PHM-Exch> PHM Comment on Director General’s paper 'WHO Reform for a Health Future' (October 15, 2011)

[Claudio Schuftan]

Chapter 1. Programmatic Priorities



PHM appreciates the summary of ‘challenges and opportunities’ (Cl 10-18)
provided by the Director General, including the reference to the widening
inequalities and problems regarding the ‘cost of technologies’.



Missing from this summary, however, was any reference to the rise and rise
of transnational corporations which straddle countries and have a great
deal of autonomy because of this.  TNCs are a major feature of the global
health environment and the challenge of regulating TNCs for public policy
purposes, including health, is one that WHO must confront.



We note with concern the proposition that “WHO should focus on what it does
best” (Cl 23). This is dangerous.  The unstated corollary is that as new
organisations arise who do some of the things WHO does, WHO should withdraw.
WHO must maintain capacity across the breadth of its constitutional mandate.
The proliferation of specialised, vertically-oriented global public private
partnerships has significant hidden costs associated with health system
fragmentation and donor incoordination; these can offset any benefits
arising from their technical specialisation.



We urge member states to be cautious about accepting the proposal for a
formal priority setting process within each of the proposed five core areas
(Cl 45-47). The paper is completely silent on what kinds of priorities
might be developed and what kind of process might be involved. To simply
endorse such a proposal would be signing a blank cheque.



We are concerned that the setting of priorities within the five core areas
would impact negatively on WHO’s work at the country level. Countries face
different problems in different circumstances and WHO needs to have a full
capacity to address the different needs of countries in relation to all
aspects of health development, health security and health systems.



We recognise that there are imbalances with respect to staffing and
expenditure across the different clusters at Headquarters, for example,
there has been severe neglect in recent years of the rational use of
medicines and of national drug policies.  However, we are not convinced
that this should be interpreted in terms of ‘prioritisation’ rather than
one of management decision making, allocating resources to the places where
they will do most good.  In large degree such failures in management are
structural in nature, linked to the ways in which tied funds distort
resource allocation and promote the autonomy of clusters.   We urge that
this proposed ‘prioritisation’ exercise be deferred while the structural
issues are addressed.


Chapter 2. Governance



PHM agrees that the Governance of WHO and WHO’s role in global health
governance are critical issues for attention in this present WHO Reform
initiative.



Considering first the role of the Executive Board, we are apprehensive
regarding the proposal for the EB to take the role of gatekeeper to the
Assembly. We recognise that not all draft resolutions are strategically
oriented, well structured and include consideration of financial
implications. The solution does not lie in gate-keeping; rather the EB
needs to work to improve the quality of the resolutions.



We agree that there is a need to strengthen the executive role of the EB
and to ensure that it more effectively oversees the work of the Secretariat.
The proposals advanced to this end need further elaboration and discussion.




We are concerned about the proposals: to impose tighter time limits on
speakers at both the Board and the Assembly; to limit the number of
resolutions coming before the Assembly (Cl 68); and to filter resolutions
coming before the Assembly for their perceived priority (Cl 72). The
capacity of member states to submit resolutions is part of the democratic
spirit of the Constitution and should not be compromised lightly.



The problem is not simply that people speak for too long; too often their
contributions are irrelevant, meandering and self-serving. If people are
addressing substantive and complex issues time keeping should be flexible.
There is a need for more interventionist chairing with respect to relevance
and substance as well as time, and for closer mentoring of new
representatives, particularly when it is evident that they are not familiar
with the issues upon which they are speaking.



We are concerned by the proposal to limit the number of progress reports to
six instances. If there is no need to continue reporting on a particular
resolution such a decision can be taken by the Board and reported to the
member states for appeal.



We strongly support the proposal that regional committees and regional
directors report formally to the Board and the Assembly (Cl 78).  However,
we have reservations about the proposal to ‘standardise’ the work of
regional committees but some process of benchmarking to find and share best
practice models with respect to regional practice would make sense.



Turning now to WHO’s role in global health governance we point to a serious
flaw in the conceptualisation of global health governance (Cl 85). To limit
the scope of global health governance to ‘policy and priority setting for
health’ excludes trade, finance and the regulation of TNCs.  These are
powerful determinants of population health. To ignore WHO’s
responsibilities in relation to these determinants is a major weakness of
this paper.



We do not agree that accountability with respect to WHO partnerships should
be given to the Standing Committee on NGOs (Cl 96). WHO’s role in relation
to such partnerships needs to be reviewed in the Board and in the Assembly
in relation to the strategic directions of the Organisation, not reduced to
bureaucratic protocol.



Finally the paper fails to deal with WHO’s relations with public interest
NGOs. This issue has been raised for decades by civil society but has thus
far been ignored.



We urge that WHO re-launch the 2001 Civil Society Initiative with a view to
deepening dialogue and cooperation with public interest NGOs at all levels
of WHO’s work. The criteria and processes for organisations entering into
official relations with the WHO need to be reviewed including a clear
distinction between public-interest NGOs and business-interest NGOs.
Chapter 3: Management Reform



PHM supports the proposals for improving organisational effectiveness,
especially the strengthening of country offices.



Many of the recommendations in this chapter are basic principles of good
management (for example, more effective knowledge management, streamlined
recruitment and selection and enhanced staff development).  We need to ask
why these have not been core features of WHO management for years.



The recommendations to increase the predictability and flexibility of
funding, including longer term commitments and increases in untied
donations will require a stronger commitment to WHO than many member states
have hitherto shown.  We urge member state representatives to communicate
clearly to their governments that WHO is in a financial crisis and that for
a relatively small increase in their contributions an institution which is
critical for achieving the MDGs can be restored to good health.



We commend the objective of organisation-wide resource mobilisation (Cl
142) but we are not confident that the five strategies offered are
sufficiently focused and have sufficient leverage. The anarchic funding
practices of recent years are in part due to the structural autonomy of the
clusters. Structural reform is a critical pre-requisite for more coherent
fund raising.



The proposal to revise the existing workforce model (Cl 150-151) appears
appropriate in overview but the devil is in the detail. It is not clear how
the new workforce model will impact on regions and countries in contrast to
Headquarters.  The balance of short and long term functions may be
different at the different levels of the Secretariat.  This should be
considered.



We note the proposed mobility and rotation framework (Cl 155). This may be
a good idea but there is no rationale provided of why mobility is to be
encouraged and what kinds of principles might govern such a system.



The need to reform the current system of ‘results based management’ is
clear.  Whether the new results chain, the revised planning framework and
the proposed new timelines will address the underlying problems is less
clear. It would make sense to trial these propositions in one of the core
areas, such as health systems strengthening.



The proposals (Cl 168-170) for a longer program budget period, for dropping
the medium term strategic plan and for moving the general program of work
to three budget cycles may all be a good ideas but the rationale is not
provided. The paper simply says that it would make it easier for donors and
‘would improve planning’.  It would be important to ensure that the longer
planning time frames do not reduce WHO’s ‘agility’.



We welcome the commitments to increased accountability and transparency (Cl
176 et seq) but most of the proposals are very general and hard to assess
for this reason. However, we particularly welcome the proposed tightening
of policy on institutional conflicts of interest.



The discussion of ‘independent evaluation’ (Cl 190 et seq) is not
clear.  Perhaps
priority might be given to developing an Evaluation Policy (Cl 196) which
might set forth more clearly the logic and processes for progressing the
other ideas presented here.



The proposal on Strategic Communications (Cl 199 et seq) appear to be more
about public relations than effective two way communication with the
various constituencies with whom WHO deals, including the public interest
NGOs.
Concluding



The People’s Health Movement is committed to a strong WHO, adequately
funded, fully utilising the powers of the Constitution, properly
accountable to member states and playing the leading role in global health
governance.



We congratulate the Director General, the staff of the Secretariat and the
Member States for progressing the Reform Initiative to this stage. PHM is
committed to Health for All, Now! and sees the restoration of WHO to its
rightful place in global health governance as fundamental to achieving this
vision.
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