WHO reform continues to confuse

The Lancet
Mar 16, 2019, Volume 393  Number 10176  p1071-1176
https://www.thelancet.com/journals/lancet/issue/current

Editorial
WHO reform continues to confuse
The Lancet
The content of a reform for WHO came as somewhat of a surprise to many in the global health community. After Dr Tedros Adhanom Ghebreyesus, in his inaugural speech, said “I do not believe in perpetual reform and I think WHO staff are reformed out”, WHO’s Director-General unveiled the result of a 20-month-long consultation for reform. Aimed to be “the most wide-ranging reforms in the organisation’s history”, according to the accompanying press release, this reform is a substantial top-heavy redesign of the internal structure of the WHO Secretariat.

The reform was announced in a speech to staff on March 6. In the speech, Dr Tedros and WHO’s six Regional Directors (RDs) took turns to speak about the reform. Historically, WHO has often been referred to as not one but seven WHOs. That RDs are locally elected, thus retaining significant autonomy over their regional and country priorities, has often been said adds fragmentation and compartmentalisation to the organisation. By calling on the RDs to be part and parcel of the announcement, Dr Tedros reiterated the message of one WHO.

The reform is aimed to “address gaps in [universal health coverage], health emergencies, and healthier populations”, guided by Dr Tedros’s Triple Billion targets. From March 15, there will be only one Deputy Director-General (DDG) reporting to Dr Tedros—Hungarian Zsuzsanna Jakab, formerly RD of WHO Europe—down from three DDGs.

The Programmes, which formerly reported directly to the Director-General, will now be led by Assistant Director-Generals (ADGs) reporting to the DDG (with the exception of the UHC and Life Course Programme led by Australian Executive Director Peter Salama who will be reporting jointly to the DDG and Dr Tedros). The new organisation of programmes reads somewhat confusingly. Where integration of the communicable and non-communicable diseases into one programme could create opportunities for more holistic approaches to disease, it is unclear why it was combined with UHC, or why antimicrobial disease was separated into a programme of its own. Importantly, the maternal, child, and adolescent health cluster, which one would expect to fall under the new UHC and Life Course Programme, seems to be missing from the organogram circulated to staff in an internal memo after the announcement, although The Lancet was told by WHO that it has not yet been finalised. This is all the more surprising given that maternal and child health was one of Dr Tedros’s five campaign priorities.

Indian paediatrician and former DDG Soumya Swaminathan was appointed to a new role, Chief Scientist, to head a division that is tasked with supporting, developing, and maintaining the excellence of the norms and standards of WHO. Notably, a new Division of Data, Analytics, and Delivery for Impact, headed by the American ADG Samira Asma, will not report to the Chief Scientist, but to Dr Tedros.

The perennial issue of WHO’s funding structure was also brought to the fore. Although WHO depends on reliable contributions from its member states, most of its funding comes from voluntary contributions, which can be highly variable and heavily earmarked for the donors’ interests. In his speech, Dr Tedros made it clear that he will be attempting a major reform of this system. The decision to take fundraising out of the programmes into a centralised fundraising department is “part of a much bigger shift in the way [WHO] generates resources, to diversify our funding base and make us less reliant on a handful of major donors”, he said. A new resource mobilisation strategy, the establishment of a so-called WHO Foundation, to develop innovative financing mechanisms, and a new yearly WHO Partners Forum were announced. This all points to the possibility that WHO’s strategy for funding going forward might be the establishment of a centralised pot of money for voluntary contributions. However, whether the member states and major donors, such as the US Government and the Bill & Melinda Gates Foundation, would be compliant with such a mechanism is uncertain. A week after the speech was given, experts contacted by The Lancet communicated their continuing confusion about this reform. As we go to press, a marked lack of communication surrounds the announcement and a detailed report explaining the specifics of what the reform means for programmes, oversight, funding, and staffing is not yet available. In the meantime, the global health community is still holding its breath, waiting to see whether this reform represents a transformational shift in vision for WHO or simply a shuffling of clusters and staff.