SIXTY-FIFTH WORLD HEALTH ASSEMBLY Provisional agenda item 12
A65/5 Add.1 26 April 2012
WHO reform Draft Twelfth General Programme of Work and explanatory notes
A65/5 Add.1
TWELFTH GENERAL PROGRAMME OF WORK 2014–2019 - DRAFT STRATEGIC OVERVIEW MISSION To act as the directing and coordinating authority on international health work, towards the objective of the attainment by all peoples of the highest possible level of health as a fundamental right.
Principles, values and fundamental approaches WHO's core functions CATEGORIES
• Equity and social justice • Global solidarity • Gender equality
• Emphasis on countries and populations in greatest need • Due consideration to the economic, social, and environmental determinants of health
• Multilateralism • Science and evidence‐based • Public health approach
• Providing leadership • Shaping the research agenda
• Setting norms and standards • Articulating policy options
• Providing technical support and building capacity • Monitoring and health trends
1
Communicable diseases
2
Noncommunicable diseases
3
Health through the life course
4
Health systems
5
Preparedness, surveillance and response
Criteria for priority‐ setting
• The current health situation
• Needs of individual countries for WHO support
• Internationally agreed instruments
• The existence of evidence‐based, cost‐effective interventions
• The comparative advantage of WHO • Epidemic‐ and pandemic‐prone diseases • Health in humanitarian crises • Environmental health risks • Food safety
PRIORITIES
• HIV/AIDS, tuberculosis, and malaria • Heart disease, cancers, chronic lung • Neglected tropical diseases diseases, diabetes (including vector‐borne diseases) • Mental disorders • Vaccine‐preventable diseases • Injuries and disabilities
• Maternal and neonatal health • Sexual and reproductive health • Child and adolescent health • Healthy ageing
• National health policies, strategies, and systems • Integrated service delivery • Regulatory capacity
Improved healthy life expectancy IMPACT
Reduced mortality due to HIV, TB, and malaria
Reduced mortality due to NCDs
Reduced maternal and child mortality
Reduced mortality due to epidemics, disasters, and shared health threats
Universal health coverage (universal access to key interventions; financial protection) ILLUSTRATIVE EXAMPLES: • WHO develops, tests and supports countries to implement new, standardized approaches to treatment and service delivery, thereby reaching 15 million people with antiretroviral therapy and reducing childhood infections by 90%, overall infections by 50%, and deaths from tuberculosis among people living with HIV by 50%. ILLUSTRATIVE EXAMPLES: • WHO facilitates international agreement on a set of voluntary global targets and a monitoring framework, and establishes systems for reporting, analysis and dissemination of results enabling Member States to track progress in relation to agreed noncommunicable disease goals. ILLUSTRATIVE EXAMPLES: • WHO's evidence‐based policies and strategies are used to support the implementation of high‐quality integrated services for pregnant women and newborn infants in countries with the highest burden of maternal and child mortality, using data from strengthened vital registration systems to monitor progress. ILLUSTRATIVE EXAMPLES: ILLUSTRATIVE EXAMPLES:
• WHO provides technical support to assess • WHO develops standards for preparedness and national health financing systems, helps to build response, assesses and provides technical capacity to track health expenditures and support to address capacity gaps, ensuring that develops, with national authorities, strategies all countries meet minimum capacity for extending financial protection, thereby requirements dictated by instruments such as the reducing the number of people impoverished International Health Regulations (2005) and the through catastrophic health expenditure. Pandemic Influenza Preparedness (PIP) • WHO regularly monitors progress in Member State Framework. • WHO's performance evaluation of commercially commitments to reduce tobacco consumption, • WHO promotes evidence‐based preventive • WHO's prequalification of drugs, vaccines and available rapid diagnostic tests enables countries provides technical support for product regulation, interventions throughout the life course, commissions diagnostics lowers prices and thereby increases • A new common operational platform for public research on cost‐effective treatment and innovative access to the necessary safe, effective, to make informed choices on selection, pricing and taxation, advises on effective health and humanitarian emergencies increases the effectiveness of WHO staff as health cluster affordable and high‐quality medical products. procurement and distribution of rapid diagnostic interventions to reduce tobacco use and develops technical solutions to facilitate independent living, managers during outbreaks and enables faster thereby contributing to the health of ageing tests for malaria thereby increasing the training packages and guidance for countries on response time and lower death toll when percentage of suspected cases that are correctly incorporating tobacco cessation into primary health populations. emergencies strike. diagnosed and treated, ensuring more sustainable care, thereby contributing to reducing tobacco malaria control, and progress towards a reduction smoking by 30%. of cases by 75% from 2000 levels.
Corporate services / enabling functions (illustrative)
CONTRIBUTION OF WHO (illustrative examples)
• Legal services • Audit and evaluation • Governing bodies
• Information technology and knowledge management • Budget, finance, accounting • Executive management
• Operations, logistics and security • Communications • Human resources 3
A65/5 Add.1
BACKGROUND 1. These explanatory notes accompany the strategic overview of the draft Twelfth General Programme of Work. 2. Article 28 of the Constitution of the World Health Organization requires that the Executive Board “submit to the Health Assembly for consideration and approval a general programme of work covering a specific period”. At the meeting of Member States on programmes and priority setting in February 2012, the Secretariat was requested to use the agreed categories and criteria in the preparation of a draft outline of the Twelfth General Programme of Work for discussion at the Sixtyfifth World Health Assembly.1 3. The Twelfth General Programme of Work will set out a strategic framework for the work of WHO for a period of six years starting in January 2014, covering three biennial budget cycles. The first full draft will be prepared by the end of June 2012 in time for discussion by the regional committees towards the end of 2012. A complete timeline for the development of both the draft Twelfth General Programme of Work and the Proposed programme budget 2014–2015 is found in the final section of these notes. 4. The draft Twelfth General Programme of Work is presented as an overview for the purposes of discussion by the Health Assembly. The purpose of these notes is to explain the terms used and to show the linkages between the different components. The notes briefly discuss the rationale for how priorities have been identified; how overall goals have been selected; and how the specific contribution of WHO to the achievement of these goals will be presented in the final document. 5. A strategic framework for the future work of WHO must necessarily be based on a robust analysis of challenges and opportunities in global health. Such an analysis was presented as the basis of the reform programme in the documents for the special session of the Executive Board in November 2011, and has informed the development of the draft to date. While not represented in the overview, the analysis of global health challenges and opportunities will be further developed in the draft to be submitted to the regional committees. 6. The draft general programme of work will be developed assuming a constant resource envelope, consistent with current levels of income and expenditure. In subsequent drafts, the general programme of work will provide a rationale for how overall financial resources will be divided between the five main categories and corporate services. At the present time, however, this remains work in progress. 7. Subsequent sections of these notes comment on each row of the overview in turn.
Mission 8. The mission statement combines the objective and principal function of WHO as set out in the Constitution of the World Health Organization (Articles 1 and 2(a)).
1
Document A65/40, Annex, paragraph 3.
5
A65/5 Add.1
Principles, values and fundamental approaches 9. The values, principles and approaches listed in this section are not exhaustive, but seek to communicate what makes WHO different, providing a sense of the moral and philosophical genotype that guides WHO’s work. For the most part they are not the subject of specific programmes, but are values, such as equity and social justice, and approaches such as promoting evidence as the basis of policy, that permeate and underpin all WHO’s activities.
Core functions 10. The core functions are set out in shortened form and are based on the six core functions in the Eleventh General Programme of Work. These in turn aggregate a longer list of functions found in Article 2 of the WHO Constitution. The core functions describe the range of actions that WHO can take in any particular technical area. Thus, in relation to any technical area of work, WHO may set norms and standards; it may provide technical support; it may shape the research agenda; and so on. The core functions are particularly important in defining WHO’s specific contribution to the achievement of health-related goals and objectives. In subsequent drafts of the general programme of work, the precise formulation of the core functions will be reviewed to ensure that they address new realities and ways of working.
Categories 11. The five technical categories were agreed at the meeting of Member States on programmes and priority setting.1 They therefore represent the highest level of strategic division of WHO’s work, and it is within each of these categories that priorities have been defined. The categories are set out here in headline form only, recognizing that some of the additional points agreed by Member States (see document A65/40 for the report by the Chairman) are reflected in the section below on specific priorities. 12. The full draft of the general programme of work will contain a section which sets out the scope of each category, showing where existing programmes fit within the five divisions. The focus of the overview is on a more limited list of priorities, and thus the full list of programmes from which these are drawn is not shown.
Criteria for priority setting 13. The criteria agreed at the meeting of Member States on programmes and priority setting are shown in shorthand form. The full text for each is found in the report by the Chairman (document A65/40). The way in which the criteria have been used to identify priorities is discussed below. 14. The content of each of the rows to this point has been agreed either in the Constitution, the Eleventh General Programme of Work, or the meeting of Member States on programmes and priority setting. The section on priorities has been reviewed and endorsed by WHO’s Global Policy Group. Subsequent sections serve only to illustrate the links in the results chain. The section on WHO’s contribution contains just two examples in each category, which show the links between outputs and higher level outcomes and impact. In the full draft this section will be much more extensive and will cover the full range of priorities. 1
A sixth category – corporate services – is addressed separately below.
6
A65/5 Add.1
Priorities 15. This section presents an initial list of priorities for each category, derived through the application of the specific criteria listed above, and informed by a broader analysis of global health. In the overview, priorities are listed as technical topics without specifying what aspect of the topic constitutes a priority for WHO. Thus, for example, HIV/AIDS is a priority for WHO, but WHO will not address every aspect of the issue. Further precision as to the nature of each priority will thus depend on the high-level impact goals with which WHO is associated and WHO’s specific contribution toward their achievement. The following paragraphs provide examples of how priorities have been identified.
Communicable diseases 16. Within this category WHO has identified a number of specific priorities. They are HIV/AIDS, tuberculosis, malaria, neglected tropical diseases (including vector-borne diseases) and vaccinepreventable diseases. The first three emerge as priorities given their disproportionately large contribution to the overall burden of communicable disease. Together they cause over 4 million deaths worldwide. Current projections suggest that, unlike other communicable diseases, HIV/AIDS deaths will increase in all except high-income countries. HIV/AIDS, tuberculosis and malaria are the subject of a wide range of internationally-agreed targets and are specifically mentioned in the targets associated with the Millennium Development Goals. From the perspective of country demand, WHO support for work on HIV/AIDS, tuberculosis and malaria is highlighted as a priority in over 80% of the 144 country cooperation strategies. 17. Acute lower respiratory infections (18%) and diarrhoeal diseases (10%) account for a significant proportion of childhood deaths. Increasing numbers of deaths from these, and other diseases, are being prevented through routine immunization. Given the power and cost-effectiveness of immunization as a public health tool, vaccine-preventable diseases have been included as a priority. 18. Neglected tropical diseases, while making a lesser contribution to overall mortality rates, are a major cause of disability, suffering and loss of productivity among some of the world’s most disadvantaged people. They are identified as priorities precisely because they have been relatively neglected; because new and more effective interventions are available; because they are associated with grinding poverty; because their reduction can help accelerate economic development; and because WHO is particularly well-placed to convene partnerships between governments, health service providers and pharmaceutical manufacturers.
Noncommunicable diseases 19. Chronic noncommunicable diseases, together with mental disorders, and violence and injuries, together constitute a growing contribution to death and disability in almost all countries. This increase will be driven by population ageing, rapid unplanned urbanization and the globalization of unhealthy lifestyles. 20. The priorities identified by the Secretariat are heart disease, cancers, chronic lung diseases, diabetes, mental disorders, injuries and disabilities. The proportion of deaths due to noncommunicable diseases is projected to rise from 59% in 2002 to 69% in 2030. Additionally, noncommunicable diseases are identified as priorities in over 90% of current country cooperation strategies. The focus on the first four diseases is additionally important given their common risk factors and recent work to demonstrate the most cost-effective interventions (particularly in contrast to the economic losses that will result from inaction). A focus on prevention, early detection and appropriate treatment will 7
A65/5 Add.1
prevent the health-care costs and personal consequences of complications and disability that result from untreated diseases. The Political Declaration1 that resulted from the High-level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases (2011) provides political endorsement both of the importance of this priority and of the leadership role expected of WHO.
Health through the life course 21. The text agreed at the meeting of Member States on programmes and priority setting (February 2012) for the category on promoting health through the life course is as follows: “reducing morbidity and mortality and improving health during pregnancy, childbirth, the neonatal period, childhood and adolescence; improving sexual and reproductive health; and promoting active and healthy ageing; taking into account the need to address determinants of health and internationally agreed development goals, in particular the health-related Millennium Development Goals”. 22. Maternal and neonatal health; sexual and reproductive health; child and adolescent health, and healthy ageing are included as priorities. Within this group, neonatal deaths account for a growing proportion of deaths as overall childhood mortality falls. Reduction in maternal mortality trails behind achievements in relation to other Millennium Development Goals. It is critical to meet women’s unmet need for family planning. Lastly, ageing of populations contributes to the changing burden of diseases in all countries. The area of health and active ageing has been relatively neglected in global health: it has much to gain from technical innovation and multisectoral responses. 23. Given that the list is extensive and comprehensive, it is proposed that an approach to work based on the life course is, in and of itself, a priority for WHO. An approach to work based on the life course recognizes the importance of not dealing with childhood, child birth or ageing in isolation, and emphasizes the importance of integration both from a service delivery perspective and from the perspective that interventions early in life can have positive impacts subsequently on health.
Health systems 24. In many countries the net effect of the increasing costs of technology, ageing populations and rising public expectations is to threaten the financial sustainability of health systems. Elsewhere, current challenges will continue, with inadequate levels of unpredictable funding, limited access to life-saving medicines and technologies, lack of financial coverage and thus a continuing daily toll of death and disability. 25. WHO will continue to work on all elements of the health system including health financing, health information, health workforce, medical products and logistics. However, an analysis of country needs – drawing both from the country cooperation strategies and from the evaluations of WHO’s work at country level – points to a different way of framing priorities. WHO should play a stronger role in helping national authorities to prepare national health policies, strategies and plans. This is in line with WHO’s convening and leadership role. A second common theme is the demand for greater support in the area of integrated service delivery. Both these priorities point to the fact that health system strengthening is a cross-cutting category that supports the achievement of goals in other strategic areas.
1
See United Nations General Assembly resolution 66/2.
8
A65/5 Add.1
26. Increasing access to medical products – drugs, vaccines and diagnostics – and their quality and safety, is a critical issue for many Member States. Of the many strategies that are available for addressing this problem, strengthening national regulatory capacity has been highlighted as a priority and is a key role for WHO. 27. Sustainable and equitable health systems are essential for changing the current health situation. Health systems have, as yet, not been the subject of specific international agreements. However, their role in the achievement of the Millennium Development Goals has been recognized at the MDG Summit in 2010, in the United Nations Secretary-General’s Global Strategy for Women’s and Children’s Health, and, specifically, in relation to vital registration in the report of the Accountability Commission.
Preparedness, surveillance and response 28. The systemic shocks experienced in the first decade of this century, from the emergence of SARS and avian influenza viruses, pandemic influenza A(H1N1) 2009 virus, the health impact of climate change and the financial crisis, to the devastating impact of tsunamis and earthquakes, highlight the importance of this category. Lessons learnt include the fact that all countries are vulnerable. Although it is tempting to see each shock as a problem that has to be addressed in its own right, events that are apparently unconnected often in fact share underlying connections and common patterns which contribute to their causes and consequences. For this reason, a more resilient world means more than handling crises better. True resilience depends on preparedness and, more fundamentally, a more just and equitable world in which the goals of social justice and environmental health compete on more equal terms with goals set for economic growth. 29. Priorities for WHO in this category are: control of emerging, epidemic- and pandemic-prone diseases; collective security against shared health threats; and effective management of health-related aspects of humanitarian disasters. Criteria used include individual country need (where over 80% of country cooperation strategies mention the need) and the contribution that these combined threats pose to human health and development. It is important to stress that the shared threats include those that are acute and urgent (such as those due to food poisoning or radiation) as well as those that are more chronic and long-term in nature (such as environmental pollution and the health impacts of climate change).
Results chain Impact 30. One role of the draft general programme of work is to set out a results chain, showing how WHO’s work at output level contributes to the achievement of a hierarchy of outcomes and impacts. A detailed description of deliverables at output level, for headquarters, regional and country offices, will then appear in the Proposed programme budget. 31. At the highest level of the chain is a limited set of impact goals. These are set out in general terms in the current overview document. A more precise framing of the goals will appear in subsequent drafts. For the most part they will be selected from pre-existing internationally agreed goals and targets that are related to agreed priorities. Thus for instance the goal for noncommunicable diseases will be selected from those to be agreed by Member States following the High-level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases. Thus, the goal might be “a 25% reduction in overall mortality from cardiovascular disease, cancer, diabetes and chronic respiratory disease between 2010 and 2025”. 9
A65/5 Add.1
32. Two further points of explanation are important. In several areas (such as HIV/AIDS) there is a wide range of internationally agreed goals. The goals chosen will be those with which WHO’s work is most closely associated (for example, reduction in mother to child transmission). Secondly, for the most part the goals do not have a one-to-one relationship with the categories. For instance, a reduction in child mortality is an impact associated with health through the life course, but it is also the best aggregate measure of progress in reducing mortality from communicable diseases. Furthermore, there is a hierarchy even within this limited set of impact goals. This is illustrated in the overview, which shows that universal health coverage, (which is not just an outcome of work in the area of health systems and services) is a necessary step in the achievement of all the impact level goals, and leads to healthy life expectancy.
Contribution of WHO 33. The part of the overview on WHO’s contribution to the achievement of goals is illustrative only at this stage. Its purpose is to extend the description of the results chain further. Specifically, it provides a few examples – but in concrete terms – of how work carried out by WHO (and linked to core functions) contributes to the achievement of higher-level outcomes and impact. The key point is to illustrate, with examples, the links in the chain between specific deliverables such as performance evaluation of a diagnostic test and a fall in malaria mortality. 34. This section will be of critical importance as the draft general programme of work is further developed, as it constitutes the heart of the business case for investing in WHO.
Corporate services 35. The final row of the overview lists a (non-exhaustive) range of corporate services. This is the sixth category agreed by Member States alongside the five technical areas that will appear in more detail in the Proposed programme budget. The corporate services are those that enable WHO to function effectively.
Timeline 36. The draft outline of the Twelfth General Programme of Work will be reviewed at the May 2012 meeting of the Programme, Budget and Administration Committee of the Executive Board and will then be considered by the Health Assembly as part of the discussion on WHO reform. Based on these discussions, the Secretariat will prepare a more detailed first full draft for submission to the regional committees in 2012 in conjunction with the draft of the Proposed programme budget 2014–2015. 37. Further drafts, based on regional committee input, of the general programme of work and the Proposed programme budget will be reviewed by the Programme, Budget and Administration Committee in December 2012 and, following further revision and development by the Board in January 2013. Final versions of both documents will be presented to the Health Assembly in May 2013.
=
=
=
10