12th Global Program of Work

12th Global Program of Work

In previous budget cycles WHO has prepared three main planning documents: the (five year) Global Program of Work (GPW), the Medium Term Strategic Plan (MTSP) and the (two year) Programme Budget (PB). As part of the WHO Reforms of 2011-12 it was decided to drop the MTSP and work solely with the GPW and PB.  This page is focused on GPW12.  See also WHO Watch's introduction to and commentary on PB14-15.

GPW12 for regional committee consultation

In early August 2012 the version of the draft GPW12 for consultation with regional committees (RCs) was posted on the WHO website.  The RCs meet from August to October.  Their comment will be available for consideration at the Extraordinary Meeting of the Programme, Budget and Administration Committee (PBAC) of the Executive Board (EB) scheduled for Dec 6-7, 2012 and will be considered again at the 132nd EB in January, 2013.  EB132 will adopt a revised version of the PB14-15 for consultation with donors to see how much and what they will be willing to fund.  A further revision of the PB will be adopted by the 66th World Health Assembly (WHA66) in May 2013 

Structure of the proposed GPW12

The draft GPW12(RC) is structured around a diagram which seeks to represent the relationships between principles, core functions, criteria, categories, priorities, impacts and outcomes. This is followed by five chapters: 

• Chapter 1 provides a short review of the changing global context in which WHO is working.
• Chapter 2 looks at some of the broad implications of this context, particularly their influence on the direction of reform.
• Chapter 3 covers the programme and priority-setting aspects of the current round of WHO reform. It discusses the six proposed programme categories; describes how cross-cutting issues will be handled; and reviews each of the agreed priorities in turn.
• Chapter 4 deals with corporate services and enabling functions.
• Chapter 5 sets out the logic underpinning the results chain and a first draft of results at impact and outcome level.

WHO Watch comment

Chapter 1, Setting the scene, provides a good account of the global circumstances which frame the context in which this GPW is set. The main headings give a sense of the issues covered: 

• new political, economic, social and environmental realities;
• a changing agenda for global health; and
• the institutional landscape for global health. 

This is an excellent scene setting chapter which touches upon some of the most important contextual issues facing WHO.  

No reference to political and economic contradictions.  Completely missing from this survey is any reference to the political, economic and strategic contradictions which shape what is possible and how change takes place.  The failure of the Doha Development Round for example reflects profound contradictions between the industrialised world and the agrarian economies of low and middle income countries.  The failure of the Durban Conference to achieve binding agreement to control climate change likewise reflects the different interests of the old industrialised and the newly emerging economies.  These kinds of strategic contradictions permeate the environment in which WHO works and everywhere shape policy making and financing in WHO although it is polite to not mention them.  

While governments take front and centre stage in these conflicts they are themselves creatures of the corporate and social constituencies who pull their strings.  The rise and rise of transnational corporations (TNCs) and their ability to get powerful nation states to advocate for their interests in intergovernmental fora is another reflection of the fractured global polity.   

These contradictions are realities and while it is polite not to mention them they have to be negotiated and WHO should be projecting leadership in terms of negotiating them.  One core strategy for negotiating such differences in perspective and conflicts of interest involves working past the TNCs and tightly committed vested interests and communicating clearly and honestly with peoples in their communities.  WHO has taken a very cautious approach to its dealings with civil society. 

Superficial references to the risks to health associated with economic globalisation.  There are references to trade and to finance in the document but they do not provide or refer to any kind of analysis of the nature of the associated risks to health. For example investment protection provisions being included in 'free trade' agreements foreshadow sharp limitations on public health regulation in relation to tobacco, food, alcohol and other key areas.  Neither does it address the limits to health care funding consequent upon the networks of tax havens and systems for tax avoidance.  See MMI comment on GPW12 submitted to Euro RC.

Limited construction of 'development'.  It is also disappointing that WHO continues to deploy the term 'development' in ways which are almost equivalent to poor countries receiving foreign assistance.  The possibility that rich countries also face development challenges (social, cultural, political as well as economic) is nowhere to be found. 

Chapter 2, deals with the role of WHO.  It commences with a re-affirmation of the principles and values enshrined in the Constitution of the Organisation and proceeds to examine the implications for strategy of the changing global environment as set out in Chapter 1.  The key implications are: 

• continuing need for attention to the social determinants of health and for SDH to be managed as a 'cross-cutting issue' with operational implications across the work of WHO; 
• the need to adapt to budget constraints and donor dependence but protect the WHO agenda from being determined by donors 'alone'; 
• the need for service integration; a focus on health systems rather than just diseases, interventions and 'target populations'; 
• the need for WHO to play a more pro-active role in coordinating and leading in both the governance of health policy issues and governance for health (referring to the determinants of health beyond the health system). 

These are all important challenges.  It is not clear that the Secretariat or the MS have any clear strategy for managing any of them. They provide four useful evaluation questions for the later chapters.  

Chapter 3 describes and explains the priorities proposed for 2014-19.  The chapter starts with the elaboration of the six broad categories which have been adopted for managing priority setting and resource allocation, and the criteria used for identifying priorities within these categories.  The chapter notes the existence of complex 'interlinkages' between the various categories and priorities.  It then proceeds to list and explain the priorities. 

Linkages and cross-cutting issues. The Secretariat is to be congratulated for highlighting the importance of linkages and cross-cutting issues but there is nothing in this document about the operational strategies which will ensure integration of the linked issues in normative work or in technical assistance.  It is good to note that health system development will be important for delivering vaccination or treating TB.  It is good to note that reducing maternal mortality will need to be informed by the cross-cutting issue of gender equality.  However, to this point there has been nothing presented from the Secretariat which shows convincingly how collaboration across the silos will be effected.   

Intellectual disability not a priority.  In speaking about disability as a priority the focus is solely on blindness and hearing impairment for both of which technological interventions are available and innovation promising.  Intellectual disability is by far the biggest sub-group by population and the quality of care available for people living with intellectual disability are in many settings terrible.  It appears that criterion No. 4 ('existence of evidence-based, cost-effective interventions and the potential for using knowledge, science and technology') has counted against intellectual disability.   

Mental health constructed largely in terms of organic psychiatric conditions ('serious mental illness') and substance misuse.  The priority to be accorded to 'mental health' is to be applauded but it is a very organic construction of mental health. Missing entirely from this presentation and from the recent report on this topic produced by the Secretariat (EB130/9) is any consideration of the social, psychological and emotional harm caused by oppression, gender violence, displacement, refugee experience, poverty, chronic unemployment, chronic hunger, minority persecution, indigenous dispossession and social exclusion. For many people the experience of growing up and living through in such circumstances is akin to post-traumatic stress with huge consequences for the individual, family and communities.  Violence and substance misuse appear both as cause and effect.  One particular consequence can be dysfunctional parenting and for the intergenerational transmission of the legacies of such trauma. It seems that the work of the Commission on SDH in this area, and in particular the work of the Social Exclusion Knowledge Network has not had the cross-cutting influence the DG had hoped for.  Further comment on WHO's approach to mental health. 

Chapter 4 discusses the corporate functions and services which support the achievement of the priorities listed in the previous chapter.  Many of these issues have been explored in the context of the discussions of WHO Reform: leadership, accountability, alignment, harmonisation, streamlined decision-making, engagement with stakeholders, etc.  The chapter discusses leadership, country presence, governance and convening and a range of corporate management issues.

Organisational implications of the 'categories'.  It is perplexing that the document makes no reference to the organisational implications of the new 'categories'.  Presumably for planning, management and accountability purposes the categories will have to be aligned in some way with the management structure and budget structure.  This implies a very significant overhaul of the existing structure of both headquarters and regional offices.  Such reorganisations take time and can have heavy costs. 

Accountability of member states.  This chapter touches issues of accountability but solely in terms of the accountability of staff and of the Secretariat.  It is unfortunate that there is no discussion of the accountability of member states.  Both Secretariat and MS frequently repeat the statement that WHO is an intergovernmental organisation, a MS driven organisation.  This suggests that it should be accountable to MSs.  However, the accountability of MS to their own governments and people for their conduct as members of WHO is in many cases quite limited and subject to distortions. 

The most obvious distortion of accountability is the donor chokehold. The Secretariat is accountable to the donors and potential donors in a much sharper way than it is accountable to MSs.   

However, the accountability of member state delegations also needs to be problematised.  Many delegates to the Assembly have not read their papers and have not fully considered the issues before the Assembly at the national level before attending. The positions adopted by many of the big powers are in some cases more directed to protecting the interests of their own transnationals, in particular, big food and big pharma, than promoting the health of the people.  Delegates and MS health ministries have very limited accountability for how they govern WHO.  

Relations with civil society.  There is very little in this draft concerning WHO's relations with civil society. (By way of contrast the Secretariat looks forward to 'constructive engagement' with the food industry.) 

The protocols governing the WHO relations with NGOs in Geneva are anachronistic and paternalistic.  NGOs need to have an approved program of cooperation to be admitted to official relations.  The protocols operating at regional committees are inconsistent and vary from easy cooperation to exclusion.  

However, the wider issue is the role of civil society (in all its complexity) in the processes of social change and health development.  The Alma-Ata Declaration celebrated the potential role that communities can play at the local level in promoting intersectoral collaboration, in extending the work of health care practitioners, in holding health agencies to account.  The Commission on SDH spoke about 'buildling a global movement' to address the SDH; clearly including civil society as part of such a movement.  The work of the Treatment Action Campaign in South Africa and the Indian Right to Health Campaign epitomise the contributions that civil society can make to health development at the local and national levels.  

Civil society has a powerful role to play in supporting WHO, in working with WHO and also strengthening the accountability of the Secretariat and the MS representatives. WHO, both MSs and Secretariat have been very cautious about facilitating such a role.  It is nowhere mentioned in this draft GPW12.  

Chapter 5 deals with the 'results chain'. In this chapter and the associated draft PB14-15 a results chain is set out which moves from resources to activities to outputs to outcomes and impacts.  Impacts are the highest level and are to be measured in terms of healthy life expectancy, universal health cover and mortality, morbidity and disease eradication. Outcomes include reduction of risk, access to services, strong health systems, resilient societies. 

A distinction is made between outcomes and impacts on one hand and activities and outputs on the other.  Outcomes and impacts are not achieved solely by WHO working alone. Rather they are driven by WHO working alongside a range of other bodies and movements and in a changing global environment; these make the attribution of particular achievements (or shortfalls) difficult.  Outputs and activities on the other hand are what WHO does and for which it should be held accountable. 

The proposed activities and outputs are elaborated in draft PB14-15.  The focus in this GPW12 is on impacts and outcomes.   

The chapter starts out with some general comments on some of the methodological issues to be negotiated in developing such a results chain.  One of these is the issue of attribution noted above.  Another is how to handle outcomes and impacts which reflect work undertaken in different categories including cross-cutting drivers. 

Validity and reliability of proposed measures.  The chapter notes repeatedly that conceptual work is continuing on the challenges of measurement.  This is needed.  Many of the proposed measures are highly problematic.  In particular the measures which take the form of 'the number of member states who have ...'.  The validity and reliability of such measures is very doubtful in some cases bizarre.

Sole reliance on quantitative indicators. Many of the issues to be assessed do not lend themselves to quantitative indicators but could be meaningfully assessed with other tools such as commentaries against standards and narrative evaluations and other qualitative tools.  

Confusion of indicators with targets.   In many cases the proposed indicators are presented as targets (with varying provenance). There seems to be no logic for complicating the results chain at this stage with targets.  Target setting is seen by some as a strategy for coordination and drive. However, target setting is not discussed in the accompanying narrative, certainly it is not evaluated as a strategy for coordination and drive.