EB130. 5. WHO Reform

Discussion

The EB had before it nine documents.  These included a general overview report (EB130/5 WHO reform) and nine more specific documents. The EB elected to consider these documents in three groups as follows:

1.  Programmes and priority setting (see below)
   • EB130/5 Add.1 Programmes and priority setting (see WW comment below)
   • EB130/5 Add.2 Distribution of financial and human resources (not yet available) (see WW comment below)
2. Governance (see below)
   • EB130/5 Add.3 WHO Governance (see WW comment below)
   • EB130/5 Add.4 Governance: stakeholders and partnerships  (see WW comment below)  
3. Managerial reforms (see below)
   1. Financing 
      • EB130/5 Add.5: Managerial reform: making WHO's financing more predictable  (see WW comment below)
      • EB130/5 Add.6: Contingency funds for outbreaks  (see WW comment below)  
   2. Organizational effectiveness
      • EB130/5 Add.7 Organizational effectiveness  (see WW comment below)  
   3. Evaluation
      • EB130/5 Add.8: WHO Evaluation policy  (see WW comment below)  
      • EB130/5 Add.9: Managerial reform: evaluation (see WW comment below)  
4. Progressing consideration of WHO Reform in the governing bodies (see below)

Programmes and priority setting

Documents 

• EB130/5 Add.1 Programmes and priority setting (see WW comment below)
• EB130/5 Add.2 Distribution of financial and human resources (not yet available) (see WW comment below)

Discussion 

The discussion about the WHO reform began with comments on document EB 130/5 Add.1 “Programmes and Priority Setting”. Commenting on the 7 proposed categories for the next general programme of work, some Latin American countries asked how these categories came to be suggested. Norway and Switzerland suggested, at this point in time, to focus on the process and criteria for priority setting rather than on the priorities themselves. On the same issue, Estonia, talking on behalf of EU, directly asked the Secretariat to set up a drafting group that should work separately during the EB, to define the Terms of Reference for priority setting through a Member States-driven process.

Beyond technical arrangements, Estonia as well as Japan and Germany pointed out that priority setting should be linked with the financial reform and that resource mobilization and allocation should necessarily be subordinated to the identified areas of work. According to Member States suggestions, priority definition should be based on a bottom-up approach taking individual country needs as a starting point. Striking a discordant note, US suggested that global objectives should guide regional and local ones and eventually go back to the centre.

The discussion on country needs led to question the resource allocation among the three level of the Organisation and the concept of country grouping proposed in the document (Par. 12). India and China highlighted how the 5 categories proposed are almost entirely based on level of development rather than on the burden of diseases and how countries in the same group can have different health needs.

Last but not least, Ecuador and France complained about the late release of the document EB130/5 Add. 1 and Add.2, which prevented Member States to adequately analyze and react on them.

Afterwards, three NGOs took the floor: Medicines Sans Frontiere, Medicus Mundi International and the People’s Health Movement, and Democratizing Global Health Coalition (a group of public interest organizations that have come together to focus on the WHO Reform). Civil society comments were recalled also in the final speech by the Director General who congratulated them by saying “You have done a lot of work and you could really highlight the important points” but she didn’t really answered the question posed.

At this point, Dr. Chan summarized the discussion and clarified that the EB documents prepared by the Secretariat were not meant to be the basis for a negotiation, but just an instrument to stimulate the discussion. She also said: “This is not a decision making time”.

Addressing Member States suggestions and concerns, she grouped the interventions into two broad categories: process and content. Concerning the content, she declared to be happy to hear that many countries agreed that priority setting should give very strong attention to country needs. Trying to address Member States concerns about the 5 typologies of country and the 7 categories of work, Dr. Chan declared that these were just a first attempt to systematize the available information as well as the current activities of the Organization.

Regarding the process, she fully agreed on the EU proposal to create a working group to set ToR and the scope for the Member State-driven process. Moreover she proposed to adopt the first option mentioned in paragraph 55 which means starting the Member States-driven process with a main meeting to be held in late February. Although this option was fully supported by many countries, others, especially the furthest (Japan) and the smallest (Bahamas and Barbados), expressed their concerns on the economical and human resources sustainability. 

See Official Provisional Summary records of this discussion at the Sixth Meeting.  A further procedural note is documented on page 14 of Meeting 10. The adoption of Decision EB130(6) is documented from page 5 of the 13th Meeting. 

Decision 

See EB130(6) WHO reform (programmes and priority setting). The Chairperson's Summary of decisions on WHO Reform also records that Programmes and Priority Setting will be discussed at the special MS meeting scheduled for 27 and 28 Feb 

Comment

See 

Governance 

Documents

• EB130/5 Add.3 WHO Governance (see WW comment below)
• EB130/5 Add.4 Governance: stakeholders and partnerships  (see WW comment below)  

Discussion 

The discussion on WHO Reform continued with comments on documents EB 130/5 Add.3 “Governance” and Add.4 “Promoting engagement with other stakeholders and involvement with and oversight of partnerships”.

The discussion initially focused on the revised timeline for meetings of the governing bodies. The document prepared by the Secretariat contained two options for addressing the challenges of the current meeting cycle of the Programme, Budget and Administration Committee (PBAC) and of the Executive Board: option 1 (move the PBAC meeting to early December and the EB session to the end of February); option 2 (move the PBAC meeting to early December and maintain the EB session in January).

The first option was the one that obtained more support. However, Norway pointed out that having the EB at the end of February would not leave enough time to get ready for the World Health Assembly. The Norwegian delegate stated also that if the timeline changes, an evaluation of the new mechanism should be undertaken. Despite the long discussion, no agreement was reached on the timeline.  The proposal of extending the session of the Board in May from one to three days was also discussed but not all the countries agreed with this suggestion and Mexico raised also the issue of the significant cost implications.

Concerning the revised Terms of Reference (ToR) for PBAC, Member States seemed quite satisfied and they didn’t propose any substantial changes.

Internal governance was another issue addressed; some Member States (i.e. Iran) asked for more clarification on the proposal of increasing the linkages between Regional Committees and the global governing bodies as well as the harmonization of the practices of Regional Committees. On linkages between global and regional governing bodies, US stressed once again (see also the discussion on priority setting) the importance for Regions to adapt to global policies rather than the opposite, highlighting a clear will to adopt a top-down approach.

Mexico, commenting on participation of various groups of stakeholders in Regional Committee meetings (Document EB 130/ 5 Add. 3, par. 3.5), noted that the external observers should not have any conflicts of interest.

The engagement with other stakeholders was one of the thorniest issue; the discussion focused on the criteria for the inclusion of non-state entities and on the need to differentiate between PINGOs (Public Interest NGOs) and BINGOs (Business Interest NGOs).  India was the only country who proposed a greater participation of civil society, and along with Barbados and Chile, among others, highlighted the need for setting out clear guidelines to protect the Organisation against potential conflicts of interest. On the same issue, France explicitly asked to establish procedures that will ensure the independence of public health experts and stated that the dialogue with other actors should happen in a consultative process, but the decision making process should remain in Member States hands. Following this observation, Norway suggested to conduct an evaluation of WHO engagement in partnerships with an evaluation of their added value.

There were obvious divergences regarding the differentiation between the different types of nongovernmental organizations that interact with WHO. Switzerland and US strongly affirmed that it is not necessary to go too far down the road in terms of differentiating between diverse types of NGOs since divisions are arbitrary and all stakeholders come to the WHO with their specific agendas. Switzerland also welcomed the proposal of increasing stakeholder involvement, both NGOs and the private sector.

After Member States interventions and NGOs statements, DG summarized the discussion and accordingly proposed a way forward. Since no agreement was reached on most of the items, she suggested the Secretariat to prepare a new consolidated document for the next World Health Assembly in which all elements discussed during the EB will be interlinked together. In this consolidated document Dr Chan will bring together proposals coming from Member States and suggestions from the Secretariat.

Concerning the ToR for PBAC, DG proposed that any Member States who have ideas and suggestions, should send them to the Secretariat by the end of February in order to be included.

Concerning the timeline for meetings of the governing bodies, since no agreement was reached, Dr. Chan proposed the Secretariat to prepare some proposals to be further discussed.

Finally, on the WHO engagement with other stakeholders, she raised the point of conflicts of interest saying: “I've never seen an organization coming to WHO without an interest. Everybody has an interest. Also Member States have interests. The interest of private sector is not so clear as well as the interest of some Civil Society Organisations. In the light of transparency, we need to improve that transparency and hold each partner accountable”. Recognizing that further discussion is needed on this knotty issue, she promised that the Secretariat will provide some proposal to stimulate the process taking into account Member States will to take oversight of the partnerships. 

See Official Provisional Summary Records of the discussion of Governance from page 14 at Meeting 6 and continued from page 1 of Meeting 7. 

Decision 

The Chairperson's Summary of the 'consensus' achieved by the Board on Governance reads as follows: 

"Member States are invited to submit comments on two of the governance reform proposals considered by this Executive Board. These are (i) the draft revised terms of reference for the Programme, Budget and Administration Committee, and (ii) proposals for increasing linkages between Regional Committees and the global governing bodies and harmonization of the practices of Regional Committees. Member States are invited to submit their comments through the password protected web site open to all Member States, before 17 February. Member States who currently do not have access to the web site are invited to contact the Secretariat for details on how to register for the site. Based on the feedback received, the Secretariat will prepare revised proposals for submission to the Executive Board at its 131st session, through the Programme, Budget and Administration Committee.

Based on the discussions in this Executive Board, the Secretariat will revise the proposed options for the schedule of the governing bodies, incorporating the proposal for a revised schedule of meetings of the Regional Committees, Executive Board and Programme, Budget and Administration Committee, and the World Health Assembly. This will include a detailed analysis of the advantages and disadvantages, feasibility and costs of the different options. The Secretariat will also take forward the work on streamlining national reporting.

Further discussion will be required on WHO's engagement with other stakeholders, including different categories of nongovernmental organizations and industry, and the proposals to review and update principles governing WHO relations with nongovernmental organizations, and to develop comprehensive policy frameworks to guide interaction with the private-for-profit sector, as well as not-for-profit philanthropic organizations. These will be held during the Sixty-fifth World Health Assembly.

We have agreed on the importance of partnerships and on the need for better management and greater oversight by the governing bodies, in particular the Executive Board. Members of the Executive Board have proposed a review of WHO's hosting arrangements, along with further efforts to harmonize work with hosted partnerships."

The finalisation of the Board's consideration of Governance is documented from page 7 of the 13th Meeting and page 1 of the 14th Meeting. 

Comment 

Managerial reforms

Documents 

1. Financing 
   • EB130/5 Add.5: Managerial reform: making WHO's financing more predictable  (see WW comment below)
   • EB130/5 Add.6: Contingency funds for outbreaks  (see WW comment below)  
2. Organizational effectiveness
   • EB130/5 Add.7 Organizational effectiveness  (see WW comment below)  
3. Evaluation
   • EB130/5 Add.8: WHO Evaluation policy  (see WW comment below)  
   • EB130/5 Add.9: Managerial reform: evaluation (see WW comment below)  

Discussion 

Managerial reform: making WHO’s financing more predictable (EB130/5 Add.5), Managerial reform: contingency fund for outbreaks (EB 130/5 Add.6), WHO evaluation policy (EB130/5 Add.8), Managerial reform: evaluation (EB130/5 Add.9)

Once the discussion on governance came to an end, the Chair requested delegates to present their comments on both financing and evaluation. The majority of Member States raised the point of the use of assessed contributions asking whether they are allocated to cover WHO core-functions or to fill up the gaps remained after the allocation of voluntary contributions. US went further pointing out that assessed contributions should not subsidize costs associated with voluntary contributions.

Addressing the issue of predictability of funding, Member States expressed their concerns about the core of the new financing mechanism presented in Secretariat document: the pledging conference. In general, the issue raised deep concerns among Member States, that showed reservations about this proposal expressing their need for clarifications. Particularly Estonia, on behalf of EU, asked how the pledging conference would increase the predictability and along with Canada, requested the Secretariat to explore other possible solutions.

On the contingency fund for outbreaks, many delegates (i.e. Senegal) supported the idea but asked for clarification on how the fund would be managed in harmonization with the Regional funds for emergencies.

Concerning the evaluation process, Member States expressed themselves on both the internal evaluation and the external one. US welcomed the proposed evaluation policy (Document EB 130/5 Add.8) and suggested to build a stronger culture of evaluation within WHO by adopting norms and standards of the UN evaluation group. While agreeing on creating a culture of evaluation - a position shared among many countries - UK stressed the need to move from the general idea to practical actions.

On the external evaluation, Senegal and Mexico stated that an independent evaluation is utmost important in order to promote the transparency and credibility of the reform process. Regarding the nature of the entity that should carry out the first stage of the evaluation, some countries proposed the External Auditor while others the Office of Internal Oversight Service. Talking about the timeline, Switzerland expressed an arguable position affirming that “we have to be careful and do not postpone the reform while waiting for an independent evaluation”. At this point in time, it is unavoidable to ask whether the external evaluation is meant to inform the reform process or to be just an academic exercise.

The floor was then opened to NGOs: Oxfam and Medicus Mundi International (MMI) with People’s Health Movement (PHM) presented their statements recalling the importance of the predictability of funds and transparency and sustainability of the proposed financial mechanism. MMI and PHM also called upon Member States to await the recommendations of the independent evaluation,before agreeing on the precise trajectory of reforms.

Dr Chan opened her summary by ambiguously saying “I didn't pay the NGOs to ask my Member States to increase their assessed contributions”. Directly addressing the questions on the use of contributions, she clarified that it was not her intention to cross-subsidize voluntary contributions with assessed contributions and stated that the assessed ones are used for core-functions and to support governing bodies meetings.

Afterwards, she tried to cope with Member States request for clarification on the pledging conference. Firstly, she apologized for being unable to come up with the right language and proposed to call the new mechanism “financial dialogue”. Then she explained how the new mechanism would work: firstly, the priorities and subsequent activities will be defined by Member States. Dr. Chan reassured the delegates saying that “We will not accept any money that do not go with these priorities”. The second phase will be the financing one whose main event is the pledging conference that will be open to Member States together with all other non-State funders.

According to DG words, today non-state donors provide up to 40% of the WHO budget and, at the same time, Member States seem not to be able to fill this gap. That is why the financing dialogue will be opened up to UN agencies and philanthropies. Addressing this issue she made a subtle distinction between philanthropies and industries precising that the latter, along with civil society organisations, will be allowed only to come and listen to.

Despite the clever analysis she proposed, a question arises: does a clear distinction between philanthropies and industries really exist considering the potential conflicts of interest both of them might have in health affairs? Moreover in her opinion, an open conference might have an additional incentive: everybody would know what the others give since pledges will be made publicly. This mechanism will increase the transparency and, in DG’s hopes, it will prevent civil society organisations from saying that WHO “is in bed with industry”.

Concerning the external evaluation, she recalled the EB Special Session decision to consult three entities: the United Nations Joint Inspection Unit, the External Auditor and the Independent Expert Oversight Advisory Committee. Recognizing Member States will to have an independent entity to carry out the evaluation, Dr Chan stated that the External Auditor would be the best option for the first stage that will be then the roadmap for the second one.

See Official Provisional Summary Record of this discussion from page 5 of the 7th Meeting. 

Decision 

The Chairperson's Summary records the following 'consensu' on Managerial Reforms: 

"The Secretariat will further elaborate the proposals for the predictable financing mechanism, and the contingency fund, based on the feedback from this Executive Board, and present these to the Executive Board at its 131st session, through the Programme, Budget and Administration Committee.

Member States are invited to submit comments on the draft evaluation policy through the password protected web site open to all Member States, before 17 February. Based on the feedback received, the Secretariat will prepare a revised draft of the evaluation policy for submission to the Executive Board at its 131st session, through the Programme, Budget and Administration Committee.

Concerning stage one of the independent evaluation of WHO, the Executive Board welcomes the offer of the External Auditor to carry this out, and expects that the report of stage one will be presented to the Sixty-fifth World Health Assembly, and will include a proposed road map for stage two of the independent evaluation. As discussed in this Executive Board, the Secretariat will update the Terms of Reference for stage one of the independent evaluation based on the written comments submitted by the Joint Inspection Unit of the United Nations system.

The Executive Board has also welcomed the agreement of the Joint Inspection Unit to update their reports of 1997 on decentralization within the World Health Organization, and 2003 on management and administration in the World Health Organization."

Process Decision on WHO Reform

The Chairperson's Summary records the following decision regarding preparation for the May 2012 meetings of the governing bodies: 

"The Secretariat will prepare a consolidated report covering all aspects of WHO reform for submission to the Sixty-fifth World Health Assembly. The report will cover the three areas of programmes and priorities, governance and managerial reforms, incorporating the outcome of the Member State-driven process on priority setting, showing linkages and indicating areas where consensus has been reached, and those areas where further discussion is required. It will include the elements of WHO reform agreed in the special session of the Executive Board in November 2011, and further elaboration of the proposals where the Executive Board has requested additional work. The report will include a draft implementation plan, with a budget and a monitoring framework, for consideration by the Health Assembly.

In line with the desire of the Executive Board to strengthen the oversight of the Programme, Budget and Administration Committee, which already has a crowded agenda for a one-day meeting, I propose that this particular May Programme, Budget and Administration Committee be extended to three days, to consider the documents on WHO reform being presented to the Sixty-fifth World Health Assembly and 131st session of the Executive Board. For the same reason, I also propose that the 131st session of the Executive Board is extended to two days, to ensure adequate time to consider these proposals."

WHO Watch comment on individual papers

Document EB130/5: WHO Reform: Report by the Secretariat

Provides a brief introduction to the following nine papers, listed below. No substantive content. 

Document EB130/5 Add.1: Programmes and priority setting

Deals with on  programmes and priority setting responds to the elements described in paragraph 2 of decision EBSS2(1) on programmes and priority setting, and subparagraph 3(c) of decision EBSS2(3) on managerial reforms by providing information on the following: 

• (a) current criteria and mechanisms for priority setting; 
• (b) description of current activities carried out at headquarters, regional and country level; 
• (c) description of the application of criteria and priorities to planning and the impact; 
• (d) proposals for how criteria and priorities could be set and applied in the future; 
• (e) detailed proposal, with a timeline, for the Member-State-driven process; 
• (f) proposals for a timeline for development of the programme budget and general programme of work for the period 2014 onwards. 

Document EB130/5 Add.2: Distribution of financial and human resources

This document provides summary information on the distribution of financial and human resources allocated to each level and cluster in response to the specific request made in subparagraph 2(b) of decision EBSS2(1). 

Document EB130/5 Add.3: WHO Governance 

This is the first of two documents on governance reform deals with the following four items from the decision EBSS2(2): 

Revised terms of reference of the Programme, Budget and Administration Committee of the Executive Board 

The SSEB requested the Secretariat to suggest revised TORs for the PBAC as part of making the governance bodies and deliberations more focused, strategic, efficient, effective.  The revised TORs make sense.

PHM remains concerned that meetings of the PBAC are closed which limits transparency.  The situation would be ameliorated somewhat if the agenda papers were published in good time and semi verbatim reports of meetings published promptly. 

Revised timelines for meetings of the governing bodies

Provides a useful discussion of the current timelines and issues arising. Offers two suggestions aimed at separating the currently adjacent meeings of the PBAC and EB in January so that the EB members have more time to consider PBAC recommendations and so that the Board has more time for substantive deliberation in May. 

Linkages and alignment between Regional Committees, the Executive Board and the Health Assembly and harmonization of Regional Committees practices

Aiming to align agendas more closely; provide for a formal annual report from regional committee chairs to the EB; standardise consideration of credentials; standardise rules regarding observiers; standardise procedures for nomination of regional director.

PHM comment. These are sensible suggestions. PHM is particularly concerned about access of civil society observers to regional committee meetings and appreciates the proposed harmonisation.  PHM and other CS organisations have previously argued for a much clearer distinction between public interest NGOs and commercial interest organisations. The Board should take advantage of the review of regional committee observer rules to make this distinction. 

Streamlined national reporting using modern tools

Outlines current reporting practices; lists some of the issues; requests more time to provide concrete recommendations.

PHM comment. This discussion of streamlined reporting is divorced from the wider issues of how membership of WHO promotes better health and better health care in countries. The Secretariat paper quotes the reporting obligations from the Constitution but the underlying logic of WHO membership and the health development strategies assumed are not explored. The purposes of data collection stem from such program logic; it would be helpful to have it explicated.  

Document EB130/5 Add.4: Governance: stakeholders and partnerships

This is the second paper on  governance reform and responds to paragraph 3, subparagraphs (d), and (e) of decision EBSS2(2). 

Engagement with other stakeholders

The paper provides a useful review of the different stakeholders with whom WHO engages and recommends a more detailed review defining more clearly the different kinds of stakeholders and developing more appropriate procedures for accepting organisations into official relations.  The paper recommends close attention to WHO's relationship with for-profit organisations, philanthropies and GPPPs with full consideration of conflict of interest provisions. 

PHM comment.  The proposed review is very timely.  CSOs will want to maintain close engagement in the review process.  The paper does not mention stakeholder engagement at the regional or country level.  These should be on the agenda.  CS engagement at the country level is critical for accountability and effectiveness. 

Member State involvement with and oversight of partnerships

The paper explores in brief some of the issues associated with WHO's involvement in partnerships of various kinds and the need for closer accountability to and involvement of member states in these partnerships. 

The paper states that the Standing Committee on NGOs is not the appropriate body to mediate this oversight and recommends that the Board takes this function on directly.  The paper suggests that Partnerships constitute a recurring agenda item on EB agendas and that the Board might guide the dialogue with such partnerships.

PHM Comment. PHM supports the goal of closer oversight of and MS involvement in partnerships. PHM agrees that the SCNGOs is not the appropriate vehicle and agrees that the function should be carried by the Board. PHM suggests that the next stage in this process would be a mapping and analysis of all partnerships with a focus on purpose, strategy, cost, effectiveness and relationship with WHO Constitution and workplan. PHM emphasises that the mapping should include consideration of operation of such partnerships at the regional and country level. 

Document EB130/5 Add 5: Making WHO's financing more predictable (and entrenching donor control)

The SSEB requested the Director-General to develop further ... a detailed proposal, for mechanisms to increase predictability of financing and flexibility of income, which supports priorities set by Member States, and a report on this to the Executive 

Document EB130/5 Add 6: A contingency fund for outbreaks

The SSEB in Nov 2011 requested the DG to prepare a detailed proposal to establish a contingency fund for public health emergencies, and a report on this to the Executive Board at its 130th session in January 2012.  EB130/5 Add.6 is the result.

This proposal derives from the 2011 Report of the Committee to Review the IHRs including WHO's response to the 2009 H1N1 pandemic.  See WHO Watch Comment on IHRs.

PHM comment. This is a sensible idea. It remains to be seen if the rich countries will fund it. They probably will, under the logic of 'health security'. The design of the Contingency Fund and its procedures will need to take issues of equity and benefit sharing into consideration.  The material developed in relation to  PIP (see TWN Statement to WHA, May 2011) and the Report of the IHR Review will be important reference points here.  

Document EB130/5 Add.7: Organizational effectiveness

• (a) clarification of the proposals with respect to enhancing the networks and relationships between regional offices, and between groups of country offices within and across regions; 
• (b) clarification of proposals for enhancing  capacity for effective resource mobilization, particularly at the country level.

Document EB130/5 Add 8: WHO evaluation policy

The SSEB in Nov 2011 requested the DG to prepare a draft formal evaluation policy, including a mechanism for oversight of evaluation by the governing bodies informed by insights provided by the Independent Expert Oversight Advisory Committee, and a report on this to the Executive Board at its 130th session in January 2012.  EB130/5Add.8 is the result.

The draft evaluation policy submitted by the Secretariat is very disappointing. On the one hand it states that the purpose of the policy includes fostering a culture of evaluation across the Organisation but the evaluation paradigm which is described is very top down and summative in orientation with an insistence that the evaluation function is owned by the Office of Internal Oversight Services.  There is a strong emphasis on 'independent' evaluation, in particular, independent of the program managers and implementers.  

The concept of formative evaluation - evaluation undertaken by program managers and implementers with a view to guiding implementation - is completely absent from this draft policy which runs counter to the idea of embedding evaluation within the organisational culture.  The image of the organisation implied in this policy is very hierarchical with evaluation results reported to the top and learnings from evaluations dictated from top down.  The draft policy does advise that WHO this draft Evaluation Policy does not encompass other forms of assessment such as monitoring, performance assessment, surveys, programme reviews and audit (all of which are considered elements of WHO's 'accountability framework').  

It is self-evident that accountability and summative evaluation are essential and that an evaluation policy should make appropriate provision for these purposes.  However, they should be balanced by an appreciation that evaluation is intrinsic to program implementation.