[Ip-health] The Wire: WHO Gets to Work: 2018 a Litmus Test for New Team

Thiru Balasubramaniam thiru at keionline.org
Fri Jan 19 02:45:04 PST 2018



WHO Gets to Work: 2018 a Litmus Test for New Team


Ambitious priorities, strained budgets and a changing political order
dominate the World Health Organisation’s upcoming annual executive board
meet in Geneva.

Grey skies in Geneva this winter betray the action gathering pace at the
World Health Organization (WHO) as a relatively new team goes about
structuring future priorities, finding ways to fund them, making fresh
appointments and trying to push through an overall shift in the way the
United Nations institution has been run for the last 70 years. A sense of
optimism continues to prevail several months into the election of WHO’s
first ever director general from Africa, Dr Tedros Adhanom Ghebreyesus. Not
surprisingly, as in any institution of global governance, this optimism
accompanies a few concerns about transparency, governance and motives –
typical of an organisation with 194 countries as members with various
political interests at stake.

Next week, the WHO’s 34-member executive board (EB) convenes for an annual
meeting from January 22-27 in Geneva to consider a packed agenda, including
reviewing an ambitious set of priorities for the organisation, discussing
reforms on governance issues, taking stock of various disease programmes,
health emergencies, cross-cutting matters such as access to medicines,
digital health technology, sharing genetic resources, and crucial
organisational matters on financing, among others.

The 142nd EB meting is significant as it is the first such meeting of the
board since Tedros assumed office in July 2017. (This is apart from the
special two-day EB meeting that took place in November 2017.)

A new draft set of priorities or the 13th General Programme of Work (GPW),
as it is called, is a signature document that seeks to mark a shift from
the administration of former director general Margaret Chan to that of
Tedros, experts say.

Apart from this ambitious document that has pleased many, the more
immediate challenges will be finding funds to pay for these priorities,
getting buy-in from countries on the goals, and how the team under Tedros
will work together on competing and opposing interests between countries.
All these elements will come together at the meeting next week, and in the
following months till the World Health Assembly in May 2018, which some say
will define the tenure of the new team.

This story will look at not only the essential aspects of the priorities,
but a few key issues on the agenda for next week.

What the last few months tell us

There is an incipient yet an emerging direction on how issues might evolve
in the course of the year, going by the eventful initial months since the
election. Apart from kick-starting discussions on strategic priorities,
Tedros made some high-profile appointments that won him praise for taking a
definite stand on addressing gender and regional diversity. This was soon
followed by a serious misstep that was called a ‘blunder’ in the
announcement – and the subsequent withdrawal – of the now-ousted Zimbabwean
President Robert Mugabe as a Goodwill Ambassador for non-communicable

There have also been some concerns on whether it was merit or political
considerations that influenced the way some directors in key positions were
appointed late last year. In particular, attention was drawn to the
appointment of Tereza Kasaeva, formerly an official at the Russian health
ministry, as Director of WHO’s Global Tuberculosis (TB) Programme. This
appointment has been conflated with Tedros meeting Russian Prime Minister
Vladimir Putin in November. Russia had pledged $15 million for fighting TB
at the WHO Global Ministerial Conference on TB, held in Moscow.

Seasoned watchers say that other donor-member states have routinely
influenced appointments at the WHO for years. “Director-level appointments
are political appointments. There is nothing surprising here. The director
general wanted to assemble his own team and he should be allowed to do
that. Only if this team does not deliver, then questions can be asked. It
is too early to pass any judgement on his intentions,” a health attaché at
a country mission in Geneva told The Wire.

There are invisible boundaries within international organisations, and
political changes will be resisted, since power has not shifted for so many
decades, the official added.

Another senior official from a developing country who spoke to The Wire,
agreed. “On these appointments, I think these are merely efforts to
micromanage Tedros. It is a way to distract him from his priorities, to tie
his hands.” It is not clear whether such appointments were clearly
political quid pro quo, and neither has it been conclusively established
that any of the appointments made so far lacked merit-based considerations.

These events could be a small indication on how much is at stake and how
fiercely changes will be resisted in the months and years to come.

The general programme of work – new priorities

The new draft set of priorities for the period 2019-2023 that seeks to
provide a direction to the way the organisation will work will surely
evolve in the course of the year, not the least because of financial and
political considerations, experts say.

Essentially, the strategic goals in GPW have been articulated as: a billion
more people benefitting from universal health coverage; a billion more to
be better protected by addressing health emergencies; by promoting
healthier populations, an additional billion must enjoy better health and

In a departure from the past, several consultations in 2017 shaped the
initial priorities. The WHO took note of some of the questions raised and
recommendations made on its goals during the special EB meeting last year.
Countries wanted to know the link between the investment case for these
priorities and budgetary realities, for example. They also had questions on
measuring impact of such priorities. (One country delegate described the
draft as a document prepared by enthusiastic consultants for an ambitious

Tedros seeks to usher in key organisational and strategic shifts in the way
it delivers health. “He has had to strike a balance, so to that extent the
GPW is a good document. These priorities will evolve a lot in the run-up to
the assembly this year. The goals also need to be realistic. WHO cannot do
everything. Where is the money?,” an official said.

The organisation’s programme budget is serviced by both assessed and
voluntary contributions. More than 80% of the total funding comes in the
form of voluntary contributions that are earmarked for spending, making it
is less flexible for the WHO to respond in emergencies. Tedros is keen to
change this.

In one of the most significant statements made by Tedros in his tenure so
far, he did not shy away from asking member-states to unearmark funding to
provide greater flexibility to the WHO to use the funds. “Give us
unearmarked funding, we will do more. Give us ownership. Change the design
of funding,” Tedros appealed to countries on resource mobilisation during
the special EB meeting last year. He also said that there was a trust
deficit amongst member states.

And sure enough, this appeal, not unnoticed, has made way into the latest
draft. The WHO has said, “Given the integrated nature of the work that is
required to implement GPW 13, more flexible financing will be critical. The
quality of funds is almost as important as their quantity. The
director-general has asked member states to unearmark their contributions.
This is a sign of trust and enables management to deliver. Increasing
assessed contributions would also give WHO greater independence.”

The WHO said that it will engage with a range of non-state actors,
including private entities. Credit: Reuters

Proposed organisational shifts

The WHO has said it would like to see greater cooperation within
departments since many of these units work in silos. “A major shift will be
to create a seamless organisation, where people’s primary affiliation is
with WHO rather than their own particular programme,” the WHO has said in
its draft strategy document. To do this, the WHO proposes that it will move
away from “categories of work which made specific diseases and health
issues more recognizable, but which also had the effect of hampering
cooperation between programmes”. Instead, it proposes focusing on outcomes
to improve priority setting and programming at the country level. “It
aligns more clearly with country planning and delivery of the work
needed…,” the WHO is of the view.

On staffing, the WHO has said that it will continue on its efforts towards
greater gender equality in its administration. (Although sceptics also
point out that addressing years of gender inequity in appointments has to
be done cautiously without compromising on merit.) Further, Tedros also
wants to increase appointments of nationals from developing countries from
less than 12% at the headquarters to a third by 2023, apart from enabling
internships for young people from the developing world. (Recent past has
already shown how contentious this can be.)

Proposed strategic shifts

The WHO aspires to provide more effective leadership at all levels, drive
impact in every country and focus on ‘global public goods’.

The WHO has said it will advocate for health at the highest political
level. Recognising that health is both technical and political, it takes
into cognizance that health has come to assume importance in high-level
political forums from the G20 to the UN Security Council.

It has also said that it will engage with a range of non-state actors.
While acknowledging that the WHO is and will remain a member state
organisation, it underscores the need to engage with non-state actors
considering the “current conceptions of global governance” – a space where
such parties have come to assume importance. “A range of political and
policy interests are influenced by a network of alliances and coalitions,
involving nongovernmental organisations, philanthropic foundations, and
private sector entities. Outreach to such actors is critical for WHO’s
work,” it says.

Perhaps some may read this as a reality the institution has to contend
with, given the deep pockets of the private sector, for example, in
battling some of the most acute health challenges of our times. Others
might look at these engagements more critically, demanding greater
scrutiny. But experts also want the WHO to pay attention to how member
states engage with non-state actors and how policies are shaped at country

On driving impact at country levels, the WHO wishes to tailor the
secretariat’s engagement with countries taking into account national
context and capacity. “In some settings, such engagement will be more
upstream – policy-related, strategic and normative − and in others, more
downstream with a focus on technical assistance, strengthening service
delivery and implementation of WHO’s normative guidance,” it adds.
Countries with diverse and complex challenges have often suffered from a
headquarter-driven, one-size-fits-all policy approach.

Even as there is a push to make the WHO more operational, justifiably in
countries with weak institutional capacities and in conflict contexts, the
focus on its normative role is clear in its priorities for the future. In
fact, countries want the WHO to protect its normative role in addition to
any increase in its operational responsibilities, putting pressure on its
already strained finances.

“WHO will strengthen its public voice – based on science and evidence – and
advocate for progress, especially in areas of particular importance
identified in GPW 13. WHO will speak up against practices from any sector
including industry that, based on evidence, are harmful to health,” it says
in the revised document.

The priorities also have a strong emphasis on the provision of global
public goods. “WHO’s normative, data, and research and innovation
activities drive the creation of global public goods. WHO’s quintessential
function is to ensure access to authoritative and strategic information on
matters that affect peoples’ health,” according to the draft document. WHO
recognises that it is unique among global health organisations in its
mandate to provide independent normative guidance – a key source of its
authority and comparative advantage.

In addition to setting norms and standards, the WHO also promotes and
monitors the implementation of these norms; in addition, monitors the
health situation and assesses health trends. It shapes the research agenda
and stimulates the generation, translation and dissemination of knowledge
and proven practices.

Commentators at People’s Health Movement have said, “The emphasis on WHO’s
normative role suggests a willingness to restrict WHO to its domain of
competitive advantage which is clearly designed to reassure donors who are
apprehensive about a more activist WHO (eg support for a sugar tax).”

Also, notably, the revised draft of priorities has also included a fuller
recognition of access to medicines under the aegis of the broader goal of
Universal Health Coverage. It recognises that the principal cause of
financial hardship is out-of-pocket payments for the purchase of medicines.
It has said that the WHO will help mobilise political capital for policies
that promote access, including access to generic medicines and innovation
and pushing for domestic investment in coverage schemes that reduces
out-of-pocket payments, among others. The draft however, fights shy of
making any mention of WHO leading negotiations on a global R&D agreement
that could set global norms for funding R&D as a public good – a long
standing demand of developing countries and other parties.

“The final gavelling on the GPW will happen over the next few months ahead
of the assembly,” one country official told The Wire.

Access to medicines discussions at the EB

Apart from the proposed priorities, other key issues will be taken up at
the meeting next week. Consultations around issues of access to medicines
continue to remain contested as before.

There are at least two separate discussions on access issues that will be
taken up next week, both of which point to small yet significant changes
under the new administration.

The issue of addressing the global shortage of, and access to, medicines
and vaccines, has been discussed at several WHO annual meetings. The report
typically takes into account developments and efforts made to address these
issues. Easier access to clinical trial data are among the policies
suggested here.

What is also important to note that this time, the document refers to the
recommendations of the UN High Level Panel on Access to Medicines which
divided countries. (The Wire had reported on how discussions on the report
where shelved during the assembly in May 2017.) This is an issue that has
festered for over a year and has witnessed strong resistance from the US.
Sources say that referencing these recommendations in an official WHO
document, deemed contentious by a section of the countries, was strongly

“This document would not have been possible in the previous administration,
where the secretariat had allegedly tried to scuttle discussions around the
UN report amongst member states. We hope that the new administration will
take a more balanced view on such matters,” one official said. In an annexe
to the document, the WHO has not only referred to the suggestions of the UN
report, but has also mapped how the WHO works within that framework.


Also read: If We Can Build Mangalyaan, Why Can’t We Do More in Health
Sciences: New WHO Deputy Director General


In addition, it is understood that Colombia, with the support of other
developing countries, and possibly a few European countries, first brought
forward a proposal on a potential roadmap for the WHO to implement policy
matters addressing key challenges on access to medicines, sources told The
Wire. Consultations among countries have resulted in a draft proposal that
has not been finalised yet, according to sources. (At this point it is not
clear, what the text of such a proposal is.)

Overall, it appears that countries are cautious about pushing resolutions
that some of the developed countries may be opposed to on such matters. “We
want to create an enabling environment so that some real progress is made
on addressing access issues in the long term,” one official noted. (Some
European countries, although troubled by high prices of medicines, want to
“cherry-pick” what is convenient for them during discussions on access, the
source said.)

The other key document on access issues that will be tabled at the meeting
is the overall programme review of the global strategy and plan of action
on public health, innovation and intellectual property – a report that was
commissioned by member states. The report reviews the implementation of the
strategy over the last decade and more. It formulates clearer goals and
estimates that a little more than US $30 million will be required to
implement recommendations to address challenges around access during
2018-2022. Among others, the report pushes for national laws to reflect
TRIPS flexibilities and improve transparency in R&D costs. Sources have
said that some of the recommendations allegedly do not have the support of
a few countries and this is being currently debated ahead of next week’s
meeting. It is hoped that the EB will decide and recommend for the adoption
of the report by the assembly later in May.

Political uncertainties and financing

The success of the administration will depend on the latitude it will have
in terms of raising resources for its goals. At the time this story went to
print, an awaited resource mobilisation strategy was not yet released by
the WHO.

Early this week, the WHO announced an indication on what such goals could
cost. The WHO has said that a high-level financial estimate for its draft
set of priorities is pegged at US $10.8 billion over the five-year period
for the ‘base segment’ of the budget. A section of the budget will be
scalable for operations including emergencies. It acknowledges that this
estimate is “top-down” and is subject to needs at the country level. It
also makes note of potential savings on economy and efficiency up to US
$440 million.

Experts also point to a worrying emphasis on value for money. In general,
wasteful expenditure in the wider UN system, including at the WHO, merit an
efficiency-based approach, but blanket adoption of institutionalised
spending cuts driven by corporate consultants can be problematic for the
implementation of complex public health programmes where investments cannot
be strait-jacketed.

In fact, a recent report by an independent expert oversight advisory
committee at the WHO, while supporting the approach warned against
“over-institutionalising” value for money in the WHO. “Value for Money, has
become a mainstream narrative which is taking hold on the WHO. They must
resist it,” one developing country official told The Wire.

Efficiency gains, although important, will be limited in their impact on
overall funding challenges that the organisation faces. Countries worry on
how the WHO can deliver without increasing assessed contributions.
Uncertainty around the role of the US in its commitments towards the WHO is
adding to a lack of clarity on how some of these issues can be resolved. US
is one of the biggest donors to the WHO (It accounted for more than 30% of
the total voluntary contributions to the WHO among member-states in 2016.)

“No one will step up in matching contributions if the US arbitrarily
decides to stop or cut funding,” an official was of the view. Although
Germany has tried to assume a leadership role on global health in forums
such as the G20, it is plagued by political instability and domestic
challenges, he noted. But not all are pessimistic on the roles of other

Donor countries are also aware that they are dealing with a different
administration. “The Tedros election was the first broad-based election
where 133 countries voted for him. He will be held to greater
accountability by many more member-states than only donor countries,” one
observer said.

Priti Patnaik is a Geneva-based journalist and researcher. She has
previously worked as a consultant in the UN system including at the WHO.
She tweets at @pretpat and can be reached at patnaik.reporting at gmail.com.

Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International
41 22 791 6727
thiru at keionline.org

More information about the Ip-health mailing list