[Ip-health] TWN Info: Reform Agenda raises concerns, DG promises inclusive process

Sangeeta ssangeeta at myjaring.net
Tue May 24 09:02:35 PDT 2011

Below is an article on discussions that took place on WHO's reform plan.

The piece below is an updated version of an article published by SUNS.

Sangeeta S. 

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
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
Many Member States also emphasised that WHO¹s 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
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
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
[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
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 world¹s 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 today¹s 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
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
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 WHO¹s governing bodies.
Hungary, on behalf of the EU, while supporting the reform, said that it
expected an inclusive process. It welcomed WHO¹s intention to identify first
the WHO¹s 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
WHO¹s future budgetary planning, adding that these issues will have to be
managed ³hand in hand², to achieve the needed reform. Hungary also
emphasized that need for a more ³disciplined 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 WHO¹s governance structure stating that ³We
believe that it is not possible to effectively reform WHO without properly
addressing the governa ceof 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 WHO¹s reform and said that WHO has a key coordinating role
in the global health architecture and is the only global health organisation
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 WHO¹s 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
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
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. +

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