TWN Info Service on Health Issues (Jul11/01)
28 July 2011
Third World Network

Dear All, 

Please find below a news report on the concept papers on reform recently released by WHO.

WHO held a mission briefing in Geneva on 1 July and thereafter released a summary of the discussion that took place during the mission briefing. The report below also contains the summary of the discussion. 

Sangeeta Shashikant
Third World Network

WHO: Vague and inadequate reform plans criticised, nothing on financing
Published in SUNS #7197 dated 25 July 2011

London, 22 Jul (Sangeeta Shashikant) -- Preliminary proposals for reform of the World Health Organisation (WHO) have been questioned and criticised.

Dissatisfaction with WHO's reform plan was revealed following a mission briefing held on 1 July 2011 by the WHO Secretariat for Geneva-based government delegates on the first draft of concept papers on the "World Health Forum", "Governance of WHO" and "Independent Formative Evaluation of the World Health Organization".

The concept papers released at the end of June and discussed with Geneva-based missions were required by decision 129(8) of the Executive Board (EB) as part of the move to set out a more transparent and inclusive process for the reform of WHO.

The concept papers do not address the most pressing issue in WHO, that is, the poor financial health of WHO. Addressing the financing of WHO was Director-General Dr. Margaret Chan's raison d'etre for embarking on the reform and the basis on which Member States supported her call for reform. And yet, mention of the matter is conspicuously missing from the papers.

[At present, Member States' assessed contributions only constitute 18% of WHO's budget. Voluntary contributions, most of it earmarked for specific projects, make up the rest.]

The EB decision also requires the creation of a platform for web-based consultations by the end of July 2011. As per the decision, regional committees are expected to hold strategic discussions on the reform process based on concept papers to be updated after Geneva-based consultations. The outcome of the regional meetings, the consultative process, and the draft proposals prepared by the Secretariat or proposed by Member States on the reform are to be considered by a Special Session of the EB that will take place on 1-3 November 2012.

The reform of WHO has taken centre stage following the last World Health Assembly in May, which saw Dr. Chan pressing for the endorsement of her report titled "The Future of Financing for WHO" (A64/4) that contained a broad, far-reaching reform agenda that would reshape the way in which the organization operates, is governed, makes decisions and is financed.

During the Assembly, several Member States expressed their discomfort over some aspects of the Director-General's reform plan, but these concerns were skilfully side-stepped by Dr. Chan, leading to the rapid adoption of the Secretariat's resolution on the reform process, which did not measure up to Member States' expectations (see SUNS #7155 dated 23 May 2011).

However, Member States' discontent with Dr. Chan's approach to reform continued to brew, forcing the matter onto the agenda of the EB that met on 25 May immediately after the conclusion of the Assembly (see SUNS #7163 dated 6 June 2011).

WHO's official summary of discussions on the mission briefing (not open to NGOs or the public) on the first draft of the concept papers reveals a general discontent by Member States with the WHO's approach to reform.

An analysis of the concept papers also reveals many shortcomings. For example, the paper on the World Health Forum (WHF) fails to justify the need for an additional forum in times of financial difficulties and to distinguish between public interest NGOs and commercial entities. As such, the paper does not address the concern that the WHF will provide strategic opportunities to the private sector to influence WHO's health agenda and the issue of conflicts of interest.

The paper on independent evaluation is limited in scope, with inappropriate time-lines that would hamper it in informing the reform process, as well as problematic proposals on how the evaluation will be undertaken. The paper on governance of WHO simply lacks basic details on the reforms proposed.

Many of these observations were also made by Member States during the mission briefing, some of which have been captured by WHO's official summary of the mission briefing.

General observations made by participating Member States were also noted by the official summary. Member States pointed out that, "The areas covered by the reform programme go beyond the three concept papers" and that, "There is a need to ensure appropriate linkages between the three papers". Further, "While the reform process should remain Member States driven, the Secretariat is encouraged to provide analyses and options to facilitate discussion among Member States".

The Secretariat has also been tasked with providing "a paper with an overview of the whole reform package"; "an additional concept paper on managerial reforms"; and "figures on the project costs for the development of the reform programme".

[Observations on each of the concept papers were also contained in the official summary. These observations are noted below following an analysis of each of the concept papers.]


According to the concept paper, "there is a need to promote greater coherence and to provide an opportunity for a more inclusive dialogue between the many different actors involved". It added that "at present ... there is no single platform that allows interaction between governments, global health organizations, partnerships, regional organizations, multilateral and bilateral agencies, philanthropic foundations, CSOs (civil society organisations), private sector organizations and other relevant stakeholders".

It claims that the Forum will make it possible "to capture a wide range of views and perspectives on major and future issues in global health" adding that, "It will not take decisions affecting individual organizations, nor will it change the decision-making prerogative of WHO's own governing bodies".

The paper proposes that the first Forum be held over three days in November 2012 and once established will be convened every two years for a further two cycles after which it will be reviewed. It also proposes that the Forum will be open to all Member States and other stakeholders but the participation should be "small enough to allow structured debate and clear conclusions".

The paper anticipates the costs to amount to $775,000 with participants largely self-financing their participation. According to the paper, the WHO Director-General will convene a steering committee of Member States and organizations to oversee preparations once the proposal is finalized in January 2012.

This WHO concept paper fails to address the many concerns of Member States and civil society raised during the World Health Assembly and the subsequent EB session last May. The suggested Forum seems to be the making of an "exclusive club" rather than an "inclusive" setting, as it is only open to a select group of entities. Moreover, to increase engagement with voices less heard, perhaps the first step should be to improve WHO's engagement with civil society by simplifying the accreditation process, allowing NGOs the freedom to make interventions without scrutiny and censorship by the Secretariat and the holding of public hearings.

The added value of an additional forum such as the Forum is questionable particularly so at a time when the WHO is in financial difficulties and is attempting to rationalize its governance structures.

The concept paper is premised on the assumption that all stakeholders are interested in advancing public health. It fails to distinguish between public interest CSOs and the commercial sector (including entities with strong links with the private sector) as well as the varying commercial or other interests that the stakeholders may have.

According to a civil society letter signed by 11 public interest groups and networks, the Forum poses "a clear risk of institutionalizing conflicts of interests in WHO". However, the concept paper fails to acknowledge the likelihood of conflicts of interests. For instance, it is unclear how WHO will ensure that influential industries such as the pharmaceutical, food and beverage industries will not influence policy-making and norm-setting in the context of WHO, through the Forum.

On a similar note, it also seems naive to assume that the Forum will capture the views of all stakeholders in an appropriate way since views are likely to vary, often with significant divergent positions. It is also more likely to be the case that the voices of a few, such as donors, private sector and other organizations close to the WHO Secretariat are likely to be captured in the conclusions of the Forum, while giving the misleading impression that it represents the view of all stakeholders.

Despite WHO's claim that the WHF will not change the decision-making prerogative of WHO's governing bodies, it is simply unlikely that conclusions emerging from the forum (that is, attended by powerful and influential health players) will not have an impact on the decisions taken by Member States at the EB. It is apparent that the WHF will provide strategic opportunities to international health players, in particular, to the donors and private sector to influence WHO's health agenda.

Several of these concerns were also raised by Member States and have been captured by the official summary.

The summary notes that several countries questioned the added value of the Forum, with concerns raised as to whether the Forum "would serve as an effective forum for hearing the voices of other stakeholders, e. g. whether civil society organizations and local communities would be engaged in the process; and how potential conflicts of interests would be addressed if the private sector participates".

There were also concerns about "the role of [the Forum], the duplication with existing forums, and whether discussions at [the Forum] would be infringing on the decision-making authority of [the World Health Assembly] and EB".

Member States also noted that "Further deliberation [was] required on the criteria for invitation, the rules of engagement, as well as the number of participants", "noting the need to get a balance between inclusiveness and having a manageable number that allows focussed and strategic discussions".

Member States also requested that the Secretariat provide "further details on the estimated costs which appear to be an underestimate; and whether the resources will be derived from WHO's existing budget or will require additional funding". Member States further questioned whether it was "premature" "to decide whether the [Forum] should be convened every two years for a further two cycles, and suggested to review after the first [Forum]".


The concept paper on independent evaluation prepared by the WHO is a proposal to conduct evaluation on its programme on health systems strengthening (HSS). The paper puts forward three aims for conducting this evaluation: (i) to develop an approach to independent evaluation of the work of WHO to improve programme performance; (ii) to enhance work in the area of health systems strengthening; and (iii) to inform the reform process.

On the link to the reform process, the paper notes: "An independent formative assessment of a thematic area of work for the Organization will also contribute to shaping and guiding several elements of WHO reform, for example, improving results-based planning and accountability, and increasing WHO's effectiveness at the country level".

The concept paper also proposes that the evaluation be carried out by an independent consortium comprising a multi-disciplinary team of 8-10 individuals, to be selected following a public "Request for Proposals" for an Evaluation Consortium and Work Plan.

The concept paper further states that the EB will provide oversight for the evaluation that includes selecting the consortium, determining and reviewing the terms of reference and work plan as well as receiving regular reports on the activities, observations and recommendations of the Consortium. The Director-General is also expected to propose that the EB establishes a sub-group of the Board as an Evaluation Oversight Committee to carry out the functions.

As WHO is embarking on the path of reform, the call for an independent evaluation is timely. While the concept paper accepts that the reform should be informed by the evaluation, the time-lines suggest that this may not happen. The paper envisages that preliminary findings of the independent evaluation will be available only by May 2012, by which time it is anticipated that specific details of WHO's reform would have been finalized.

Logically, findings of the evaluation should guide the reform of WHO including by identifying areas that need to be reformed and specifying actions that need to be undertaken to effect change. This will ensure that WHO's reform agenda is evidence-based. However, as noted, the time-lines of reform and evaluation are at odds. In addition, the limited scope of the evaluation raises questions as to whether WHO's performance can be evaluated on the basis of evaluation in the sole area of health systems strengthening (HSS).

[HSS covers only 1 out of 8 programme cluster areas of WHO. Hence, other critical programme areas such as Family and Community health; HIV/AIDS, TB, Malaria and neglected diseases; Non-communicable diseases; Innovation, Information and Evidence and Research; and Health Action in Crisis, that are of critical importance to developing countries will be left out of the scope.]

However, it appears from the concept paper that WHO is determined to embark on reforming the Organisation without the benefit of a comprehensive independent evaluation.

The concept paper also proposes a bidding process from which the consortium will be selected, adding that the consortium will be free of conflicts of interests. However, the paper fails to shed light on whether WHO will be targeting consultancy service providers such as McKinsey/Deloite, or academia or CSOs or all of the above including private sector entities.

It also does not set out the definition of "conflicts of interests" that will apply. For example, would consultancy service providers that provide services to the pharmaceutical and other industries be excluded from the process? Further, the concept paper fails to explain how exactly the process and the selection will be free of conflicts of interests, and the procedure that will be followed if the proposals received through the bidding process are generally not satisfactory.

Following these concerns and shortcomings, it seems inappropriate for an independent evaluation to be conducted by a group of persons selected through a bidding process.

Similar concerns have also been raised by participating Member States. The official summary notes that, "There were questions as to why the focus is put on ‘health systems strengthening'"; and "whether other areas (such as health promotion and prevention) could also be covered".

"There were concerns about the time-line, with proposals to advance the schedule. It was suggested that, instead of waiting for the EB meeting in January 2012 to start the evaluation, the EB bureau could act as the interim oversight team to get the work started earlier", the official summary adds.

According to the official summary, "Questions were raised about the feasibility of using the JIU mechanism for the evaluation" and "It was noted that given the technical and programmatic nature of the evaluation (in para 4 of the paper), this is outside the scope of the JIU". [JIU refers to the UN's Joint Inspection Unit].

The official summary also notes that Member States also requested more information on the selection of the consortium, and that "It was suggested that selection of the consortium should also be Member States driven and conflict of interest must be avoided".

"The Secretariat committed to provide draft Terms of Reference for consultation and review by bureau of the EB".


This concept paper identifies four broad areas for reform.

The first is the need for "the governing bodies' work to be more focussed and strategic so that they effectively carry out their Constitutional functions". This includes "alignment of the governing bodies' resolutions with corporate priorities, ensuring a more strategic and disciplined approach to decision-making by the [World] Health Assembly and enabling the necessary oversight of programme and financial implementation, including the fiscal soundness of Organizational practices."

The second area of reform is better alignment between the global and regional governing bodies, to achieve greater coherence and avoid duplication between the two levels.

The third area of reform proposed is "better sequencing of the different governing body Meetings" which includes "strengthen the role of the Programme, Budget and Administration Committee of the Executive Board, and to review the timing and duration of its meetings in order to increase its oversight and preparatory functions, in particular with regard to the consideration of the Proposed programme budget; to ensure that the Board and its committees address a number of issues - especially managerial matters - more effectively and take final executive decisions on them without referral to the Health Assembly; to plan a leaner but more substantive agenda of agreed technical and policy priorities for the Health Assembly and thus facilitate more strategic debate; to explore the need for further subsidiary bodies of the Board, for example, on programme development; and to consider a more tactical use of the Independent Expert Oversight Advisory Committee, for example, requesting it to perform thematic reviews".

The fourth area of reform proposed is the "promotion of more active engagement and participation of all Member States in the governance of the Organization" which includes "more informed participation by all Member States so that the governance processes are truly inclusive; and increased attention to the re-balancing of the way in which Member States exercise their role as informed and active participants of the governing bodies by, for example, provision of sufficient briefing on the historical and technical background of issues under consideration".

The concept paper further suggests the setting up of an open-ended working group of the EB with the mandate of developing the agenda for change in the domain of WHO's governance.

At the May EB, Member States requested the Secretariat to prepare concept papers with the aim of facilitating discussion on WHO reform. However, the concept paper on the "Governance of WHO" fails to provide much insight on the problems related to "Governance", the reasons for reform, the possible solutions and the action that may need to be taken to implement the solutions. For example, while the concept paper speaks of the need for better alignment between the global and regional governing bodies, the paper is silent on the source of, and reason for the lack of coordination and duplication between global and regional governing bodies as well as options to ensure better alignment.

Further, the proposal of an open-ended working group of EB suggests that Member State participation in the working group would be limited. (The EB is limited to 34 Member States already.)

On this concept paper, the official summary notes that "governance of WHO refers not only to ‘governing bodies'", but is a "broader concept". It further notes that "The proposed four areas to be covered in the paper are generally supported", however, "The Secretariat is requested to provide further elaboration, include more analysis and provide some options to facilitate further discussion".

It also states that, "Further information is requested in particular on the following areas - ‘the regional and country offices dimensions', ‘governance at the three levels of the WHO', and ‘the method of work of the governing bodies'".

On the open-ended working group of the EB, the official summary states: "There were questions on whether participation would be restricted to EB members. It was noted that in accordance with the Rules of Procedures of the EB, all Member States can participate on an equal footing. The EB can decide to limit the number of participants, but only in exceptional cases". +