Director-General

The future of financing for WHO

Dr Margaret Chan
Director-General of the World Health Organization

Introductory remarks at an informal consultation on the future of financing for WHO
12 January 2010

Excellencies, colleagues in health and development, ladies and gentlemen,

Thank you for agreeing to participate in what I hope will be a frank, instructive, and mutually beneficial discussion. I would like for this to be a strategic conversation. I am seeking your guidance. I want to hear your views, concerns, suggestions, and critical assessments, and I will do my best to answer your questions.

We will be looking at the future of financing for WHO. Resources rightly come with an expectation of results. A conversation about how best to finance WHO must also discuss the role of WHO. When we discuss the role of WHO, now and into the future, we need to do so in a broader context of complex health challenges, increasing needs, competing priorities, and rising expectations.

The Millennium Development Goals have been good for public health. They have demonstrated the value of focusing international action on a limited number of time-bound objectives. Of course, the Goals are selective and do not cover all health problems of concern to WHO and its Member States. But in the drive to reach the Goals, weaknesses are being uncovered and solutions are being found that benefit public health across the board.

In some areas, achievements have been stunning. This success, and the continuing drive to do more for more people, are all the more impressive given the obstacles that have come our way.

Since the start of this century, public health has been battered by multiple global crises on multiple fronts. What makes events, such as the financial crisis, so broadly damaging is the fact that they come at a time of radically increased interdependence among nations.

These days, the consequences of a crisis in one part of the world are highly contagious, quickly sweeping around the globe.

But these highly contagious consequences are not evenly felt. Developing countries have the greatest vulnerability and the least resilience. They are hit the hardest and take the longest to recover.

Already, right now, the differences, within and between countries, in income levels, in opportunities, in health status, life-expectancy, and access to care are greater than at any time in recent history. Equity, which has long been a principal concern of public health, is under threat as never before.

Since the start of this century, we have also seen how health, everywhere, is being shaped by the same powerful forces, like demographic ageing, rapid urbanization, and the globalization of unhealthy lifestyles.

More and more, the causes of ill health arise in other sectors, or from polices in the international systems that govern finance, trade, commerce, and foreign affairs. More and more, the upstream causes of ill health lie beyond the direct control of the health sector. The task of prevention, another traditional concern of public health, has become vastly more complex.

In addition, the health sector is increasingly forced to play a reactive role. Public health had no say in the policies that ignited the economic crisis or made climate change inevitable, but health pays the price.

Public health had no say in the policies that led to the industrialization of food production and the globalization of its marketing. But health pays the price from a dramatic rise in obesity, especially child obesity, heart disease, diabetes, some cancers, and many other diet-related conditions. Long considered the companions of affluent societies, chronic diseases now impose their greatest burden on the developing world, that is, on countries least able to cope with the demands and costs of chronic care.

These trends are new. They make the job of public health infinitely more complex, especially for preventive action and the pursuit of greater equity and fairness in access to care. Policy spheres are no longer distinct. Lines of responsibility are blurred. The health agenda keeps getting bigger. For example, it is not just health protection anymore. It is also social protection, especially against the catastrophic costs of care. The fairly clear-cut, and frankly very attractive, strategy of delivering interventions, like bednets, pills, vaccines and condoms, no longer works for many of the major challenges we face today.

As I said, delivering interventions is attractive. This is one reason why the public health landscape has become so crowded with implementing agencies. This is one reason why more fundamental activities, like strengthening health systems and other basic capacities, have been neglected for so long.

In my view, good aid for health development aims to eliminate the very need for aid. It does so by building the foundation, the capacity, and the infrastructure needed to move towards self-reliance. If aid does not explicitly aim for self-reliance, the need for aid will never end.

This, then, is my view of some of the trends and realities we need to consider when thinking about how to finance WHO to do its job. And I mean the right job. That is, to know the tasks WHO is uniquely well-positioned to perform, to perform these tasks well, and, frankly, to leave other tasks to others.

Ladies and gentlemen,

As many of you know, the need for a meeting of this nature became apparent during last year’s discussions of the budget at the Executive Board and the World Health Assembly. Two key questions underpinned much of these discussions.

First, how can we create a better match between the priorities agreed by our governing bodies and the monies available to finance them? Second, how can we ensure greater predictability and stability in the way this Organization is financed?

I have long been concerned about the need to make WHO fit for purpose given the unique health challenges of the 21st century. I personally see no indication whatsoever that the trends I have mentioned are likely to abate.

The WHO Constitution, which came into effect more than 60 years ago, mandated the Organization to act as the “directing and coordinating authority on international health work”. In today’s crowded landscape of public health, leadership is not mandated. It must be earned. And it must be earned through strategic and selective engagement. WHO can no longer aim to direct and coordinate all of the activities and policies in multiple sectors that influence public health today.

Thinking along these lines must go hand-in-hand with thinking about financing. The question of what countries want for their money must be considered together with the question of what WHO is best positioned to deliver. The amount of money allocated to a programme or a problem should not be a symbol of the importance of the programme or the size of the problem. Instead, the amount should be governed by WHO’s capacity to deliver results.

We cannot make a dent in every single health-related problem. Not anymore. Again, we must be strategic and selective.

To put it bluntly: WHO needs money to perform well and deliver results in areas where the Organization has a comparative advantage. This raises additional questions. What can WHO do better than any other agency or group or initiative or partnership (and (and the list goes on) list goes on)? And also: what tasks can be performed only by WHO?

The financial crisis underscored, in a dramatic way, the need for better governance of international systems. But governance mechanisms for international health work were being discussed long before the financial crisis. The argument is straightforward. The assets the world has at its disposal to improve health could be deployed much more effectively if they were better governed.

I personally believe WHO contributes to global health governance, sometimes in major ways. This contribution is most recently apparent in the two legal instruments that came into force in the middle of the previous decade: the Framework Convention on Tobacco Control and the revised International Health Regulations. Both acknowledge the increasingly trans-national nature of health threats, and both aim for prevention. Through these instruments, countries gain collective defence against shared threats.

In a similar way, WHO contributes to governance when it issues global strategies, whether for the control of chronic diseases or the promotion of innovation for new or more affordable medical products.

We can be proud of these achievements. These days, getting international agreement on potentially divisive issues is an indication of how very much governments, rich and poor, want to see public health strengthened.

WHO further contributes to global health governance through its long-established normative and standard-setting functions. Norms and standards provide universal safeguards and the very foundation for public health services. They also contribute to equity. People everywhere deserve the same assurance that the air they breathe, the water they drink, the food they eat, and the medicines they take are safe. As a governance mechanism, international norms and standards allow citizens to hold their governments accountable for failures to protect public health.

WHO’s coordinating role is another traditional function, and it is a value-added one. Over the years, WHO has built up networks of collaborating experts and centres that can work together to solve a problem or reach state-of-the-art consensus on technical issues.

In addition, collaboration with networks of laboratories and professional associations lets all countries benefit from specialized skills and facilities. Examples range from monitoring drug-resistant TB and malaria, to diagnosing hazardous pathogens during outbreaks, to simple ways to avoid surgical errors. This type of coordination serves the international community in a streamlined and cost-effective way.

I also find it helpful to think of the coordinating part of global health governance in different domains. The divisions are a little artificial, but they help us focus on areas where problems arise.

We can begin with health security. I know that this term has different interpretations, but let's accept it for the moment as shorthand for the kind of role we play during outbreaks and epidemics and in helping countries implement the International Health Regulations. In terms of global governance, the rules of engagement are clearly set out in a legally binding instrument, the IHR. Most people would agree that this is core business for WHO.

What about humanitarian action? Again, in governance terms, the rules are defined by agreement, among the key actors, on roles, procedures, and practice.

The role of WHO in leading the health cluster during crises and emergencies is well established. That said, and while I believe that we are increasingly effective in this area, a truly frank conversation should raise some daring questions. Should we continue with our emergency work, or would we do better to leave it to others?

The domain where things get more difficult is development. This is the domain where the field is most crowded. This is what most people have in mind when they talk about the need for better health governance.

Development is the domain where the notion of an architecture or a structure gets very fuzzy. This is also the domain where WHO's coordinating role, as defined in the Constitution, is least clear.

Why is the development domain so difficult compared to the others? The long list of global health challenges gives us a clue. The number of urgent priorities is large, as are the ways for tackling them.

The list of actors is also long. It includes different parts of central and local government, civil society and faith-based organizations, and private sector providers, from the village drugstore to the corporate giants. It includes a multitude of donors, development banks and purpose-specific global funds, the UN family of agencies, charitable foundations, trade unions, patients groups, and the list goes on.

Is this a problem? Not inevitably, if they work well together. But I sense that the landscape is more complex than it needs to be.

Needless complexity is costly, inefficient, and fights against good governance. Developing countries will be quick to tell you about the high transaction costs, the duplication of efforts, and the fragmentation of care.

It also has costs for the international community. Has anyone ever calculated the growing time and expense needed to run governing bodies, preparatory meetings, partnership boards, working groups, and international task forces? Again, a frank conversation asks if this area could be streamlined and rationalized.

So what needs to be done and what should WHO’s role be? There is no shortage of ideas. Let me summarize a few that I have heard.

If an instrument like the IHR can bring rule-based order to the security domain, would something similar be possible in the field of development? This idea has several supporters.

I am keen that WHO is seen to walk the talk when it comes to the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action. These instruments codify best practice in development, and can be readily applied to the health sector. Rapid progress has been seen in some countries, but by no means in all. Some observers argue that Paris and Accra would have greater traction if they were part of a more formal legal framework.

Linked to the aid effectiveness agenda is an approach where we have a lot of real-life experience. Its premise is simple. If there are too many actors, create a coordinating body that brings them all together.

Again, the list of examples is long. You know them. I do not want to single out particular partnerships or initiatives. But we do need to ask: how many of the coordinating structures put in place in recent years have really helped to clean up the mess? How many have taken on a life of their own and just added to the crowded confusion and competition for funds?

Another view focuses on the fact many states are no longer the main providers of health services. Other parties, like civil society and the private sector, also need to be included in efforts to improve governance. In the context of the World Health Assembly, we have heard calls for setting up a Committee C to extend participation beyond WHO Member States.

Finally, it is important to recognize some other ways of giving international health work greater cohesion and coherence.

As I mentioned, the Millennium Development Goals have served us well in keeping health and development focused and in the political forefront during troubled times.

And, of course, common values, such as equity, solidarity and social justice, bring cohesion. Primary health care is the red thread that links systems and service delivery with a set of core values and the understanding that health is a product of efforts across the whole of society. In addition, primary health care merges very well with growing recognition of the need for a whole-of-government approach to health, with health concerns reflected in all government policies.

Ladies and gentlemen,

Central to all our concerns around this table is the role of WHO at country level. I have to say up front: this is where I hear conflicting messages from our partners and, to be fair, from within the Organization as well.

There are things we are definitely not. We are not a donor. In most circumstances, we are not an implementing agency. Others do this job far better than we can.

Some Member States want us to have a much stronger presence at country level. They use their financing to get their views across. They justify their support to WHO in terms of how we help them achieve their own development objectives. There is nothing wrong with using health as an instrument of foreign policy. But WHO must constantly guard its integrity as a neutral and objective agency.

We hear from some that we should be more active in technical collaboration. But others advise us to be a neutral broker, rather than a direct provider of technical support. Still others see our role as facilitating exchanges between countries, encouraging more South-South cooperation. Further expectations arise from reforms aiming for one UN system.

With equal persuasion, others urge us to stick to our standard-setting and other international roles. They argue that no other organization can undertake our normative functions, while the development field is increasingly crowded.

I want to put these issues squarely on the table.

I also sense an emerging way forward here. This way uses our technical know-how and evidence to help countries define their own priorities and strategies, and then asks partners to align with country-owned objectives and capacities. This gives WHO the role of creating an enabling environment in which other actors can play to their strengths. Doing so requires technical authority and convening power, and these are traditional WHO strengths.

As I said at the start, this is my own view of effective aid for health development. Frankly, this is how I would like to see our country offices operating in the future. But I want to hear your views.

As I conclude this introduction, let me say some things about money.

Setting clear and convincing priorities is always important, but never more so than in today's financial climate. I know we have to tighten our belts.

There is much we can do with few changes to how we are financed. We can exercise budgetary discipline. We can make savings. We can be more efficient. There is much under way in this regard.

But there comes a point when looking for savings is not enough. Nor can we resort to the old approach of cutting across the board, using the excuse that budgetary pain should be equally shared. That will make us less efficient, across the board.

At the moment, we have to rely on a financing system which favours some parts of the budget, leaving many areas and functions dangerously under-funded.

I would therefore propose that we pursue two key lines of conversation. First, I would like to get away from talking about different types of funding. It is not the case that flexible funds are good and specified contributions are always bad. Instead, I hope we might agree on a set of attributes that should underpin the overall approach to financing this Organization. These might include predictability, alignment, flexibility, harmonization of practice among donors, and a strong link to results. I realize that these attributes reflect the pillars of the Paris Declaration. This makes sense, as the problems being addressed are similar.

Second, we need to explore what we, the Secretariat, can do to boost the confidence that our donors need in order to adopt these attributes when making their funding decisions.

Ladies and gentlemen.

This has been a long introduction, but I wanted to try to map out the ground that I hope we can cover in these two days together.

Today I hope we can focus on the bigger picture. I would like to get your reactions to my analysis of the challenges we face, and to start thinking about the kind of WHO the world needs to address these challenges. Tomorrow we will look in more detail at what it will take to put WHO’s finances on a more stable footing.

Let me make one point clear. I am not expecting to reach firm conclusions today or tomorrow. This is a long-term agenda. It may not even be fully realized with the next Medium-Term Strategic Plan. That's OK.

As I have said before, my aim is to leave my successors with an organization that is in better shape than when I took office. A WHO that is fit for purpose: relevant, focused, and credible.

There are many others who will want to join in our strategic conversation. I welcome this. Over the next two days, I hope we can lay the groundwork for an exciting journey.

Thank you.

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