New approach to financing
Professor Thomas Zeltner talks on the future of WHO financing
Professor Thomas Zeltner: former Director-General of the Swiss National Health Authority and Secretary of Health of Switzerland, has a long history as an innovative and progressive leader in national and international public health. In June, WHO Director-General, Dr Margaret Chan appointed Professor Zeltner as her Special Envoy. Andrew Cassels, WHO Director of Strategy, met Professor Zeltner to talk about his role and perspectives on WHO financing.
AC: When the DG asked you to be her Special Envoy on financing, what did she actually ask you to do?
TZ: To listen to the Member States. She said, “The first question I am interested in is what do Member States really want WHO to do?” The first question was on the mandate or scope of work of WHO, and from there to find areas of consensus.
AC: And how did you go about it?
TZ: First of all I started speaking to people in-house, which was very interesting. I met with people from different levels of the organization, including several Directors and three Regional Directors. Obviously their views were very diverse.
AC: Would you like to characterize the diversity?
TZ: The diversity is one of the challenges for WHO. Regional Directors’ commitment to public health has two dimensions: regional and global. The Directors have their own scope of work and their own priorities. Everybody feels that their area is the most important and that it does fit into the whole basket of activities. What was very interesting was that everybody said -Yes! We need to have a global vision, but...
Measures already taken have resulted in savings of more than $200 million.
AC: …but what…..?
TZ: …each person I spoke to said that his or her version of the vision is the most important! After talking to WHO staff I started to talk to the Missions in Geneva. Many diplomats do not have a public health background or experience from Ministry of Health; instead they always see the world through a global multilateral lens that does not include health.
AC: So how did the foreign ministry perspective of Geneva missions influence their perspectives on the problem of financing of WHO?
TZ: Many of the missions thought that financing is not the key problem for WHO. They think more about the governance of the Organization - how decisions are made; to what extent multilateral decision-making still has a value; why have organizations like Global Fund, UNAIDS, and others emerged and should the emergence of new organizations continue? Everybody knows that multilateral organizations are very slow in decision-making and have difficulties reaching consensus. So if someone is interested in fast moves – other organizations might be more interesting.
AC: Where do they see, in this new world, the role of the multilateral organizations such as WHO? If they are slow in decision making, where do they have a value?
TZ: There is no doubt that everybody thinks that global ownership, the common good, joint decisions and democratic decision-making have value. When it comes to normative functions - that is the only way to go. Health becomes more and more global and in need of regulations and guidance. I think they agree on that.
AC: My sense when talking to Member States is that there are different groups of opinions. How would you characterize the difference between them?
TZ: You should distinguish between the missions in Geneva and the capitals. The messages from the missions in Geneva might not always be in line with the messages from the Ministries of Health. I went to the EURO Regional Committee Meeting in Malta, the PAHO Regional Committee in Washington DC, and the Eastern Mediterranean Regional Committee in Cairo. And at those meetings you meet the Ministers of Health and their staff, highly interesting, and very different from Geneva.
AC: And how would you characterize their views of WHO?
TZ: Very different from region to region. And different from individual to individual - depending on how long they have been involved in international work. WHO is extremely complex and it can be difficult to understand how these organizations work. To add to the equation you have rotation of Ministers.
AC: So in a sense you are explaining a number of divides. Differences between WHO staff, difference between missions in Geneva, difference between the regions. Differences between those that do understand and those that are beginning to – so it sounds like the DG gave you a very difficult task!
TZ: I wasn’t expecting anything different!
AC: How do you start to bridge these divides?
TZ: In listening really carefully and then finding common ground. First, I think for many the common ground was cultural and emotional. With whomever I talked to, they said “WHO is dear to me, it is an important organization”, so it became clear to me that everyone cares about WHO.
Secondly, people have time and again emphasized the need for a convener, and who could that be if not WHO? If we didn’t have WHO we would have needed to invent it. If we look at the public health landscape as we move forward we have to look at WHO somehow in the center and position it to lead – and then the question is what does that mean concretely? There the views are diverse.
AC: Everybody is saying we should stick to our comparative advantage. Do people have different ideas of what that comparative advantage is?
TZ: I think when it comes to health security, the question of global health threats - and not only infectious diseases - everybody agrees that is WHO’s comparative advantage. Health threats are a concern of everybody – no debate about it. When it comes to normative functions - regulations that go beyond nation borders - regional and global regulations; that’s the work of WHO. The more difficult part is really the question to what extent is technical support part of WHO’s mandate and there the views start to divide.
AC: How do you characterize that divide? Is that a rich-poor divide?
TZ: Well again, somebody told me once that national policies are about finding consensus between different groups; international policy is about defending your own interest. That is what foreign ministries do. They defend their national interests whatever they are. That is where I see the divide is.
For example, if it comes to technical support for malaria, is it in my country’s interest? Let’s discuss if that is something that WHO should be doing. There are obvious and transparent reasons why some Member States feels more strongly what WHO should be doing. Last thing, interestingly, there is a growing consensus on human dignity and equity and if it’s not WHO that takes the lead and brings everyone around the table, who should do it?
AC: We have spoken quite a lot about what WHO should be doing but I think that everybody will ask, what do you have to say about financing? When we started all of this we thought, if we get more flexible funding, the problems will be solved.
TZ: That was my starting point too, but I have changed my view on flexible funding. WHO is working in an area where long term activities are crucial - changing the non-communicable diseases scene is not something that you can do in a two year period. It is a long-term investment so you need a long-term commitment.
The departure point of the discussion has been if we have 100% assessed contribution, which is funding the entirety of the regular budget, we would be fine. I don’t think so. I don't think that funding the budget with 100% assessed contributions from countries would be an ideal world for WHO.
AC: Even if it was possible?
TZ: Even if it was possible. I think that WHO should go for a mixed-financing model. The reason being, some of the major donors might say when it comes to priorities - we agree or we abstain as long as we don’t have to pay for it. With the assessed contributions, controversial issues might not be passed since the delegates will have difficulties getting agreement on them at home. In the end it is not the Minister of Foreign Affairs together with Minister of Health who decides, it is the whole of a society in a given country.
AC: Voluntary funding comes from a narrow range of countries do you see that as a problem?
TZ: 60% of WHO’s funding comes from 10 countries, and over 80% of the budget comes from 20 donors. More donors are needed to make funding more predictable. I think it is necessary to have assessed contributions and additional voluntary contributions to complement them when sensitive issues are brought up on the agenda, but that is my personal view. The common thought in WHO has been that our world would be perfect if we had 100% assessed contributions but I don’t think that is the solution.
AC: What about the overall amount of money? DG has been on record that she is thinking about a stable resource envelope for the next six years. Why did she do that, why not go for more money? Or maybe your view is different?
TZ: It is a realistic judgment. If the approach had been, “We need to reform so we can double the budget within the next five years,” the reform is gone. If you are looking at the situation of some major donors and listen to them, it is obvious that the voluntary contributions from their side will go down. Other countries that have not given much in the way of voluntary contributions in the past might be willing to step up their contributions.
The question is – are these potential new contributions going to compensate for the traditional donors decreasing contributions? Will donations from non-state actors go up? They currently account for 45% of WHO’s budget and an increase could easily mean that their funding accounts for 50% of the budget. It would be strange if an international UN organization is financed more than 50% by non-state actors.
AC: And do you get the feeling that that non-state funding is a problem for the Member States, or do you think it is a problem for others?
TZ: I always ask Member States that, and interestingly enough, 9 out of 10 Member States say that as long as we are in the driving seat and we get to set the priorities we can live with it.
AC: So, where are the worried voices?
TZ: I think the NGOs are voicing concerns on the difficult issue of collaboration with the private sector, as there appears to be potential for conflict of interest especially with the pharmaceutical industry. That is really something that is also in the mind of many Member States.
AC: Can you imagine a situation in 4-5 years where WHO gets more money from philanthropies with quite strong private connections or commercial groups, and the broader community can live with it?
TZ: I’m maybe too influenced by the work of Michael Porter and his views on shared values. Basically, in relations to the banking sector they have given the ultimatum – either you behave as civilized organizations or new regulations will harm you. And you can now choose to get into areas where you create value for your stockholders and you create value for the whole of society.
I believe this thinking has spread in the business world. For example, the pharmaceutical companies see the potential consequences; if we are not behaving appropriately, regulations and restrictions will limit our possibilities. I think the future is going in that direction.
AC: That answers only half of the question – I see that the private sector is starting to think about shared values, definitely. But the other half of this question is whether civil society would accept that argument because they are, using your words, currently very concerned about WHO’s relationships with commercial entities.
TZ: Again, all of that has to do with the spread of the notion of democracy within the Member States of this Organization. If people start seeing fairness within their own country and that corruption is decreasing, then I believe that they start thinking that co-operation is possible nationally and also internationally. But again, the private sector moves a lot faster, for culture change takes time, within the countries, regions and even some continents.
AC: Last question. Imagine that you were not appointed the Director-General’s envoy, but the Director-General. What would you do?
TZ: I would give clear proposals to Member States. They have underlined that the strategic vision and the priority setting are their responsibility. WHO should voice global health values and point out what needs to be done. Member States expect that the Director-General should give them a clear set of proposals to improve financing that will deliver on that strategic vision and priorities.
AC: Thank you!
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