WHO signals intent to trim sails

The year 2012 is poised to become a time of substantial change for the World Health Organization (WHO), which plans on initiating reforms to improve its leadership, increase cooperation between member states and become more efficient and transparent. Though the proposals for reform have only been described in broad strokes thus far, one thing is certain: It all begins with money.

“This WHO debate about reform has been going on for a while, and much of the concern is about the way it is financed,” says Dr. Andrew Cassels, director of strategy in the office of the director-general of the WHO. “Our budget is made up of 25% membership fees, which everybody pays, and 75% comes from voluntary donations. That 75% is pretty heavily tied to certain areas, so some objectives get good funding and others less so. Can we do something about increasing the flexibility of our financing? That’s where we are starting.”

The financing reforms will be implemented in conjunction with a narrowing of WHO’s focus to five core areas: health development, health security, strengthening health systems and institutions, generating evidence on health trends and determinants, and convening for better health (www.who.int/mediacentre/news/notes/2011/eb_20111104/en/index.html).

WHO’s executive board also indicated during a special session in November 2011 that it supported proposals forwarded by member states and the director-general which are aimed at strengthening governance, improving financing, facilitating communication across the organization, and increasing transparency and accountability.

The integral financing issue is scheduled to be addressed at a January 2012 meeting of WHO’s executive board. Part of the strategy will likely include dealing with donor nations in the aggregate rather than individually, which will enable each country to learn what others are doing, Cassels says. It would also enable countries to cooperate to achieve international health goals and help to reduce gaps in funding in certain areas. From there, work can begin on a framework for more detailed priorities.

“The whole thing comes together at the World Health Assembly in May,” Cassels says. “We will be clear on the proposed reforms. We will know then which ones will fly and which ones will drop.”

The World Health Organization’s executive board met in Geneva, Switzerland, in November 2011 to discuss agency reforms.

Image courtesy of Reuters/Michael Buholzer

Many experts on global health have claimed WHO is overcommitted and overextended, and that reforms to narrow its focus are long overdue (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-3933). WHO can afford to cut certain programs, the experts suggest, because countless other health agencies have been created in recent years to address particular health concerns, including charities, nonprofits, United Nations agencies, global and regional funds, global health missions and product development partnerships with a collective annual budget of US$22 billion (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-3701).

“I don’t think the organization is in crisis. This is not the first time the WHO has been through a reform process,” says Rachel Irwin, a researcher in the Global Health and Security Programme at the Stockholm International Peace Research Institute, a think tank based in Sweden. “What the WHO does well is provide a forum where health priorities can be created and standards can be made. It holds meetings that bring people together to hash out global health issues. It has the most democratic forum for these discussions to happen in. Other global health initiatives are not as inclusive.”

And though there are more health organizations now than ever before, it is still important that WHO continue to do what it does well, says David Stuckler, a lecturer in sociology at the University of Cambridge in the United Kingdom. “I strongly believe that many of the challenges we face are truly global. Chronic disease is one of those challenges,” says Stuckler. “No country on its own can stop threats that transcend borders.”

How can the WHO better address these types of international health threats?

It all comes back to money, says Stuckler. “In 1980, three-quarters of the money was in the regular budget. The problem is, now three-quarters of the budget is the voluntary budget. Within the regular budget, money is relatively aligned with health needs. But if you look in the voluntary budget, there is a major misalignment.”

Addressing that problem appears to be a major priority for Dr. Margaret Chan, the director-general of WHO. Health priorities should not be set according to the sources of financial contributions, Chan stated in a recent address (www.who.int/dg/speeches/2011/reform_priorities_01_11/en/index.html). “Priorities must be driven by burning unmet health needs, and not by resources.”

“Money follows priorities, and not the other way around,” Chan added.