WORLD HEALTH ORGANIZATION EXECUTIVE BOARD 105th Session Provisional agenda item 2 EB105/7 15 December 1999
Working in and with countries Report by the Director-General
INTRODUCTION 1. WHO works to promote synergy between communities of countries to address issues of global and regional significance – working with countries – and to support the specific health development needs of individual countries – working in countries. It is generally agreed that WHO’s work in countries needs to be more strategic and more focused in order to achieve a greater impact. 2. Strengthening WHO’s country work has been a long standing concern of WHO’s governing bodies. The issue of country offices has been discussed regularly by the Executive Board for a number of years. In 1 993, the Executive Board Working Group on the WHO Response to Global Change recommended a series of changes1 which were followed up and reported on to the Board at its ninetysixth session in 1995. 2 At the same time, an independent study sponsored by a number of governments (the Oslo Group) was undertaken to review WHO’s support to programmes at country level. The study report introduced the concept of “essential presence” in order to tailor WHO’s support more effectively to country health development needs, country capacity, and the work of other actors in the health sector.3 Both the Executive Board Working Group and the Oslo Group stimulated new thinking about WHO’s role and work, particularly in countries in greatest need. 3. Since July 1998, a fresh look has been taken at actions required to improve the performance of WHO country offices and to intensify efforts to tackle unresolved difficulties. 4. A Working Group on Partnership with Countries, with membership from country offices, regional offices and headquarters, concluded in December 1998 that a number of factors within WHO were inhibiting performance at country level, such as lack of a holistic approach to health and health sector development, the fragmentation and inadequate prioritization of activities, a culture of supplydriven programme delivery, and insufficient attention to products or achievements. Recommendations included the development of country-specific medium-term strategies, better coordination with other development partners, and a more coherent, integrated and results-oriented approach to planning, budgeting and evaluation.
1 2 3
See document EB92/1993/REC/1, Annex 1. Document EB96/7.
Cooperation for health and development: the World Health Organization’s support to programmes at country level. London, London School of Hygiene and Tropical Medicine, 1997.
EB105/7
5. The first global meeting of WHO Representatives, in which the Director-General, Regional Directors and other staff participated (Geneva, February 1999) considered strategies for improving the effectiveness of country work in the context of the changing relationships in international health work. It concluded, inter alia , that the main thrust of technical cooperation with countries should focus on fewer priorities; that greater authority, matched by increased responsibility and accountability, should be delegated to WHO Representatives for management, budget control, fundraising, and personnel matters; and that headquarters and regional office support for country programmes should be negotiated with, and coordinated by, the WHO Representative. 6. In April 1999 a cabinet paper outlined a framework for action, featuring for decentralization to country offices the development of country strategies, coordinated support from regional offices and headquarters, and staff and systems development. 7. A key aspect of global change is the significant increase in the number of international agencies active in health and development, requiring a new approach to partnership at country level. Moreover, the nature of development cooperation is also changing. Virtually all agencies have adopted a poverty focus in their work. Better governance is becoming an explicit concern for development assistance and debt relief. 8. A number of new modalities is rapidly gaining currency within the international community. These include, at the macro level, the World Bank’s Comprehensive Development Framework and Poverty Reduction Strategy Paper, and the United Nations Development Assistance Framework (UNDAF) and, at sector level, the sector-wide approach for health development. Whereas the development framework, the strategy paper and UNDAF are concerned with overall economic, social and institutional development, the sector-wide approach brings together governments and donors in the development of coherent health sector policies and the negotiation of expenditure frameworks which reflect agreed priorities. These approaches represent significant change, moving from a situation in which key documents are produced by development agencies, particularly the international financial institutions, to a process resulting in national ownership, with governments taking the lead in formulating policies and consulting with civil society. 9. A high-level conference, organized by WHO and hosted by the United Kingdom Department for International Development (London, May 1999), represented a significant step in articulating a new agenda for international health, highlighting the improvements health can make to international development and poverty reduction, and exploring new ways for development agencies to work together. Preparatory work is now under way on a follow-up meeting.
WORK IN PROGRESS Strengthening country offices 10. Recruitment of WHO Representatives. The profile of WHO Representatives has been revised to take account of the changing context and demands of health and development. A broader range of candidates are now considered for these positions and all new appointments are reviewed by the Director-General and Regional Directors. Efforts are under way to bring about more rotation and greater mobility among WHO staff working at different levels and in different regions. 11. Delegation of authority. A review of delegation of authority within the Organization has been initiated by the Director-General.
2
EB105/7
12. Capacity-building and staff development. Both the quality and quantity of country office staff are being examined. This involves: • review of staffing patterns to cover key areas of expertise through a combination of international and national staff; • development of a range of training modules for WHO Representatives and field staff, many of them designed for distance-learning techniques. Topics of particular importance include health systems development and informatics; • introduction of up-to-date information technology to ensure access to the Internet and improve ease of communication between different levels of the Organization. 13. Criteria for country presence. The Executive Board in decision EB102(1) requested the Director-General to determine whether the type of WHO representation in each country was appropriate, according to a formula similar to the one used for budgetary purposes. It is recognized, however, that the application of a formula is but one factor in reviewing WHO’s presence in countries. The issue of country presence is currently being reviewed within the Organization, and additional criteria are being determined. The review is also considering situations in which multicountry offices and increased use of intercountry resource persons may be appropriate.
Country cooperation strategies 14. In response to the findings and recommendations of the different working groups and meetings, a process has been introduced for the formulation of country cooperation strategies, which is carried out jointly by the regional offices and headquarters. Such strategies are the practical, country-based expression of the corporate strategy for the WHO Secretariat,1 taking account of global and regional directions and priorities, while responding to country needs and acknowledging country realities. They provide a framework which encompasses the entirety of WHO support, ensuring that the different levels of the Organization complement one another. Elaboration of the strategies involves review and analysis of country-specific development challenges and health needs, of the activities and approaches of other development partners, and of WHO’s own strengths and weaknesses. 15. The process builds on existing experiences and aims to share and improve, not replace, the approaches of different regions to programme development and to capacity-building. Work is currently under way in one to three countries per region, involving all three levels of the Organization through joint missions and intensive consultation, to produce a replicable process. During 2000 it is expected that intensive joint efforts at global and regional levels will further develop the process and extend it to an increasing number of countries through a growing network of staff from country and regional offices and headquarters, resulting in a corporate approach to strategy development at country level. The resulting instruments will be sufficiently flexible to accommodate different country contexts and respond to changes and new opportunities as they arise.
1
See document EB105/3.
3
EB105/7
LIAISON AND SUPPORT MECHANISMS Regional offices 16. Country support arrangements differ widely between regional offices. A review of best practice is currently being undertaken in the spirit of learning from others’ experience. All regional offices are re-examining current arrangements for supporting country and intercountry work, with the aim of improving guidance on global and regional priorities, supporting the formulation of country cooperation strategies, and facilitating the exchange of experiences and the flow of up-to-date relevant information in both directions.
Headquarters 17. The liaison office for support to WHO country offices will extend its terms to cover liaison with regional offices. The concept of serving as a “help desk” to direct inquiries from different levels of the Organization to the appropriate source is being put into practice. A database on developments at regional and country levels is being compiled.
WORKING WITH OTHER DEVELOPMENT PARTNERS 18. Within the changing context of development assistance, WHO’s crucial role is to provide guidance on health policy and resource allocation within the health sector, and to argue the case for health within the process of overall development and poverty reduction. Working with governments and with development partners – the international financial institutions, the bilateral donors and organizations of the United Nations family – WHO is well positioned to act as broker and arbiter, helping to shape the rules of engagement between government, development agencies and civil society in promoting equitable and sustainable health for all. 19. In 1999 a number of new processes were established and existing ones strengthened to intensify dialogue and cooperation between WHO and other organizations. WHO has joined the United Nations Development Group and is now directly involved in guiding efforts to strengthen collaboration between organizations of the United Nations system at country level, including preparation of common country assessments and of a common harmonized planning framework. WHO also acts as the secretariat of the Inter-Agency Group on Sector-Wide Approaches and Development Cooperation. 20. In collaboration with the International Monetary Fund and the World Bank, WHO is defining and selecting key indicators and benchmarks for monitoring sector performance and providing support to heavily indebted poor countries in formulating pro-poor health and development policies.
=
=
=
4