Irrespective of all the ambitions for the future and earnest intentions to reform the administration, ultimately it will be financing that will dictate how far WHO can go.
This is the first article in a two-part series on the 142nd Executive Board meeting at World Health Organization.
Geneva: “The Executive Board meeting is a battleground for competing interests,” an official of World Health Organization (WHO) remarked, overlooking the gathering where scores of delegates from various countries had assembled for a week-long discussion to flag issues, guard their turfs, raise discontent and align on mutual interests.
The annual meeting of WHO’s 34-member Executive Board (EB) which concluded last week marked early boundaries within which global health policies and politics will now take shape over the coming months. The meeting witnessed a relative isolation of the US and its allies. The US is one of the biggest donors of the organisation, and its position on a range of issues from universal health coverage, access to medicines, sexual and reproductive rights and WHO’s role in advocacy and its normative work, has implications on how WHO and its member states will work together in the medium-term, experts say.
While country positions do evolve due to political interventions from capitals, in the run-up to the World Health Assembly in May later this year, the EB meeting indicated that deliberations at WHO will remain taut.
The election of WHO’s first African Director General, Tedros Adhanom Ghebreyesus, appears to have set in motion changes at the organisation that perhaps cannot be reversed easily. While it is too early to tell how far-reaching these changes will be, the dynamics have surely altered.
“No one is expecting revolutionary changes, but incremental changes are positive and welcome,” one cautious delegate said.
Widespread changes are not expected given serious financial constraints. Donor countries and funding organisations have a tight control on its finances – this will likely not change radically anytime soon – despite appeals of Tedros for greater flexibility on the way funds committed to the organisation are spent. However, on certain issues including on a wider push for universal health coverage, and consequently, improving the access to medicines, there is a small shift. The change in the way WHO will engage with the private sector is also palpable going by the public statements of its leader.
The Wire presents this wrap of the EB meeting that took place in Geneva during January 22-27. For this story, we spoke to more than 20 delegates from country missions, analysts, commentators, advisors and others during the period of the week to understand and interpret the emerging changes taking shape at WHO, in addition to monitoring discussions at the meeting.
In this two-part series, the story first addresses discussions on reforms, governance and priorities. The next part will address access to medicines and the increased push for engagement with the private sector.
Rains battered Geneva as the EB at WHO gathered for its 142 session. Although the board has 34 members, non-EB member countries also attend the meeting in addition to observers, representatives from the civil society, a significant and rising number of participants affiliated to associations of the private sector, among others. Some have called it a “mini-assembly” (referring to the annual meeting of all 194 member states in May every year).
Few other major international organisations webcast their board meetings, let alone enable attendance of large numbers of non-board members as does WHO, experts note. This slows decision-making, causes duplication and impacts governance, some say. WHO has sought to reform some of these governance processes to streamline decision-making and reduce inefficiencies.
The meeting began with a sobering recognition to reality of delivering healthcare, when in his opening remarks Tedros paid homage to polio workers who were killed in Pakistan earlier this month. Countries quickly got to down business – first, by deferring any discussion on reforms. The board decided to defer the discussion on organisational reforms to May at the 143rd session of the board, immediately following the World Health Assembly this year. Several countries voiced concern on the decision to defer the discussion. The delegate from New Zealand said during the meeting, “Governance delayed is governance denied.” One source said that Tedros perhaps did not want to begin the meeting by getting drawn into the reforms discussions that have carried on since 2011.
India, which does not have a seat at the EB, has expressed reservations on governance proposals that deny non-EB members an opportunity to voice their concerns during the meeting. Given high disease burdens in low- and middle-income countries such as India and others, decisions at the EB affect the most vulnerable populations in the world.
In one of many statements the country made at the meeting, India said, “There is no doubt that the WHO needs a transformation through an ongoing reform process to meet new and emerging global health challenges. We need a more participative and equitable EB. Non-members should have an equal stake in determining the agenda and resolutions for the World Health Assembly. EB and WHA are part of a continuum and should not be dissected in an artificial manner…”
The discussions on reforms will continue in the coming months.
Country buy-in for priorities of the future
The ambitious priorities called the Draft 13th General Programme of Work for the period 2019-2023, that the Tedros administration has put together, was revised and approved by the EB last week, after countries suggested amendments. This will now be considered by the 71st World Health Assembly in May this year. The next few months will see more deliberations, as these priorities get honed and shaped by available financial resources, before they are finalised. Going forward, more clarity will be sought on including the Impact Framework, the breakdown of the estimated $10.8 billion ‘financial envelope’ to deliver the priorities and the investment case.
The priorities were discussed earlier at the meeting of the Programme, Budget and Administration Committee of the EB, where several issues were raised whether the financial estimate was realistic in terms of fundraising, the budgetary impacts of the organisational shifts, and the impact that those shifts would have on normative work.
Several times during the meeting, Tedros asked member states to decouple the endorsement of the priorities that were aspirational in nature, from the budgetary aspects of financing the plan. “Endorsing priorities does not mean endorsing the resources required to deliver them,” he said during his remarks at the meeting. (His commitment to getting the plan of work endorsed was further illustrated by cancelling his visit to Davos later in the week.)
To be sure, it was also pointed out that the new administration was the first of its kind to even spell out an estimate, so early in its tenure, on what these priorities might cost.
Several countries told The Wire that it is important to address the financing of the plan in line with the ambitions. “Without money, the general programme of work is just a piece of paper. We want to know which programmes will be better funded,” one delegate said. A few countries made a note of deliberate efforts to “separate” the discussion on the financing from the priorities and wondered why it was so.
“Depending on which parts of the plan eventually get funded, one can infer what kinds of private interests will have a share in the pie,” one civil society delegate who works on the interface between the private sector and multilateral institutions, told The Wire.
Financing – the crux
Irrespective of all the ambitions for the future and earnest intentions to reform the administration, ultimately it will be financing that will dictate how far WHO can go, several country delegates explained.
As mentioned before, the organisation’s programme budget is serviced by both assessed and voluntary contributions. More than 80% of the total funding comes in the form of voluntary contributions that are earmarked for spending, making it difficult for WHO to decide how it wants to spend the money. Like his predecessor Margaret Chan, Tedros has already repeatedly asked countries to un-earmark the funding that donor governments and other parties give to WHO.
During the EB, he reiterated this by saying that the quality of funding must change, while noting the growing support for untied funding. Earmarked funding contributes to fragmentation in resources and efforts. It results in silos inside WHO, he said. External factors control internal functioning of the organisation and the priorities of WHO, he added, in one of the several strong statements he made on financing matters. WHO manages nearly 3,000 separate grants, increasing transaction costs, Tedros had said earlier.
Tied funding directly influences WHO’s work and priorities. “One of the reasons the rich countries are so determined to maintain the donor chokehold over WHO is the potential significance of the Organisation’s treaty making powers,” according to analysis on the EB by People’s Health Movement.
Observers do not expect large donors to respond to Tedros’s appeal and un-earmark their funding, certainly not significantly. “At most one can expect, 10% of the overall funds to be un-earmarked. It will not be significant,” an EU country delegate was of the view. Countries also expect Tedros to come back at a later stage and ask for higher assessed contributions. According to the last updated figure, assessed contributions were less than $1 billion. Many experts are of the view that WHO’s financial crises must be addressed by increasing assessed contributions by 5-10% in the coming years. (India, for example, reportedly contributes more to the International Telecommunication Union than to WHO according to a recent briefing by The Brookings Institution.)
Tedros also said that WHO will need a fraction of resources needed for overall goals of global health. There has to be a change in the quality and not quantity of funding, he said. An expert who has tracked the evolution WHO finances, said that traditionally the organization did not have huge budgets, but emergencies operations in the last few years have come to demand greater financial resources.
During the meeting, Brazil asked WHO to elaborate on how a more operational approach (that also involves greater role in fighting emergency outbreaks) will not result in less coherence and more fragmentation in the allocation of financial resources.
Tedros outlined how WHO will raise additional resources including working with other UN organisations and other parties. His team is working on a resource mobilisation strategy that potentially involves several innovative mechanisms to finance goals. Details are not yet public.
He said that WHO will not compete for the same resources to raise funds. And in fact will help other actors including GAVI and The Global Fund to Fight AIDS, Malaria and TB, with their replenishments to meet larger goals of global health. It is unclear why WHO with its own financial troubles, would help these actors, since they are better funded than WHO, in addition to having dedicated and sophisticated teams working on fund raising. One source said that WHO is largely absent and is not seen lobbying politicians in western capitals unlike other actors to raise funds.
Putting the numbers in perspective, in 2017, the World Health Assembly approved a budget of $4.4 billion for 2018-2019 for WHO. In comparison, last year, the Global Fund Fifth Replenishment Conference secured pledges of financing for the 2017-2019 period. Of the total $12.9 billion raised at the conference, $12 billion were pledged by donor governments.
Financing will be important to deliver WHO’s most pressing challenges and goals. While Sri Lanka called for WHO to consider a binding convention on universal health coverage and health financing, the US has highlighted the role of the private sector for delivering universal health coverage.
Despite the financial crunch, some member countries were cautious about WHO embracing the push for efficiency and the use of the value for money approach. A delegate from Bahrain told the gathering, “We are not looking for the lowest-carrier approach. We want more health.”
Expectations from Tedros
Tedros has said that he wants to make WHO a modern organisation and has estimated the next 18 months for the transformation of the institution.
But some questions were raised on the duration of the transformation period. Few countries privately expressed concerns on the role of an informal group of advisors who have worked with Tedros since before his election campaign and continue to play an important role at WHO, while noting their contributions.
“It is not clear for how long the advisors will continue and in what capacity. It is of concern in what manner does their advice find way into WHO policy. What is their accountability in this process?” one country delegate asked. It is beginning to constrain the role of the appointed WHO senior leadership, the source added.
Overall, though, the DG enjoys strong yet tempered support from member states. There is also recognition that a director general from the Global South will be asked and be held accountable to similar standards, like anyone else. “Tedros has an overwhelming mandate. While funding issues are critical to his aspirations for WHO, he must deliver,” one developed country delegate said.
Every new administration opens up opportunities to set the agenda, and member states cutting across regions are coming together to work with Tedros and his team. The heterogeneous approach amongst European Union countries on some issues including access to medicines, is only one example.
The Wire will elaborate on how contested discussions on the access to medicines unfolded over several days during the meeting in the next part of this two-part series.
Priti Patnaik is a Geneva-based journalist and researcher. She has previously worked as a consultant in the UN system including at the WHO. She tweets at @pretpat and can be reached at [email protected]