World Health Organization Organisation mondiale de la Santé EXECUTIVE BOARD 102nd Session Provisional agenda item 5.1 EB102/2 27 April 1998
WHO reform WHO country offices: criteria for classifying countries on the basis of need Report by the Director-General
In January 1998, a report on WHO country offices, focusing on the development of criteria for establishing a WHO country office that emphasize the priority placed on countries in greatest need, was presented to the Executive Board.1 The report proposed appropriate mechanisms for WHO representation and coordination at country level according to the economic development and health status of the Member States, and considered also how the functions could be improved while concentrating more of WHO’s scarce resources in countries in greatest need. The Executive Board decision EB101(6), inter alia, requested the Director-General to develop further the criteria for classifying countries on the basis of need, in conformity with those provided in resolution EB101.R10 on regular budget allocations to regions, and to report on the results to the Executive Board at its 102nd session.
INTRODUCTION 1. An objective of WHO at country level is inter alia to support governments, upon request, in strengthening health services to provide information, counsel and assistance in the field of health and to establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health administrations and professional groups. Various ways in which the Organization’s activities can be coordinated at country level, from a large WHO country office (in a country in greatest need) to no actual representation (as in developed countries), were suggested in document EB101/5 together with criteria for various types of representation. 2. As health and economic status improve, the need for technical cooperation should change, which also implies both a change in the WHO resources allocated at country level and in WHO representation.
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3. Various mechanisms to adjust the present method of allocating WHO’s resources at country level have been suggested, taking into account population size, and using the Human Development Index and immunization coverage as indicators for WHO country contributions. 4. This report reviews the usefulness of these criteria for the flexible adaptation of WHO coordination at country level.
POPULATION COMPONENT 5. The population of WHO Member States and Associate Members ranges from 1600 (Tokelau) to 1 243 738 000 (China). Three categories of countries were defined according to their population size: countries with a population of less than 300 000 (31 countries); countries with a population between 300 000 and 50 million (146 countries); and countries with a population of more than 50 million (22 countries). 6. For countries with a population of less than 300 000, which receive a limited regular budget allocation and for which the Human Development Index is usually not available, it is suggested that less costly arrangements other than WHO country offices, such as liaison offices or shared country offices, be utilized. At present all of these countries except five are already using liaison offices or shared offices. 7. In the 17 developing countries with a population exceeding 50 million (Bangladesh, Brazil, China, Egypt, Ethiopia, India, Indonesia, Islamic Republic of Iran, Mexico, Nigeria, Pakistan, Philippines, Russian Federation, Thailand, Turkey, Ukraine and Viet Nam), owing to the magnitude of their health problems, ministries of health are usually supported by the donor community, including other organizations of the United Nations system, through an important technical field presence. In these countries the tasks of advocating WHO policies, providing high-level policy advice to the government and to donors, and helping the government coordinate external assistance require a strengthened WHO country office. Some of these countries also house regional offices for various organizations of the United Nations system or development banks, which require WHO presence to ensure that health aspects are given due consideration in their activities. In some of these countries WHO country offices also administer the subregional activities in smaller surrounding countries. 8. For all other countries, representing the majority of WHO Member States, the suitability of using indicators proposed for WHO regular budget allocation was reviewed.
HUMAN DEVELOPMENT INDEX AND IMMUNIZATION CRITERIA FOR THE ESTABLISHMENT OF WHO COUNTRY OFFICES IN COUNTRIES WITH A POPULATION SIZE OF BETWEEN 300 000 AND 50 MILLION 9. The Human Development Index is a composite index strongly correlated with other health indicators such as maternal mortality rate, infant mortality rate and under-five mortality rate. However, it tends to give greater emphasis to socioeconomic development and to respond slowly to changes in health services. A rapid improvement in health services may therefore not necessarily translate into an equally rapid change in the Index. 10. Immunization coverage for diphtheria, pertussis and tetanus (DPT3) is the only widely available index reflecting health service performance. Having a relatively low correlation with the Human Development Index, it is attractive as a supplementary index. However, immunization coverage should be used with caution as a substitute for performance of health services, as it can vary rapidly, for example, after an intensive immunization campaign. Furthermore, as countries are rapidly closing the gap between the ideally achievable immunization coverage and their current coverage, other widely available health service performance indicators are needed.
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COUNTRY BUDGET ALLOCATION AND OTHER INDICATORS 11. As this report was written during the period in which the budget allocation model was being reviewed, it was not possible to use the likely size of WHO country allocations as a criterion for determining the level of representation at country level. However, the size of the WHO country allocation and of the extrabudgetary funds and other contributions administered by WHO at the country level are clearly a major factor in determining the size of the WHO country office and the numbers and type of staff. 12. More qualitative information on, for example, exposure to emergencies, equity, capacity to implement programmes and activities, as well as the need to effect coordination with other agencies that have large country or regional offices, existing subregional (intercountry) or interregional programmes, for example, should be used for further adjustment.
SUGGESTED GROUPING OF MEMBER STATES WITH A POPULATION SIZE OF BETWEEN 300 000 AND 50 MILLION 13. The Human Development Index (HDI) and immunization coverage already proposed as indicators for the allocation of resources at country level might be used to group Member States according to their economic and health status and to the performance of their health services, especially in the vast majority of countries where the population is between 300 000 and 50 million. Suggested ranges of indicator for the four categories of countries identified in document EB101/5 are shown in the table.
SUGGESTED RANGE OF INDICATORS FOR CLASSIFYING COUNTRIES WITH POPULATION 300 000 TO 50 MILLION Human Development Index 0.000-0.699 0.000-0.699 0.700-0.899 >0.900 and or and and Immunization coverage (%) <60 <60 60-80 >80
Countries Group 1 Group 2 Group 3 Group 4
Suggested level of WHO representation Strengthened WHO country office Limited WHO country office Liaison office Focal point at national level supported by national authorities
14. It should be emphasized that these ranges are to be used flexibly and for guidance only when grouping countries. The indicators will help to establish a common assessment framework for all WHO regions. It will be necessary to establish a fixed schedule for reassessing the situation as well as for preparing guidelines to encourage the use of other mechanisms for coordination at country level. 15. The precise extent and composition of WHO country presence should be jointly decided by the government and WHO taking into account, in addition to the above criteria, the national health priorities and WHO priorities, the capacity of the country health system and the aims of bilateral and multilateral cooperation.
ACTION BY THE EXECUTIVE BOARD 16. The Board may wish to recommend the following:
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(1) Regional Directors should determine, in consultation with countries, whether the type of WHO representation in each country is appropriate, taking into account the Human Development Index and immunization coverage as indicators, and retaining the possibility of modifying representation in some countries; (2) Regional Directors should report to the Director-General on their progress in reassessing and redefining WHO representation according to specific needs and situations in countries; (3) the Director-General should develop guidelines for Member States, according to national capacity, to assume greater responsibility for coordination with the Organization.
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