Geneva: Grey skies in Geneva this winter betray the action gathering pace at the World Health Organization (WHO) as a relatively new team goes about structuring future priorities, finding ways to fund them, making fresh appointments and trying to push through an overall shift in the way the United Nations institution has been run for the past 70 years. A sense of optimism continues to prevail several months into the election of WHO’s first ever director general from Africa, Dr Tedros Adhanom Ghebreyesus. Not surprisingly, as in any institution of global governance, this optimism accompanies a few concerns about transparency, governance and motives – typical of an organisation with 194 countries as members and various political interests at stake.
Next week, the WHO’s 34-member executive board (EB) convenes for an annual meeting from January 22-27 in Geneva to consider a packed agenda, including reviewing an ambitious set of priorities for the organisation, discussing reforms on governance issues, taking stock of various disease programmes, health emergencies, cross-cutting matters such as access to medicines, digital health technology, sharing genetic resources, and crucial organisational matters on financing, among others.
The 142nd EB meting is significant as it is the first such meeting of the board since Tedros assumed office in July 2017. (This is apart from the special two-day EB meeting that took place in November 2017.)
A new draft set of priorities or the 13th General Programme of Work (GPW), as it is called, is a signature document that seeks to mark a shift from the administration of former director general Margaret Chan to that of Tedros, experts say.
Apart from this ambitious document that has pleased many, the more immediate challenges will be finding funds to pay for these priorities, getting buy-in from countries on the goals, and how the team under Tedros will work together on competing and opposing interests between countries. All these elements will come together at the meeting next week, and in the following months till the World Health Assembly in May 2018, which some say will define the tenure of the new team.
What the last few months tell us
There is an incipient yet emerging direction on how issues might evolve in the course of the year, going by the eventful initial months since the election. Apart from kick-starting discussions on strategic priorities, Tedros made some high-profile appointments that won him praise for taking a definite stand on addressing gender and regional diversity. This was soon followed by a serious misstep that was called a ‘blunder’ in the announcement – and the subsequent withdrawal – of the now-ousted Zimbabwean President Robert Mugabe as a goodwill ambassador for non-communicable diseases.
There have also been some concerns on whether it was merit or political considerations that influenced the way some directors in key positions were appointed late last year. In particular, attention was drawn to the appointment of Tereza Kasaeva, formerly an official at the Russian health ministry, as director of WHO’s global tuberculosis (TB) programme. This appointment has been conflated with Tedros meeting Russian President Vladimir Putin in November. Russia had pledged $15 million for fighting TB at the WHO Global Ministerial Conference on TB, held in Moscow.
Seasoned watchers say that other donor-member states have routinely influenced appointments at the WHO for years. “Director-level appointments are political appointments. There is nothing surprising here. The director general wanted to assemble his own team and he should be allowed to do that. Only if this team does not deliver, then questions can be asked. It is too early to pass any judgement on his intentions,” a health attaché at a country mission in Geneva told The Wire.
There are invisible boundaries within international organisations, and political changes will be resisted, since power has not shifted for so many decades, the official added.
Another senior official from a developing country who spoke to The Wire, agreed. “On these appointments, I think these are merely efforts to micromanage Tedros. It is a way to distract him from his priorities, to tie his hands.” It is not clear whether such appointments were clearly political quid pro quo, and neither has it been conclusively established that any of the appointments made so far lacked merit-based considerations.
These events could be a small indication on how much is at stake and how fiercely changes will be resisted in the months and years to come.
The general programme of work – new priorities
The new draft set of priorities for the period 2019-2023 that seeks to provide a direction to the way the organisation will work will surely evolve in the course of the year, not the least because of financial and political considerations, experts say.
Essentially, the strategic goals in GPW have been articulated as: a billion more people benefitting from universal health coverage; a billion more to be better protected by addressing health emergencies; by promoting healthier populations, an additional billion must enjoy better health and well-being.
In a departure from the past, several consultations in 2017 shaped the initial priorities. The WHO took note of some of the questions raised and recommendations made on its goals during the special EB meeting last year. Countries wanted to know the link between the investment case for these priorities and budgetary realities, for example. They also had questions on measuring the impact of such priorities. (One country delegate described the draft as a document prepared by enthusiastic consultants for an ambitious politician.)
Tedros seeks to usher in key organisational and strategic shifts in the way it delivers health. “He has had to strike a balance, so to that extent the GPW is a good document. These priorities will evolve a lot in the run-up to the assembly this year. The goals also need to be realistic. WHO cannot do everything. Where is the money?,” an official said.
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 is less flexible for the WHO to respond in emergencies. Tedros is keen to change this.
In one of the most significant statements made by Tedros in his tenure so far, he did not shy away from asking member-states to unearmark funding to provide greater flexibility to the WHO to use the funds. “Give us unearmarked funding, we will do more. Give us ownership. Change the design of funding,” Tedros appealed to countries on resource mobilisation during the special EB meeting last year. He also said that there was a trust deficit amongst member states.
And sure enough, this appeal, not unnoticed, has made way into the latest draft. The WHO has said, “Given the integrated nature of the work that is required to implement GPW 13, more flexible financing will be critical. The quality of funds is almost as important as their quantity. The director-general has asked member states to unearmark their contributions. This is a sign of trust and enables management to deliver. Increasing assessed contributions would also give WHO greater independence.”
Proposed organisational shifts
The WHO has said it would like to see greater cooperation within departments since many of these units work in silos. “A major shift will be to create a seamless organisation, where people’s primary affiliation is with WHO rather than their own particular programme,” the WHO has said in its draft strategy document. To do this, the WHO proposes that it will move away from “categories of work which made specific diseases and health issues more recognizable, but which also had the effect of hampering cooperation between programmes”. Instead, it proposes focusing on outcomes to improve priority setting and programming at the country level. “It aligns more clearly with country planning and delivery of the work needed…,” the WHO is of the view.
On staffing, the WHO has said that it will continue on its efforts towards greater gender equality in its administration. (Although sceptics also point out that addressing years of gender inequity in appointments has to be done cautiously without compromising on merit.) Further, Tedros also wants to increase appointments of nationals from developing countries from less than 12% at the headquarters to a third by 2023, apart from enabling internships for young people from the developing world. (Recent past has already shown how contentious this can be.)
Proposed strategic shifts
The WHO aspires to provide more effective leadership at all levels, drive impact in every country and focus on ‘global public goods’.
The WHO has said it will advocate for health at the highest political level. Recognising that health is both technical and political, it takes into cognizance that health has come to assume importance in high-level political forums from the G20 to the UN Security Council.
It has also said that it will engage with a range of non-state actors. While acknowledging that the WHO is and will remain a member state organisation, it underscores the need to engage with non-state actors considering the “current conceptions of global governance” – a space where such parties have come to assume importance. “A range of political and policy interests are influenced by a network of alliances and coalitions, involving nongovernmental organisations, philanthropic foundations, and private sector entities. Outreach to such actors is critical for WHO’s work,” it says.
Perhaps some may read this as a reality the institution has to contend with, given the deep pockets of the private sector, for example, in battling some of the most acute health challenges of our times. Others might look at these engagements more critically, demanding greater scrutiny. But experts also want the WHO to pay attention to how member states engage with non-state actors and how policies are shaped at country levels.
On driving impact at country levels, the WHO wishes to tailor the secretariat’s engagement with countries taking into account national context and capacity. “In some settings, such engagement will be more upstream – policy-related, strategic and normative − and in others, more downstream with a focus on technical assistance, strengthening service delivery and implementation of WHO’s normative guidance,” it adds. Countries with diverse and complex challenges have often suffered from a headquarter-driven, one-size-fits-all policy approach.
Even as there is a push to make the WHO more operational, justifiably in countries with weak institutional capacities and in conflict contexts, the focus on its normative role is clear in its priorities for the future. In fact, countries want the WHO to protect its normative role in addition to any increase in its operational responsibilities, putting pressure on its already strained finances.
“WHO will strengthen its public voice – based on science and evidence – and advocate for progress, especially in areas of particular importance identified in GPW 13. WHO will speak up against practices from any sector including industry that, based on evidence, are harmful to health,” it says in the revised document.
The priorities also have a strong emphasis on the provision of global public goods. “WHO’s normative, data, and research and innovation activities drive the creation of global public goods. WHO’s quintessential function is to ensure access to authoritative and strategic information on matters that affect peoples’ health,” according to the draft document. WHO recognises that it is unique among global health organisations in its mandate to provide independent normative guidance – a key source of its authority and comparative advantage.
In addition to setting norms and standards, the WHO also promotes and monitors the implementation of these norms; in addition, monitors the health situation and assesses health trends. It shapes the research agenda and stimulates the generation, translation and dissemination of knowledge and proven practices.
Commentators at People’s Health Movement have said, “The emphasis on WHO’s normative role suggests a willingness to restrict WHO to its domain of competitive advantage which is clearly designed to reassure donors who are apprehensive about a more activist WHO (eg support for a sugar tax).”
Also, notably, the revised draft of priorities has also included a fuller recognition of access to medicines under the aegis of the broader goal of Universal Health Coverage. It recognises that the principal cause of financial hardship is out-of-pocket payments for the purchase of medicines. It has said that the WHO will help mobilise political capital for policies that promote access, including access to generic medicines and innovation and pushing for domestic investment in coverage schemes that reduces out-of-pocket payments, among others. The draft however, fights shy of making any mention of WHO leading negotiations on a global R&D agreement that could set global norms for funding R&D as a public good – a long standing demand of developing countries and other parties.
“The final gavelling on the GPW will happen over the next few months ahead of the assembly,” one country official told The Wire.
Access to medicines discussions at the EB
Apart from the proposed priorities, other key issues will be taken up at the meeting next week. Consultations around issues of access to medicines continue to remain contested as before.
There are at least two separate discussions on access issues that will be taken up next week, both of which point to small yet significant changes under the new administration.
The issue of addressing the global shortage of, and access to, medicines and vaccines, has been discussed at several WHO annual meetings. The report typically takes into account developments and efforts made to address these issues. Easier access to clinical trial data are among the policies suggested here.
What is also important to note that this time, the document refers to the recommendations of the UN High Level Panel on Access to Medicines which divided countries. (The Wire had reported on how discussions on the report where shelved during the assembly in May 2017.) This is an issue that has festered for over a year and has witnessed strong resistance from the US. Sources say that referencing these recommendations in an official WHO document, deemed contentious by a section of the countries, was strongly contested.
“This document would not have been possible in the previous administration, where the secretariat had allegedly tried to scuttle discussions around the UN report amongst member states. We hope that the new administration will take a more balanced view on such matters,” one official said. In an annexe to the document, the WHO has not only referred to the suggestions of the UN report, but has also mapped how the WHO works within that framework.
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In addition, it is understood that Colombia, with the support of other developing countries, and possibly a few European countries, first brought forward a proposal on a potential roadmap for the WHO to implement policy matters addressing key challenges on access to medicines, sources told The Wire. Consultations among countries have resulted in a draft proposal that has not been finalised yet, according to sources. (At this point it is not clear, what the text of such a proposal is.)
Overall, it appears that countries are cautious about pushing resolutions that some of the developed countries may be opposed to on such matters. “We want to create an enabling environment so that some real progress is made on addressing access issues in the long term,” one official noted. (Some European countries, although troubled by high prices of medicines, want to “cherry-pick” what is convenient for them during discussions on access, the source said.)
The other key document on access issues that will be tabled at the meeting is the overall programme review of the global strategy and plan of action on public health, innovation and intellectual property – a report that was commissioned by member states. The report reviews the implementation of the strategy over the last decade and more. It formulates clearer goals and estimates that a little more than US $30 million will be required to implement recommendations to address challenges around access during 2018-2022. Among others, the report pushes for national laws to reflect TRIPS flexibilities and improve transparency in R&D costs. Sources have said that some of the recommendations allegedly do not have the support of a few countries and this is being currently debated ahead of next week’s meeting. It is hoped that the EB will decide and recommend for the adoption of the report by the assembly later in May.
Political uncertainties and financing
The success of the administration will depend on the latitude it will have in terms of raising resources for its goals. At the time this story went to print, an awaited resource mobilisation strategy was not yet released by the WHO.
Early this week, the WHO announced an indication on what such goals could cost. The WHO has said that a high-level financial estimate for its draft set of priorities is pegged at US $10.8 billion over the five-year period for the ‘base segment’ of the budget. A section of the budget will be scalable for operations including emergencies. It acknowledges that this estimate is “top-down” and is subject to needs at the country level. It also makes note of potential savings on economy and efficiency up to US $440 million.
Experts also point to a worrying emphasis on value for money. In general, wasteful expenditure in the wider UN system, including at the WHO, merit an efficiency-based approach, but blanket adoption of institutionalised spending cuts driven by corporate consultants can be problematic for the implementation of complex public health programmes where investments cannot be strait-jacketed.
In fact, a recent report by an independent expert oversight advisory committee at the WHO, while supporting the approach warned against “over-institutionalising” value for money in the WHO. “Value for Money, has become a mainstream narrative which is taking hold on the WHO. They must resist it,” one developing country official told The Wire.
Efficiency gains, although important, will be limited in their impact on overall funding challenges that the organisation faces. Countries worry on how the WHO can deliver without increasing assessed contributions. Uncertainty around the role of the US in its commitments towards the WHO is adding to a lack of clarity on how some of these issues can be resolved. US is one of the biggest donors to the WHO (It accounted for more than 30% of the total voluntary contributions to the WHO among member-states in 2016.)
“No one will step up in matching contributions if the US arbitrarily decides to stop or cut funding,” an official was of the view. Although Germany has tried to assume a leadership role on global health in forums such as the G20, it is plagued by political instability and domestic challenges, he noted. But not all are pessimistic on the roles of other countries.
Donor countries are also aware that they are dealing with a different administration. “The Tedros election was the first broad-based election where 133 countries voted for him. He will be held to greater accountability by many more member-states than only donor countries,” one observer said.
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]