TWN Info Service on Health Issues (Nov11/02)
8 November 2011
Third World Network

WHO: Debate over proposed Reform Agenda and priority-setting
Published in SUNS #7253 dated 3 November 2011

Geneva, 2 Nov (K. M. Gopakumar and Heba Wanis*) -- A proposal for reform of the World Health Organisation (WHO) has evoked concerns among governments.

The Executive Board (EB) of the WHO is meeting in a Special Session convened on 1-3 November to consider the Reform Agenda put forward by Dr. Margaret Chan, the Director-General of the organisation.

Member States, in their opening statements on 1 November, expressed concerns including over the speed of the reform process; lack of information, analyses and independent evaluation to guide the reform; WHO's donor-driven approach and growing partnerships; the scope of independent evaluation; and proposals to limit WHO's scope.

The EB meeting has also decided to establish a process for priority-setting of WHO's programme activities as part of the reform agenda. Member States are now engaged in informal consultations to work out the details of this new process.

This decision was taken following discussion on the proposal on "Programmes and Priority Setting" contained in the Director-General's report on "WHO reforms for a healthy future" (EBSS/2/2).

The consolidated report consists of three chapters dealing with three pillars of reform, viz. programmes and priority-setting, governance, and management reform. It contains a total of 100 specific proposals with 18 recommendations for adoption by the EB.

The consolidated report is based on critical feedback received from Member States on four concept papers prepared by the Secretariat based on an EB decision in May 2011 (SUNS #7197 dated 25 July 2011).

The Director-General's reform agenda proposed in the EB's January session has attracted some controversy particularly over the lack of direction and the process driving the reform. It was hurriedly adopted by a World Health Assembly (WHA) resolution despite concerns expressed over the content and process.

Dissatisfaction with the Director-General's reform agenda led to Member States establishing a more member-driven process at the May EB session following the WHA. The EB meeting also decided to hold a Special Session in November to discuss the reform agenda (see SUNS #7077 dated 31 January 2011, SUNS #7155 dated 23 May 2011, and SUNS #7163 dated 6 June 2011).

Chan, in her opening statement to Member States, noted the unique role of WHO, i. e. its "staying power", adding that WHO's name "carries clout" and emphasizing its role in fighting for prevention.

Chan reassured Member States that WHO, in "the interest of safeguarding public health", was "not afraid to speak out against entities that are far richer, more powerful, and better connected politically than health will ever be", adding that "we need to maintain vigilance against any real or perceived conflicts of interest."

Chan stressed that WHO would "speak out to make sure that developing countries, and health, get a square deal in international negotiations".

"Finally our functions, taken in their entirety, are genuinely unique. The world needs a global health guardian, a custodian of values, a protector and defender of health, including the right to health," Chan added.

Chan also highlighted the reality of a new era of financial austerity, the need for efficiency and measurable results, especially at the country level as well as radically different ways of interlinking responsibilities at (WHO) headquarters, regional, and country levels that share the same objective, noting how rigid and unresponsive WHO's management systems had become.

She noted that, "The case for reform is clear. The world needs a strong WHO to lead global efforts to improve health", adding that "The world needs a WHO that has a wise and broad vision, is quick to act, and never afraid to act in the interests of public health. That is part of safeguarding and protecting health. And that requires a WHO that is effective, efficient, transparent, and accountable".

Chan also noted that, "... some reforms can move forward quickly" while "Others need to be considered with great care".

She also stressed that since the proposal for a World Health Forum received little support, this will not be pursued by the Secretariat.

Member States presented a sobering response to Chan's Reform Agenda.

Senegal, on behalf of the member states of the African Regional Office (AFRO), stated that WHO should continue its leadership in global health governance. It said that an independent evaluation is a prerequisite for any decision regarding WHO reform, adding that the scope of independent evaluation should be broadened to cover the entire organization, its technical activities, management and governance arrangements, with the aim of revealing gaps in the organization, at all levels. An independent evaluation would inform objectively as to the reforms that should be undertaken, it added.

China noted that even though the Director-General's report is more specific than the previous one, the analysis is not sufficiently detailed to inform decision-making. It called for more deliberation, adding that reform should not be finished overnight.

Chile called for more details on each issue, adding that more time was required for discussion among Member States in order to make an informed decision. It also stressed that Member States should take ownership of the reform process and that regional committees should be given time to define priorities. It cautioned that financial issues should not be put above health policies.

Norway stressed the need to build trust among Member States and cautioned against the speed of the reform process, stating that Member States should not go too fast. WHO reform needs broad support in order to be effective, it added. It also said that even though donors have a huge influence in setting priority, all Member States should have an equal say in the priority-setting of WHO. It also stressed the need to strengthen democratic dimensions by ensuring greater coherence between priorities set amongst all Member States and subsequent financing.

India identified three concerns in the context of reform, viz finance, governance and partnership. It said that there was a need for more predictable funds and called for a flexibility of funding up to 50 per cent consisting of both assessed and core voluntary contributions. It noted the importance of strengthening the governing bodies but expressed concern on the proposal to use the Executive Board to restrict access to the World Health Assembly. It also expressed concerns over accountability and the role of partnership in the decision-making process.

Brazil said it views WHO's reform from the perspective of the strengthening of multilateralism, adding that WHO reform should be debated in an open-ended setting so that every single member of this organization can contribute to the reform of an institution that belongs to all of us.

WHO's comparative advantages stem from its legitimacy as a global intergovernmental body, Brazil said, adding that Members cannot lose sight of the increasingly political importance and global character of issues discussed in WHO. Members should benefit from the reform by enhancing interaction between the political and technical dimensions of WHO so as to make sure that WHO will continue to play a leading role in global health.

Brazil said that "there should be no hurry" in reforming WHO, as the implications need to be well understood by all Member States. It added that it is a matter of concern for us that some decisions have already been taken to downsize some units within the Secretariat, further adding that this was done without proper consultations with Member States. It stressed that since WHO is in the midst of a reform process, such decisions should have waited for the results of the reform exercise.

Brazil further said that Members need to engage in a confidence-building exercise and confidence can only come out of a transparent and inclusive process, adding that Members cannot rush into precipitated decisions and there is a need for more time to discuss, understand and make collective and proper deliberations.

Bolivia expressed the hope that the focus on results-based funding would not compromise the multilateral spirit of priority-setting reflected in Article 19 of the WHO's constitution. It also called for the increased involvement of civil society and agreed with India's suggestion on financing to retain the public nature of WHO.

Zimbabwe stressed the need for a Member-State-driven process, adding that priority-setting should be informed by the mandate of the organisation and that financial constraints should not be the only thing that drives priority- setting. It also expressed concerns over the danger of partnerships because it brings vested interests into the WHO.

The EB also began discussion on the proposals contained in the Director-General's consolidated report on WHO's programmatic work.

The consolidated report proposes to limit the WHO's programme activities into five areas, viz. health development (determinants, risks, diseases and conditions); health security (public health and humanitarian emergencies); strengthening health systems and institutions; evidence on health trends and determinants; and convening for better health.

The report further proposes the possibility of priority-settings at two levels of the organisation, viz. flagship priorities and priorities within five core areas of work. Proposed flagship priorities are: communicable and non-communicable diseases; strengthening health systems; increasing equitable access to medicines and vaccines; and support to countries for the achievement of the health-related Millennium Development Goals.

On priority-setting within the five core areas, the report remarks that "the five areas are not priorities per se as they exclude very little, but can be used as a framework for determining what WHO should and should not do".

The report calls for priority-setting by Member States by agreeing to a set of criteria which could include burden of disease, needs and demand of Member States, and current capacity and mandate at different levels of the organisation. Further, the report suggests that "consideration must be given to priority setting among the six core functions and between the five areas of work".

However, the report does not explain the six core functions.

[The core functions of the WHO are mentioned in the General Programme of Work 2006-2015. They are: providing leadership on matters critical to health and engaging in partnerships where joint action is needed; shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; setting norms and standards and promoting and monitoring their implementation; articulating ethical and evidence-based policy options; providing technical support, catalysing change and building sustainable institutional capacity; and monitoring the health situation and addressing health trends. These are believed to be a modification of functions listed in a document titled "A Corporate Strategy for WHO Secretariat" adopted in 1999.]

The report recommends the Executive Board "to endorse the direction for WHO's work and to request the Secretariat to develop further proposals for priority setting, to be submitted to the Board in January 2012, through the Programme, Budget and Administration Committee".

Introducing this agenda item at the current Geneva meeting, Chan called it the "hardest part of the reform".

She said that priority-setting should be the force that drives all reforms, so that reform follows priority functions and money follows agreed priorities. She added that WHO has unique strengths to take on some specific priorities, and that other priorities are better left to others. She also noted that areas identified in the document are not specific priorities, but rather a "framework".

"Priority setting is a collective responsibility of the Secretariat and Member States", she added.

However, Member States were not ready to endorse the proposed recommendation and instead advocated a Member-driven process for priority-setting of the WHO programme. Several countries welcomed the five areas of work but demanded a Member-driven process for priority-setting.

Morocco, on behalf of the Eastern Mediterranean Regional Office (EMRO) Member States, placed great emphasis on determining priorities at the country and regional levels. While agreeing with Chan on the five priority areas identified, Morocco said that there was more to be achieved, proposing the creation of a working party to propose strategic policy for the next 9 years.

Nigeria, on behalf of AFRO, drew the EB's attention to a crowded global health architecture, adding that WHO should move to greater clarity on its role and function. It welcomed the proposed focus on communicable and non-communicable diseases, stating that this will ensure proper management of the current high disease burden especially in developing countries.

Iran said that priority-setting as well as determining any kind of criteria is a prerogative of Member States. It called upon the organisation to give more weight to problems at regional and sub-regional levels, noting that priority-setting is neither "free size" nor "one-size-fits-all".

Chile noted the role of regional and sub-regional organisations in identified regional priorities which reflect those of Member States in these bodies calling for stronger country representation.

Other Member States, however, were of the view that the EB should focus on the process and mechanism of priority-setting rather than agreeing on specific priorities. Among these countries were Barbados, Spain and Switzerland.

Brazil, a non-EB Member, said that it wished to see a sixth priority area added, that is, comprehensive coordination of global health, adding that the convening role of WHO is not enough.

On the identified core areas and priorities, Brazil asked how they relate to the constitutional functions of the WHO, and to the current mid-term strategic plan. It noted that social determinants of health (SDH) were not reflected in the Director-General's report, referring to the successful conference in Rio de Janeiro on SDH last month and calling on the WHO to advocate for SDH within the UN system.

Brazil also proposed separating regional and global priorities, in a way that would divide the work between the two levels.

In response to Brazil's queries, Chan defended the convening function of the WHO as a function of the head office, referring to the numerous Intergovernmental Working Groups held recently such as those on the Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property; Substandard, Spurious, Falsified and Counterfeit Medical Products; Pandemic Influenza Preparedness; and Director-General Election.

"It's difficult to be a coordinator. Nobody likes to be coordinated", she added, preferring to use the term "facilitation".

On core areas and priorities, Chan invited the EB to a dialogue on the General Programme for Work, asking for guidance from Member States in order to develop the next work programme.

(* With inputs from members of the Peoples' Health Movement: Alice Fabbri, Ilaria Camplone, Natalie Eggermont, Thomas Schwarz, and Sangeeta Shashikant.) +