WHA65 12. WHO Reform

Posted Mon, 2012-02-06 11:03

Key documents

WHO Reform. Consolidated report by the DG (Document A65/5)
Draft Twelfth General Program of Work and explanatory notes (Doc A65/5 Add.1)
Independent Evaluation Report (Stage 1), presented by the External Auditor (A65/5Add. 2),
Draft Evaluation Policy for EB131/3
Report by the Chairman of the meeting of Member States on programmes and priority setting 27 to 28 February 2012 (Doc A65/40)

The issues before the Assembly

WHO Reform

The DG presents a Consolidated Report (CR) on decision making and progress with respect to WHO Reform (A65/5). The CR is structured around 16 ‘decision points’ for decision by the Assembly.

Endorse EB Chairman’s report from February meeting of MS on priority setting (A65/40) and guide further development of the draft 12th GPW (A65/5 Add.1, see below also);
Endorse a set of principles regarding governance of WHO;
Scheduling of the meetings of governing bodies (WW comment);
Alignment between the work of regional committees and the EB;
Harmonisation of procedures and protocols across regions (WW comment);
Revised terms of reference for the PBAC;
Streamlining decision making in governing bodies (WW comment);
Engagement with stakeholders and partnerships (WW comment);
Strengthening technical support to MS (WW comment);
Staffing policy and practice (WW comment);
The new ‘financing dialogue’ (WW comment);
Internal controls;
Accountability, risk management, conflict of interest and ethics (WW comment);
Evaluation policy;
External auditor’s Independent Evaluation (Stage I)
Strategic communications

Draft outline GPW12

This draft outline of the GPW 2014-19 (Document A65/5 Add.1) is presented first to the PBAC and will then be considered by the Assembly. A more detailed version will be considered by the regional committees in late 2012; a revised version goes to by the PBAC in December 2012; and then to the EB in Jan 2013 and for final adoption by the Assembly in May 2013.

The draft outline GPW is scheduled for discussion with the DG’s Consolidated Report on WHO Reform because it seeks to operationalise the principles developed in the WHO Reform discussions.

See WW comment on GPW below.

Stage I Evaluation Report on WHO Reform Program (A65/5Add. 2)

At WHA64 a decision was taken to hold a special session of the EB in November 2011 and the DG was commissioned to prepare papers for this meeting. One of the papers circulated in July 2011 dealt with evaluation. These papers were reworked into a single paper for the EBSS.

The EBSS (in EBSS2(3))

“4. Decided to proceed with an independent evaluation to provide input into the reform process through a two-stage approach, the first stage of which will consist of a review of existing information with a focus on financing challenges for the Organization, staffing issues, and internal governance of WHO by Member States, following up where possible to produce more information in response to questions arising from the Executive Board at its special session. Ideally, stage one should be completed in time for the Sixty-fifth World Health Assembly;”

“5. Decided further that the first stage review will also provide a roadmap for stage two of the evaluation, the goal of that second stage being to inform the Sixty-sixth World Health Assembly, through the Executive Board at its 132nd session, as an input into the general programme of work. Stage two of the evaluation will build on the results of stage one and further consultations with Member States, focusing in particular on the coherence between, and functioning of, the Organization’s three levels. As one input into reform, this evaluation will proceed in parallel to other aspects of the reform;’

An independent evaluation of the WHO reform process was conducted in February/March 2012 by the Comptroller and Auditor General of India.

The Assembly is invited to note the findings of the Evaluation Report of Stage 1 (A65/5 Add.2) and recommendations, as well as the Roadmap for Stage II.

See WW comment on Evaluation Report below.

Report of debate on WHO reform at WHA65

After a procedural hitch (confusion about how to proceed) there was a general discussion although some confusion about whether it was general or general plus programs and priorities.

Much of the attention of the Committee was taken up by a long running debate over the proposed five ‘categories’ which figure centrally in the draft outline GPW.

Paraguay, Bolivia, Brazil and Colombia argued that there should be a new category, perhaps called Social Determinants or Sustainable Development. Clearly UNASUR had prepared for a campaign around the effective absence of SDH from the draft outline GPW.

Turkey, Japan, Bahrain and China all stated that they agreed with the five proposed categories.

USA and France were more aggressive stating that since the five categories had been adopted at the EB “there is no question of going back to the old discussion”. This is quite inappropriate.

Canada, UK and Switzerland took a more nuanced approach. They argued that SDH was a cross cutting issue and that the GPW needed to show somehow how the various cross cutting issues would be planned, budgeted and accounted for. Social determinants of health are relevant to all of the ‘categories’. Switzerland proposed staying with the five criteria recognising that a cross cutting issue on SDH called health dets and equity. Canada pointed out that the management of cross cutting issues and the ‘priority topics’ need to be properly accounted for in the GPW and PB.

The NGO Forum on Health also pointed out that A65/5 is not clear on how the right to health will be achieved in relation to other instruments. It needs to be mainstreamed into WHO's work and proririties. The Right to Health needs to be integrated into the draft 12th GPW

There were several comments on the GPW. Ecuador noted the need for more clarity in the GPW. Norway and Denmark (speaking on behalf of the EU) commended the Secretariat for the outline GPW.

Paraguay (speaking for UNASUR) and Switzerland felt that the GPW was too strongly medical rather than health focused.

Cuba and Germany commented that work on priority setting had not yet been reported: The work on priority setting has still to take place.

The DG explained that the draft priorities list will be based on CCS in consultation with the Global Policy Group.

Switzerland advised that many donor states did not have CCSs with the Secretariat. Switzerland has established a CCS between Switzerland and WHO.

Several states spoke about issues which they believed should be included as priorities in the new PB. Saudi Arabia argued that visual impairment should be a priority. Mongolia argued that zoonotic diseases should be prioritised under the communicable disease category. and argued for environmental determinants of health to be included as a new category.

El Salvador asked for priority to go to environmental and occupational toxins under the NCDs category..

Sweden, Norway, Japan, Lithuania and Egypt all spoke about the proposed Financing Dialogue. In general they were cautious, emphasising that the governing bodies have to remain in charge of the WHO agenda.

Sweden emphasised the need for transparency. Norway emphasised that the purpose of the Financing Dialogue must be to finance the priorities set by the WHA. Lithuania (on behalf of the EU) stated that the EU will continue to financing to be in line with priority settings A successful financing mechanism needs WHO to say no to funds that doesn’t go in line with WHO priority settings

Ecuador speaking on behalf of UNASUR emphasises the need for predictable financing and regrets that it has been so hard to get agreement on increased assessed contributions.

Thailand commented that we have had zero grow of assessed contribution for two decades. We should pay more for this organization. It's a pity that the document doesn't challenge MS on this issue.

Oxfam called for a fundamental shift in how WHO is financed: increase assessed contributions.

Switzerland spoke about the need for changes to the rules to limit number of agenda items. Turkey asked for clear explanation on this proposal.

New Zealand supported the proposed harmonisation across regional committees. Indonesia supported the initiatives for closer alignment between RC and HQ.

Ecuador spoke about COI. Important but hard

Estonia (on behalf of the EU) spoke in support of the closer involvement of civil society and NGOs in the work of WHO but there will be a need for clarification on which the different categories and the areas of engagement and called for an explicit policy paper on the relations of the WHO with different categories of stakeholders.

Consumers International & IBFAN stated that improvement in WHO’s relationship with public-interest NGOs is needed. Such improvement may even require restricting engagement with actors promoting commercial interests. Consultations on this matter should build on key recommendations of the 2002 Review Report by the WHO Civil Society Initiatve and a thorough review of current practice regarding civil society.

After this general round of comments the Committee focused on Priority Setting.

The discussion on priority setting and on the Draft Twelfth General Programme of Work (GPW 12) started with Brazil stating that they were not ready to endorse the Chair’s summary produced after the February meeting. Brazil affirmed that more clarification and more discussion was needed since the document does not capture all countries’ positions.
UNASUR backed Brazil and went further suggesting to introduce a sixth category on social determinants of health (SDH). Some countries expressed their concern on re-opening an issue that was already discussed during the February meeting while Switzerland affirmed that SDH should rather be a horizontal bar cutting across all categories.
Many countries aligned themselves either with UNASUR (Cuba, South Africa) or with Switzerland (China, EU,Lebanon, Botswana, Senegal).

Dr Chan recognized that more work is to be done on priorities and that the next version of the GPW 12 will provide more details. She also tried to reassure Member States saying that either as a cross-cutting issue or as a priority, funds need to be provided for SDH. She also stated “if it is an independent category, you may get a bit more visibility, but that’s all. The categories will not get money, but the priorities will get money”.

Thailand, trying to find a compromise, suggested to rename the third category as "Social Determinants of Health and Health Promotion through the Lifecourse ". However, no consensus was reached on this suggestion.

At the end of the debate, two decisions were taken:

1. concerning the Chair’s summary produced after the February meeting, the word “endorse” was replaced by the word “welcome” following the suggestion from Brazil

2. paragraph 1b under programmatic reform was amended following a proposal by Switzerland who suggested to insert after the words “World Health Assembly” the phrase "especially concerning health determinants and equity".

WHO reform: Priority setting

UNASUR backed Brazil and went further suggesting to introduce a sixth category on social determinants of health (SDH). Some countries expressed their concern on re-opening an issue that was already discussed during the February meeting while Switzerland affirmed that SDH should rather be a horizontal bar cutting across all categories.

Many countries aligned themselves either with UNASUR (Cuba, South Africa) or with Switzerland (China, EU, Lebanon, Botswana, Senegal).

Trying to find a compromise, it was also suggested to rename the third category as "Social Determinants of Health and Health Promotion through the Lifecourse ". However, no consensus was reached on this proposal.

At the end of the debate, two decisions were taken:

1. concerning the Chair’s summary produced after the February meeting, the word “endorse” was replaced by the word “welcome” following the suggestion from Brazil

paragraph 1b under programmatic reform was amended following a proposal by Switzerland who suggested to insert after the words “World Health Assembly” the phrase "especially concerning health determinants and equity".

Decisions of WHA

See Decision WHA65(9) from page 5 of Decisions doc (A65/DIV/3)

PHM Comments (pre-WHA)

General comment: Key issues for WHA65

WHO is in crisis. There are broadly two aspects to this crisis: financial and administrative.

First, WHO does not have enough money to do what it needs to do (to do what the member states want it to do). Second, WHO does not have control over most of its revenue which is ear-marked donations. In large degree the financial crisis has arisen because the rich countries, led by Europe and the USA are unwilling to agree to increased 'assessed contributions' (untied). Since the mid 1980s the US has sought to control what WHO does by threatening to withhold or reduce contributions to its budget; most famously in relation to the WHO code on the marketing of breast milk substitutes and secondly in relation to WHO's work on essential drugs and rational drug use. The need to increase assessed contributions and increase the proportion of donor money which is not earmarked hangs over all of the discussions of WHO reform.

The administrative dimension of WHO's crisis is complex. It can be traced in some degree to the founding structures and in part to the political pressures on WHO at different times in its development. However, in large degree the administrative weaknesses are a consequence of the increasing significance of tied donor money and the fragmentation of the Organisation as clusters have to compete with each other to win funds to do the donors' bidding. The power of the donors (private, governmental and intergovernmental) over WHO's agenda has compromised its management.

The focus of discussion within the EB and the WHA has moved over the last two years of the present reform debate. In the DG's presentation to the Jan 2011 EB there was a focus on WHO's role in global health governance and the proposal for a new global health forum (which later morphed into a 'pledging conference'); secondly on priority setting ('WHO is too ambitious; needs to focus'); and third on management ('WHO is not able to respond with speed and agility'). At the WHA in May 2011 the issues were characterised as: core business, organisational effectiveness, management and accountability, human resources, financing and communication, and effectiveness at country level. In the lead up to the Special Session of the EB in November 2011 the three main areas were: programmatic priorities; governance and managerial reform. In the lead up to the regular EB in Jan 2012 the topics were: priority setting, allocation of resources within the Secretariat, governance of WHO, stakeholders and partners, predictability of funding, funding outbreaks, evaluation.

The Chairman's Report from EB130 (A65/40) deals with criteria for priority setting (five broad criteria); high level categories for planning, managing and funding WHO's work (five main areas of work); and a roadmap for developing and adopting the new (12th) General Program of Work (2014-2019).

The outline GPW(2014-19) to be submitted by the Secretariat will be considered by the Program Budget and Administration Committee before the WHA; it will be considered by the WHA and then by the regional committees in the latter half of 2012 and will be adopted by the WHA in May 2013.

The key issues therefore before the WHA65 are:

the continuing basic issues of assessed contributions and the power of rich member states to control and contain what WHO does, regardless of governing body resolutions;
the specific administrative and management issues which continue under discussion; eg priority setting, 'partnerships' (and conflict of interest), contributing more effectively at the country level, etc
the shape and content of the GPW(2014-19).

Commenting on some of the Decision Points in A65/5.

3. Scheduling: giving the donors control of the agenda?

The 65th WHA is invited to consider a number of options for re-scheduling the meetings of governing bodies. It appears that the favoured option would involve the annual cycle starting with regional committees in the first quarter of the year followed by the PBAC and EB leading then to the ‘financing dialogue’ with donors and ending with the Health Assembly in the last quarter.

This arrangement would have the EB prepare a draft program budget which then goes directly to the donors (the financing dialogue) and only after the donors have decided what to fund does it come to the Assembly, scheduled in the last quarter of the year.

It is hard to avoid the image of the Secretariat auctioning its programs to the donors and then presenting the assembly with a fait accompli with respect to the program budget.

Apart from this indignity, the proposed arrangement will give Secretariat inadequate time to prepare for the new programme to start in January.

5. Harmonising across regions

The DG brings forth a number of initiatives and proposals for harmonising (or standardising) the ways in which the regions work.

We are concerned about the passage in para. 33 which would allow Regional Committees to invite the observers that “they wish to attend”. If accreditation follows a known official procedure, then there is no place for picking and choosing which organisations get accredited. There is a pressing need to reform the procedures, rules and protocols for the participation of civil society in global and regional governing bodies.

WHO is a member state body and this is part of its strength. However, there is untapped value to be gained from building a more collaborative relationship with public interest civil society organisations at the country, regional and global levels.

Closer involvement of civil society as observers in RCs would strengthen the accountability of regional committees and bring fresh perspectives for discussion. Civil society collaboration would add value to program implementation as well as policy making and accountability.

7. Streamlining decision-making in governing body meetings

Under this heading the DG refers to a number of proposals for tighter discipline on late resolutions; for new mechanisms to vet resolutions coming to the governing bodies and for arbitrary limits on repeat progress reports.

We support more discipline in managing late resolutions submitted to the WHA.

We firmly oppose the proposal that Officers of the Board might curtail the right of MSs to propose resolutions to the governing bodies. There may be merit in reflecting on earlier resolutions and seeking coherence between resolutions on related subjects but this should not restrict the sovereign right of MS to table resolutions on matters they deem important.

We reiterate the intergovernmental nature of the WHO, and of the processes taking place within its governing body meetings. In this context, we wish to caution against the seemingly increasing trend of using summaries of discussions developed by Chairs of intergovernmental meetings.

The Chairman’s summaries under recommendation in para. 43 have no legal status and are not binding documents. They are not decisions, and do not reflect the intergovernmental nature, or capture the diverse opinions, of the meetings they summarise. They also face the difficulty of implementation, hence accountability, because of lack of consensus (necessary for any intergovernmentally agreed text).

We urge MS to delete points (a), (c) and (d) from para. 43.

8. Effective engagement with other stakeholders

The DG reviews the different kinds of partnerships and relationships that WHO engages in, including: with other intergovernmental bodies, private sector organisations and non-government organisations.

We appreciate the commitment to review WHO’s relationship with NGOs at global, regional and country levels and the recognition of the importance of discerning clearly between different types of NGOs engaging with WHO.

We note with concern the recent trend for the Secretariat to hold separate consultations with public interest organisations and private interest ones including the private sector. Ensuring transparency in such processes necessitates the presence of all stakeholders in the same room for discussion.

We appreciate also the focus on clearer protocols for managing conflicts of interest of various kinds and look forward to finalisation and implementation. We urge an explicit commitment to excluding private sector entities from direct involvement in policy-formation and norm-setting activities.

9. Strengthening technical support to Member States

The DG articulates a commitment to strengthening technical and policy support to member states and reports on a number of initiatives to this end. We commend this commitment and the progress which has been made.

We appreciate that the value of policy dialogue at the country level including civil society is recognised and the new emphasis on the role of the WHO country office in promoting such dialogue. Community based NGOs can contribute to policy formation and to constituency development for policy implementation.

We appreciate the commitment to refine the role of country cooperation strategies (CCS) in shaping the WHO work program and in particular the recognition that the objectives articulated in the CCS must be funded. PHM calls for greater accountability and transparency with respect to CCSs.

10. Staffing policy and practice

The DG reports on a number of initiatives designed to promote improved staff performance, and a more flexible mobile workforce.

WHO works in a complex and shifting environment and getting staffing policies and practices right is of critical importance for the organisation and for global health. There is a range of debates over regional representation, recruitment policies, types of employment and mobility.

There are clear risks associated with the proposed move to short term contracts, greater mobility and contracting out. If these options have been subject to robust analysis and evaluation this work should be published.

It will be difficult for member states to endorse a particular staffing strategy in the absence detailed description and evaluation of current practice and evaluation of options for policy reform.

11. Financing dialogue

The DG’s comments on results based financing and the so-called financing dialogue presume the continued freeze on increases in assessed contributions. This freeze is disabling WHO. We urge MS to re-open consideration of a substantial increase in assessed contributions. We urge donors to convert earmarked contributions to untied grants.

The DG commits to ‘results-based budgeting and resource allocation’ based on the new (12th) general program of work (GPW). We have commented elsewhere that the outline GPW which has been published (A65/5 Add1) is completely silent with respect to planning for, budgeting for and accountability for cross-cutting issues such as the right to health, trade and health, gender equity and the social determinants of health.

The discussion of the scheduling of governing body meetings and the timing of the financing dialogue highlights the power that donors will have over the Program Budget before it is adopted by the Assembly. This is not compatible with the claim that WHO is a MS driven organisation.

13. Accountability, risk management, conflict of interest and ethics

The DG provides a detailed discussion of conflict of interest and describes the role of the new Ethics Office in managing COI.

The DG foreshadows a new transparency and disclosure policy to be unveiled at the EB in Jan 2013.

PHM Comment on the Draft Outline GPW

The ‘cross-cutting’ issues (in particular, social determinants, trade relations, the right to health, primary health care, gender equity) are completely neglected in this GPW and in the DG’s Consolidated Report.

PHM recognises the logic of adopting a particular set of categories for budgeting purposes. Such categories are always going to be arbitrary and carry the risk of privileging those categories as against alternative possible categorisations.

A more coherent and integrated GPW requires effective planning, budgeting, evaluation and accountability mechanisms for the cross cutting issues as well as the ‘categories’ which are adopted as line items for budget purposes.

These cross cutting issues include social determinants, trade, the right to health, primary health care and gender equity. In this GPW some of these issues are identified as over-arching principles (PHC and trade are completely absent) but there is nothing in the GPW or the DG’s Consolidated Report about strategic planning and accountability in relation to issues.

The achievement of the right to health and gender equity for example can only be assessed in relation to what is happening on the ground in countries. There should be robust reporting from country and regional offices on the achievement of these objectives.

WHO’s evaluation framework needs to make provision for meaningful evaluation in relation to all of the agreed cross cutting issues, at the global, regional and country levels including targets and milestones..

The planning function is also vulnerable in relation to the cross cutting issues. The draft GPW identifies Preparedness, Surveillance and Response as one of the five categories. The risk is that the cross cutting issues of human rights, the role of primary health care, gender issues and social determinants in epidemics and disasters will be neglected. Disasters, including ‘natural’ disasters always impact more devastatingly on the poor who suffer lack of basic housing and sanitation.

The Rio Declaration on Social Determinants of Health has called for monitoring and accountability mechanisms. (See also resolution WHA62.14 on Reducing health inequities through action on the social determinants of health.) The WHO EB endorsed the Rio Declaration in its 130th session last January, and recommended to the 65th WHA a draft resolution text with that very content (EB130.R11).

There is no reference in the GPW to the issues of planning, evaluation and accountability in relation to SDH, at the time when MS are about to consider a draft resolution on the matter!

PHM Comment on the Stage I External Evaluation Report

The Evaluator has COMPLETELY failed to address the first term of reference.

The team has undertaken an evaluation of the WHO Reform Program as implemented so far (see Stage I Evaluation Report, from page 57). This they were not asked to do; at least, not by the Executive Board. The (unmandated) evaluation of the Reform Program is very positive.

The evaluator has created a new set of terms of reference for the evaluation which bear no relationship to those adopted by the EB (see page 9).

He has not reviewed the existing information with respect to finance, staffing and internal governance. This he was asked to do.

He has provided a ‘road map’ for Stage II of the Evaluation (which was part of the brief) but in view of his very positive assessment of the reform process to date - an assessment which was not commissioned by the EB - it would seem unwise to proceed on the basis of his advice (unless with extreme caution) and unwise to rely on him to undertake the next stage of the evaluation.

See Statement by PHM to Committee A

PHM post debate comment

The outstanding issue at the heart of the current WHO reform program is the failure of the MS to increase the level of assessed contributions and the consequent exposure of the Organisation to the dictates of the donors. WHO is not in control of its own agenda.

A small number of MS will speak these truths publicly. Many more will say so privately. Meanwhile the donor states are happy to continue to exercise donor control and the middle income countries, especially the BRICS, who would be required to significantly increase their contributions if ACs were increased, seem to be happy for the extra burden to remain with the high income countries, even if it is disabling WHO. The LDCs remain silent publicly for fear reprisals in bilateral aid relations.

The current solution is the ‘financing dialogue’ which has been wrapped in various assurances including the expectation (from some MS) that the DG will refuse donations which are not in line with the Organisation’s priorities. While there is much uncertainty about how the financing dialogue will work and the kinds of outcomes it might achieve, it could not be worse than the present arrangements which are much less transparent with much looser links to the Organisation’s priorities. Whether it will be significantly better is a matter for varying degrees of scepticism.

Critical to the regime being developed is the articulation of clear priorities. This has been an article of faith among all of the MS who have been driving the reform process but there have been no operational decisions about how to derive priorities. The DG announced during the WHA that she will work with the regional directors to derive Organisation-wide priorities from the country cooperation strategies (CCS). There is a certain elegance to this concept if indeed the CCSs capture the local manifestations of the global barriers to HFA. However we need to ask how validly the CCSs reflect the country specific priorities (as opposed to expectations of what WHO can deliver) and how easily country priorities can be extrapolated to global priorities.

The DG promises that the outcome of her prioritisation process will produce a first draft priorities list only and that MS will have the final say. However, according to the new schedule the draft PB to be adopted at the EB in Jan 2013 will provide the basis for the financing dialogue in the first quarter of 2013 so the priorities offered to donors will be those developed by the DG as modified by the EB before the methodology and outcomes have been considered by the WHA.

The WHA will be asked to consider and confirm the GPW and PB in May 2013 but only after the priorities adopted by the DG and EB have been offered to the donors. Since both the DG and the EB members know very well what sorts of projects the donors would like to fund the whole process is rather compromised.

The relative roles of the DG and the MS in decision making is problematic in other respects including the proposed restrictions on the right of MS to submit resolutions to the EB and the rising role of Chairpersons’ Summaries as a way of drawing conclusions from inconclusive debates. Meanwhile new HR policies and practices, critical parts of the reform program are being put in place with very little participation by MS. The Stage I Evaluation Report was supposed to assemble the available information needed to inform decision making regarding the reform process but was diverted into a quite unusual evaluation of the reform process to date (with the effect that the information required remain unassembled and the MS receive a very positive evaluation of the reform program which they had not requested).

Another critical area of the new arrangements which will have to be resolved without WHA consideration is the handling of the ‘cross cutting’ issues, including social determinants of health, the right to health, gender equity and primary health care. The DG has declared that she personally will ‘look after’ these areas but she has offered no methodologies for assuring systematic planning and policy making, budgeting, accountability and profiling of these areas. It appears that such methodologies are still to be developed.

The consequence of these decisions (and non-decisions) is that WHO’s agenda will continue to be determined by rich MS, intergovernmental donors and private philanthropies. Most of these players have quite specific interests (and perspectives) which they are actively promoting through their donations to the WHO. These interests, in many respects, run counter to the interests of most of the MS.

MS representatives have a moral obligation to speak out against these arrangements. There is an urgent need for civil society action to save WHO from itself.

Previous Reports and Commentary

See WHO-Watch Topic Page on WHO Reform
See Medicus Mundi WHO Reform portal
See Reports and Commentary from WHO Watch at January 2012 EB
See DG Summation of Discussions at Jan EB
See WHO Report of Resolutions and Decisions
See DG's page on WHO Reform

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