The World Health Assembly, the annual meeting of the World Health Organization (WHO), takes place this week in Geneva, with internal reform high on the agenda. A Chatham House report released tomorrow on reform of the WHO, deriving from 18 months of deliberation by a high-level working group, challenges the organization and its member states to ensure that its reform process produces more than cosmetic change.
When the WHO was founded in 1948 the world was a very different place – the social, political and economic changes that have occurred since then would have been beyond the imagination of the WHO’s founding fathers (who were indeed all men). As also would the health challenges the world now faces. AIDS, a killer pandemic but also a transformative experience for global health and its institutions, was decades in the future, and even the harmful impact of tobacco was not formally recognized by the WHO until 1970.
Yet the WHO’s constitution was in many ways far-sighted. It provided a wide ranging definition of health – encompassing physical, mental and social well-being not just the absence of disease or infirmity; it set for the organization a very ambitious objective – attainment by all peoples of the highest possible level of health; it listed 22 different functions which, consistent with its objective, ranged well beyond the purely medical to address many of what we would now call the ‘social determinants of health’; and it was ambitious about the WHO’s role – to be the directing and coordinating authority for international health work.
The WHO’s current reform programme focuses on two key issues: how to better align the priorities agreed by its governing bodies with the available finance, and how to ensure greater predictability and stability of financing to facilitate better internal planning and management. This is against the background of an organization whose predictable ‘regular budget’, financed by member state assessed contributions, now amounts to only about 25 per cent of total income, with the rest being mainly in the form of voluntary contributions, provided mainly by governments and foundations, usually earmarked for use in specific ways agreed between the donor and the WHO. In 2013, the Bill & Melinda Gates Foundation became WHO’s biggest funder, bigger than any of its member states.
There is therefore a disjunction between what the WHA decides the WHO should do, and the means available to the WHO to implement those decisions. The ‘regular budget’ is insufficient to meet even the cost of the WHO’s headquarters office, let alone the six regional and 150 country offices that absorb two thirds of its budget.
Other issues include: How can the WHO, as an intergovernmental body, effectively incorporate non-governmental stakeholders, including from the private sector? How can the WHO, primarily composed of health professionals, effectively address the social determinants of health? And what role should the WHO play as a leader in the governance of the health sector, and in influencing policies outside the health sector that affect health?
The reform programme accordingly focuses on a myriad of measures to improve WHO’s systems for priority setting, governance and management. As in any bureaucracy such a programme involves the production of mountains of reports and recommendations which the WHO’s governing bodies have to consider. Ironically this undermines the reform objective of reducing the workload of the governing bodies to enhance the quality of their deliberations. The WHO’s Executive Board in January this year in fact had the longest agenda in its history. The WHO has encapsulated the complexity of the reform programme in this extensive diagram.
The working group at Chatham House tried to step outside this complexity and identify the key elements that should feature in the reform programme for the WHO. In particular, it was able to consider structural and governance issues which have been almost wholly ignored in the internal reform process. Many of these centre on the WHO’s unique arrangement whereby the heads of the six regional offices are elected by regional member states. This means that regional directors are accountable to their regional members not to their nominal chief, the director-general of the WHO. A common saying is that there are not one but seven WHOs.
Adding on the further layer of the 150 country offices means that managing WHO in a coherent manner, and imposing common priorities, is a near impossible task. This top-heavy governance arrangement, and the three tiers of the organization, makes the WHO not only difficult to manage but also very costly to run – an independent evaluation estimates that administration costs take up 30 per cent of its budget.
Moreover, this governance and financing structure provides perverse incentives. Member states do not pay directly for their regional and country offices, which they therefore perceive as a free good, irrespective of the value of what they do. Why question a gift? For example Nigeria pays about $360,000 annually as its WHO subscription in return for which it benefits from the WHO’s largest country office of nearly 350 people at an annual cost of about $36 million. And the structure encourages the exercise of patronage, for example government officials using the organization as a means to place themselves or their colleagues in well-paid jobs in regional and country offices.
The gravy train aspects of the system are therefore a threat to the WHO’s technical integrity and its focus on public health objectives. And they are also an obstacle to reform. That is why little or no heed has been paid to suggestions made over the last 20 years for reforms to the regional and country offices, and why it is not a live issue in the current reform.
The big question is whether meaningful reform of the WHO is really possible given the political dynamics inherent in the organization. The Thai delegation at the 2011 WHA was in no doubt that it was not – the reforms proposed by the WHO were ‘less than cosmetic’. The working group has considered proposals that are ‘more than cosmetic’ in the hope that these will stimulate serious consideration by member states.
The report ‘What’s the World Organization For?’ and its companion ‘Shared Responsibilities for Health: A Coherent Global Framework for Health Financing’ will be published and launched in Geneva tomorrow.
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