On 1 July 2011, the World Health Organization (WHO) convened a Mission Briefing in Geneva for WHO delegates to discuss WHO reform. As noted in KEI’s blog from 30 May 2011, “WHO Executive Board Decision 129(8): WHO reform for a healthy future“, the 129th session of the WHO requested the Director-General to “prepare by the end of June 2011, three concept papers which will be further revised on an ongoing basis through the consultative process, on the following issues: governance of WHO, independent evaluation of WHO, and the World Health Forum, as outlined in resolution WHA64.2”.
WHO’s reform process is predicated on the goals of securing “greater coherence in global health” and furthering WHO’s role as the “directing and coordinating authority on international health work”. Inextricably linked to the WHO reform process is the question of the future of financing of the WHO given its reliance on donor funding; 80 percent of WHO’s budget comes from extra-budgetary contributions and 20 percent coming from assessed contributions by Member States. Of these extra-budgetary contributions, 80 percent are specified contributions with obligations to spend on earmarked projects and 20 percent are flexible. At the 128th session of the WHO Executive Board, Dr. Margaret Chan (Director-General, WHO) presented the “Implementation of Programme budget 2010-2011:update (EB128/23)” informing the stunned EB that in a best-case scenario, WHO would have a shortfall of US$ 200 million in the 2010-2011 biennium while a worst-case scenario projected a shortfall of US$ 600 million.
World Health Assembly resolution WHA64.2 mandated WHO’s concept paper on the World Health Forum to set out “objectives, number of
participants, format and costs”.
With respect to purpose, the concept paper states the following:
The purpose of the World Health Forum will be to explore, in an informal and multistakeholder setting, ways in which the major actors in global health can work more effectively together – globally and at country level – to increase effectiveness, coherence and accountability and to reduce fragmentation and duplication of effort.
With respect to outcome, the concept paper notes:
The forum will provide an opportunity to hear a diversity of views and to capture elements of best practice. The initial outcome will be a report on principles and approaches in line with the Forum’s overall purpose. The focus will not just be on the work and role of WHO, but on ways of improving health outcomes through policy coherence and more effective collective action across a range of organizations and partnerships.
With respect to specific objectives, the concept paper states:
Specific objectives for the World Health Forum will be to (a) identify the major obstacles and constraints to more collaborative work across all the partners engaged in global health; (b) to define principles and approaches that will promote policy coherence and more effective working relationships at global and country level; and (c) to outline the steps needed to translate principles into practice.
According to the concept note, the WHO views itself as the directing and coordinating authority for global public health and endeavors, through the World Health Forum, to promote greater coherence in international health work among various actors. The concept paper stresses that currently,
“there is no single platform that allows interaction between governments, global health organizations, partnerships, regional organizations, multilateral and bilateral agencies, philanthropic foundations, CSOs, private sector organizations and other relevant stakeholders… As an informal, multi-stakeholder body the World Health Forum will make it possible to capture a wide range of views and perspectives on major current and future issues in global health. It will not take decisions affecting individual organizations, nor will it change the decision-making prerogative of WHO’s own governing bodies. The conclusions of the Forum’s deliberations will be transmitted to the World Health Assembly via the Executive Board, as well as being available to all participating organizations.”
In terms of format, the WHO proposes that the World Health Forum convene biennially with its inaugural meeting set for the first three days of November 2012 “for a further two cycles, after which it will be independently reviewed.”
In terms of participation, WHO notes:
“The Forum will be open to all Member States. Representatives of all major global health organizations and partnerships will also be invited. Other participants will be invited from CSOs, academic institutions/think-tanks, professional associations, foundations, and the private sector. The aim will be to attract a number of participants sufficient to ensure a diversity of viewpoints, institutions and geographical representation, but small enough number to allow structured debate and clear conclusions [Footnote 1]. While limiting the size of individual delegations may be necessary to ensure manageable numbers, the Forum will be web-cast to increase access to a wider audience. It may also be possible to explore the possibility of using web based technology to allow more direct interaction prior to the Forum itself.”[Footnote 1:] For comparison, the Global Forum on noncommunicable diseases which preceded the recent Moscow Ministerial meeting attracted around 300 people. GAVI’s partnership Forum has around 350 participants, and the Global Fund’s equivalent about 400. By way of contrast the World Economic Forum in Davos invites around 2 500 participants. The World Social Forum in 2011 attracted 75 000 people and the most recent World Urban Forum in 2010 organized by UN Habitat attracted nearly 14 000 participants.”
In terms of budgetary implications, WHO stated the costs of hosting the World Health Forum would be USD $675,000 and an additional USD $100,000 needed for preparatory activities.
The following text is WHO’s official summary of the discussions at the mission briefing it sent out to member states on 4 July 2011 on WHO reform including the concept papers on World Health Forum, Independent Evaluation and Governance.
WHO Reform: Mission Briefing (1 July 2011)
Summary of discussionsGeneral comments
1. The areas covered by the reform programme go beyond the three concept papers. There is a need to ensure appropriate linkages between the three papers.
2. While the reform process should remain Member States driven, the Secretariat is encouraged to provide analyses and options to facilitate discussion among Member States.
3. The Secretariat would provide additional information as follow –
• a paper with an overview of the whole reform package
• an additional concept paper on managerial reforms, which will be available
later
• figures on the project costs for the development of the reform programme
Specific comments on the concept papers
Concept paper on governance1. It is noted that governance of WHO refers not only to “governing bodies”, but is a broader concept. The proposed four areas to be covered in the paper are generally supported. The Secretariat is requested to provide further elaboration, include more analysis and provide some options to facilitate further discussion.
2. Further information is requested in particular on the following areas-
• the regional and country offices dimensions
• governance at the three levels of the WHO
• the method of work of the governing bodies3. Open-ended working group (OEWG) of the Executive Board (EB) – There were questions on whether participation would be restricted to EB members. It was noted that in accordance with the Rules of Procedures of the EB, all Member States can participate on an equal footing. The EB can decide to limit the number of participants, but only in exceptional cases.
Concept paper on independent formative evaluation1. Scope and focus of the evaluation – There were questions as to why the focus is put on “health systems strengthening”; whether other areas (such as health promotion and prevention) could also be covered.
2. Schedule – There were concerns about the time-line, with proposals to advance the schedule. It was suggested that, instead of waiting for the EB meeting in Jan 2012 to start the evaluation, the EB bureau could act as the interim oversight team to get the work started earlier.
3. The role of the Joint Inspection Unit (JIU) – Questions were raised about the feasibility of using the JIU mechanism for the evaluation. It was noted that given the technical and programmatic nature of the evaluation (in para.4 of the paper), this is outside the scope of the JIU.
4. The consortium – Further information on the selection of the consortium was requested. It was suggested that selection of the consortium should also be Member States driven and conflict of interest must be avoided.
5. The Secretariat committed to provide draft Terms of Reference for consultation and review by bureau of the EB.
Concept paper on World Health Forum (WHF)
1. Added values of WHF – While several countries support the concept of the WHF, some posed questions about its added value.
2. Concerns – Concerns were raised as to whether the WHF would serve as an effective forum for hearing the voices of other stakeholders, e.g. whether civil society organizations and local communities would be engaged in the process; and how potential conflicts of interests would be addressed if the private sector participates.
3. Role of WHF – Concerns about the role of WHF, the duplication with existing forums, and whether discussions at WHF would be infringing on the decision-making authority of WHA and EB.
4. Participants – Further deliberation required on the criteria for invitation, the rules of engagement, as well as the number of participants; and noting the need to get a balance between inclusiveness and having a manageable number that allows focused and strategic discussions.
5. Estimated costs – The Secretariat is requested to provide further details on the estimated costs which appear to be an under estimate; and whether the resources will be derived from WHO’s existing budget or will require additional funding.
6. Periodicity – Some considered that it is premature at this stage to decide whether the WHF should be convened every two years for a further two cycles, and suggested to review after the first WHF.