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WHO: Past, Present and Future

Reforming WHO: the art of the possible A. Cassels*, I. Smith, G.L. Burci World Health Organization, Switzerland It is increasingly common to read, in this volume and others like it, that the international health architecture is overly complicated and fragmented.1,2 It suffers from a surfeit of new initiatives, purpose-specific funding mechanisms and advocates for special causes. Repetition of this orthodoxy is usually followed by two lines of argument: one which stresses the urgency of bringing order to the global system; the other speculates about the future of WHO. This paper describes aspects of the current WHO reform programme. Many of the problems we discuss are not new3 and a journey, that began some four years ago, will continue to have many twists and turns. The present reform programme was initiated, not by dissatisfied Member States, but by a Director-General who foresaw the need for change. The agenda has also evolved over time, starting not with issues of governance, architecture or organizational structure, but with financing e and with a concern for the quality more than the quantity of WHO’s income. With some parts of the programme wellfunded and others chronically under-resourced, and most voluntary contributions highly earmarked, initial discussions focused on greater flexibility of finance.4 Inevitably, however, the debate about greater flexibility soon opened up several more fundamental issues: about priorities, focus and core functions; about WHO’s role in a changing world at country and global level; and about the structures, incentives and management systems needed to attract and retain talented staff and to ensure accountability for resources and results. These three areas e priorities, governance and management e provide a basic framework for understanding WHO reform.5 Priority setting is a particular challenge in a multilateral organization. WHO’s 194 Member States have different needs and different interests. Some place greatest value on a handson country presence; others on the development of norms, standards and global public goods; others again value WHO as an effective advocate for health in the political fora that

address social and economic determinants of health. Secondly, unlike a donor or development agency, WHO cannot simply limit the geographical or technical areas in which it works and drop everything else. Rather, it is more like a government that signals priorities in education and food security, while recognizing that its still retains responsibility for defence, housing and health. Following a consultative process WHO has defined six priorities for the next six years. Together they provide focus and direction, they stand out from the body of WHO’s work, while integrating efforts across traditional technical boundaries. Individually, they represent areas where WHO seeks to lead the global debate and are thus linked to WHO’s role in health governance. They are closely associated with the priorities of the current leadership (Box 1).6 The governance component of reform has two elements. The first is concerned with the way WHO is governed by its Member States and envisages a more strategic, disciplined and coherent approach to the way the organization is run, with better linkages between the six Regional Committees, the Executive Board and the World Health Assembly (WHA). The second element is more outward looking and concerned with WHO’s role in the governance of health at global, regional and national level. Progress has been slow on both counts, but the issues raised are important in understanding the dynamics of change.7 For the internal agenda a strategic approach implies, among other things, a more effective gatekeeper role of the Executive Board and, linked to this, fewer but more influential resolutions at the WHA. For many Members these objectives pose few problems, but for others they are seen to impinge on issues of national sovereignty. Thus meetings of the Executive Board (and indeed other governance committees) are attended by a growing number of Member States. While nonMembers are excluded from voting, all have the right to speak and indeed participate actively in the Board’s discussions. Similarly, many Member States are reluctant to accept

* Corresponding author. World Health Organization, Geneva, Switzerland. Tel.: þ41 22 791 2080. E-mail address: [email protected] (A. Cassels). 0033-3506/$ e see front matter ª 2013 World Health Organization. Published by Elsevier Limited on behalf of The Royal Society for Public Health. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2013.12.006

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Box 1 WHO Leadership priorities 2014e2019.  Advancing universal health coverage: enabling countries to sustain or expand access to all needed health services and financial protection and promoting universal health coverage as a unifying concept in global health.  Health-related Millennium Development Goals e addressing unfinished and future challenges: accelerating the achievement of the current health-related Goals up to and beyond 2015. This priority includes completing the eradication of polio and selected neglected tropical diseases.  Addressing the challenge of non-communicable diseases and mental health, violence and injuries and disabilities.  Implementing the provisions of the International Health Regulations: ensuring that all countries can meet the capacity requirements specified in the International Health Regulations (2005).  Increasing access to quality, safe, efficacious and affordable medical products (medicines, vaccines, diagnostics and other health technologies).  Addressing the social, economic and environmental determinants of health as a means to promote health outcomes and reduce health inequities within and between countries.

any limitations on their right to propose subjects for debate at the Board or the WHA. WHO’s role in global health governance raises a different but no less difficult set of issues. In essence what is envisaged is that WHO needs to be better equipped to fulfil the mandate in its Constitution to be the ‘directing and coordinating authority in international health’.8 This in turn requires that there is a clear understanding of what this phrase implies 60 years after the constitution was drafted. Secondly, whatever form coordination takes, it requires that WHO engage effectively with a much wider range of stakeholders e from different parts of governments, civil society, the private sector and other non-state actors e than was the case in 1948. Without such engagement, it is unlikely that coordination at global or national level will be effective. But therein lies the challenge for an inter-governmental organization in a multistakeholder world. How to secure meaningful engagement on one hand, whilst ensuring, to the satisfaction of a critical audience, that WHO’s normative role is fully safeguarded from vested interests, and that the prerogative of governments to have an exclusive role in decision making is preserved? Addressing these concerns is currently the focus of governance reform. The management component has many elements. We focus here on financing, as progress is central to overall success. There are several dimensions to the problem. Membership fees (called assessed contributions, or AC) finance about one-quarter of the current budget. While an increase in the proportion of the budget funded from this source is desirable,

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a significant change in the scale of assessment is unlikely in the short term. The remaining finance therefore has to come from voluntary contributions, many of which are highly specified for particular programme or geographical areas. Moreover, a significant proportion of voluntary contributions are provided by national development agencies and thus favour activities that are in line with the achievement of their aid objectives at country level, as opposed to normative work or the development of global public goods. Lastly, while government funding still constitutes 51% of WHO’s voluntary income, the remaining 49% now comes from non-state sources, including philanthropic foundations other UN and intergovernmental bodies.9 The focus of financing reform has been to change the way the budget is approved and financed. First, priorities and the programme to implement them are agreed by Member States exclusively at the WHA. Second, Member States are now asked to approve the whole budget (whereas in the past they only approved the use of assessed contributions). The significance of this step is not that States are legally bound to finance the whole budget, but that their approval shows endorsement of all the programmes, the estimate of resources required and the results that the budget contains. Thirdly, agreement on the entire budget is followed by a financing dialogue in which all financiers of WHO e state and non-state e can participate.10 The financial dialogue aims to change what was a somewhat opaque process of bilateral negotiations into a more open, transparent and collective discussion of how the budget agreed by Member States can be financed in a way that is both stable and predictable. Flexibility of funding, as we mentioned at the outset, remains important, but alignment with agreed priorities is now the paramount concern. As a last word, many of the papers in this volume illustrate the fact that proposals for the reform of WHO and the rationalization of the global health architecture tend to come with their own in-built world view (pro- or anti-UN, for or against private sector engagement, developmental versus normative, rights-based versus needs-based, and so on). Our position, based on several years of working at the interface between a complex, decentralized secretariat and 194 Member States, is more pragmatic. A vision of an organization that is better able to fulfil its potential is essential, but even that vision evolves over time, and the means of achieving it requires flexibility, patience and persistence. We thus continue to focus on the art of the possible.

Author statements Disclaimer The views expressed are solely those of the authors and do not necessarily reflect the policies or positions of the World Health Organization.

Ethical approval None sought.

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Funding None declared.

5.

Competing interests None declared.

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Switzerland, http://www.who.int/dg/who_ futurefinancing2010_en.pdf; 12e13 January 2010 (accessed 12 November 2013). WHO. WHO Reform. Consolidated report by the Director-General. http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_5-en.pdf (accessed 12 November 2013). WHO. 12th general programme of work (2014e19). http://apps. who.int/gb/ebwha/pdf_files/WHA66/A66_6-en.pdf (accessed 12 November 2013). WHO Reform. Stage 2 evaluation. Preliminary report. SA: PricewaterhouseCoopers; 2013. http://www.who.int/about/ who_reform/whoreform-stage2evaluation-pwc-2013.pdf. WHO. Constitution of the World Health Organization. In: Article 2 (a). Basic documents. 47th ed. World Health Organization; 2009 [chapter II]. WHO. Financial report and audited financial statements for the year ended 31 December 2012. http://apps.who.int/gb/ebwha/pdf_ files/WHA66/A66_29-en.pdf (accessed 14 November 2013). WHO. Investing in the World’s Health Organization. Taking steps towards a fully funded programme budget 2014e15. http://www. who.int/mediacentre/events/2013/financing_brochure_ 20130620.pdf (accessed 14 November 2013).

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