TWN Info Service on Intellectual Property Issues (May11/06)
26 May 2011
Third World Network

WHO: Reform Agenda raises concerns, DG promises inclusive process
Published in SUNS #7155 dated 23 May 2011 (updated 24th May 2011)

Geneva, 20 May (Sangeeta Shashikant) -- A number of Member States of the World Health Organization (WHO), while recognising the need for the organization to reform, have raised concerns over the reform plan that has been proposed by the organization's Director-General Dr Margaret Chan.

These concerns were voiced at the sixty-fourth World Health Assembly (WHA) taking place in Geneva from 16-24 May.

Although the reform plan that was discussed by the WHA is titled "The Future of Financing for WHO" (A64/4), it however contains a broad, far-reaching agenda that is likely to reshape the way in which the organization operates, is governed, makes decisions and is financed.

The reform plan is also likely to redefine WHO's role in public health issues at the international level.

The broad reform plan led to many Member States expressing their concerns.

In particular, concerns were raised over the lack of detail on the reforms proposed, the stress on "donor-funding", especially funding from private entities to resolve the financial difficulties of the WHO, as well as over proposals such as the convening of the World Health Forum, which is likely to increase the influence of the private sector and donors in setting the health agenda in the WHO.

Thailand called the reforms "superficial", adding that they are likely to fail.

Brazil stressed that the reform process must be funded through regular budgetary funds, in response to WHO's proposal that the development of the reform programme be partially funded by the Bill and Melinda Gates Foundation (A64/4 Add.1). India queried how the WHO intended to achieve the objective of making 40% of its funding flexible, when funding is donor-driven.

Many Member States also emphasised that WHO’s reform process must be driven by the Member States themselves, based on consensus, be incremental and ensures that the decision-making power of the WHO remains with the Member States.

These concerns were seemingly quelled by the Director-General (DG), with

promises to continue to consult with Member States until they are satisfied with the reform. This led to the endorsement of a resolution (A64/54) on the matter.

The resolution endorses the agenda for reform as set out in document A64/4 and urges Member States to support the implementation of the reform programme. It also requests the Executive Board to establish an appropriate process to examine the issues related to WHO's governance identified in A64/4.

[An Annex to A64/4 briefly outlines the timeline for the reform process. WHO will develop elements of the programme of reform, based on expert guidance, and consultations with Member States, partners and staff between June and October 2011. WHO will also undertake an Independent formative evaluation of the work of WHO between July 2011 and Dec 2011. Further in January 2012 the 130th Executive Board will discuss the report on the programme of reform followed by consideration of the programme of reform by the 2012 World Health Assembly.]

The approved resolution further requests the DG:

--  to present a detailed concept paper for the November 2012 World Health Forum, setting out objectives, numbers of participants, format and costs to the Executive Board at its 130th session in January 2012;

--  in consultation with Member States to develop an approach to independent evaluation, and to present a first report on the independent evaluation of the work of WHO to the Sixty-fifth World Health Assembly in May 2012;

--  to present an update of progress to the Sixty-fifth World Health Assembly, through the Executive Board.

The WHO reform plan, at its heart, is aimed at addressing the financing challenges faced by WHO in achieving greater predictability and flexibility in financing, to ensure that adequate financial resources are available to meet the objectives set out by Member States. 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.

Despite this scenario, the reform plan prescribes more of the same as a solution, i.e. it proposes that WHO attracts donors and explores new sources of funding, for example, "by drawing on Member States with emerging economies, foundation[s] and the private and commercial sector". However, it acknowledges that such funding is unlikely to be flexible.

A related document A64/INF.DOC/5 titled "Reforms for a Healthy Future: Development Plan" states that the expected outcome of the reform process on finance is to ensure that at least 40% of income will be fully flexible.

However, the document does not provide any details on how it will attain this outcome. The same document lists the outputs of its financing proposal as including a corporate mobilization strategy, a proposal for a replenishment model, an expanded resource base including a mechanism to pool funds from private entities, and a strategic communications strategy.

The reform plan also links financing of WHO to redefining WHO's role in global health, as it anticipates flexible funding as a potential outcome, on the assumption of greater confidence in WHO's policies and practices, and the implementation of the reforms set out.

According to some critiques, this suggests that a critical component of the reform plan is to redefine the role of WHO in global public health, to make its role more palatable to donors in the hope of attracting more flexible donor funds. The reform plan also lacks creativity on how to improve WHO's financing, as it fails to emerge with any new workable strategy to improve the predictability or sustainability of WHO's financial situation.

However, what has generated uproar among the Non-Governmental Organizations (NGOs) is the proposal to hold a World Health Forum (WHF) in Geneva in the last quarter of 2012, with its deliberations being reported to the Executive Board. The concern among the NGOs is that the WHF will provide strategic opportunities to the private sector to influence the health agenda of the WHO.

The reform plan also envisages changes in the management and governance structure of the WHO including focusing WHO in the core areas of business and prioritizing its work;  redefining the role of the governing bodies of the organization, that is, the Executive Board and the World Health Assembly, as well as reviewing the relationships between different governance meetings including the Programme, Budget and Administration Committee of the Executive Board.

Director-General Dr. Chan, in introducing the reform plan on 17 May, said that reform is not a reaction to the financial crisis, but rather a broader opportunity for WHO to change and become more effective, efficient, responsive, objective, transparent and accountable.

Dr. Chan also said that the assessed income had eroded through inflation and currency exchange, adding that donors also faced constraints. She stressed the need to look at new ways that it can be raised, and promised to consult extensively with Member States at every stage of the process.

Following Dr. Chan's introduction, many Member States took the floor to address the WHO's reform plan.

Algeria, on behalf of the 46 countries of the African Regional Office (AFRO), said that WHO reform was timely to reinvigorate the work of the Organization as the world’s leading technical authority on health, in light of its rich experience. There was indeed a need for clearer definition of the role of WHO in the context of myriad challenges, old and new, as well as of the growing number of organizations working on health issues, it added.

It also highlighted that although the distinction between developed, developing and emerging economies has become blurred in today’s world, the gap in development between countries is a reality that should be taken into account in any burden sharing initiative.

It also added that it was essential that the reform process be member state-driven in all its aspects, adding that the reform should not in any way undermine the exclusive role of the decision-making bodies of the Organization in the field of normative action and standard-setting, which should remain one of the WHO's core functions.

It stressed on some key elements that the African Region wishes to see as part of the reform. The elements are: fully involving Member States at all stages of the proposed reform process; establishing a more detailed timetable for implementation of the reform than that included in the annex to Doc/A64/4; strengthening planning budgeting and regular evaluation to improve governance; avoiding duplication with other international organizations working in the field of health; strengthening national capacities for expertise to improve the quality of policies and national health plans; strengthening the technical support of WHO at country level; assisting Member States to ensure coordination with development partners; establishing priorities within the programs based on disease burden, taking into consideration the requests of Member States; conducting reforms at country office level in close collaboration with Member States concerned; implementing human resources policy that combines skills and balance and equity between regions; and elaborating a policy for mobilizing resources that would more effectively trigger the interest of traditional donors and attract new donors as well as increase unearmarked voluntary contributions.

India noted that more money does not mean that the global health agenda will be served. It also pointed out that it is not clear how WHO intended to achieve the objective of making 40% of its funding flexible.

On the World Health Forum (WHF), India said that there has been no debate on the contours of the forum, adding that since details of the forum will be presented to the WHO's Executive Board (EB) next January, this would deny the rest of the Member States (that are not EB members) to have a say on it.

It recommended a more transparent system on how the WHF would be held. It also sought an explanation as to whether the WHF would have a greater influence on WHO decision-making.

Brazil stressed on inclusiveness and transparency as key elements to build confidence and ensure a sense of ownership among all Member States over this reform process and this institution, adding that WHO needs to rediscover and better value its fundamental multilateral identity.

It further said that as the UN health agency, the WHO's role as the leading coordinating health authority must be reinforced. Several adjustments are required to adapt the Organization to growing and pressing demands, as well as to an increasingly complex international architecture. It stressed that the reform process must encompass basic principles such as that it must be Member-State-driven, be based on consensus and must be incremental.

Brazil also said that it was urgent to listen more attentively to what civil society has to say and less to private donors. WHO needs to prioritize collective interests and better manage conflicts of interest and corporate demands, it said, adding that if Member States were really sincere about a reform for a healthier future, the main goal of the Organization must be social justice, equality and fairness in access to health for all.

Brazil further noted that to fulfill its mandate, WHO requires an adequate structure, an appropriate internal governance and a competent staff that is able to think strategically, to develop and implement policies, projects and programmes according to WHO's governing bodies' resolutions and decisions.

The WHO's core business is the promotion of the right to health, Brazil said, adding that the strengthening of health systems, access to medicines and addressing social and economic determinants are public health priorities to be pursued at all levels. It noted that while the elements were highlighted in the document, there was a further need to define how these proposals can be supported and implemented.

On the elements of the programme of reform, Brazil stressed that consultations with Member States must be prioritized, using the views of experts and proposals as a "reference" and not as a "guidance".

It also expressed discontent with regard to the report on financial and administrative implications (A64/4 Add1), saying that in order to avoid conflicts of interest, only regular budgetary resources should be used to finance the reform process.

Brazil also expressed deep concern regarding the contents of the "development plan" - which it noted was circulated quite late – in particular, the reference to "a mechanism to pool funds from private entities". It also said that it was not ready to approve such a document and needed more time to analyse all the elements and to finetune the proposals.

On the issue of financing, Brazil said that predictability and sustainability were key, adding that it was the collective responsibility of Member States to support WHO to fulfill its Constitutional objective, which is the "attainment by all peoples of the highest possible level of health".

Thailand noted that WHO is a donor-driven organization, working according to the donors' mandate. It said that WHO has expanded in the past decade without a real increase in its regular budget. It stressed the need for an organization where there is no voluntary earmarked funding and is one that Member States own.

It also viewed the reform agenda as being "superficial". It further called for a new global health organization that is inclusive and where partners work together based on trust and where Members can express their public spirit. It stressed the need for a new global health under a new structure, adding that it was not convinced about the WHF. It said that WHO was not in need of "reform" but rather a "rebirth".

Thailand also expressed its conviction that the DG's reform proposal would fail.

Zimbabwe said that it was important not to lose sight of the fact that the reform was to address the financing of WHO, and as such, the future financing should form the core of the reform and complemented by the other areas. It expressed its scepticism with the idea of the WHF, saying that it would like to see more detailed information on it. It also said that reform should be implemented as a package, informed by the outcomes of the evaluation.

South Africa noted that the reform plan was an important milestone in WHO's growth. It also said that the reform process should be inclusive, participatory and transparent, further stressing that Member States should be key players in the process. It called on WHO to work with Member States to develop a detailed plan through a process that is thorough and swift.

It added that WHO needs to be focussed and to retain its standing as a specialized agency that leads in normative work, is globally empowered, produces results, and strives to be an organisation that is responsive to needs. It also noted the need to explore models and approaches to financing.

Iran said that the process of reform should be Member-driven and based on consensus. It also said that Member States should not lose sight of the fact that WHO is not a business concern but an organization with lofty goals and principles. While stressing the importance of country offices, it pointed to the need for more coordination and delineation of roles among country offices, regional offices and headquarters.

It also called for greater engagement with civil society organizations, while stressing the need to maintain WHO's role in global health governance. In addition, it also urged donors to be more flexible and to better utilize available resources to fulfill the organization's mandate.

Sri Lanka called for more details on how the organization will carry out the reforms with regard to the programmes, administration arrangements and also to strengthen the presence of WHO in countries and regions.  It also stressed that decisions taken at the WHF cannot and should not overshadow decisions taken by WHO’s governing bodies.

Hungary, on behalf of the EU, while supporting the reform, said that it expected an inclusive process. It welcomed WHO’s intention to identify first the WHO’s core functions and following this to set priorities. As next step WHO should focus on the main areas of its functioning such as planning and management, HR policy, organization and lastly the financing aspects of WHO should be defined, it added. It also supported independent evaluation by an external entity.

It stressed that there was a strong link between the reform process and WHO’s future budgetary planning, adding that these issues will have to be managed ‘hand in hand’, to achieve the needed reform. Hungary also emphasized that need for a more disciplined approach to priority setting and to increase efficiency, effectiveness, accountability and transparency at all levels of the organization. It also said that better alignment between budget and revenue is a key component and supported WHO looking into the advantages of a replenishment model.

It urged member states and donors to gradually move away from earmarked WHO funding towards funding its general budget.

It also said that it was open to the participation of other stakeholders and the WHF, but stressed on the need for WHO to maintain independence and credibility. Further, it said that the WHF should be kept under review, given the additional costs involved.

The EU requested the DG and the Secretariat to develop a detailed concrete development plan with specific actions and timelines for each element of the reform process such as global health priority challenges, governance, future of financing, organization and staffing matters and evaluation.

It also supported reforms to WHO’s governance structure stating that ‘We believe that it is not possible to effectively reform WHO without properly addressing the governace of the organization’.

The US said that the DG's reform agenda was a solid basis to move forward. It however added that development of a detailed implementation plan will be important for bringing greater clarity. It stressed the link between addressing WHO's financing and broader reforms in the WHO plan, as well as for the evaluation process to look at strategic themes to achieve the aims set out by the DG.

Finland, on behalf of the Nordic countries, while endorsing the DG's reform agenda, also noted that the focus should be on identification of functions in different core areas, as priorities may change over time; that mainstreaming certain policy areas such as gender was important; and that the budget must be realistic and should be the main instrument for resource allocation, while stressing that results-based planning was important.

It further stressed that financing of WHO should not jeopardize the independence of WHO.

Finland also highlighted that the modalities of evaluation have to be determined by Member States. On the proposed WHF, it noted the need to determine the exact purpose of the forum, in particular, identifying the boundaries between the WHF and other forums.

Germany endorsed WHO’s reform and said that WHO has a key coordinating role in the global health architecture and is the only global health organization endowed with a comprehensive mission and universal legitimacy. WHO must take on the role of a superordinate coordinator in order to avoid inefficiency and duplication of work, it added In the future, there needs to be a clearly defined division of labour in global health, it further said

It also said that while setting priorities, member states will also have to name areas, which will not be WHO’s priorities in the future. It also added that a transparent organizational chart of WHO below the director's level as well as better understanding of the clusters and existing programmes in Headquarters as well as in the regions with the available funds and personnel, was needed.  Only once we have a transparent evidence base, will we be able to discuss areas that may be taken over from other key players in the future, it said, adding that only then was it possible to define the division of labour between WHO and other actors such as GAVI, UNAIDS, UNDP, the World Bank and the Global Fund.

It also called for a clearer mechanism to regulate the interaction between the regional and the global level of the organisation.

On the issue of financing, Germany said that it supported attracting new donors but noted that this policy contradicts WHO's assumption that a higher share of flexible money is needed. It also said that earmarking should not necessarily be a major problem if it is better coordinated and streamlined.

It then called for a streamlined, centralized approach to fund-raising adding that clusters should not be competing with one another asking donors for earmarked funds only to be used for the purposes of an individual cluster. It also said that member states have to openly discuss the problem of not raising appropriate overhead costs while raising earmarked funds as otherwise earmarked projects are being subsidised with assessed contributions.

Responding to the numerous concerns raised, Director-General Dr. Chan said that she would embark on a transparent and inclusive process with Member States, civil society, global health initiatives and the private sector from specific sectors.

Dr. Chan said that as the chief technical and administrative officer, she will oversee the reform process with the Global Policy Group, made up of herself, the Deputy Director-General and the six regional directors.

She further said that she will use a step-by-step and incremental approach, beginning with managerial reform. On independent evaluation, she said that WHO's core role in strengthening health systems in all countries is important and that the evaluation is to determine if WHO has internal capacity.

Dr. Chan also said that WHO was not going to dilute the technical support of countries in implementing the health policy strategy plans. She added that WHO was looking at taking a coordinated approach with other health actors.

Dr. Chan concluded by stating that she will "consult, consult and consult" until Member States are "satisfied" with the reform process. +