MANILA — The World Health Organization has published the draft of its 13th General Program of Work and in it provides some early indications on the direction the U.N. agency proposes to take.
As per the draft, published on November 1, the WHO identified three overarching priorities with accompanying targets: 1 billion more people with essential health services coverage; 1 billion more people made safer; and 1 billion lives improved. The latter covers a more specific list of targets based on the Sustainable Development Goals.
The priorities are followed by discussions on proposed changes to the WHO’s way of working, such as stepping up global health leadership and driving impact at the country level by understanding and responding to different countries’ health systems and needs.
Internally, the WHO aims to transform its operating model to one that seems to place huge emphasis on its country-level presence. It aims to have highly skilled country representatives who can be the organization’s health ambassadors, helping raise funds and advocate for its work, but also be effective managers. The institution also aims to conduct an analysis and evaluation of its business processes and to invest in “user-friendly, high-quality, and fit-for-purpose IT systems.”
But the document is very much a work in progress. Far from being final, the draft GPW is only the beginning of a more detailed discussion on the WHO’s priorities and direction.
A few highlights
Part of the report sheds light on where the WHO plans to be more operational and how it may approach those areas.
“WHO will take operational action in a limited set of highly fragile, vulnerable, and conflict-affected states such as (at the time of writing), Iraq, Syrian Arab Republic, and Yemen,” according to the 25-page draft document.
The institution proposes to apply this approach in “some 10 states,” but it can vary in terms of scope, countrywide or in areas where service delivery is almost nonexistent and the WHO is seen as the “provider of last resort.”
Service delivery includes coordinating the health cluster in a specific country or setting, and the “direct provision of services and supplies.”
However, the draft is scant on detail regarding how the WHO plans to deliver on this, particularly on the issue of capacity, or what it means by the “services” to be provided. The U.N. agency has been known for settings norms and standards in global health practice and providing guidance in health emergencies. But it has not functioned the way other global health players — such as Doctors Without Borders or the International Medical Corps -— have operated for years.
The draft also highlights the gender imbalance that permeates senior-level positions within the organization, and provides a specific diversity target for director-level positions. It includes proposals to achieve gender parity among WHO directors as well as member state delegations to the World Health Assembly by 2023. It also seeks to increase to 35 percent the number of directors at headquarters who are developing country nationals.
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Only 31 percent of the heads of member state delegations who came to the 70th World Health Assembly in May 2017 were women, and only 11.7 percent of D1 and D2 director-level positions at headquarters come from developing countries, according to the draft.
It is proposed that efforts toward improving diversity across the organization include or start at the level of WHO internships, “at which point a cascade of non-diversity may begin.”
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The document also includes several additions. Among them is the inclusion of palliative care when referring to universal health coverage, which members of the global health community pointed out was not mentioned in the concept note released in August.
“Universal health coverage includes health promotion, preventive services, diagnostics, and medicines for communicable and noncommunicable diseases (which are a key driver of out-of-pocket costs) and curative and rehabilitation services,” according to the concept note.
A whole paragraph has also been dedicated to the issue of access to affordable and quality-assured medicines, a contentious issue that many in the global health community are expecting WHO Director-General Tedros Adhanom Ghebreyesus to take up as a priority for collective action and discussion during his tenure, as Devex reported on his first 100 days in office.
The draft does not mention what advocates often underscore as critical points in discussions of access to medicine, such as delinkage and intellectual property rights. But Peter Singer, senior advisor to the director-general, told Devex the WHO recognizes the significance of access to medicine to achieving universal health coverage.
“This is an issue on which different member states have very different views, and I think what the draft does is take the issue very seriously,” Singer said.
“I believe there are dedicated sessions on that very topic for negotiations among member states,” he added, but made no official claim on when that might happen or in what particular governance meeting.
A question of priorities
One of the most anticipated parts of the draft is on priorities. This has been the subject of many member state interventions in official WHO meetings and dialogues for years, and one that members of the global health community have also recognized as a key decision point for the organization.
But, while the document identified its priorities, the question lingers: What will the WHO not do?
The GPW, being a draft, will likely see multiple iterations over the course of the next few months. Devex notes this first draft has already contained quite a few additions and subtractions. For example, SDG 5.3, which talks about eliminating harmful practices such as child, early, and forced marriages and female genital mutilation among women and girls, and SDG 16.2, which talks about ending the abuse, exploitation, trafficking, and other forms of violence and torture against children, are not included in the current draft of the WHO’s impact framework, which typically lists the WHO’s priorities along with specific targets.
But Singer won’t go into specifics, and instead highlighted the effort that has been to prioritize.
“I think what you see here is a very, very strong effort and focus toward prioritization. For many years, member states have been asking WHO to focus and to prioritize. And so this draft general program of work is an effort to do that,” he said. “So WHO will really, really focus its efforts, and you can see that, and it’ll do less of things that are not in that particular focus.”
But he admitted it was a question people often ask the organization.
“Sometimes people ask us a question about what we won’t do, and they’re expecting you to say something like, ‘Well, it’s not gonna deal with dental health or something,’” he said.
But “member states do expect WHO ... to have a wide range of knowledge to continue its strong normative work. WHO has to have expertise to help countries on their requests in universal health coverage. So [the] more as I see it, it’s really a question of more focusing on the highest value areas,” he said.
Extensive consultations have taken place prior to the release of the draft GPW, but public consultations are again open for the current draft, and Tedros is expected to discuss it with the WHO’s executive board at a special session in late November.
“WHO doesn’t want to unnecessarily duplicate the work of other partners. WHO wants to enhance the work of other partners, with the ultimate goal of achieving better health for all,” Singer said. “So there is a broad-based approach and a holistic approach in here through the global leadership based on the SDGs, the very foundation of the SDGs, and through emphasis on partnerships.”
Financing, another pointed issue for the organization, was also mentioned in the draft, underscoring the mutual roles of both the Secretariat and of member states in fully financing the organization’s program of work.
“Member States should work with the Secretariat to raise the necessary funds for the organization to deliver the General Programme of Work which they have approved. Earmarking will need to decrease to give WHO the needed flexibility to deliver on GPW 13,” according to the document.
There are few concrete details describing how this will be achieved in practice beyond what the document refers to, such as high-level advocacy, multisectoral dialogue, and the WHO providing evidence of the impact of its work to national governments as well as international donors. But Singer pointed out that it’s not an implementation plan.
“Keep in mind the GPW is a strategic plan, so it’s here to set a strategic direction. It needs to be implementable, but it’s not necessarily an implementation plan per se,” he said. “But you did [mention] the core issue about financing, which is that WHO is here actually to advocate for financing for health in general. And that ties obviously very closely with the stepping up of global leadership, and working in concert with [civil society and] ministers of health to ensure that heads of state, finance, and others understand the value and importance of health to their people.”
Along with the draft’s focus on impact is an emphasis on measurements, a review of the WHO’s structure and approach, and ensuring WHO staff are “fit for purpose.”
The WHO notes it will monitor the targets set out in the draft framework, and produce “regular scorecards” that include both quantitative indicators and “qualitative country success stories.” These will be reviewed externally by an independent panel.
The WHO will also employ an inverted pyramid model, placing emphasis on its country structures, from staffing to empowering its country offices with “sufficient programmatic, financial, administrative, and management autonomy.” It will also boost its visibility and advocacy role by placing more communication officers in countries.
The draft also points to cultural reorientations and upskilling of the WHO’s workforce, a review and refining of management and administrative capacities, roles, policies, and procedures, as well as an analysis and evaluation of current WHO business processes.
These suggest real, practical changes inside the WHO. But again, the document does little to detail what those changes are, raising more questions than answers.
For example, the draft refers to “enhancing the quality of leadership at country level to ensure a new generation of high-calibre WHO representatives who are strong and effective health leaders and diplomats and well suited to the country priorities they are to address.” But it stops short of saying whether this will be done by training current country representatives or through a recruitment drive during which the WHO will seek candidates that meet those skills it has laid out in the document.
“WHO representatives must be highly skilled to serve as WHO’s health ambassadors, leaders, and managers, combining technical expertise, programme management, advocacy, resource mobilization, and diplomatic skills,” according to the draft.
In the earlier concept note, a reference was made to enhancing the “quality of leadership at country level through targeted recruitment and training, building upon lessons learned from the best performing country offices and make it more attractive.”
Singer answered positively when asked whether there will be real, practical changes within the organization, and whether Tedros has made it clear how decisions will be made to ensure the organization moves forward with its goals. But the senior advisor also noted that the changes were “evolving at this time” and therefore was unable to provide specifics.
“I know I’m talking generically, [but] anyone who’s interested in changing an organization recognizes that first you have to see where the real bottlenecks are. What I mean by that is the things that really need to be changed with the greatest priority. You need to see which of those can be done relatively quickly, because some change is fast, some change is slow. And then you need collective decisionmaking on actually making changes,” he said, referring to a note in the document that says the WHO’s Global Policy Group — composed of the director-general, his deputy directors-general, and the regional directors — will oversee the implementation of these organizational changes.
Read more Devex coverage on the World Health Organization.