EXECUTIVE BOARD Special session on WHO reform Provisional agenda item 3.1
EBSS/2/INF.DOC./6 25 October 2011
WHO reform The Director-General has the honour to transmit to the Executive Board the report provided on behalf of the Directing Council of the Pan American Health Organization (Regional Committee for the Americas) in line with operative paragraph 4 of decision EB129(8). The report is provided in the annex.
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PAN AMERICAN HEALTH ORGANIZATION WORLD HEALTH ORGANIZATION
51st DIRECTING COUNCIL 63rd SESSION OF THE REGIONAL COMMITTEE Washington, D.C., USA, 26-30 September 2011
Agenda Item 8.2
CD51/INF/2, Rev. 1, Add. I (Eng.) 30 September 2011 ORIGINAL: ENGLISH
REGIONAL CONSULTATION ON WHO REFORM Summary Report of the Roundtable Discussions
Introduction 1. The World Health Organization (WHO) has embarked on a comprehensive reform process that will enable its continued leading role as the world’s premier technical authority on health. The expected outcomes of the reforms aim to refocus WHO’s priority program areas (core business) to address the 21st century health challenges facing countries; reform its financing and management to address health challenges more effectively; and transform WHO governance to improve public health, allowing it to play a larger role in global health governance as well. Among its priority program areas (core business), WHO has identified the areas of health systems and institutions; health and development; health security; evidence on health trends and determinants; and convening for better health. 2. WHO reform is envisioned as a Member State-driven, inclusive consultative process that deliberated during the 2011 Regional Committee meetings and culminated at the 65th World Health Assembly in 2012. In support of this process and pursuant to the resolutions and decisions of the 64th World Health Assembly and 129th Session of the Executive Board, WHO has prepared three concept papers on 1) Governance of WHO; 2) Independent Formative Evaluation of the World Health Organization, and 3) the World Health Forum. These have been uploaded to a web-based consultation platform until 1 November 2011, together with an overview of the overall components guiding the WHO reform process and a summary of the 1 July briefing of Geneva-based missions by the Director-General of WHO.
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3. The Pan American Health Organization (PAHO) has emphasized the need to engage countries in the ongoing WHO Reform debate, with PAHO/WHO Country Offices providing support to stimulate country debate among national authorities, including the offices of foreign affairs, as well as partners in the international community and other key stakeholders. Feedback from such discussions will inform the Special Session of the Executive Board on the reform process scheduled for 1–3 November 2011. The Regional Director of the Americas Regional Office of WHO, Director of the Pan American Sanitary Bureau (PASB) has called on Member States to ensure their active participation in the WHO Reform process. 4. On 27 September 2011, the 51st Directing Council heard presentations from PASB Director Dr. Mirta Roses Periago and WHO Director-General Dr. Margaret Chan on the rationale, scope, and process of WHO reform, based on information document CD51/INF/2 Rev.1. Roundtable discussions were held with the participation of all Member States, with countries deliberating on a number of key questions: (a) (b) (c) Reaffirming the mission and core functions of WHO (per the WHO Constitution), what are the specific aspects that need to be highlighted in the reform/change process? Do the five priority program areas (core business) proposed sufficiently express the mandates and scope of WHO’s work? Given an increasingly complex scenario in global health, how can the authority and leadership of WHO be strengthened by embracing all voices (internal and external governance)? In line with the Results-based Management (RBM) framework, what are the necessary changes for securing the appropriate level and balance of funding and accountability mechanisms? The following represents a summary of the outcomes of the roundtable discussions.
(d)
5.
General Comments from the Roundtable Discussions 6. In each of the roundtable discussions, Member States expressed their appreciation to WHO for initiating the discussion on reform, noting the need within the current global health context and specifically taking into consideration the multiplicity of stakeholders in global health, the role of health in development, global governance in health, the current global economic crisis, which necessitates improved efficiency and prioritization in the work areas of WHO. Member States commended PASB for including the discussion on WHO Reform in the 51st Directing Council agenda, considering the need to address inequalities that exist within the Region. 7. The Member States agreed with the PASB Director’s call for the Region to participate actively in the reform debate, some countries indicated the need to provide additional comments or position papers to WHO in the coming weeks and others requested the opportunity for further analysis at the country and subregional level. A number of Member States, moreover, expressed specific support for the positions stated in the WHO Reform Mission Consultation (15 September).
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8. Some general concern was expressed that the documents on WHO reform lack sufficient detail and that the policy documents presented for the proposed reforms needed further elaboration. Furthermore, some Member States felt that the overall timeline, as well as the timeline for certain initiatives, including the independent evaluation, were unfeasible and that for this reason either the scope of reform or the respective timeline would have to be adjusted accordingly. 9. With regard to the reform process, Member States noted that the analysis should be broad-based, including discussion on the core work areas of WHO, and not limited to managerial and financial issues or internal bureaucratic processes within WHO. It is a process that should be spearheaded by the Member States in an iterative and consultative manner, allocating the necessary resources and time to complete the process. The issues of global governance in health, the role of WHO, and the governance of WHO were central to the roundtable discussions, which included stakeholder participation in the global public health policy agenda. Member States noted the importance of the role of all stakeholders in the attainment of global health goals and targets, and the example of the recent UN High-level Meeting on Non-Communicable Diseases was noted on several occasions in this regard. Nonetheless, Member States also noted the need for an in-depth discussion on the proposal to establish a World Health Forum. Specific aspects to be highlighted in the reform/change process, noting the mission and functions of WHO 10. The Member States specifically reaffirmed that the reform should be based on the principles of the Constitution of WHO and that reform must result in a WHO that has a more enhanced and effective steering role in global health, taking into consideration the mandate provided through its Constitution and its core mission in public health. In reaffirming this mission, the Member States considered that part of the WHO reform process must include a more detailed review and alignment of existing Governing Bodies, the setting of priorities, and the decision-making process. 11. The Member States noted that, as part of the reform process, WHO should consider and take advantage of the wide variety of experiences at the regional, subregional, and country level in the development and implementation of technical cooperation strategies, linkages with subregional integration mechanisms, and the establishment of mechanisms for intersectoral coordination at all levels with partners and stakeholders. Priority program areas (core business), the mandates and scope of WHO’s work 12. There was broad general consensus that the priority areas currently being proposed required further discussion based on a more in-depth analysis of the needs of the Member States, and the current and future capacity of WHO to respond. Further analysis was also requested in examining the role of WHO at the global, regional, and national level in the preparation and implementation of cooperation strategies in health. Some Member States noted that resolutions of the Governing Bodies (GB) of WHO can be effectively linked and implemented through subregional strategic plans and agendas, for example through
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integration mechanisms such as the Caribbean Community (CARICOM), Hipólito Unanue Agreement (ORAS-CHU), Central American Integration System (SICA), and Union of South American Nations (UNASUR). 13. A number of Member States indicated the importance of approaching each of the core work areas in a broad and integrated manner, for example in addressing the determinants of noncommunicable diseases, or in implementing the work program in public health, innovation, and intellectual property, each of which requires a broad intersectoral approach. Member States noted the importance of strengthening health systems based on primary health care, recognizing that health systems had advanced considerably over the past 60 years and noting the challenges remaining to ensure universal access and quality of care. Some Member States also called on WHO to strengthen its role in the negotiation of global agreements to advance health, as has been successfully achieved in the area of tobacco control and the International Health Regulations. Other Member States noted the opportunity that the reform process presents for WHO to improve communication with its Member States in the key work areas. 14. Some Member States noted that the identification of priority areas would facilitate resource mobilization from partners and donors who could readily subscribe to the specific areas identified. In addition, improved prioritization within the core areas of work would support a programmatic approach to resource mobilization and allocation, with a move away from the current trend of funding specific programs preferred by donors. This could ultimately lead to an improvement in the current financing of WHO. Member States also underscored the need to increase efficiency in resource utilization, promoting the decentralization of resources to regional and country offices in alignment with the regional, subregional, and national priorities defined. WHO Leadership and Authority (Governance) 15. Member States concurred with the two dimensions of governance highlighted by the WHO Reform process of global health governance and WHO’s internal governance. Strengthening WHO’s internal governance would enable WHO to play a more decisive and effective role in the conduct of global health governance. 16. In this regard, Member States advocated for more optimal use of WHO’s Governing Body structure, starting with the Programme, Budget and Administration Committee. A key step toward achieving this was to empower the Executive Board’s (EB) decision making, allowing for a leaner and more strategic agenda at the World Health Assembly. Currently, the distinct roles of the EB and World Health Assembly (WHA) are blurred, with the EB generally becoming a mini-WHA. Clarity in the terms of reference of GB structures needs revisiting to address aspects such as the sequencing of meetings, active participation of the Member States, and balanced representation and participation. This will make it possible to distinguish strategic, technical, and managerial issues from those related to governance. Prior preparation of EB members was deemed critical to the performance of the EB. It was noted that the Director-General had reiterated the need to reduce the number of items being brought
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before the WHA. Furthermore, not all debates necessarily needed to end with a resolution. Member States also recommended the costing of all items included in resolutions. 17. The proposed establishment of a World Health Forum (WHF) elicited considerable comments by the Member States. Member States agree on such a forum, as long as the sovereignty and decision-making power of the countries is maintained. 18. Some Member States recognized the importance of having a mechanism that would facilitate the engagement of multiple stakeholders to effectively address today’s health challenges. A WHF could be used as a forum for debate on major global issues that have previously been discussed at WHA/EB. However, the concept and principles behind the World Health Forum need further refinement. 19. Suggestions were also made about exploring other means to engage multiple stakeholders in global health. The recent process for stakeholder engagement for the noncommunicable diseases, in particular the Forum held in Moscow (2011), was offered as an example. Member States also noted that leadership must be assumed at the governmental level and that a multistakeholder forum may not actually contribute to the resolution of issues that require action by the Member States themselves—an aspect that was not appropriately addressed in the documents provided. 20. Member States expressed concern about how the proposed Forum would maintain the supremacy of Member State decision-making at the WHA, and the linkages with current governance mechanisms within WHO and the UN system in general. Questions were raised about its influence on the usual decision-making process and the process for defining global mandates, if any. In this regard, Member States cautioned about asymmetries in the discussions between donor and recipient countries. This is also the case for the participation of industry and its strong lobbies. Concerns were expressed by Member States about the WHO’s relationship with the private sector and potential conflicts of interest. Finally, further definition was required of how the Forum would be rendered operational throughout the three levels of the Organization. 21. Member States requested a careful analysis of partnerships, citing numerous cases of partnerships that were born in WHO but are now disengaged and duplicating its work, fragmenting the use of limited resources. These partnerships do not benefit all WHO countries. There was a call for a debate among the Member States on the purpose and relevance of establishing global partnerships. It was noted that some of these partners no longer seek guidance from WHO, nor do they abide by its rules. A stronger set of instruments is needed to ensure that partnerships under WHO work in a manner consistent with Member States’ needs and priorities, benefitting all Member States alike. 22. Member States emphasized the importance of defining the new leadership role that the Organizations (both PAHO and WHO) will have in the sphere of global health, which includes many new actors and other important sectors with an impact on health. This will also require strong human resources and communication plans.
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23. Leadership must be built up from the Member States, who retain the ultimate responsibility for setting the priorities of WHO. Member States alluded to the perception that they were true decision-makers within the Organization, rather than playing the passive role of a sounding board. 24. The Reform process should carefully consider the governance role of the Organization in coordinating, negotiating, and positioning based on the right to health. For example, the new leadership role requires the Organization to have the ability to coordinate or negotiate when necessary, but also take a firm stand on critical issues that are non-negotiable (e.g. tobacco control). 25. Countries identified as a critical point the strengthening of WHO’s leadership role and authority to direct efforts pursuant to the mandates of the Member States. By the same token, delegates emphasized the need for the Organization to exert greater leadership in influencing global health. 26. Member States considered that their legitimacy is being compromised due to the disproportionate funding by some partners. They cautioned that large funding partners should not dictate the policies and norms of the Organization through financing. They emphasized that the financial contributions of countries to global health initiatives and accountability structures needed to be aligned with policy priorities, and ideally, be channeled under the decision-making authority of the WHA. A key aspect of improved governance was to factor in the achievement of objectives of national health plans, articulated with subregional and regional priorities. Results-based Management, Financing, and Accountability 27. Member States noted the challenges for WHO in improving transparency and accountability. They called on the Organization to prioritize the needs and interests of the Member States, especially when dealing with large international and multilateral donors, which sometimes impose rigid plans and programs, giving Member States little flexibility to allocate resources efficiently according to their specific contexts. 28. Member States expressed their concern at the fact that over 80% of the Organization’s resources come from voluntary contributions, which has serious implications for the governance of the Organization, to address its mandates and the priorities of the Member States. Member States considered that funding should be flexible and aligned with the established priorities. There is a need to review regulations governing the financing of the Organization, including controls to ensure the effective and efficient use of resources. The criteria for country resource allocation need to be reviewed to go beyond the discussion of income level and include elements of absorption capacity and inequities at the national level. 29. Member States expressed their support for independent evaluation as a means to ensure the impartial and transparent assessment of performance. It was noted that for financial reform, it is imperative to undertake an analysis of the sources and use of operating funds against total costs.
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Deliberations by the Member States 30. On 28 September, the above considerations from roundtable discussions were presented in plenary by the Rapporteur of 51st Directing Council. Thereafter and at the invitation of the President of the Directing Council, Member States engaged in the following additional deliberations. 31. Member States expressed gratitude for the opportunity to discuss the issues at the Directing Council, specifically through the roundtables, indicating that for the most part, the summary report expressed the diversity of their views. They noted the importance of the process for WHO and its Member States, stating that it presented a unique and rare opportunity for reform and for the effective participation of Member States in the reform process. In addition, given the complexity of multilateral organizations such as WHO, the process offered Member States the opportunity to participate in the review and reform of existing platforms and governance mechanisms, the prioritization of essential functions, and the development of work processes in a manner that adequately responds to current country needs and health problems. 32. A number of Member States noted that important reforms had already taken place in the Region of the Americas, specifically “PAHO in the 21st Century,” in which PAHO achieved institutional reform based on the key health challenges identified by Member States and by means of a transparent and participatory process. Recognizing the importance of this process for WHO reform, Member States requested the Director of PASB to include a summary of the reference document in the report of this regional consultation (see Annex). 33. The Member States requested WHO to review the six proposed core areas of work to determine whether they will respond in a manner that addresses the current needs of health systems. The World Conference on Social Determinants of Health to be held on 19-21 October 2011 will highlight the multiplicity and complexity of the factors that impact health, which will need to be considered in identifying the real value added of WHO for Member States. Universal access to health, social inclusion, knowledge and technology transfer, and health technology development were identified as key issues by Member States that would require specific consideration in the WHO reform process for global and regional action and within the context of south-south cooperation. 34. The Member States pointed out that WHO is not a financial agency but an agency specializing in international technical cooperation in health. As such, it should assume the leadership of the health sector, not by transforming itself into a series of technical programs in health, but by building consensus around clear health objectives and integrating health policy with the multiple stakeholders that have progressively displaced WHO in its normative role and coordination function. 35. UNASUR countries stressed the need for WHO to facilitate the gradual recognition and incorporation of regional and subregional integration mechanisms. These mechanisms represent complementary alternatives to respond to the health needs of the countries, as well
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as an opportunity to build relations between WHO and the regions and between regions and countries. 36. The Member States were in agreement on the need to improve linkages between the EB and the World Health Assembly, with meetings of the Regional Committees, and to review the calendar of meetings of the WHO Governing Bodies. In this regard, it will be necessary to ensure that the role of each is clearly defined and complementary so that the Organization can move forward with the development of cost-effective work programs. 37. A review of WHO governance was requested from the standpoint of the resolutions adopted by the World Health Assembly, addressing apparent distortions being created due to the impact of voluntary contributions earmarked for specific objectives. Some Member States reiterated the importance of reviewing the WHO financing structure and examining the flows of voluntary and regular funding, while other Member States pointed out that voluntary funding from donors represents a significant opportunity for the Organization: it was noted that donors are working together to align resources with the Organization’s priorities. 38. The World Health Forum was considered in the Member States’ deliberations, with a few countries expressing agreement in principle, but most noting the need for further discussion, given the reservations and concerns expressed—particularly with regard to the overarching objective of the Forum, the stakeholders that would participate in it, and the linkages with the existing governance and decision-making process of WHO. 39. With regard to management reform, the Member States noted the need to improve linkages between the different components of the reform being proposed in the reference documents and management processes. Countries noted the need to review work flows from the country offices, the regional offices, and within WHO Headquarters in order to optimize processes and avoid the duplication of efforts. New instruments will be required to strengthen cooperation between countries in different WHO regions, facilitate south-south cooperation, and improve interregional country capacity building, important elements for building selfreliance and achieving sustainable development. 40. The external evaluation of WHO was considered in the deliberations, noting its importance and highlighting the need for the process to engage the active participation of all Member States, not only the experts identified by WHO. It was suggested that WHO wait until the reform process is completed before launching the external review, that the external evaluation report be presented to the World Health Assembly (and not only to the EB) when all Member States are present, and that WHO facilitate independent secretarial support for the external evaluation process. 41. Finally, the Member States requested that WHO facilitate a Member State-driven process, where countries would be given greater opportunity to thoroughly discuss the reforms on a regional collaborative basis. Countries noted that the reform will need to take place over a sufficient period of time and that the process should not be hurried, given importance of the outcomes for the Organization. Some Member States committed to actively participating in the special meeting of the Executive Board on the issue in November, and
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Mexico, as a member of the EB stated its willingness to bring the outcomes of the regional consultation to the EB meeting. Closing remarks of WHO Director-General, Dr. Margaret Chan, and the Director of the PASB, Dr. Mirta Roses Periago 42. In presenting her final remarks, the Director-General, Dr. Margaret Chan, acknowledged the contributions of Member States to the process, as well as the request for more detail moving forward. She noted that WHO needed to show the interconnection between the different components of the reform, between the three reference papers, and the management reform proposal. Dr. Chan informed the Directing Council that before the special Executive Board meeting in November, WHO would provide a single paper consolidating the various components and demonstrating the linkages between internal WHO and global health governance, and the role of WHO in coordination and negotiation in global health. 43. Dr. Chan noted that WHO needed to be careful not to rush into strategic decisions on some critical issues which would have a long-term impact. At the same time some reforms, especially managerial, could be moved forward to improve transparency and accountability for Member States. It will be necessary to separate the discussions on strategic issues that will need input from Member States from the managerial aspects to improve efficiency and transparency, particularly in the evaluation of performance. In this regard, the DirectorGeneral highlighted the importance of ensuring independence in the external evaluation process so that the Member States receive information that will guide future change. 44. The Director-General also noted the importance of the PAHO in the 21st Century reform process and informed the Directing Council that it would be reviewed further as part of the learning process for WHO reform. 45. The Director of the Bureau of PAHO, Dr. Roses Periago, thanked the Directing Council for its deliberations and noted the importance of continuing the dialogue through regional forums and the web-based platform. Dr. Roses also noted the importance of the subregional integration mechanisms in facilitating debate given the countries’ familiarity with discussing issues in these forums. She reminded the Directing Council that examples of other forums that facilitate exchange among stakeholders existed within the Region, for example: the CARICOM forum to facilitate consultation with civil society, youth, and the private sector, organized prior to the meetings of heads of State precisely to gather opinions to inform decision-making; the Secretariat of the Ibero-American Summits; and forums within the Organization of American States. The Director noted the need to examine these forums, including internal regulations and processes, to determine how they ensure representation of stakeholder opinion while at the same time preserving the political decision-making capacity of the countries pursuant to the constitutions of the integration mechanism. 46. Dr. Roses confirmed the need to develop new instruments and technical cooperation platforms that will facilitate intercountry and cross-regional exchange and cooperation. The Director highlighted the need to strengthen links between the regional committee meetings of
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WHO and the Executive Board at WHO, ensuring in particular the necessary preparation of regional representatives in meetings of the EB. It will be necessary to ensure that the EB does not become a mini-World Health Assembly; with the reduction in its executive capacity, it will become less efficient and countries will not receive information and feedback on the decisions made. It is important to improve the representation of all countries in the EB or any other working group or governance structure in the Organization, as the countries elected are in fact representatives of a broader universe or collectivity of countries, and the Member States should feel that that their opinions are well-represented in these structures. Regional representatives participating in normative processes and discussions within the Organization also need preparation, as these processes not only impact the central level of the Organization but must respond to the needs of all Member States. 47. The Director confirmed that the PASB would provide additional information on the PAHO in the 21st Century process to support WHO reform. Dr. Roses concluded the discussion by reiterating that it was not the constitution and structure of the Organization that were in question, but the mechanisms, work flows, procedures, and respective instruments, which were of the utmost importance as they are institutional processes that have been adopted by the Organization in its entirety. As such, their modification requires the participation of all levels of the Organization, from the country to the global level, to ensure that resources allocated produce the results expected by the Member States.
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PAHO IN THE 21st CENTURY REFORM PROCESS 1. In 2003, PAHO Member States created the Working Group “PAHO in the 21st Century” with the goal of reflecting upon the current trends in the Region that were generating new public health demands and new public health actors engaged in international technical cooperation in health, which in turn was influencing and changing the role and functions of PAHO. Inspired by the document “Globalization and Health” presented to the 132nd Executive Committee, the Government of Mexico proposed the formation of the working group to explore the future of the Pan American Health Organization and ensure the Organization’s ability to tackle the new challenges of the millennium. This working group spearheaded the multi-year institutional reform process of the Pan American Sanitary Bureau. What follows is a brief overview of that process and its principal milestones. 2. In September 2003, the 44th Directing Council passed Resolution CD44.R14 creating an open-ended working group (WG) comprised of selected members of the Executive Committee, as well as representatives from organizations with experience in institutional/organizational reform in the UN system or public and private sectors and representatives of any Member State wishing to participate. The Committee also agreed that the nine Members of the Executive Committee, with support from the Secretariat, would draw up the terms of reference and work plan for the group. To ensure equal representation from all the subregions, the Executive Committee appointed Argentina, Barbados, Costa Rica, and Peru to the WG, and selected the Minister of Health of Barbados to coordinate the group. 3. In February 2004, the WG held its first meeting in Roseau, Dominica, with the participation and representation of nine Member States in addition to those in the WG, namely Antigua and Barbuda, Bahamas, Chile, Dominica, France, Mexico, the United States, Uruguay, and the Netherland Antilles. In addition, the Director of Governance of WHO and the NGO, Latin American and Caribbean Association for Public Health Education also participated. Another meeting was held in Washington, D.C. in March. By June 2004 the WG’s first Progress Report was submitted. A virtual site had been created to facilitate information sharing and make the process accessible to all Member States. A Consultative Group on the Regional Program Budget Policy was created to prepare a preliminary analysis of financial and intangible resources. In addition, several Member States prepared preliminary reports for the consideration of the group: the United States undertook the analysis of the human resources component; Peru prepared a preliminary report on the evolving nature of partnerships and alliances in international health development pertinent to PAHO’s role; Argentina prepared a report on regional and global public health goods in the 21st Century and their relation to PAHO’s mandates; Costa Rica analyzed various modalities of technical cooperation in health; and Barbados reviewed the governance of PAHO. The Secretariat’s contribution to the preliminary analyses was its drafting of a paper on the challenges to public health in the Americas in the coming years. A third meeting was held in San José, Costa Rica in July 2004. The goal was for the process to remain highly participatory. 4. Notable among the initial results of this process was the identification of key themes recognized as a priority by PAHO’s Member States: public health challenges for the 21st
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century, global public health goods, governance, resources (financial, technological, and human), technical cooperation modalities, and strategic partnerships. The WG’s terms of reference and work plan were submitted to and approved by the 135th Session of the Executive Committee in October 2004. The WG was tasked with preparing a final report in the form of policy recommendations on how PAHO (both Member States and Secretariat) should respond to the health challenges of the 21st Century in the Americas and how best to contribute to the goals outlined in the United Nations Millennium Declaration, ensuring alignment and cohesiveness with the UN system. The final report was submitted to the PAHO Directing Council in September 2005. 5. In February 2005 a 5th meeting was hosted at the PAHO HQ Office in Washington, D.C. The WG’s next steps for 2005 included the preparation of a progress report on its activities for submission to the Subcommittee on Planning and Programming in March 2005, an update to Member States during the World Health Assembly in May 2005, and a final report to the next Executive Committee in June and the Directing Council in September of that same year. 6. In June 2005, the final report of the WG was submitted to the 136th Session of the Executive Committee. The WG had held six meetings and identified the main challenges to public health in the Region, as well as the role of international cooperation in addressing them. WG members and participants divided up the topics identified and prepared documents as inputs for this report. The report had seven sections: introduction, a description of the strategic challenges for public health in the Americas, international cooperation in health and the role of PAHO, PAHO governance, financial and human resources of PAHO, technical cooperation approaches and strategies, and, in the final section, the WG’s recommendations on PAHO in the 21st Century. 7. Simultaneously, the Secretariat prepared and presented a document entitled “Update on the Process of Institutional Change within the Pan American Sanitary Bureau” to the same Executive Committee. The document reported on the parallel and complementary internal efforts at institutional strengthening that had been ongoing since 2003 within the Secretariat as part of the Organization’s Roadmap Initiative.1 It provided a status report on the progress made in institutional change during 2004–2005 and introduced monitoring milestones and expected results of the change process for the period 2005–2007, including the PAHO Roadmap for Institutional Transformation initiative. 8. The 136th Session of the Executive Committee, through Decision CE136(D3), further requested the Secretariat to present to the 137th Session of the Executive Committee a proposal on the process for streamlining the governance mechanisms of the Organization, particularly with regard to: (a) reform and simplification of the Subcommittees, (b) the 1
The Roadmap for Institutional Transformation consisted of 11 initiatives: Country Support Unit Organizational Review, Country-focused Cooperation, Regional Public Health Plans, Regional Forum, Knowledge Management Implementation, Leadership Learning and Development, Resource Mobilization Strategy, Standards for Accountability and Transparency, Human Resources Strategy, Internal Communication, and External Communication. Over 175 staff members participated in these initiatives.
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process for electing the Director of the Pan American Sanitary Bureau, and (c) improvement and strengthening of the rules and procedures of the Governing Bodies, taking into account the recommendations made in the WG’s report on PAHO in the 21st Century, the deliberations of the Subcommittee on Planning and Programming, the deliberations and recommendations of the Subcommittee on Women, Health, and Development, and those of the 136th Session of the Executive Committee. 9. In September 2005, the final report of the Working Group on PAHO in the 21st Century was submitted to the 46th Directing Council. The report included recommendations in the following key areas: public health goods; science, technology, research, and strategic supplies; development of associations and partnerships and the role of PAHO; technical cooperation modalities in health; governance; and human resources. 10. In June 2006, at the request of the 136th Session of the Executive Committee, a report of the Working Group on Streamlining the Governance Mechanisms of PAHO was submitted to the 138th Session of the Executive Committee. Information on the following key issues was presented: process for the election of the Director of the Pan American Sanitary Bureau; improvement of the Rules of Procedure of the Directing Council; the abolishment of the Subcommittee on Women, Health, and Development; the establishment of the Subcommittee on Program, Budget, and Administration. 11. In September of 2006, during the 47th Directing Council, another update was given by the Secretariat regarding the institutional strengthening process of the Pan American Sanitary Bureau. As in previous meetings of the Governing Bodies the document provided a status report on the internal processes that were accompanying Governing Bodies processes for institutional strengthening of the Secretariat. The document reflected the Bureau’s commitment to implementing the Strategic Plan 2003–2007 and included the recommendations of the Working Group on PAHO in the 21st Century, the Internal and External Auditors reports, and the report of the Joint Inspection Unit. Also in that 47th Directing Council, a resolution was issued for the Improvement of the Rules of Procedure of the Directing Council. 12. The table attached provides more detailed information on the highly participatory, constructive and Member State-driven process that was undertaken and includes links to the various documents and resolutions associated with the transformation of the Pan American Health Organization. As can be noted, the transformation did not take place overnight, but rather involved a great deal of work, discussion and interaction among Member States and the Secretariat.
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Chronological Overview of the PAHO in the 21st Century Institutional Reform Process In 2003, the Member States of PAHO decided to create a Working Group “PAHO in the 21st Century” with the goal of considering current trends in the Region that were generating new public health demands and new public health actors in international technical cooperation in health, which in turn were influencing and changing the role and function of PAHO. The Governing Bodies process that accompanied that reform effort is detailed in the documents below:
PAHO in the 21st Century Governing Bodies Process DATE 23–27 Jun 2003 GOVERNING BODY AND SESSION 132nd Session of the Executive Committee PROGRESS Document “Globalization and Health” presented to the Executive Committee, which inspired the Government of Mexico to propose the creation of a Working Group to discuss PAHO’s future. Discussions of the Executive Committee DOCUMENTS AND RELEVANT LINKS Document CE132/15 http://www.paho.org/english/gov/ce/ce 132-15-e.pdf Document CE132/FR; p. 7 http://www.paho.org/english/gov/ce/ce 132-fr-e.pdf Document CD44/6 http://www.paho.org/english/gov/cd/c d44-06-e.pdf Resolution CD44.R14 http://www.paho.org/english/gov/cd/c d44-r14-e.pdf
22–26 Sep 2003
44th Directing Council/ 55th Session of the Regional Committee
Government of Mexico, through Document CD44/6, A PAHO for the 21st Century, proposes the formation of a working group to explore the future of the Pan American Health Organization and ensure the Organization’s ability to tackle the new challenges of the millennium. Resolution of the 44th Directing Council to establish an open-ended working group comprised of selected Members of the Executive Committee; representatives of organizations with experience in the area of institutional and/or organizational reform in the UN system and in the public/private sector; and representatives of Member States wishing to participate, ensuring equal distribution among subregions. Discussions of the 44th Directing Council
Resolution CD44/SR/6 http://www.paho.org/english/gov/cd/c d44-sr6.pdf
Annex
Annex
PAHO in the 21st Century Governing Bodies Process DATE 26 Sep 2003 GOVERNING BODY AND SESSION 133rd Session of Executive Committee PROGRESS A decision is made by the Executive Committee to establish a working group to review the situation of PAHO in the 21st century. The Committee appoints Argentina, Barbados, Costa Rica, and Peru to represent it on the working group. The Committee also agrees that the nine Members of the Executive Committee, with support from the Secretariat, will draw up the terms of reference and work plan for the group. First meeting is held by the Working Group in Roseau, Dominica, on 26-27 February 2004. Additional Member States are represented at the meeting. DOCUMENTS AND RELEVANT LINKS Document CE133/FR, Rev. 1; p. 12 http://www.paho.org/english/gov/ce/ce 133-fr-e.pdf
24–26 Mar 2004
21–25 Jun 2004
38th Session of Subcommittee on Planning and Programming of the Executive Committee 134th Session of the Executive Committee
Document SPP38/FR; p. 51 http://www.paho.org/english/gov/ce/sp p/spp38-fr-e.pdf
First Progress Report is submitted after two meetings in early 2004. A virtual site is opened to facilitate information exchange and is made accessible to all Member States that wish to participate. Consultative Group on the Regional Program Budget Policy designated to prepare preliminary analysis of financial and intangible resources, and U.S. volunteers to analyze human resources component (Annex I of the report). Four countries prepare preliminary analysis for the terms of reference (Annex II): • Evolving Nature of Partnerships and Alliances in International Development in Health Pertinent to PAHO’s Role (Peru); • Regional and Global Public Health Goods in the 21st Century and Their Relationship with PAHO’s Mandate (Argentina); • Modalities of Technical Cooperation in Health (Costa Rica); • Governance of PAHO (Barbados). First draft on the Challenges in Public Health in the Americas for the Coming Years is presented as Annex III.
Addendum CE134/6, Add. I http://www.paho.org/english/gov/ce/ce 134-06a-e.pdf
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PAHO in the 21st Century Governing Bodies Process DATE GOVERNING BODY AND SESSION Discussion of the Executive Committee PROGRESS DOCUMENTS AND RELEVANT LINKS Document CE134/FR ; p. 8–15 http://www.paho.org/english/gov/ce/ce 134-fr-e.pdf
27 Sep–1 Oct 2004
45th Directing Council/ 56th Session of the Regional Committee
Progress Report of the Working Group on PAHO in the 21st Century - process still in the review phase, with an exchange of opinions among the actors. Comments made underscore the need to better define certain concepts and definitions, to back up opinions or recommendations better, and to broaden the analysis of some issues. Preliminary analyses mentioned in CD45/18 are presented for the information of the 45th Directing Council. Working Group on PAHO in the 21st Century: Terms of Reference and Work Plan The Working Group is expected to prepare a final report in the form of policy recommendations on how PAHO (Member States and Secretariat) ought to respond to the main health challenges of the Americas at the beginning of the 21st Century and to contribute to the objectives formulated by the United Nations in the Millennium Declaration. The final report will be presented to the PAHO Directing Council in September 2005. Report of the Working Group presented to the Subcommittee on Planning and Programming of the Executive Committee. 5th Meeting of the Group held in February 2005 at PAHO Headquarters in Washington DC. The Working Group’s next steps for 2005 include submission of a progress report on its activities to the Subcommittee on Planning and Programming in March 2005, an update to Member States during the World Health Assembly in May 2005, and a final report to the next Executive Committee and Directing Council meetings. Annex 1 (of Doc. SPP39/7) indicates in greater detail the key milestones for the Working Group in the coming months.
Document CD45/18 http://www.paho.org/english/gov/cd/C D45-18-e.pdf Document CD45/INF/4 http://www.paho.org/english/gov/cd/c d45index-e.htm Document CE135/6 http://www.paho.org/english/gov/ce/ce 135-06-e.pdf
1 Oct 2004
135th Session of the Executive Committee
16–18 Mar 2005
39th Session of Subcommittee on Planning and Programming of the Executive Committee
Addendum SPP39/7, Add. I http://www.paho.org/english/gov/ce/sp p/spp39-07a-e.pdf
Annex
Annex
PAHO in the 21st Century Governing Bodies Process DATE GOVERNING BODY AND SESSION PROGRESS The consolidated document on the discussions of the Working Group as of 18 February 2005 is attached as the Annex 2 (of Doc. SPP39/7). This document summarizes the contributions of the Working Group. Report of the Working Group on PAHO in the 21st Century presented to the Executive Committee. The Working Group (WG) held six meetings and identified the main challenges to public health in the Region, as well as the role of international cooperation in addressing them. WG members and participants divided up the topics identified and prepared documents as inputs for this report. This document, which the WG submitted to the Executive Committee, was the final report, the product of the deliberations and agreements reached in the WG. The report has seven sections: introduction, a description of the strategic challenges for public health in the Americas, international cooperation in health and the role of PAHO, PAHO governance, financial and human resources of PAHO, technical cooperation approaches and strategies, and, in the final section, the WG’s recommendations on PAHO in the 21st Century. Executive Committee decides to: Request the Secretariat to submit a proposal to the 137th Session of the Executive Committee on the process for streamlining the governance mechanisms of the Organization, particularly in regard to: (a) reform and simplification of the Subcommittees, (b) the process of electing the Director of the Pan American Sanitary Bureau, and (c) improvement and strengthening of the rules and procedures of the Governing Bodies, taking into account the recommendations made in the report of the Working Group on PAHO in the 21st Century, the deliberations of the Subcommittee on Planning and Programming, the deliberations and recommendations of the Subcommittee on Women, Health, and Development, and those of the 136th Session of the Executive Committee. 19 DOCUMENTS AND RELEVANT LINKS
20–24 Jun 2005
136th Session of the Executive Committee
Addendum CE136/5, Add. I http://www.paho.org/english/gov/ce/ce 136-05a-e.pdf
Document Decisions of the 136th Session of the Executive Committee http://www.paho.org/english/gov/ce/ce 136.d1-3-e.pdf
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PAHO in the 21st Century Governing Bodies Process DATE GOVERNING BODY AND SESSION PROGRESS Document entitled “Update on the Progress of Institutional Change within the Pan American Sanitary Bureau” is presented to the 136th Executive Committee for its information. It provides a status report on progress made in institutional change during 2004-2005 and introduces monitoring milestones and expected results of the change process for the period 2005-2007. This document introduces the PAHO Roadmap for Institutional Transformation to the Executive Committee, reporting on the parallel and complementary internal efforts at institutional strengthening that have been ongoing since 2003. Discussions of the Executive Committee DOCUMENTS AND RELEVANT LINKS Document CE136/14 http://www.paho.org/english/gov/ce/ce 136-14-e.pdf
20–24 Jun 2005
136th Session of the Executive Committee
26–30 Sep 2005
46th Directing Council/ 57th Session of the Regional Committee
Final Report of the Working Group on PAHO in the 21st Century presented to the Directing Council. The report includes recommendations in the following areas: • Public health goods • Science, technology, research, and strategic supplies • Development of associations and partnerships and the role of PAHO • Technical cooperation modalities in health • Governance • Human Resources For more detailed information regarding these recommendations, please refer to p. 24 of the report. Resolution CD46.R2 regarding the Institutional Strengthening of the Pan American Sanitary Bureau Specific mandates: 2. To acknowledge the report of the Working Group on PAHO in the 21st Century and its recommendations. 3. To commend the Director for the institutional changes within the Pan American Sanitary Bureau implemented to date.
Document CE136/FR; p. 18–22 http://www.paho.org/english/gov/ce/ce 136-fr-e.pdf Document CD46/29 http://www.paho.org/english/gov/cd/C D46-29-e.pdf
26–30 Sep 2005
46th Directing Council/ 57th Session of the Regional Committee
Resolution CD46.R2 http://www.paho.org/english/gov/cd/C D46.r2-e.pdf
Annex
Annex
PAHO in the 21st Century Governing Bodies Process DATE GOVERNING BODY AND SESSION PROGRESS 6. To request the Director to: (a) implement the recommendations of the Internal Auditor; (b) complete the implementation of the recommendations of the Special Report of the External Auditor, particularly those focusing on complaints management systems and human resources; (c) take into account the findings of the report and recommendations of the Working Group on PAHO in the 21st Century, the institutional changes within the Pan American Sanitary Bureau, and the recommendations of the Special Report of the External Auditor, when preparing the next Strategic Plan for the work of the Pan American Sanitary Bureau. Report of the working group on streamlining the governance mechanisms of PAHO DOCUMENTS AND RELEVANT LINKS
19–23 Jun 2006
138th Session of the Executive Committee
Document CE138/5 (Eng.) http://www.paho.org/english/gov/ce/ce 138-05-e.pdf Addendum (summary notes) CE138/5, Add. I http://www.paho.org/english/gov/ce/ce 138-05a-e.pdf Resolution CE138.R20 http://www.paho.org/english/gov/ce/ce 138.r20-e.pdf Resolution CE138.R22 http://www.paho.org/english/gov/ce/ce 138.r22-e.pdf Resolution CE138.R13 http://www.paho.org/english/gov/ce/ce 138.r13-e.pdf Resolution CE138.R12 http://www.paho.org/english/gov/ce/ce 138.r12-e.pdf
Resolution CE138.R20 Report of the working group on streamlining the governance mechanisms of PAHO: Process for the election of the director of the Pan American Sanitary Bureau Resolution CE138.R22 Report of the working group on streamlining the governance mechanisms of PAHO: Improvement of the Rules OF Procedure of the Directing Council Resolution CE138.R13 Report of the working group on streamlining the governance mechanisms of PAHO: Abolishment of the Subcommittee on Women, Health, and Development Resolution CE138.R12 Report of the working group on streamlining the governance mechanisms of PAHO: Establishment of the Subcommittee on Program, Budget, and Administration 21
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PAHO in the 21st Century Governing Bodies Process DATE 25–29 Sep 2006 GOVERNING BODY AND SESSION 47th Directing Council/ 58th Session of the Regional Committee PROGRESS Update on the process of institutional strengthening of the Pan American Sanitary Bureau In consideration of Resolution CD46.R2, this document provides a status report on the process for institutional strengthening of the Pan American Sanitary Bureau, including progress made on initiatives and the institutional change being undertaken by the Secretariat. The work reflects the Bureau’s commitment to the implementation of the Strategic Plan for the Pan American Sanitary Bureau for the Period 2003-2007 and incorporates the recommendations of the Working Group on PAHO in the 21st Century, Internal and External Auditors’ reports, and the report of the Joint Inspection Unit. Resolution CD47.R4 Process for the Election of the Director of the Pan American Sanitary Bureau Resolution CD47.R6 Improvement of the Rules of Procedure of the Directing Council DOCUMENTS AND RELEVANT LINKS Document CD47/33 http://www.paho.org/english/gov/cd/C D47-33-e.pdf
Resolution CD47.R4 http://www.paho.org/english/gov/cd/C D47.r4-e.pdf Resolution CD47.R6 http://www.paho.org/english/gov/cd/C D47.r6-e.pdf
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Annex