Comments on ‘The future of financing for WHO’ 64th World Health Assembly (WHA), May 2011 Distinguished delegate of the WHA, People’s Health Movement (PHM) is a global network of organisations and individuals working locally, nationally and globally in more than 80 countries for ‘health for all’. Our basic platform is articulated in the People’s Charter for Health which was adopted at the first People’s Health Assembly in Dhaka, Bangladesh in December 2000. More information about PHM can be found at www.phmovement.org. PHM is committed to a stronger World Health Organisation (WHO), adequately funded, fully utilising the powers of the Constitution and playing the leading role in global health governance. PHM follows closely the work of WHO, through the governing bodies and the secretariat at all levels. Across our networks we have technical experts and grass roots organisations with close interests in many of the issues coming before you over the next few days. Over the last week, 30 members of the PHM WHO liaison group from over 20 countries have been working through the WHA Agenda with the assistance of high level experts from a number of collaborating networks and NGOs. This workshop was part of our Global Health Governance Initiative (a joint project of PHM, Third World Network, Health Action International, Medicus Mundi International and Medico International) which involves both watching and advocacy. We are particularly concerned regarding the Director General’s (DG) report “The Future of Financing for WHO: Reforms for a Healthy Future” (Doc. A64/4). The WHO is facing a financial crisis: programmes, projects and staffing face the prospect of being disbanded; the dominance of tied donor funding is having a terrible effect on administration. The WHO is also suffering from a crisis of identity and legitimacy; its role and mandate have been diluted and usurped by the proliferation of new actors in the field of global health. Inefficiencies within the organisational processes remain unresolved. These crises have been building over several decades. They also reflect questions about the role of the UN, the sovereignty of nation states and the democratic deficit that exists at the global level of governance more generally. The driver of the reforms foreshadowed in the DG's report is the financial crisis in which the WHO finds itself. In accordance with the demands of the donors, the report simply addresses issues of effectiveness, efficiency, responsiveness, objectivity, transparency and accountability (A64/4, p.6). However, while the report sets out broad directions for the WHO, it has few concrete recommendations and inadequate analysis of the financial crisis. Most worryingly, the key document – the “detailed development plan for the programme of reform” (A64/4, p.6, footnote 2) – has not been posted even a few days before the Assembly. Calling for endorsement of a general plan without detail is asking member states to sign a blank cheque. Core business The focus on “core business” could well turn out to be a narrowing of the mandate of the WHO. The DG has previously stated that certain key areas of work of the WHO, including action on the social determinants of health, human rights and gender, are to be ‘mainstreamed’. Mainstreaming is a euphemism and will lead to reduced focus, analytic capacity and drive. There are powerful interests that would like to see WHO restricted to a technocratic role on communicable disease control and ‘health security’, and distanced from issues such as economic development, justice and peace, despite the fact that these are critical determinants of health and are wholly encompassed in the WHO Constitution. Organizational effectiveness There is a need for greater coherence between the country, regional and global levels of the WHO. But there is nothing in the report about the concrete changes required. The issues of accountability, coordination and management are complex and difficult. But it’s time to stop talking about organizational effectiveness and to start drawing up an agenda and implementing real reform. Management and accountability The WHO has not escaped from the new religion of performance-based funding. Of course, the WHO should have clear plans and be capable of self-evaluation and impact monitoring, but subjecting itself to a narrow form of performance management could undermine its mandate, authority and independence. Much of what the WHO does (convening, facilitating, leading, advocating, coordinating and persuading) cannot be measured through simplistic performance-related results and indicators. Management and accountability in the WHO call for leadership and diverse methods of evaluation. As the directing and co-ordinating authority on international health work, the WHO should also take the lead in promoting accountability and transparency in its functioning and the fulfilment of its mandate. This should include transparent and participatory audit of its movement towards achievement of the ‘highest attainable standard of health for every human being’, including provision for the ‘right to information’ for its constituents. Human Resources (HR) The goals of reform should precede changes to HR policies, planning and management. However, the need to downsize is preceding and informing the process of reform. It is a direct response to the WHO’s financial crisis, and not to a rational and evidence-based determination of staffing needs for the fulfilment of its mandate. Of course there are many improvements that need to be made to the WHO’s systems of recruitment and HR management but the evidence and logic to support reducing the number of core staff and supplementing them with temporary staff and sub-contractees has not been presented. Financing and communication To fulfil its mandate the WHO needs a budget that is adequate, predictable and untied. WHO’s state of financing is untenable; only 18% of WHO’s funding comes from core, assessed contributions. The rest is cobbled together from multiple streams of voluntary donations, grants and in-kind support, much of which is conditional. A high proportion of voluntary contributions by member states undermines the organisation’s independence and results in huge inefficiencies. Increasing dependence on private philanthropies and corporates carries serious risks of further distorting WHO's priorities. It is time that the assessed contributions formula for countries is reviewed and revised; and it is time for a fair and adequate system of public financing for the WHO. We propose that member states collectively commit to increasing assessed funding so that it reaches 50% of the overall budget over the next five years. The report calls for the WHO to widen its resource base by drawing on the private and commercial sector but it makes no mention of how its independence will be protected, nor does it say anything about the management of institutional conflicts of interest. WHO should set a cap on the amount of tied funding received from the corporate sector. Independent monitoring of public-corporate relationships are required to prevent or deter unsafe or inappropriate relationships from forming. The funding of WHO programmes by corporates and other donors should be explicitly identified on the website. These safeguards to prevent the privatisation of the WHO and the corporate capture of policy making should be spelled out before setting off a revitalised programme of private and corporate fundraising. WHO’s effectiveness at country level Effectiveness at the country level should be “a key outcome of reform and an immediate priority in the agenda for organisational alignment”. WHO does have a role in promoting inter-agency cooperation but its unique role is supporting access to evidence, information and best practice in the fields of social determinants, intersectoral collaboration, primary health care, health system strengthening, health care financing, rational use of medicine and other critical areas. Whether this is carried out through country representatives or regional offices, WHO should be accountable at the global, regional and country level for the effectiveness of these functions and for the protection of people’s health. Global health governance It is essential that the reform of the WHO be framed around the health needs of people instead of being centred upon the financial crisis. Health policy making over the last 30 years has been distorted by the pressure of odious debt, the defence of intellectual property and the rationalisation of an unjust global economy. The WHO should speak truth to power. The proposed World Health Forum has the potential to promote the interest of the private sector at the expense of a member states’ driven process. The rationale and need for such a forum is not made clear; and there is no discussion about how such a proposal would avoid undermining or duplicating the role and mandate of the WHO. The WHO must not pursue public-private partnerships without ensuring safeguards against corporate influence over policy making and pernicious conflicts of interest. We urge you to consider the risks of this proposal and hope you will not to endorse it in its current form.