EXECUTIVE BOARD Special session on WHO reform Provisional agenda item 3.1
EBSS/2/INF.DOC./8 25 October 2011
WHO reform
The Director-General has the honour to transmit to the Executive Board the report provided on behalf of the Regional Committee for the Western Pacific, in line with operative paragraph 4 of decision EB129(8). The report is provided in the annex.
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ANNEX REPORT OF THE REGIONAL COMMITTEE FOR THE WESTERN PACIFIC
COORDINATION OF THE WORK OF THE WORLD HEALTH ASSEMBLY, THE EXECUTIVE BOARD AND THE REGIONAL COMMITTEE: Item 16 of the Agenda (document WPR/RC62/11) • WHA64.2 WHO reform and EB129(8) WHO reform for a healthy future
The DIRECTOR, PROGRAMME MANAGEMENT, introduced the item, explaining that the overall goal of the WHO programme of reform was to ensure that WHO adapted to a world that had changed significantly since the founding of the Organization. He outlined the three main aims of the reform: greater coherence in global health, with WHO playing an enabling role; improved health outcomes, meeting the expectations of Member States and partners; and an effective, efficient, responsive, objective, transparent and accountable organization that was "fit for purpose". He also noted the areas covered by the main proposals for financial and managerial changes. As requested in Decision EB129(8), he called on the Regional Committee to engage in strategic discussions regarding the WHO reform process in order to provide input to the special session of the Executive Board scheduled for November 2011. The representative of FRANCE summarized the principles that her country would be upholding during the special meeting of the Executive Board to be held at the beginning of November 2011. WHO should refocus itself on its main normative functions, which were standardization, making recommendations, health monitoring and technical assistance. The budgets required for the proposed reform should be reviewed, especially those for the proposed new structures. The work of the regional committees should be aligned with the outcomes of the World Health Assembly. In order to ensure the independence of the Organization, especially with regard to the profit-making private sector, any consultative mechanism with such parties should be subject to principles defined by public authorities, as health was a global public good. The representative of CHINA said that the overview of the reform process presented in the concept document was comprehensive, but the five core areas of business were too broad, covering all of WHO’s work; furthermore, those areas were very similar to WHO's current six core functions. The areas should be described in more detail. With respect to governance, that of countries, the regions and WHO Headquarters should be more clearly differentiated, with a clear system of accountability. An
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outcome-based evaluation was needed of the Organization: WHO Headquarters should focus on technical standards, guidance and guidelines; the regional and country offices should focus on support to Member States in implementing work, so that accountability was more clearly defined, and management and governance were more pragmatic and effective. Financing should be handled by a dedicated agency or office, to avoid internal, irrational competition. With regard to innovative financing, WHO should accept donations from nongovernmental organizations and corporations. He welcomed the proposed independent evaluation of WHO, but, given the limited time and resources, the evaluation should be selective. It might be based, for example, on primary health care, which provided telling case studies that were typical and representative and could be used as indicators of the feasibility of the strategies, planning and implementation proposed by the governance of WHO. The proposed world health forum would reflect the dynamics of the current scenario, which was that there were now more diversified partners and financing channels. WHO was the only health organization in the United Nations family and should therefore play a more important role. The forum would be a platform for expressions of opinion by partners and nongovernmental organizations, which would provide information for decision-making by the World Health Assembly. The concept paper did not, however, clearly state the positioning or the organization of the proposed forum. It should be an informal discussion, and the outcomes should be submitted to the Executive Board, which would formulate resolutions for consideration by the World Health Assembly, if necessary. To ensure wide representation and pragmatic outcomes, there should be a limited number of invited participants, chosen on the basis of geographical distribution; nongovernmental organizations should be included. The financing of WHO reforms should be derived from a set proportion of countries' assessed contributions. China would be actively involved in the WHO reform process. The representative of JAPAN said with regard to WHO governance that streamlining of the three layers of the WHO structure was important, with greater coordination and clear delineation of each. As mentioned in the concept paper on managerial reform, qualified experts should be allocated to the right positions, for example with the roster system for human resource management. With regard to the proposed open-ended working group, his country recognized the importance of the participatory approach but considered that maximal use should be made of existing structures: the World Health Assembly, the Executive Board and the Programme, Budget and Administration Committee of the Executive Board, rather than creating a new body at a time of financial difficulty. Similar reservations applied to creation of a world health forum, given that the views of multiple stakeholders were expressed in the World Health Assembly.
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The most difficult and important issue in WHO reform was assessed and voluntary contributions and their relation to financial flexibility. The suggestion by the WHO Secretariat—to increase the percentage of the Organization's budget that is predictable to at least 70%—would require further discussion by Member States. Japan would work with other Member States, current donors and emerging economies to stabilize WHO's financial situation. The representative of the REPUBLIC OF KOREA commented on the changing global health environment, which required rapid joint responses to health emergencies and the prevention and control of noncommunicable diseases in a climate of financial restraint in donor countries. With respect to governance, WHO must strengthen its leadership in setting the direction of programmes involving multiple stakeholders, clarifying the role of each, so as to avoid duplication and ignoring areas of need. His Government expected WHO to take the lead in discussions on improving the current situation in the world health forum. It would not be enough, however, to create interaction channels; a separate mechanism should be established to collect information on the work of different actors, in order to promote coherence, execute funds in an integrated manner and analyse programmes comprehensively. With regard to WHO's internal governance, the functions of Headquarters and the regional and country offices should be coordinated, to maximize performance in countries. Headquarters should focus on high-priority core business, and delegate regional issues to the regional offices. With respect to the information provided by WHO, Member States reported their health situations to WHO, but they did not receive adequate feedback in a form that suited their needs. Budget execution should be more fully disclosed. It was difficult for Member States to judge whether funds were being used transparently and efficiently on the basis of the general information provided to the World Health Assembly and the Executive Board. His Government pledged its full support to the discussion on WHO reform and the development of an action plan. The representative of AUSTRALIA said that reform was always difficult, but it was even more difficult at a time of financial restriction and global health crises. Work progressed through the World Health Assembly and the regional committees, but Member States appeared to be schizophrenic: they wanted WHO to be economical, highly targeted and efficient, but they wanted WHO’s support immediately. Member States should therefore reform their view of what they expected of the Organization. The representative of China had pointed out that the five core areas could include all the work of WHO. The challenge was to exercise discipline and to identify priorities. She welcomed the
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focus in the concept papers on increasing transparency and improving governance. WHO’s role must be clarified, both internally, in terms of the instruments available to the Organization to carry out its work , and with respect to others. With regard to the proposed world health forum, there were many more players in the global health family than before, and it would be important to understand their business and motivation and use their capacity in order to improve global health. The purpose and the nature of the engagement must, however, be clear. Management and governance were crucial in the reform process to ensure streamlining, improved coordination and clarity with regard to the functions of Headquarters, the regional offices and the Member States. Even if the instruments of the Organization were reformed, however, the Member States must define the real priorities. All countries were undergoing financial strain. The assessed contributions did not cover the majority of WHO’s work; therefore, the strategic objectives should be reconciled with the available resources. She looked forward to further discussion at the upcoming meeting of the Executive Board. She asked the Director-General to define the reform agenda precisely, not with vague language to address sensitive issues. There must be a mature discussion among Member States to address the crucial issues for global health. The DIRECTOR-GENERAL said that the reform had been initiated to ensure that WHO remained relevant and addressed both its existing agenda and emerging problems. Member States were shareholders of WHO. If WHO were run only by international civil servants, there would be no monitoring of resource expenditure; that was the responsibility of its 194 Member States. When the Organization had been founded 64 years previously, it had been the only multilateral health organization in the world. Now, there were many global players, including civil society, academia, research institutions and the private sector. Governments alone could not improve health. As the representative of France had said, health was a global public good. WHO must find ways to work with all stakeholders to find public health solutions. The budget that Member States approved every two years represented only 20% of its budget. The other 80% consisted of voluntary contributions, mainly from countries of the Organisation for Economic Co-operation and Development and also from foundations and other United Nations agencies. Collectively, only 52% of the budget was received from Member States. Only 20% of the budget, that part received as assessed contributions, was flexible; the remainder was closely earmarked, as required by national legislation, and could not be used for work in other areas.
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That meant funding gaps in many areas; the situation also meant that funds were unpredictable. During the World Health Assembly in May 2011, 28 resolutions had been drafted, negotiated, revised and finally approved, but the majority could not be implemented because of lack of financing. Because of the diversity of Member States, objections would be made to cutting any programme owing to lack of funds. It was up to Member States to define priorities; then, they should negotiate which of them could be financed. Some countries expressed conflicting directions in the regional committees and at Headquarters. A world health forum had been proposed to give a voice to stakeholders other than Member States; it would not usurp their decision-making power. Before Member States set the direction and priorities of the Organization, they should be aware of what those other entities could contribute. All the regions should agree on constitution of the forum. As it had been proposed that existing mechanisms could be used, options other than the forum would be presented at the special meeting of the Executive Board. Consultations with civil society and the business sector had been successful in the case of pandemic influenza preparedness, and that model for capturing the views of stakeholders had not incurred further costs. WHO needed its partners, such as the Global Fund and Roll Back Malaria. The aim of the reform was not to expand WHO membership but to consolidate existing partnerships. Some Member States that were on the board of such organizations took different stands in regional committee meetings and in their roles as representatives of partners. Another problem was that decisions on priorities in the World Health Assembly were often taken by ministers of health, whereas funding was decided on by ministers of foreign affairs or development, who might not have the same priorities. It was up to Member States to align their priorities with those of their funding bodies. Responding to the representative of the Republic of Korea, she said that the Secretariat would give more details for expenditure of the 20% of real money that the budget represented. As the donors of voluntary contributions were unwilling to pay all or any of the 13% programme support costs, WHO had to cross-subsidize such contributions with assessed contributions, acting as subcontractor to governments and agencies. Only a few countries allowed for flexibility in their voluntary contributions. With respect to internal governance, all regions expected WHO to strengthen country offices to improve country performance They also wanted Headquarters to concentrate on setting standards and issuing guidelines. However, the regions also had an important role to play. It had been suggested that
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WHO should abolish its regional offices, but in her view they played a vital, cohesive role. There were more and more regional and subregional entities that could become involved in implementing programmes and the regional office had a key role in that respect , as well as in helping countries to learn best practices from each other.. Coherent interaction among different agencies was important. WHO sometimes went beyond its mandate, but so did other organizations, which acted as implementing agencies when their role was in financing. Many countries were members of a wide range of agencies, but they did not maintain synergy in the priorities of those agencies. It was important to improve the alignment among the various Governing Bodies of WHO, such as improving the coherence between the World Health Assembly and regional committee meetings. It was the role of the Executive Board to maintain oversight of the Organization's work, but it was acting more like a mini-Assembly. It was up to countries to oversee the work of the Board but not to interfere in that work. (She had learnt at the Regional Committee Meeting of the Americas that the term 'openended working group' was considered in that Region to refer to a working group in which there was no negotiation. In the concept paper submitted to the Executive Board at its special session, therefore, the term would be changed.) It would be up to the Member States to ensure that the special session was effective. Every item could not be discussed by all 194 Member States, so countries should form a committee to ensure that the Secretariat moved forward. In response to the remarks of the representative of China, she agreed that the five core areas of the Organization covered all its activities and were eternal. WHO was the only democratic health organization in the world in which each country had one vote, ensuring representation and legitimacy. Each regional director decided in consultation with Member States which global priorities applied to the region. The success of WHO depended on strengthening the country offices, and informing and empowering country offices was the first priority of the reform. With respect to innovative financing, it would not be realistic to increase assessed contributions in the short term. Countries could contribute by providing bilateral support, experts or commodities, depending on their levels of development. In response to the comment that the core areas lacked detail and clarity, she said that a consolidated report would be prepared combining the three concept papers, which would contain all the options, proposals and choices discussed at the regional committee meetings. With regard to managerial issues, countries should indicate the directions they wished WHO to take, and the details would be added at Headquarters. The right level of detail would be struck in the final document, without making it unreadable.
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She agreed with the representative of France that WHO should refocus its work on its normative function, technical support, monitoring and evaluation. Although health was a global public good, the private sector could make a reasonable profit once it had declared its interests. It would have no influence on WHO's normative function. None of the regions had asked her not to reform WHO. The Organization had to adapt to changing circumstances. The reform would be a continuous process, some actions being taken rapidly while strategic decisions would require more discussion. Member States agreed that an independent evaluation of WHO's performance in health systems strengthening was important. It had been suggested that a more comprehensive overall review be conducted, without involving an outside consultation consortium, but views differed on the scope and conduct of such a review. Managerial reform should be discussed on the basis of results-based planning, management, monitoring, evaluation and accountability. With regard to the financing of the Organization, work at the three levels should be synergistic but also attributable to the organizational level at which it was done. The DIRECTOR, PROGRAMME MANAGEMENT, said that a key input to the special session of the Executive Board would be a consolidated paper bringing together the three components of the proposed WHO reform, with their links. The second input would be a report on the conclusions of the six regional committees. The Board's decisions would be transmitted to its next session, in January 2012, and then to the World Health Assembly. The CHAIRPERSON recalled that the Member States were WHO. They must therefore reform themselves, especially as ministers of health.
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