The real drivers of WHO's agenda — and why those need to change

The World Health Organization has been pummeled by sharp criticism after its initial slow response to the Ebola outbreak in West Africa — so much so that reforms were deemed necessary. A few weeks ago, WHO member states adopted a resolution that calls on the U.N. health agency to implement a slew of reforms. The goal is twofold: get Ebola cases in West Africa down to zero, and improve the overall capacity of the organization to respond to outbreaks and emergencies — a response no doubt to the inefficiencies member states found in WHO’s Ebola response. But this is not the first time the health agency has tried to implement reforms. It is still in the middle of completing a sweeping reform agenda, which WHO has been struggling to fully implement, covering aspects such as staffing-to-program alignment, appointments of highly qualified people at regional and country level, and streamlined communication across the three levels of the organization. A number of these reforms are set to be completed by year’s end; others have just two more years. Christian Lindmeier, communications officer at WHO’s headquarters in Geneva, told Devex that the challenges the organization is facing in implementation are not unique and are “typical” for any organization trying to implement a concept, such as policies, frameworks and processes. “This is a phase that requires a shift in ownership. And while challenging and time-consuming, some good successes have been made and reported to the governing bodies,” he said. The WHO official did acknowledge that delays were also due to “conflicting resource needs” related to the Ebola response. A number of key WHO staff — and attention — are deployed on the ground in West Africa to respond to the ongoing outbreak. But Pulitzer Prize-winning journalist Laurie Garrett, now a senior fellow for global health at the Council on Foreign Relations, told Devex this is the best time for the organization to try and change things, no matter how difficult or exhausting it may be. “The best time to try and change things is in a crisis,” she emphasized. “As soon as a crisis is behind everybody, all the old ways return. And the same old political maneuvering suddenly is back in place. This is precisely the time.” What needs to change And one key element that needs to be straightened out in the reform process, according to the global health expert, is WHO’s true mandate. In Article 2 of WHO’s constitution, the U.N. health agency’s role in emergency and outbreaks is to “furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of governments.” But there still seem to be expectations that despite this mandate, WHO will still have a strong capacity to respond to the Ebola outbreak. And when it did not deliver, many in the development community found it “abominable.” Garrett believes the U.N. agency should be able to do technological assessments and crisis interventions, while also providing technical guidance to different types of health issues, as well as to boost countries’ health systems — which should be reflected in WHO’s mandate. And then there’s the issue of “dead weights” in the U.N. system — people who aren’t doing their jobs or aren’t pushing the institution forward, but that the organization is stuck with. “It turns out [that] it’s very, very expensive to fire someone or lay someone off who is high ranking and has worked for a U.N. agency for more than a decade. You have to buy them out of their contracts,” she said. “It’s easy to shift around when everybody’s got money.” But, Garrett emphasized, when you don’t have money, it’s not that easy to resteer the ship, find more competent staff and demonstrate that competence — not length of service — is the ultimate factor as to whether somebody keeps their job. The global health expert further noted that the blame for all of the inadequacies critics have panned shouldn’t be pinned on WHO alone. When you have member states that have not voted to increase the percentage of their assessed contributions — or that percentage of money they are expected to pay on an annual basis based on their country’s wealth — and a body of donors that prefer to earmark their voluntary contributions, then “there’s not a lot WHO can do.” “You can’t expect the fire department to show up with five brand new hook and ladders when your house is on fire, if you’ve been cutting their budget to the point where they are driving an ancient fire truck that’s 50 years old and they’ve got six old geezer volunteer firefighters sitting on it,” Garrett said. “And then you’re going to turn around and say, my house is on fire.” While the organization has been operating on what Lindmeier described as a “stable budget,” it’s clear that WHO’s funding model is a big source of frustration and limitation for the agency. Dues from member states, while highly flexible, cover only up to 25 percent of the whole WHO budget; the bulk still comes from voluntary contributions from member states, U.N. agencies, foundations and even from the private sector — but not all of it is highly flexible, and most are earmarked for a particular set of priorities. Who’s funding WHO? This funding conundrum has long been a challenge for WHO, which had to deal with an unbalanced balance sheet given the multiple health issues it needed to address. An analysis of WHO’s 2014 funding shows that specified voluntary contributions — or those earmarked for a specific program category — have increased more than 80 percent from the previous biennium period to $3.28 billion. Excluding U.N. agencies and public-private partnerships like Gavi, the Vaccine Alliance, the top 10 donors in this list contribute 43 percent to WHO’s $3.97 billion budget for 2014-2015. Devex took a closer look at WHO’s top voluntary donors, comparing their assessed contributions with their voluntary contributions, and identified their funding priorities. We found that while the budget for outbreaks and crisis response — $515 million — has now exceeded WHO’s original allocation of $228 million, in terms of priorities, it still comes second to polio, which continues to receive the bulk of funding from some of the biggest health spenders. The Bill & Melinda Gates Foundation, for instance, contributed $309.96 million to polio eradication, as opposed to just $10.7 million to outbreaks and crisis response. Almost all of Rotary International’s contributions also went to the same infectious disease. Member states are pushing for WHO to implement a slew of reforms, but they should follow it up with support and while at it, a change in how they fund the organization. “Much of the donor community is eager to see WHO do this, because otherwise who the heck is going to stop epidemics … [But] if the nations of the world refuse to pay their dues, which have not been raised in more than 20 years, and refuse to mobilize budgets in an appropriate way, and allocate funding to deal with epidemics response and surveillance, then there’s not a lot WHO can do,” Garrett stressed. For 2016-2017, WHO’s draft proposals sets two budget scenarios for member states to consider. The first is close to the 2014-2015 budget; the second slightly higher at $4.26 billion to account for staff costs that’s been getting harder for the organization to absorb due to inflation. Outbreaks and crisis response in the proposal stands at nearly the same levels, although Lindmeier said WHO intends to staff up in the emergency and outbreak response so expect Director-General Margaret Chan to suggest a budget increase in this area. What other changes need to happen to strengthen WHO's capability to respond to global health emergencies? Have your say by leaving a comment below. Check out more insights and analysis for global development leaders like you, and sign up as an Executive Member to receive the information you need for your organization to thrive.