'What worries me is not the money for WHO' — Tedros

MANILA — The draft 13th General Program of Work cut across discussions at last week’s 142nd executive board session of the World Health Organization. But while some stakeholders perceived progress on the current draft, questions remain, including the nagging question on how WHO Director-General Tedros Adhanom Ghebreyesus would be able to finance his vision for the organization.

The GPW serves as the organization’s strategic plan for the next five years. It contains details on the organization’s overarching goals, priorities, and planned changes in its way of working. While Tedros and his advisers note the current GPW is in line with the Sustainable Development Goals, it also serves as living evidence of some of the WHO aid chief’s campaign promises, from addressing gender gaps in WHO’s senior leadership to a central focus on universal health coverage.

“As soon as I started, there were three things I was trying to do. One is keeping the WHO afloat … the second is a focus on priority issues, time sensitive issues like emergencies, [and] the third was building WHO for the future,” he told Devex in an exclusive interview prior to the executive board session.

The draft program discusses WHO’s triple billion targets, and proposes strategic and organizational “shifts” that would see the organization placing more emphasis on its work in countries. It also places emphasis on results rather than outputs. A number of member states and observers find it to be deeply ambitious, but some of its proposed contents have drawn concern from member states.

“The ‘more operational’ word was creating some confusion,” Tedros admitted. In the second draft, issued early last month, the term has been scraped. Member states had raised questions over whether WHO was going into unchartered territories, moving away from its normative setting functions to take up service delivery work on the frontlines — like what organizations such as Médecins Sans Frontières or International Medical Corps do. But the director-general clarified that operational meant mainly coordinating the work of WHO and partners on the ground.

“We will support them based on the situation for instance. We will identify services that will address the certain gaps we see, or in emergency situations to address the outbreak,” he said. But “it’s not going to be like more surgery. There will be areas where there is a serious gap, and [when] there is no one — even MSF is not around — then [we] would be compelled or forced to take some direct services, which we did by the way in Iraq, in Mosul. We hired people from the locals to be involved in providing services, because some of the population were completely devoid of services, and there was no partner to take over.”

“This happens in rare occasions, but it really saves lives. And at the end of the day we should see our service in terms of saving lives, in terms of saving the vulnerable,” he added.

But there is no competition between that “operational” role and WHO’s normative work, the director-general stressed. WHO’s work will continue to focus on making regulatory recommendations, setting norms and standards based on scientific evidence and advice from technical experts, and issuing health assessments and statistics. And they plan to strengthen it further by expanding WHO’s engagements with middle- and high-income countries, even if only for policy dialogue.

Setting priorities

After a series of revisions, member states have agreed to move the draft 13th GPW for consideration of the 71st World Health Assembly in May. But that’s not to say it’s current form is final; member states could still open the document for discussion — and additional revisions — if they wish to do so.

Some member states say they still have questions, including concerns over what the secretariat means by “vulnerable settings/states.”

Early on, representatives from Sweden and Canada commented that the document was weak on language on women’s sexual and reproductive health and reproductive rights.

“It doesn’t reflect WHO’s mandate nor the director-general’s strong commitment to the issue,” said the representative from Sweden during one of the sessions.

Tedros said, to him, the action required to achieve universal access to sexual and reproductive health and reproductive rights, or SRHR, is more important than investing time changing the wording in the document, which he said is aligned with the SDGs, whose wording took years in negotiation.

“While Canada would have preferred stronger language in the Rev 2, as you know the WHO has a consensus based governance, and we feel that all parties found common ground. What is important for us is that WHO has the mandate to undertake its role in SRHR. That is certainly the case in the GPW,” Canada’s representative to the WHO Executive Board told Devex when asked whether their calls for stronger language on SRHR were satisfied.

In addition, other important related documents, such as the Impact Framework by which WHO will measure its work on the GPW, the financial estimate and investment case for the plan, have yet to be finalized.

Tedros also made it clear that WHO will focus only on those issues included in the GPW, a message that could lead to heavy lobbying in the next few months among member states and organizations whose interests have yet to be fulfilled in the current draft.

“WHO will not do things that are not included in the GPW,” he said.

Currently, it still isn’t clear what could possibly fall outside of WHO’s priorities, and how WHO will arrive at those decisions. The point of prioritizing means some issues will be more important than others.

Tedros has underscored that delivering on the triple billion targets mentioned in the draft GPW is not WHO’s responsibility alone. In fact, WHO’s role will likely “be small,” he said, explaining that achieving the targets will be a shared goal between WHO, other organizational partners, and countries themselves.

“We have two responsibilities here. One, we will convene and coordinate the overall global health movement, and second, with that, we will also identify our share and measure our contribution,” he said.

“This is a very, very strong commitment. We’re making ourselves vulnerable ... because it’s very, very important. People are saying, ‘oh, this is very ambitious, and you know you’re taking risks because this is something that WHO may not be able to manage.’ But I believe that it’s doable, because we’re not saying everything will be done by WHO. We will do it with others,” he added.

Financing WHO and the global health agenda

In response to member states’ and observers’ questions on how much it will need to fully finance WHO’s proposed program of work for the next five years, the WHO secretariat published a draft financial estimate in time for last week’s executive board session. The amount: $10.8 billion over the five-year period.

The figure, according to the document, is a combination of estimated yearly baseline budget for WHO, and estimated additional investments required as part of the aid agency’s efforts to strengthen its work at the country level, maintain capacities budgeted and funded by the Global Polio Eradication Initiative, and increase WHO’s leadership, advocacy work, data mining, communications, and resource mobilization at all levels of the organization. It also reflects potential savings arising from expected efficiency gains from the GPW that could be worth as much as $440 million in total.

This is not yet final, and the document notes this will be further refined by taking a bottom-up approach to fully reflect and obtain a more accurate picture of the needs on the ground, and the capacities WHO will need to respond to them. Member states also still have questions on how the secretariat was able to arrive at the figure, and note in its recommendations to the 71st WHA that approval of the 13th GPW “does not imply approval of the financial estimate.”

But the question that arises is how WHO plans to attract as much money to fulfill its estimated budgetary needs to implement the GPW, at a time when traditionally generous nations such as the United States are pulling back on its commitments under a new administration.

Tedros said he is strengthening WHO’s resource mobilization unit, an idea he already floated in his first press conference after being elected director-general.

He also talked about finding innovative ways of raising funds, but did not elaborate further.

However, one idea he floated around during Monday’s session has to do with the provision of in-kind support. The secretariat, he said, is currently mapping the capacities of countries to contribute to a global “health reserve army” that can be deployed within 72 hours of an emergency.

“Once that mapping process is finalized, we have agreed with GOARN [the Global Outbreak Alert and Response Network], we will come back to ask you to commit as many people as possible, and to fund their deployment wherever they are needed in the world,” he said. “This will effectively constitute a large stock of in-kind support stationed in many countries around the world, human resources and finance, and represents a new mechanism of resource mobilization.”

In our interview, he also said he’s convinced that the U.S. will continue supporting WHO.

“My first trip while I was still DG elect in June was to the U.S. And I met several officials, including President Trump and also the people from the Congress and the Senate. And I left actually convinced that there will be bipartisan position, especially in terms of financing WHO. So that’s what I expect,” he said.

But while some raise concerns for WHO’s budget, funding WHO’s work doesn’t appear to worry Tedros as much — at least in the immediate term — as that for the wider global health agenda.

“On resources, if we start working together, we won’t have concerns on resources,” he told member states following a round of interventions during his “dialogue” with them. He said WHO staff are coming up with “crazy” or transformative ideas to raise funding. He also anticipates fresh funding from “new donors,” although again he did not elaborate further.

“It’s going to be challenging, but as a team we are confident,” he said. “Of course I have asked you, when it comes to funding for WHO, we [are asking] flexible and predictable financing. Some of you are worried when I talk about how to finance the GPW, [but] it’s not the amount of money, but the quality of it, to be honest. I would go for the same amount of funding, without increasing the level of it, if I can have it in a flexible way.”

One of his three “challenges,” or calls to action for member states, is to commit to unearmarked funding for WHO, along with committing personnel and resources for their deployment in emergencies, and concrete commitment toward UHC.

But he said he worries for others, such as the Global Fund and Gavi, the Vaccine Alliance, and whether they can access the money needed sustain their life saving work.

“What worries me is not the money for WHO. What worries me is the resources for the global health agenda,” he said in the interview. “We need to help them have successful replenishments, so we have enough resources to address the global health agenda.”

Since taking office, Tedros has made this concern over global health funding clear. It has been reflected in his earlier engagements with the Chinese government, for example, where he asked not only funding for WHO, but for countries along China’s Silk Road.

And he believes unlocking enough resources for global health lies not so much in what donors can provide, but in countries’ commitment to invest and mobilize sufficient resources for the health of their own populations.

“We are talking to member states to mobilize domestic resources [and] we are discussing with them, saying that whatever comes from outside is actually a complement, and the resources by and large should come from domestic resources,” he said.

He however acknowledged that the “global gag rule” imposed by the current U.S. administration will have major impacts on women, especially those who have less.

“The issues related to reproductive health, family planning, if there is a shortage of commodities for family planning, those who will be affected are women in poor, poor countries. I hope that is understood and that they’re able to see the consequences,” he said. “But at the same time, WHO is working with other partners to understand the gap and resolve the gap that we’re facing.”

*Update, Feb. 3, 2017: This article has been updated to clarify that the draft 13th General Program of Work discusses WHO’s triple billion targets.

This is the first of a three-part series of our exclusive interview with WHO Director-General Tedros Adhanom Ghebreyesus.

Read more Devex coverage on the World Health Organization.