6 33 emro amro Region AFR AMR EMR EUR SEAR WPR By (C+D+G) 7.3056 5.6491 4.4519 6.9613 4.3424 5.2898 Region AFR AMR EMR EUR SEAR WPR By (D+F) 5.2833 6.5929 3.7093 8.8664 3.7904 5.7577 total afro euro searo DALY 50445 16665 26075 16953 24804 14739 149682 proportion (C) 0.3370 0.1113 0.1742 0.1133 0.1657 0.0985 1 5400504 259120616 13439200 360408528 6219696 211411456 856000000 Population & DALY of 2005 wpro 1758067 259129142 1661719 412171270 880661 149295731 538555 140430352 884811 147454106 718107 362251852 6441919 1470732452 22830.65568 50445.39141 16665.03728 26075.40988 16952.68592 24803.91091 Budget proportion (D) 0.0063 0.3027 0.0157 0.4210 0.0073 0.2470 1 Percentage of total budget 0.6309 30.2711 1.5700 42.1038 0.7266 24.6976 100 DALY/100000 population 14739.43852 HPI 0.415 0.116 0.276 0.137 0.294 0.125 1.363 Proportion (F) 0.3045 0.0851 0.2025 0.1005 0.2157 0.0917 1 1-HDI 0.539 0.151 0.363 0.143 0.376 0.217 1.789 Proportion (G) 0.3013 0.0844 0.2029 0.0799 0.2102 0.1213 1

Parameters and calculations used in various scenarios/options on health metrics for regional membership of the WHO Executive Board (Contd…) Region AFR AMR EMR EUR SEAR WPR Total Region AFR AMR EMR EUR SEAR WPR Total Region AFR AMR EMR EUR SEAR WPR Total By (A+B+C+D+F) 6.7838 5.5614 3.9767 7.1137 4.7847 5.7798 34.0000 By ( A+B+C+D+G) 6.7621 5.5566 3.9795 6.9737 4.7471 5.9809 34.0000 By ( A+C+D+F) 7.5322 5.7843 4.2603 7.7301 3.7882 4.9050 34.0000 Region AFR AMR EMR EUR SEAR WPR Total Region AFR AMR EMR EUR SEAR WPR Total Region AFR AMR EMR EUR SEAR WPR Total By (D+F) 5.2833 6.5929 3.7093 8.8664 3.7904 5.7577 34.0000 By (B+C+D+F) 6.4538 5.4103 4.0460 6.5579 5.4964 6.0356 34.0000 By ( A+C+D+G) 7.505108949 5.77829343 4.263773842 7.555143791 3.74123189 5.156448097 34 Region AFR AMR EMR EUR SEAR WPR Total Region AFR AMR EMR EUR SEAR WPR Total By (D+G) 5.2291 6.5810 3.7163 8.5165 3.6965 6.2606 34.0000 By (B+C+D+G) 6.4267 5.4043 4.0495 6.3830 5.4494 6.2871 34.0000 Region AFR AMR EMR EUR SEAR WPR Total Region AFR AMR EMR EUR SEAR WPR Total By (C+D+F) 7.3418 5.6571 4.4472 7.1945 4.4050 4.9544 34.0000 By (C+D+G) 7.3056 5.6491 4.4519 6.9613 4.3424 5.2898 34.0000

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Parameters and calculations used in various scenarios/options on health metrics for regional membership of the WHO Executive Board (Contd…) EB size = 35 Region AFR AMR EMR EUR SEAR WPR Total Number of states 46 35 21 53 11 27 193 Proportion of WHO members (A) 0.2383 0.1813 0.1088 0.2746 0.0570 0.1399 1 Population per region 718107 884811 538555 880661 1661719 1758067 6441919.466 Proportion per region (B) 0.1115 0.1374 0.0836 0.1367 0.2580 0.2729 1 DALY 50445 16665 26075 16953 24804 14739 149681.89 proportion ( C ) 0.3370 0.1113 0.1742 0.1133 0.1657 0.0985 1 5400504 259120616 13439200 360408528 6219696 211411456 856000000 Budget proportion(D) 0.0063 0.3027 0.0157 0.4210 0.0073 0.2470 1 Percentage of total budget 0.6309 30.2711 1.57 42.1038 0.7266 24.6976 100 HPI 0.415 0.116 0.276 0.137 0.294 0.125 1.363 Proportion (F) 0.3045 0.0851 0.2025 0.1005 0.2157 0.0917 1 1-HDI 0.539 0.151 0.363 0.143 0.376 0.217 1.789 Proportion (1HDI) (G) 0.3013 0.0844 0.2029 0.0799 0.2102 0.1213 1

Region AFR AMR EMR EUR SEAR WPR Total

By(A+C+D) 6.7861 6.9463 3.4850 9.4373 2.6830 5.6623 35.0000

Region 7 AFR 7 AMR 3 EMR 9 EUR 3 SEAR 5 WPR 34 Total

By (A+B+C+D) 6.06 6.41 3.35 8.27 4.27 6.63 35.00

Population & DALY of 2005 wpro searo euro emro amro 1758067 259129142 1661719 412171270 880661 149295731 538555 140430352 884811 147454106 afro 718107 362251852

DALY/100000 population 14739.43852 24803.91091 16952.68592 26075.40988 16665.03728 50445.39141

Region AFR AMR EMR EUR SEAR WPR Total

By (C+D+G) 7.5205 5.8153 4.5828 7.1660 4.4701 5.4454 35.0000

Region AFR AMR EMR EUR SEAR WPR Total

By (D+F) 5.4387 6.7868 3.8184 9.1272 3.9019 5.9270 35.0000

Region AFR AMR EMR EUR SEAR WPR Total

By (A+B+C+D+F) 6.9833 5.7250 4.0937 7.3229 4.9254 5.9497 35.0000

Region AFR AMR EMR EUR SEAR WPR Total

By (B+C+D+F) 6.6437 5.5694 4.1650 6.7508 5.6580 6.2131 35.0000

Region AFR AMR EMR EUR SEAR WPR Total

By (D+G) 5.3829 6.7745 3.8256 8.7670 3.8052 6.4448 35.0000

Region AFR AMR EMR EUR SEAR WPR Total

By (C+D+F) 7.5577 5.8235 4.5780 7.4061 4.5346 5.1002 35.0000

Parameters and calculations used in various scenarios/options on health metrics for regional membership of the WHO Executive Board (Contd…) Proportion of WHO members (A) 0.2383 0.1813 0.1088 0.2746 0.0570 0.1399 1 Proportion per region (B) 0.1115 0.1374 0.0836 0.1367 0.2580 0.2729 1

Region AFR AMR EMR EUR SEAR WPR Total

Number of states 46 35 21 53 11 27 193

Population per region 718107 884811 538555 880661 1661719 1758067 6441919.466

DALY 50445 16665 26075 16953 24804 14739 149681.89

proportion ( C ) 0.3370 0.1113 0.1742 0.1133 0.1657 0.0985 1 5400504 259120616 13439200 360408528 6219696 211411456 856000000

Budget proportion(D) 0.0063 0.3027 0.0157 0.4210 0.0073 0.2470 1

Percentage of total budget 0.6309 30.2711 1.57 42.1038 0.7266 24.6976 100

HPI 0.415 0.116 0.276 0.137 0.294 0.125 1.363

Region AFR AMR EMR EUR SEAR WPR

By(A+C+D) 6.7861 6.9463 3.4850 9.4373 2.6830 5.6623

Region 7 AFR 7 AMR 3 EMR 9 EUR 3 SEAR 5 WPR

By (A+B+C+D) 6.06 6.41 3.35 8.27 4.27 6.63

Population & DALY of 2005 wpro searo euro 1758067 259129142 1661719 412171270 880661 149295731

DALY/100000 population 14739.43852 24803.91091 16952.68592

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