A Global Village
Issue 5 » The Right to Health

Reforms for a Healthy Future?

WHO in Critical Negotiations

Rob Doble, London School of Hygiene and Tropical Medicine

Health Organisation (WHO) is considering reforms which WHO Director-General, Margaret Chan, says will bring the biggest changes to the agency in its 63 year history. Spurred by serious financial difficulties, the organisation is currently having an identity crisis with a need to redefine itself and how it operates in order to ensure it is fit for purpose in the new global health landscape of the 21st century. But what reforms are being proposed? What have the reactions been? And what are the next steps?

Since the early 1990s, the WHO has faced sustained concerns over what its role in global health should be and how it should best do this. Despite having the constitutional mandate ‘to act as the directing and coordinating authority on international health’1, this has been challenged and complicated in recent years by the emergence of new, often issue-focused, global health initiatives (e.g. Global Fund to fight HIV/AIDS, TB and Malaria, and the GAVI Alliance), bilateral programmes (e.g. US PEPFAR) and philanthropies (e.g. Bill and Melinda Gates Foundation). At the same time, WHO has found its budget squeezed and increasingly inflexible. Despite overall financial resources for global health increasing significantly (from US$5.7bn in 1990 to $26.9bn in 2010), much of this money has largely bypassed the WHO2. A drive from donors to have more control over WHO funds has led the organisation to increasingly rely on voluntary, extra-budgetary funds (EBFs) – contributions which are often earmarked for specific WHO programmes or projects. EBFs have grown from 25% of the total budget in 1970 to 40% in 1980, to more than 50% in 1990 and 77.3% in the 2008-2009 budget3. This restricts WHO’s flexibility and skews global health priorities toward donor demands – for example, 60% of EBFs in 2008-2009 were for infectious diseases compared with 3.9% for non-communicable diseases.

Margaret Chan has
characterised WHO as
“not [being] an inclusive
organisation” andsaid
WHO needs to open up
and hear the voice of
different sectors

It was these financial concerns, raised during the World Health Assembly (WHA) in 2009, which sparked the current reform process. It prompted the WHO Director-General, Margaret Chan, to hold an informal consultation in January 2010 to discuss how to better align WHO’s objectives with the money available to them and to ensure greater predictability and stability of financing. However, it soon became clear during this meeting that improvements in financing first require greater clarity about the current role of WHO – i.e. defining WHO’s distinct contribution to global health, what functions should constitute its core business, and how it can improve its operations4.

The January 2010 consultation concluded that WHO should have a tighter and more focused agenda and improve how it communicates its results as part of a revised resource mobilisation approach. In addition to the WHO being more selective about its priorities and functions, the January 2011 WHO Executive Board (EB) called for reforms to also capitalise more on WHO’s leadership position in global health and improve its flexibility. Subsequently a report and development plan was prepared for the WHA in May 2011 which outlined three key elements of the reform programme:

1. Plan for strengthening WHO’s central role in global health governance (GHG);

2. Clear articulation of WHO’s unique role and functions;

3. Detailed plan for managerial reform.

Talking Shop
Firstly, on WHO’s role in global health governance, Margaret Chan has characterised WHO as “not [being] an inclusive organisation”4 and said WHO needs to open up and hear the voice of different sectors. She has also been quite adamant that WHO should contribute to rectifying what she has termed silomania whereby institutions work to protect their turf and focus on their specific area which she argues has created fragmentation and a lack of coherence in global health today. Her proposal is for WHO to convene a multi-stakeholder forum for global health, a World Health Forum (WHF). This would bring together Member States, civil society, the private sector, academia, and international organisations to discuss how to effectively work together to address key problems in global health and amplify important issues on which others, and not just WHO, may act.

It has been proposed that the first WHF would be in November 2012, over three days and convened every two years for two further cycles and then independently reviewed. For a clearer idea of what such a forum might look like, we can refer to the recent WHO Global Forum on meeting the challenge of non-communicable diseases (NCDs) in April 2011 in Moscow. This meeting brought together governments, civil and patient associations, private sector, and professional groups and was described by Chan as a “groundbreaking meeting for WHO”, marking “the beginnings of a different WHO”.

However, the idea of a WHF did not receive a particularly warm welcome at the WHA this year, and has to date been the most controversial aspect of the WHO reform programme. During the WHA many Member States and NGOs criticised the lack of detail provided and expressed concerns about how a WHF might interfere with WHO governance processes (i.e. how will the WHF affect the role of the WHA as the main governance body deciding on global health priorities and policy). Particular concerns were also raised regarding the potential increase in influence the WHF could give to the private sector and donors in setting WHO’s agenda and the global health agenda generally. Some NGOs such as the International Baby Food Action Network (IBFAN), MSF Access Campaign and People’s Health Movement (PHM) issued press releases calling for the WHF to be stopped arguing that the WHO’s claims that the forum will not usurp the decision-making power of WHO’s own (member-state based) governance are not credible, especially since the forum proposal fails to define who would participate and how it will address conflicts of interest. For some Member States such as Brazil, concerns regarding the World Health Forum were part of larger issues with WHO’s proposed relationship with external stakeholders, notably proposals for the Gates Foundation to partially fund the reform programme and for the WHO to seek to attract new donors including ‘pool funds from private entities’5.

Consult, Consult, and Consult
Margaret Chan did, however, manage to pass a resolution supporting the proposed reforms, steering it through the stormy waters of the WHA by promising inclusiveness, that Member States would have the biggest voice in the reforms, and that she would “consult, consult, and consult” until Member States were happy. Yet at the WHO EB session immediately following the WHA, Member States and NGOs pushed to make the resolution clearer in mandating WHO to be more transparent, inclusive and consult with Member States. This included a request for the WHO to produce a more detailed concept paper on the World Health Forum by the end of June 2011 and consult with Member States to feed into a special WHO EB session in November 2011. The NGO Third World Network has described this step as “significant in that Member States pushed to regain control of WHO’s critical reforms which has hitherto been driven by the Secretariat”.

There are some serious
concerns about whether
the proposed reforms
are the right ones, in
particular there is much
scepticism surrounding
the WHF and the
potential opening up of
WHO to both new sources
of money and greater
potential private sector

The concept paper (WHF) was produced on 22nd June 2011 and discussed at a WHO Mission Briefing in Geneva on 1st July 2011. However, while the concept paper does give a bit more clarity, it is still very vague and according to records from the meeting it appears that the paper did little to quell Member States concerns and questions. Member States still seem to be concerned as to what function the WHF provides and how it may interfere with WHO governance and priority-setting, together with logistical questions regarding how it would be funded, who would participate, and why the proposal is to not evaluate until after six years. Equally, some NGOs (IBFAN, PHM, Health Action International, Medicus Mundi etc) have remained critical, sending an analysis to Member States in advance of the WHO Mission Briefing6. This analysis criticises the “very weak” rationale behind the creation of a WHF stating that it is unlikely to achieve coherence and calls for proper accountability rather than generic coherence. It also criticises WHO’s poor delineation between private interest organisations and public interest ones which are both being put under the civil society umbrella. Instead of a WHF, these NGOs call for WHO to “undertake and properly resource public hearings, i.e. mechanisms of open consultations on specific subject matters” which would be more oriented towards gathering information and voices from different sectors but more flexible in their format than a WHF and without creating more structures and bureaucracy or interfering in WHO governance.

Indeed, with such a mixed response, it remains to be seen how, and indeed if, the WHF will emerge to facilitate further engagement between WHO, Member States and diffuse external actors.

Core Competencies
With a need to provide greater clarity about the current role and direction of WHO in terms of attracting both financial and cross-sectoral support, five areas of core business are outlined:

1. Convening for better health: Bringing together experts to prepare technical guidelines for decision-makers and convening negotiations for health regulations and treaties;

2. Generating evidence on health trends and determinants: Collecting, analysing and disseminating health data and strengthening health information systems that yield and use this data;

3. Providing advice for health and development: Providing advice to health and development partners on health issues linked to the UN Millennium Development Goals (MDGs) and issues with high cost implications for low- and middle-income countries;

4. Coordinating health security: Increasing the preparedness of other institutions’ for health security risks, coordinating those directly implementing response programmes, and implementing the recommendations of the International Health Regulations (IHR) Review Committee;

5. Strengthening health systems and institutions: Providing strategic advice to guide decision-making on how to strengthen health systems, focusing on making evidence available in ways that help decision-makers weigh up the merits of different options in light of national circumstances.

Here, there were concerns that WHO was positioning itself in an overly normative and technocratic role. NGOs such as MedicusMundi International Network and People’s Health Movement, in official interventions during WHA discussions, stressed that WHO should not be consigned to becoming a technical agency with no political or legal role.

Recent events at the
WHA also demonstrate
that Chan’s leadership
and ability to deliver a 
‘Member-State driven’
process with effective
consultation will be key
to seeing the reforms
through to final approval
at the WHA in 2012

More Meat
Financial pressures have forced the WHO to go back to the drawing board and fundamentally re-examine what its role in global health should be in today’s populous global health governance landscape. This article has shown that there are some serious concerns about whether the proposed reforms are the right ones, in particular there is much scepticism surrounding the WHF and the potential opening up of WHO to both new sources of money and greater potential private sector influences. Furthermore, some commentators have characterised the current reform plans as too vague, insufficiently clarifying what WHO’s priorities should be, and failing to adequately address WHO’s financial problems (i.e. how to get more flexible funding or voluntary funds which better align with WHO’s priorities). Recent events at the WHA also demonstrate that Chan’s leadership and ability to deliver a Member-State driven process with effective consultation will be key to seeing the reforms through to final approval at the WHA in 2012. Over the coming months, WHO will have to put more meat on the bones of its proposals and provide a clearer vision for its role in global health with Member State, stakeholder and donor buy-in if it is going to really deliver the biggest changes in the agency’s history and rectify its financial situation. If Chan can not achieve this, it may well put her own prospects for re-election in danger with her term of office ending in June 2012.

Rob Doble is a PhD student in the Department of Global Health and Development at the London School of Hygiene and Tropical Medicine. His research focuses on the role of NGOs in global health governance.

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[1] WHO (2006) Constitution of the WHO.
[2] Butler D. (2011) Revamp for WHO. Nature. 473(7348): 430-1.
[3] WHO (2010) Draft Proposed Programme Budget 2010-2011.
[4] Chan M. (2011) Closing Plenary at the WHO Global Forum: Addressing the Challenge of Noncommunicable Diseases.
[5] WHO (2011) The Future of Financing for WHO. Report by the Director-General on Reforms for a Healthy Future:  
       Development Plan.
[6] Democratising Global Health Coalition (2011) Letter to WHO regarding Concept Papers on the WHO Reform Papers.