Discussion on the future financing of the WHO


18 August 2010

During the 127th meeting of the Executive Board in January of 2011, the World Health Organization will be presenting a report on The Future Financing for WHO. The debate around this topic is covering critical issues such as the role of WHO and the nature of its core business in a changing environment of global health, approaches to technical cooperation, mechanisms and/or criteria for defining priorities, greater predictability and flexibility of funding, as well as greater alignment of donor funding with agreed priorities. Global Health Europe would like to extend this discussion to stakeholders beyond the WHO member states.

The consultation launched by Director General Chan asks eighteen strategic questions grouped under eight main headings of (a) WHO's core business, (b) Health and development, (c) Partnerships, (d) WHO country support, (e) Technical collaboration, (f) Implications for WHO governance, (g) Priority setting and communication, and (h) Implications for financing.

Follow this link to view the official consultation page: https://www.who.int/dg/future_financing/consultation/en/index.html , as well as the Report from the informal consultation convened by the Director-General in January 2010: https://www.who.int/dg/future_financing/who_dgo_2010_1/en/index.html

some of the responses from member states, including the UK, Germany, Norway, France, Netherlands, Denmark, Finland and Armenia can already be viewed online: https://www.who.int/dg/future_financing/comments/en/index.html

Click the below link to view a discussion paper that reflects the views of WHO Europe's Regional Director on what constitutes the key issues linked to the future of financing for WHO so far as the European Region is concerned, notably the Region's core functions and priorities, as well as issues related to their adequate and sustained funding: http://www.euro.who.int/__data/assets/pdf_file/0011/119558/RC60_edoc18.pdf

You can also view a new GHE Issue Brief that explores the potential for European leadership for a more effectively funded WHO.

A note has been created to provide a framework for discussions during the 2010 WHO Regional Committees. The issues and questions below are drawn from the initial consultation, early responses to the web questionnaire, and informal discussions with Member States at the Sixty-third World Health Assembly and 126th session of the Executive Board. to leave your comments please log-in.

1. WHO's core business

  • Questions about the way WHO is financed cannot be tackled without prior discussion of priorities and the changing nature of WHO's core business. At the initial consultation, normative and standard-setting work was generally seen as being core business and central to maintaining WHO's role as the world's technical authority on health issues. Similarly, there was a consensus around WHO's role in relation to surveillance and response to international health threats. On other aspects of WHO's core business opinions were more diverse.
  • There are many different perspectives on how priorities in global health should be defined, and thus on where the boundaries of WHO's work should be drawn. Questions arise about WHO's role in relation to the social determinants of health and the links between health and other areas of global and national policy including trade, security, intellectual property, the environment, economics, education, human rights and foreign affairs.

While health is indisputably central to human development, many of the social,
economic and environmental determinants of ill-health lie beyond the control of the
traditional health sector. What should be the extent and nature of WHO's involvement in addressing the broader determinants of health?

  • The negotiation of treaties and international agreements such as the Framework
    Convention on Tobacco Control, the International Health Regulations, the Global
    Strategy and Plan of Action on Public Health, Innovation and Intellectual Property, and the Code of Conduct on Health Worker Recruitment have a major influence on global public health. The demand for WHO to facilitate intergovernmental negotiations which set out rules, responsibilities and commitments appears to be increasing. Given the sensitive nature of the issues, negotiations can be time- and resource-intensive, and reaching common ground can be elusive.

What are the implications for WHO's staffing, skill mix and ways of doing business if this trend continues?

  • In the face of more, and more unpredictable, crises that impact on health, there is a general consensus that WHO should continue to be engaged in humanitarian action. WHO's role in coordinating the health cluster in declared emergencies is generally accepted, but it can be strengthened. There is also a view that WHO should act as the world's health conscience - drawing the attention of political leaders and their populations to the major drivers of health and disease, including the impact of conflict.

What is WHO's comparative advantage in the domain of humanitarian action, given the role of other international and nongovernmental organizations? How can work in this area be made more effective?

2. Health and development

  • In low- and middle-income countries, governments seek to improve health outcomes with limited resources. They are too often faced with a proliferation of partners that compete for national resources, provide conflicting advice and influence priority-setting in different directions. In relation to health security and humanitarian action, governance/coordination arrangements are reasonably well-established. In the more crowded domain of health and development, this is not the case.
  • It is also the domain of WHO's work where the views of Member States are most
    divergent. Some urge WHO to withdraw from the development field altogether, in favour of more normative work. Others suggest that WHO should situate itself as one among other actors - based on a clear understanding of comparative advantage. Others again insist that WHO be more assertive in coordinating other actors and thereby help to reduce growing fragmentation.
  • International resources for health have increased significantly, but at the price of greater fragmentation. The incentives that influence the structure and functioning of the international system too often favour high-profile, issue-specific initiatives. Coordinating bodies tend to take on a life of their own, competing for funds with those they wish to coordinate. Small secretariats tend to grow, and mandates expand in proportion. The net result is that the countries that are most in need of external support are often those that have to bear the greatest transaction costs in managing a diverse network of partners.
  • While better coordination at global level is necessary and urgent, it will be insufficient without the development of national policies, strategies and plans around which development partners can align their support (see section 4 below).

What should be WHO's objectives in relation to the governance of health and
development at a global or regional level, and how might they best be achieved?

3. Partnerships

At global level, it is useful to distinguish between partnerships established primarily to raise and channel funds and those concerned primarily with advocacy. In relation to the former, the issue is one of clarity of role: ensuring that standards and protocols developed by WHO are used in the development and implementation of proposals, and that financing organizations do not establish competing normative capacity.

How should WHO seek to define a clear division of labour based on its comparative
advantage in relation to funding partnerships such as GAVI and the Global Fund?

  • The role of global partnerships that see their role primarily in terms of advocacy and/or policy coordination is more controversial. One view holds that such partnerships risk duplicating the convening and coordinating role of WHO, and that demands by partnerships for human and financial resources can undermine the capacity of the Organization in which they are hosted. The alternative view - equally strongly expressed - is that some global health issues require a response that is both rapid and focused and that engages stakeholders - as equal partners - who are not automatically part of WHO's normal constituency.

What are the potential advantages and/or drawbacks of partnerships hosted by WHO? How should they evolve in the future?

  • While WHO's natural partner at country level is the ministry of health, there is a need to embrace other ministries (particularly of finance and foreign affairs) as well as to be more effective in forming a wider network of relationships with those who influence and inform national health policy in central or local government, in parliaments, civil society and the private sector.
  • There is evidence that the approach of "delivering as one" across the United Nations system can have positive results. WHO has been urged to continue with its support for United Nations reform, accepting the authority of others when it is appropriate to do so or proactively seeking a lead role where this can add value. An alternative view suggests that the benefits of working as part of an integrated UN country team are far from guaranteed. Proponents of this view would prefer that WHO revert to a situation where specialized agencies stick to dealing with their own natural counterparts at country level.

How can WHO more effectively develop effective partnerships at country level, while remaining the key supporter of the ministry of health and playing an active role in the United Nations country team and the wider network of development partners?

4. WHO country support

  • As an organization of Member States, WHO should be of demonstrable value to all countries, with support geared to their particular needs and circumstances. In some countries, support is provided through a physical presence and a WHO country office, but in others it is not.

What criteria should be used to ensure a good match between the level of WHO support and a country's development needs? In what way can effective support be ensured in Member States with no country office? How can the idea of phasing out the need for a country office be made attractive to the countries concerned?

  • Robust national policies and strategies, developed and owned by national authorities, are the bedrock around which harmonization and alignment can take place. In countries where WHO is physically present along with many other development partners, the primary role is not one of coordination but of facilitation. In line with the Paris Declaration and the Accra Action Agenda, articulating national policies, strategies and plans is a country responsibility3. The role of WHO is firstly to assist national authorities as they seek to coordinate development partners and ensure alignment with national priorities. Secondly, the role of WHO is to improve the quality of national strategies and not act as the referee in determining their content.

In countries with many development partners, how can WHO become more effective in supporting national authorities as they seek to coordinate development partners?

  • Despite codes of practice and memoranda of understanding to guide behaviour,
    indiscipline among partners remains rife. Incentives for the staff of development
    partners, including WHO, need to be aligned with the principles of the Paris Declaration to make a real difference.

What does WHO itself need to do in order to be more compliant with the objectives of the Paris Declaration and the Accra Agenda for Action?

5. Technical collaboration

  • Technical collaboration and support to countries has been and remains one of WHO's core functions - from the Constitution to the Medium-Term Strategic Plan 2008-2013. It is therefore of concern when the consultation pointed out that this is the area in which WHO's performance most needs to be improved.

In what areas of technical support provided by WHO is improvement most needed, and how can this be brought about?

  • It was also suggested that WHO should focus its technical support at a more strategic and less operational level. This kind of support may require different staff profiles in country offices - specifically, fewer people with greater breadth of experience. It will also pose a challenge in terms of how to measure the outcome of such strategic support.
  • The demand for technical support has been greatly increased by the need for countries to prepare proposals for submission to global health initiatives. This has prompted suggestions that WHO should consider new approaches to the way in which it provides technical support. Rather than seeing itself solely as a provider of technical support - responding to country requests to assist in proposal development and implementation - WHO should consider acting as a "broker", helping national authorities to access the best people and institutions; ensuring the quality of services provided; and building the requisite capacity in governments to manage the process themselves.

Should WHO place more emphasis on new approaches to technical collaboration: for instance, by acting less as a provider and more as a broker; organizing exchanges of experience between countries; and/or facilitating south-south collaboration?

6. Implications for WHO governance

  • There was a broad consensus at the informal January 2010 consultation that the issues raised need to be addressed proactively and with real intent to bring about change, albeit without recourse to changing WHO's Constitution.
  • It was also agreed that national governments are no longer the only or even the most influential actors in shaping global health policy: a wider range of actors now play a role, including civil society organizations, philanthropic foundations, patient groups, private companies, trade associations and many others.
  • Given the increasingly prominent role of philanthropic foundations and public/private partnerships, neither are national governments the only significant financiers of WHO.

Should the governance of WHO should reflect this reality and become more inclusive of other stakeholders, including civil society and the private sector? If so, what would be the best way of making this happen?

7. Priority-setting and communication

  • Underpinning all of the issues discussed so far lies the question of how WHO sets
    priorities. This issue is particularly acute at a time when resources are scarce and the need for consolidation is paramount. Questions then arise about the means by which priorities are set; the extent to which priorities respond to country needs (and how these needs are determined); and the framework within which strategic choices are made (between strategic objectives; between headquarters, Regions and countries; between normative and technical collaboration, and between different domains such as humanitarian action, health and development, health security, etc.).

Given the competing demands facing the Organization, what criteria and/or mechanisms should be used to define overall priorities? In which areas is WHO's role indispensable, as opposed to being complementary to the roles of others?

  • Health remains politically prominent as a global issue and a national concern for both developed and developing countries. However, the priorities for the Organization are determined, WHO has high brand value and social capital, and trust in the Organization is one of its biggest assets. That said, there is a continuing need to persuade parliaments, and their constituents, of the value of WHO - both in terms of achievements and value for money. Good public communications, especially in donor countries, combined with effective country-level performance, are key to influencing decision-makers.

How can WHO better communicate the relevance and impact of its work to a wider
audience, including demonstrating convincingly how it adds value to development
budgets of donor countries?

8. Implications for financing: not more but better

  • The way in which WHO is financed is a key determinant of how the Organization
    performs and how, de facto, priorities are determined. The difficulties inherent in the current situation, where less than 20% of income comes from assessed contributions, while the majority of voluntary contributions are highly earmarked, are well understood. Better alignment between resources and agreed priorities is critical, yet it is hard to achieve given the present division of income. Equally, however, there is little prospect that assessed contributions will increase to past levels. New approaches are therefore needed.
  • To redress the current situation, changes are needed both on the part of donors and on the part of the Secretariat. From the donor side predictability is key, to facilitate realistic planning and provide the security needed for management reform. In addition, it is important to avoid situations where, because of an insistence by voluntary donors on artificially low overhead rates in the form of project supports costs, assessed contributions end up being used to subsidize any shortfalls. Contributions should thus be based on the principle of full cost recovery.

What more can be done by donors to increase the predictability and flexibility of funding to WHO?

  • The Secretariat too needs to change. Increasing donor support for more, and more flexible, funding will only result from greater clarity of purpose, tighter priorities, greater efficiency, excellence in delivery, timely reporting and the capacity to communicate effectively about how and where results are being achieved.

What can the Secretariat do to make it easier for donors to provide funds in a way that permit greater alignment with agreed priorities?

  • While maximizing the use of existing sources of finance and increasing the efficiency with which those funds are used, WHO has also been urged to innovate - both in terms of widening the current network of donors and by exploring new processes for raising funds that would help increase flexibility and predictability.

How might WHO most effectively explore new processes for mobilizing resources and new sources of funds?



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