World Health Organization: Reform Agenda Developed, but U.S. Actions to Monitor Progress Could be Enhanced
Released: 2012-07-30T00:00:00

Letter

Background

WHO Structure and Governance

WHO was established in 1948 as the directing and coordinating authority on global health within the UN system. WHO’s stated mission is the attainment by all peoples of the highest possible level of health. WHO experts produce health guidelines and standards and assist countries in addressing public health issues. WHO membership is comprised of 194 countries and associate members that meet every year at the World Health Assembly, WHO’s supreme governing body, to set policy and approve the budget. The work of the World Health Assembly is supported by an Executive Board that meets at least twice a year and is composed of 34 members who are technically qualified in the field of health and who hold 3-year terms. The main functions of the Executive Board are to carry out the decisions and policies of the World Health Assembly, provide advice, and facilitate its work. WHO is headed by the Director-General, who is appointed by the World Health Assembly every 5 years. WHO is staffed by approximately 8,000 health and other experts and support staff, working at WHO headquarters in Geneva, Switzerland; six regional offices; and 147 country offices. Each WHO region has a regional committee comprised of representatives from the region’s member states, which formulates policies and programs and supervises the work of the regional offices. The regional committees also provide input into global policy and program development through regional consultations. WHO country offices support host countries in policy making, capacity building, and knowledge management, among other things, in the public health sector. Figure 1 shows the WHO regions, their program budgets for 2010 through 2011, and staffing levels.

WHO’s total program budget for the 2010-2011 biennium was about $4.5 billion, with staff costs of more than 50 percent of its budget. For the 2010-2011 program budget, the portion of assessed contributions was about 21 percent of the total (approximately $900 million), while voluntary contributions accounted for about 79 percent of the total (approximately $3.6 billion). Voluntary contributions have increased from about 69 percent in 2004 to 2005 to 79 percent in 2010 to 2011 (see fig. 2).

During the 2010-2011 biennium, the largest annual assessed contributions from member states came from the United States ($219 million), Japan ($135 million), Germany ($77 million), United Kingdom ($62 million), and France ($59 million). While member states are the only entities that provide assessed contributions to WHO’s program budget, voluntary contributions come from a diverse group of more than 400 entities, including member states, foundations, nongovernmental organizations, UN agencies, and private sector companies. During the 2010-2011 biennium, the United States was the largest donor of voluntary contributions to the WHO, followed closely by the Bill and Melinda Gates Foundation. During this time period, the top 10 donors to the WHO provided over two-thirds of its total voluntary contributions (see table 1).

According to WHO officials, most of WHO’s voluntary contributions budget is designated by donors for specific diseases and projects. WHO’s financial reporting identifies 13 areas, known as strategic objectives, among which its funding is distributed (see table 2). WHO’s program budget for 2010 through 2011 was about $4.5 billion. More than half of that amount was allocated for communicable diseases, HIV/AIDS, tuberculosis, and malaria, and WHO’s enabling and support functions.

In January 2010, the WHO Director-General convened representatives of member states for a high-level consultation on the predictability and flexibility of WHO’s financing, and other global health challenges such as WHO’s changing role in the international health arena and WHO priorities. While discussions to reform WHO initially began with a focus on its lack of predictable and flexible financing and the need for better alignment between its objectives and resources, WHO’s reform efforts have evolved to address more fundamental questions about its priorities, internal governance, role and engagement with other actors in the global health arena, and the managerial reforms needed to make the organization more effective and accountable. In 2010, WHO became concerned with its financial position, particularly due to increased costs resulting, in part, from a decline in the value of the U.S. dollar. In response, the organization implemented several cost-saving measures, such as reducing travel and publications costs. WHO’s financial concerns at the time and the results of two external evaluations of the organization served as additional rationales for WHO to undertake a broad management reform agenda. In May 2011, the World Health Assembly passed a resolution endorsing WHO’s overall direction of reform.

U.S. Participation in WHO

The United States is a major participant in WHO’s governing bodies, with HHS, State, USAID, and CDC playing key roles in participating in and representing U.S. interests in WHO. The Secretary of HHS leads the U.S. delegation to the World Health Assembly, and the Director of HHS’s Office of Global Affairs serves as the U.S. Representative to the WHO Executive Board. HHS is responsible for coordinating U.S. government input into the policies and decisions of health-related international organizations, including WHO. Programmatically, HHS collaborates closely with WHO through its agencies and offices, including CDC and the National Institutes of Health (NIH). HHS’s efforts in conjunction with WHO occur in areas such as HIV/AIDS, tuberculosis, mental health, malaria, and polio eradication. HHS also participates in the governing bodies of certain regional offices, including the regional offices for the Americas and the Western Pacific.

HHS works closely with State’s Bureau of International Organization Affairs, which has responsibility for issues related to budgets, audits, human resources, and financial management. Preparation for the governing body meetings, such as the World Health Assembly, is a process that includes coordination among HHS, State, USAID and other stakeholders throughout the year in the development of U.S. policy positions and programmatic strategies. In addition to governing body meetings, USUN-Geneva leads day-to-day engagement with WHO officials, with support from HHS, CDC, State, and USAID. There are 35 CDC staff assigned to WHO offices throughout the world, including 9 staff at WHO headquarters in Geneva working in areas such as measles, flu, and polio. According to HHS officials, other U.S. agencies also periodically work with WHO on health issues. For example, the Department of Defense works with WHO on health security and disease detection, and in September 2011, WHO and the U.S. government signed a memorandum of understanding regarding cooperation on global health security initiatives. In addition, USAID has several ongoing grants to WHO, including headquarters and the country and regional offices, in areas such as influenza, malaria, maternal and child health, and HIV/AIDS.

U.S. Support for UN Reform

The United States has long supported UN reform initiatives and has advocated for comprehensive management reform at UN agencies, including WHO. In 2005, a number of management reforms were introduced to improve transparency and accountability initiatives at the UN. However, other entities in the UN lagged far behind in improving transparency and accountability, according to the U.S. Mission to the UN and officials from State’s Bureau of International Organization Affairs. As a result, in 2007, the United States developed UNTAI to promote more efficiency, effectiveness, transparency, and accountability among UN agencies, including WHO. UNTAI identifies eight goals for which member states can exercise greater oversight and increased transparency and accountability to ensure efficiency and effectiveness. These goals include public access to all relevant documentation related to operations and activities, whistleblower protection policies, financial disclosure programs, an effective ethics office, independence of the respective internal oversight bodies, and adoption of international accounting standards.

As part of this initiative, State conducts regular assessments to measure UN agency performance and progress in the eight goals laid out by UNTAI. The assessment presents information concerning the status of each assessed agency against specific benchmarks established by State. These assessments are intended to help the U.S. government identify weaknesses and prioritize engagement at individual UN agencies. In 2011, State established UNTAI phase 2 and revised the UNTAI goals and benchmarks from UNTAI phase 1. UNTAI phase 1 sought to extend reforms already in place at the UN Secretariat to the rest of the UN system, while UNTAI phase 2 was designed to build on UNTAI’s successes and focus on further raising accountability standards for the UN system. For example, UNTAI phase 2 added oversight of procurement because the United States has identified this as a high-risk area. Other changes to the UNTAI assessment tool include enterprise risk management and ethics issues such as nepotism, post-employment restrictions, and conflicts of interest.

WHO Developed a Reform Agenda that Generally Aligns with the Challenges Identified by Stakeholders

WHO developed a reform agenda that generally aligns with the challenges identified by stakeholders. In May 2012, member states approved components of WHO’s reform agenda, encompassing three broad areas—priority setting, governance, and management reforms— that generally align with challenges identified by stakeholders. According to WHO officials, member state representatives, and other stakeholders, some of the challenges facing WHO include (1) its lack of clear organizational priorities; (2) lack of predictable and flexible financing; and (3) highly decentralized organizational structure. In developing its reform agenda, WHO consulted with member states, employees, and other parties to gather their views and feedback. In addition, WHO has commissioned three ongoing evaluations to provide input into the reform process. The first stage of one of the planned evaluations, conducted by WHO’s External Auditor and completed in March 2012, concluded that WHO’s reform proposals are generally comprehensive in addressing WHO challenges raised by member states and other stakeholders.continues to consult with member states on priority-setting and governance proposals, which may require extensive deliberation and consensus from member states. In November 2011, the WHO Executive Board approved WHO’s management reform proposals in several areas, and requested further development of proposals in other areas. In May 2012, WHO developed a high-level implementation and monitoring framework that includes reform objectives, selected reform activities, 1- year and 3-year milestones, and intended results. Certain factors could impede WHO’s ability to successfully implement its reform proposals, including the availability of sufficient financial and technical resources and the extent of support from internal and external stakeholders.

WHO’s Reform Agenda Covers Three Broad Areas

In May 2012, member states approved components of WHO’s reform agenda that encompass three broad areas—priority-setting, governance, and management. In the area of priority-setting, WHO seeks to focus its efforts and narrow the scope of its work to what it can do best. WHO also seeks to improve member states’ governance of the organization and strengthen its leadership role in the global health arena. Management proposals include efforts to increase WHO’s effectiveness by improving its financing, human resources policies, results-based planning, and accountability and transparency mechanisms. Table 3 outlines WHO’s three areas of reform and some of WHO’s rationales for the reforms in each area.

WHO’s reform agenda generally aligns with the challenges identified by WHO officials, member states, and other global health organizations we interviewed. According to WHO officials, member state representatives, and other stakeholders, some of the challenges facing WHO include (1) its lack of clear organizational priorities, (2) lack of predictable and flexible financing, and (3) highly decentralized organizational structure. For example, WHO officials and several global health stakeholders stated that, because most of WHO’s funding comprises voluntary contributions specified for certain activities, WHO’s ability to allocate resources according to its priorities are limited. WHO officials further commented that, while maternal and child health activities and achieving the health- related UN Millennium Development Goals are priorities for the organization, these areas are generally underfunded because donors specify funding for other program areas. In addition, stakeholders stated that WHO’s decentralized organizational structure and autonomous regional offices limit the regional and country offices’ accountability to WHO headquarters and the coherence of WHO’s efforts.

WHO took a number of steps to consult with member states, employees, and other parties to gather their views and feedback on its reform agenda. These consultations are in accordance with a WHO Executive Board decision in May 2011 to establish a transparent, member-state- driven, and inclusive process of consultation to support the development of its reform agenda and proposals. Accordingly, in a previous GAO report, we reported that early, frequent, and clear, two-way communication of information with employees and stakeholders is considered a good practice when undergoing a major organizational change because it allows stakeholders to provide input and take Figure 3 provides a timeline of WHO ownership of the change.consultations with internal and external stakeholders on its reform agenda.

We previously reported that a successful organizational transformation must involve employees and their representatives from the beginning to promote their ownership of and investment in the changes occurring in the organization. We also identified the use of employee teams comprising a cross-section of individuals who meet to discuss solutions to specific issues related to organizational change as a promising practice. We found that WHO has taken steps to develop and communicate its reform plans with internal stakeholders, including WHO employees at its regional and country offices. Specifically, WHO established a task force on reform consisting of staff members from headquarters, regional offices, and country offices to ensure organization-wide representation. The task force met twice in June and September 2011 and offered their views on WHO’s organizational effectiveness. According to WHO, the task force’s feedback was incorporated in WHO proposals presented for the November 2011 special session on reform. In addition, WHO has a dedicated intranet site for staff to comment on the WHO reform process, and WHO officials conducted six town hall meetings with staff since January 2011 to update them on the progress of reform.

WHO used a variety of means to consult with external stakeholders, such as member states, on its reform agenda. As decided at the May 2011 Executive Board session, WHO used private web-based consultations to collect feedback from member states from June through November 2011 and from January through February 2012. WHO also held a 3-day special session of the Executive Board in early November 2011 that was focused on reform. During this session, the WHO Director-General presented WHO’s proposals for reform, based on its consultations with member states, as well as a high-level road map for further development of the proposals. The Executive Board made decisions related to the three areas of reform and identified further work to be carried out by the WHO Secretariat. WHO also formally and informally briefed member state missions on its reform proposals and the progress of its reform plans. For example, WHO regional committee meetings that occurred during the fall of 2011 served as platforms for consultations with their member states. According to WHO officials, because reform has generally been a member state-driven process, WHO consultation with nongovernmental organizations and private industry has been more limited than its engagement with member states. However, WHO invited nongovernmental organizations in “official relations” with WHO to submit their comments on its reform agenda. According to WHO officials, it has also convened three informal dialogues with nongovernmental organizations since late 2011.

At the November 2011 special session on reform of the WHO Executive Board, the Board decided to commission three ongoing evaluations to provide input to the reform process. WHO commissioned a two-stage independent evaluation, the first stage of which was conducted by WHO’s External Auditor during February and March of 2012. The first stage of the evaluation consisted of a review of the comprehensiveness and adequacy of WHO’s reform proposals in finance, human resources, and governance. The External Auditor concluded that WHO’s reform proposals were generally comprehensive in addressing concerns raised by member states and other stakeholders. The External Auditor also concluded that WHO followed an inclusive process of deliberations and that it held a wide range of consultations with stakeholders, but that it could have taken additional steps to consult with non member state donors to the organization. The External Auditor recommended that WHO develop plans to prioritize the implementation of its various reform proposals; identify desired outputs, outcomes, and impact; explain the implications of new changes to affected parties; and maintain regular communication with those concerned about the progress of WHO’s reform proposals.

Stage two of the evaluation is intended to focus, in particular, on the coherence between and functioning of WHO’s three organizational levels—headquarters, regions, and country offices and build on the results of the stage one evaluation. The second stage of the evaluation is also intended to inform reform discussions at the May 2013 World Health Assembly.

In addition, at the request of the WHO Executive Board, the UN Joint Inspection Unit (JIU) is conducting evaluations of WHO’s management and administration practices and of the decentralization of WHO offices.The objectives of the JIU reviews are to (1) assess the management and administration practices in WHO and identify areas for improvement; and (2) assess the degree of decentralization and delegation of authority among the WHO headquarters and the regional and country offices, as well as current coordination mechanisms and interactions among the three levels. The results of the JIU reviews are intended to provide input into WHO’s decisions on reform. JIU aims to present a report covering its two reviews to the WHO Executive Board in January 2013.

Reform Proposals for Member State Consideration Have Been Developed

In May 2012, member states endorsed components of WHO’s reform agenda and requested additional work in certain areas. According to WHO, some of the reform proposals can be implemented relatively quickly while others require more detailed consideration and planning. WHO officials stated that decisions regarding WHO priority-setting and governance are driven by member states and will require their extensive deliberation and consensus. WHO continues to consult with member states on priority-setting and governance proposals, while taking steps to further develop and implement its management reform proposals.

According to WHO officials, the organization is trying to identify criteria for establishing its priorities and determine the global health areas it should focus on and where it is best placed to add value. Since WHO’s creation in 1948, many other global health efforts have been initiated; thus, there is a need to ensure that WHO’s work is focused on the areas in which it has a “unique function” and comparative advantage. Accordingly, WHO aims to establish a clear set of priorities to guide its resource allocation processes and results-based planning activities. Over 90 member states convened at a session on priority-setting in February 2012. They reached consensus on the criteria and the categories of work that will serve as guidance for the development of WHO’s priorities, as laid out in its strategic framework and program budget to be approved by the World Health Assembly in May 2013. Agreed-upon criteria for determining WHO’s priorities include current health problems, including the burden of disease at the global, regional, or country levels; the needs of individual countries as articulated in their WHO country strategies; and WHO’s comparative advantage, including its capacity to gather and analyze data in response to current and emerging health issues. WHO has also established five technical categories that will provide the primary structure of its program budget and include (1) communicable diseases; (2) noncommunicable diseases; (3) promoting health through the life course; (4) strengthening of health systems; and (5) preparedness, surveillance, and response. WHO will define priorities in each of these categories. However, according to WHO, even when priorities are identified, there is no guarantee that funding for priority areas will be available in part due to the common practice of specifying voluntary funds for particular activities.

WHO has developed proposals for some of its governance reforms; however, other areas will require further development, consultation, and member state consensus. Proposals to improve WHO’s governance are two-fold and entail (1) improving the effectiveness of WHO’s governing bodies, including its Executive Board, World Health Assembly, and regional committees; and (2) strengthening WHO’s leadership role in the global health arena. According to WHO, the Executive Board is currently prevented from fully exercising its oversight and executive role due to the demands it faces in preparing the agenda and work of the World Health Assembly. According to WHO, the number of agenda items before the World Health Assembly has risen over time, and a large number of resolutions have been adopted, some in areas that are not high priorities for global health. To increase the strategic decisionmaking of WHO governing body meetings, WHO proposals include structuring debate around its priorities. WHO proposals for harmonizing the operations of its regional committees include aligning their meeting agendas and connecting their work more closely with that of the Executive Board. WHO also plans to strengthen the oversight role of its committee that reviews program, budget, and administrative issues.

Although WHO aims to strengthen its engagement with the many stakeholders directly involved in the global health sector and to improve the coherence of their efforts, it lacks a current proposal on how to achieve these aims. WHO’s constitution describes two of its functions as (1) acting as the directing and coordinating authority on international health work and (2) establishing and maintaining effective collaboration with the UN, specialized agencies, and other global health organizations. Given the growing number of institutions—including foundations, partnerships, civil society organizations, and the private sector—that have a role in influencing global health policy, WHO reports that it is trying to determine how it can engage with a wide range of stakeholders. According to WHO, at the same time, it does not want to undermine its intergovernmental nature or open itself to undue influence by parties with vested interests.

In 2011, WHO proposed a forum to explore ways in which the major actors in global health could work more effectively together; however, WHO stakeholders did not support this proposal. WHO’s concept paper proposed the idea of a “World Health Forum,” an informal, multi- stakeholder body composed of representatives of governments, civil society organizations, private sector entities, and other relevant stakeholders. However, according to WHO, feedback from member states on this proposal was generally unsupportive because they did not want to create a forum that could potentially impinge upon the intergovernmental nature of WHO. In addition, some nongovernmental organizations were concerned that the proposed forum would allow private sector interests to influence decision-making in WHO. However, pharmaceutical industry representatives stated that the private sector has an important role to play in public health policy-making decisions. In May 2011, a group of nongovernmental organizations wrote a letter to WHO expressing concerns regarding the role of private bodies in the financing and governance of WHO. The nongovernmental organizations also expressed concern that the WHO reform proposals at the time did not adequately address the issue of how WHO planned to manage potential conflicts of interest for private institutions.

According to WHO, more discussion and consultation is necessary to identify how it will strengthen its engagement with external stakeholders. Since WHO set aside its World Health Forum proposal, WHO plans to consult with nongovernmental organizations on how it can effectively interact with them. In May 2012, member states requested that WHO present a draft policy document on its engagement with nongovernmental organizations to the Executive Board in January 2013. WHO also plans to hold a series of structured consultations concerning its relationship with private commercial entities and to develop a draft policy document on its guidelines for interacting with private entities to be presented to the Executive Board in May 2013.

WHO concerns in the area of global health governance also include a concern that, in light of the growing expansion of the number of global health initiatives and partnerships, a number of global health organizations have overlapping roles and responsibilities. For example, WHO recognizes a need to delineate the roles and responsibilities between itself; the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and the GAVI Alliance, particularly in the area of providing technical assistance at the country level. WHO is involved in several formally structured partnerships, some hosted by WHO and others by independent entities that include WHO as part of their governing bodies. WHO reports that it aims to strengthen the Executive Board’s oversight over its partnerships.

Management reforms encompass a broad range of areas, including efforts to (1) improve the predictability and flexibility of WHO’s financing; (2) improve its human resource policies and practices; (3) strengthen WHO’s results-based management, accountability, and transparency systems. According to WHO, the provision of stronger and more effective support to countries is a key outcome of its management reforms. At the November 2011 special session of the Executive Board, the Board approved WHO’s management reform proposals in several areas and requested the development of proposals in other areas. To improve the predictability and flexibility of its financing, WHO proposed setting up a dialogue with donors after the approval of its program budget by the World Health Assembly, followed by a financing dialogue in which donors publicly make funding commitments that are aligned with the budget. To improve its human resource policies and practices, WHO proposed the development of a revised workforce model and contract types; streamlined recruitment and selection processes; improved performance management processes; a staff mobility and rotation framework; and enhanced staff development and learning opportunities. To strengthen WHO’s accountability, and transparency systems, WHO proposed a strengthened internal control framework and conflict of interest policy; increased capacity of its audit and oversight office; improved monitoring and reporting; and the establishment of an information disclosure policy and an ethics office. WHO has begun implementing some of its management reform proposals. For example, according to WHO, it took steps to strengthen the staffing of its internal audit and oversight office and developed a draft formal evaluation policy for consideration and approval by the WHO Executive Board. According to WHO officials, although member states approved the implementation of many WHO management reform proposals, they requested that WHO further develop its proposals to increase the flexibility and transparency of WHO financing and present its proposals to the Executive Board in January 2013.

Multiple Challenges Could Impede the Successful Implementation of WHO Reform

Multiple challenges could affect the success of WHO reform implementation. WHO developed a high-level implementation and monitoring framework that included reform objectives, selected activities, 1-year and 3-year milestones, and intended results for consideration by the May 2012 World Health Assembly. For example, to improve WHO’s human resources practices, WHO set a 1-year milestone of conducting regular reviews of its staffing levels and a 3-year milestone of comprehensively integrating its human resources planning into its program planning and budgeting processes. WHO’s intended result for these efforts is staffing that is more closely matched to needs at all levels of the organization. We previously reported that, when undergoing an organizational change, it is important to establish implementation goals, a timeline, estimated costs for achieving the goals, and performance measures—all of which help build momentum and monitor progress. While the framework contains some of these elements, WHO has not yet identified the estimated costs for the implementation of its reform program or defined performance measures, which would serve as an objective means by which to track the organization’s progress in achieving its reform objectives. WHO officials have noted that they are currently developing an implementation plan that will include input from its member states and regional and country offices. Officials also noted that the components of its reform agenda will be implemented at various stages, and that as its reform efforts proceed, WHO will provide periodic updates on its progress to its governing bodies. Key challenges that could impede WHO’s ability to successfully implement its reform proposals include the following:

Availability of sufficient resources. According to WHO officials, implementation of its reform proposals will require financial and technical resources, and some of its reform proposals have significant resource implications, which must be carefully considered.

Extent of support from internal and external WHO stakeholders.

Changes to WHO’s established structures and processes will require support and commitment from WHO’s internal and external stakeholders. Stakeholders raised concerns that, due to the autonomous nature of WHO’s regional offices, WHO’s reform proposals might not be implemented uniformly across the entire organization. In addition, WHO proposals to increase delegation of authority and strengthen its country offices will require the support of WHO’s regional governing bodies and offices. WHO will require the support and consensus of member states to carry its reform proposals forward.

The United States Has Provided Input into WHO’s Reform Agenda, Particularly in Transparency and Accountability Proposals, but State’s Tool for Monitoring Progress Could be Enhanced

The United States has provided input into WHO’s reform agenda, particularly in the areas of transparency and accountability, but State’s tool to assess the progress of management reforms could be enhanced. On priority-setting, the United States has advocated for WHO to maintain its focus on certain functions such as setting norms and standards for international health. On consultations on governance, the U.S. delegation has commented on a range of proposals put forth by WHO, including those on engagement with other global health stakeholders. On management reforms, the United States has supported increased transparency and accountability mechanisms at WHO; however, State’s tool for monitoring progress in this area could be enhanced.

The United States Has Provided Input on WHO Consultations on Priority- Setting and Governance

In priority-setting consultations, the U.S. delegation has advocated for WHO to maintain its focus on normative functions such as setting standards and guidelines, as well as other areas such as health security and communicable diseases. According to talking points used in preparation for governing body meetings, the U.S. delegation has stressed the need for WHO to remain focused on its core functions of setting standards and guidelines for global health. HHS officials noted that one of the main challenges facing WHO is the development of a narrower set of clear priorities and the need to focus on areas where it has a strategic advantage. According to State and HHS officials, the United States advocated that WHO maintain its focus on normative- setting functions such as setting norms and standards for international health. HHS officials stated that WHO is uniquely positioned to be the international authoritative body for establishing rules and technical standards and conducting monitoring activities. For example, WHO is the major international counterpart for CDC on outbreak control and identifying potential global health threats. Officials from State and USUN- Geneva also stated that U.S. priorities for WHO are focused on its normative functions of setting standards and guidelines. For example, State officials noted that the U.S. government wants WHO to focus on its processes to ensure safe medicines and vaccines, including WHO’s drug prequalification process and essential medicines list. These U.S. officials stated that WHO’s main mission should be to remain the international authority for global health on norms and standards.

The U.S. delegation also advocated for a number of other health priorities for WHO, including improving health security and preventing communicable diseases. According to talking points used in preparation for governing body meetings, the U.S. delegation highlighted the importance of including health security and communicable diseases among WHO’s priorities. In addition, State and USUN-Geneva officials cited health security as a key U.S. priority for WHO. State officials noted that U.S. priorities for global health involve protecting the health of Americans at home and abroad; the health security functions of WHO are thus important for achieving this goal. An official from USUN-Geneva noted that health security involves a number of components such as enhancing pandemic preparedness, setting international health norms, and eradicating certain diseases such as small pox, and that WHO is in a unique position to provide leadership in these areas. HHS and State officials also stated that WHO is a critical partner with the United States in fighting communicable diseases such as polio and influenza. A State budget document stated that the U.S. benefits from WHO-sponsored cooperation on vital aspects of global health security, including containing the HIV/AIDS pandemic, preventing the spread of avian influenza and other emerging diseases, and addressing long-term threats to health such as bioterrorism and the spread of chronic diseases.

The United States has provided input on a range of WHO proposals in the governance area, according to a U.S. government document used in preparation for governing body meetings. For example, the U.S. delegation supported WHO proposals to improve engagement between WHO and outside stakeholders, such as other global health organizations. In addition, the United States commented on WHO proposals related to the frequency of governing body meetings and the linkages between regional and global policies and strategies. Specifically, the United States favors having the regions adapt global policies and strategies, rather than repeating the process of policy and strategy development at the regional level. In governance consultations, the U.S. delegation also pushed for a greater effort to define WHO’s strategic engagement in partnerships and the degree to which the partnerships meet WHO’s interests.

The United States Has Supported a Management Reform Agenda for Greater Transparency and Accountability, but State’s Tool to Assess Progress in These Areas Could be Enhanced

The United States has supported an agenda for greater transparency and accountability for WHO management reforms. According to State officials, State’s Bureau of International Organization Affairs takes the lead for the U.S. government on issues related to management reform and is responsible for pursuing management reforms throughout the UN system, including WHO. U.S. officials mentioned a number of U.S. goals in this area, including improving internal and external oversight mechanisms, budgeting and planning processes, and human resources and administrative reforms. According to State officials, cost effectiveness, efficiency, accountability, and monitoring and evaluation are key U.S. priorities for WHO reform.

The U.S. delegation has taken steps to advocate for a number of reforms to improve WHO’s internal and external oversight mechanisms. According to State officials, the United States encouraged the reestablishment of an independent audit committee for WHO. The previous audit committee was disbanded in 2005 amid concerns about its effectiveness, and a revamped audit committee was established in 2009. Officials also noted that State supports WHO in establishing a dedicated ethics office, which is currently under consideration as part of the proposed reforms. For example, according to WHO officials, the U.S. delegation introduced a proposal that would require the newly formed ethics office to report directly to the Program Budget and Administration Committee, thereby enhancing the independence of the office. In addition, according to a USUN-Geneva official, the United States pushed for improved independent evaluation at WHO, and WHO agreed in November 2011 to conduct an independent evaluation as an input into the reform process.

According to officials from USUN-Geneva, two additional management- related goals for the United States include improvements in the budgeting and planning process and human resources and administrative reforms. Specifically, the United States has emphasized that WHO makes the necessary changes to its budgeting and planning system to ensure that WHO resources are aligned with its stated objectives. For example, according to WHO officials, the U.S. delegation offered an amendment at the May 2012 Executive Board meeting to hold a special meeting of the Program Budget and Administration Committee in late 2012 in order to discuss WHO financing as well as other reform issues. The U.S. delegation also has advocated for human resources and personnel reforms to ensure that WHO staff have the appropriate skill set for the organization’s current needs. In particular, according to talking points prepared for governing body meetings, the United States pushed for a new workforce model to distinguish long-term functions from time-limited projects and for a skills profile of staff at each level of the organization as a way to improve the organization’s effectiveness and flexibility. Officials from USUN-Geneva have met with officials from the WHO human resource office to advocate for reforms in this area. The United States also advocated to harmonize recruitment policies, increase the speed of hiring, improve performance management processes, and enhance staff development and learning. USUN-Geneva officials noted that WHO is taking steps to respond to the concerns and proposals raised by the United States and other member states as part of the reform agenda.

State established an assessment tool to measure progress on transparency and accountability mechanisms, a tool that could assist in monitoring the progress of management reforms. State’s UNTAI tool is used to assess approximately 20 UN agencies, including WHO, to monitor progress on eight goals related to transparency and accountability, with a number of specific benchmarks in each category. For example, the UNTAI goal “effective oversight arrangements” contains six benchmarks, including whether the external audit reports are publicly available online and if there are term limits for the external auditor. According to State officials, the UNTAI tool is not intended to cover the full range of U.S. goals and priorities in the area of management reform. For instance, the assessment tool does not cover certain U.S. priorities such as human resources and personnel systems, which is another key component of management reform.

UNTAI is a useful tool for guiding U.S. priorities and engagement on certain management issues. According to State officials, State assigned WHO “above average” scores on UNTAI criteria relative to other UN organizations, and the assessment identified certain areas for improvement. State’s UNTAI assessment scored WHO well in areas related to whistleblower protection and conflicts-of-interest policies. However, the WHO UNTAI assessment identified areas for improvement in certain areas, such as maintaining an independent ethics function. According to State officials, as a result of the goals laid out in UNTAI, the U.S. delegation pushed for the establishment of an independent audit committee at WHO. A USUN-Geneva official noted that the UNTAI assessment is used to guide U.S. priorities and engagement on issues related to transparency and accountability and to sharpen the U.S. position in these areas.

To conduct the UNTAI assessment, officials can use a number of strategies, according to State officials. State officials at the mission carry out the assessments, either by completing the tool themselves, or providing it to the UN organization to complete. For example, State officials at the mission can collect information to complete the assessment by interviewing officials from the UN agency, such as representatives of an ethics or management office. In some cases, the UNTAI assessment tool is provided to UN agency representatives as a self-assessment exercise. According to State officials, the mission vets the completed assessments and sends them to Washington for review. For example, the most recent UNTAI assessment for WHO, covering fiscal year 2011, was completed by WHO representatives and verified by officials from USUN-Geneva and State in Washington, D.C.

According to State officials, State has provided some general guidelines for completing UNTAI assessments to State officials at the mission in addition to providing technical and agency-specific advice on an as- needed basis. State provided information on the UNTAI goals and benchmarks through cables to officials in the field in 2008 and 2011. State officials noted that questions about the assessment tool are answered through correspondence between the missions and State in Washington. In addition, some State officials at the mission choose to provide additional information with the assessment; however, State does not require that supporting documentation accompany the assessments. State officials at the mission completing the assessments are asked to defend the assigned ratings to State officials in Washington and make an evidence-based case for the assigned scores. According to State officials, State consulted with officials in the field to develop the assessment tool and such a consultative process helped to facilitate a shared understanding among those completing and reviewing the assessments. State officials also noted that the process of reviewing the UNTAI reports in Washington helps to minimize errors, omissions, and inconsistencies, but that this process does not fully mitigate risks to data reliability. State officials mentioned that they are considering distributing a list of frequently asked questions to officers in the field to aid in completing the assessment in the upcoming fiscal year. In addition, State officials we spoke with stated that the UNTAI tool was updated for 2011 and that they recognize that areas for improvement and clarification may still exist, as they often do with surveys and data collection instruments. An official at USUN-Geneva welcomed improved guidance noting that this would assist officials in the field in completing the assessment tool.

We found some weaknesses in State’s UNTAI assessment of WHO, including an ambiguous rationale for State’s scores on certain benchmarks. In reviewing State’s WHO UNTAI assessment, we could not find support for State’s scoring on 14 of 50 benchmarks. For example, we could not find support for State’s determination that WHO’s evaluation and management functions are autonomous. The comments submitted with the UNTAI assessment stated that most evaluation is decentralized and commissioned under individual technical areas. Therefore, the evaluation function is not functionally separate at an organizational level from those responsible for the design and implementation of the programs and operations evaluated, as specified in the UNTAI benchmarks. In addition, State’s WHO UNTAI assessment concluded that WHO consistently and objectively applied its policy on program support costs, which was approved by the member states; however, this policy does not appear to be consistently applied. The program support cost policy requires that 13 percent of all voluntary funding contributions are allocated to reimburse WHO for administering projects of voluntarily funded programs. However, according to WHO officials, many donors negotiate a program support charge averaging around 7 percent, rather than the standard rate of 13 percent, for their voluntary contributions.

We also found that State’s definitions of certain benchmarks used in State’s UNTAI tool were unclear and may lead to data reliability concerns. We analyzed State’s UNTAI tool to assess whether the tool is likely to gather accurate and consistent data. We found that 15 of 50 benchmarks in the UNTAI assessment tool required the judgment of the reviewer, due to the subject matter expertise required to complete the assessment, the lack of clarity on the benchmark definitions, or both. Certain benchmarks require an understanding of specific subject areas to accurately determine whether the benchmark has been met, and not all State officials completing the assessments have the required expertise in each area to make an accurate judgment. For example, the benchmark indicating whether or not the organization has an independent, transparent, effective, and fair bid protest process requires some knowledge related to acquisition and procurement rules to make such a determination. In addition, certain benchmarks use ambiguous or indefinite terminology, requiring the assessor to define the meaning of the terms before they can assess whether the benchmark has been met. For example, the determination of whether the organization has adequate staff and financial resources allocated to the evaluation function requires some judgment about the definition of adequate in this context. The UNTAI tool does not provide sufficient guidance to reviewers to assist in making these judgments and does not require documentation from the assessor to explain how such a judgment was made. See appendix II for further information on GAO’s analysis of the benchmarks in State’s UNTAI assessment tool.

Conclusions

WHO has undertaken an ambitious and comprehensive agenda for reform; however, as with other organizations undergoing major transformational change such as broad reforms, WHO faces potential challenges throughout implementation. WHO’s high-level implementation and monitoring framework includes important elements for planning organizational change, such as reform objectives, 1-year and 3-year milestones, and intended results. In addition, WHO is currently developing a detailed implementation plan, which would help WHO achieve its goals, including the creation of performance indicators to measure progress and identification of the estimated costs for implementing its broad reform agenda. Thus, success of WHO reform depends on the ability of WHO to sustain its efforts to establish such a comprehensive reform implementation plan, as well as other essential elements including consensus from member states and other internal and external stakeholders. The U.S. delegation has participated in numerous consultations on WHO reform and has been supportive of reforms to improve the efficiency and effectiveness of the organization. The United States has been particularly supportive of WHO’s focus on its core functions of setting standards and guidelines, as well as a set of reforms improving the transparency and accountability mechanisms of the organization. State’s UNTAI assessment is a useful tool for shaping U.S. engagement with WHO and monitoring WHO progress in implementing certain management reforms related to UNTAI goals and benchmarks. However, there are weaknesses in the UNTAI assessment tool that generate concerns over the reliability of the information generated in these assessments, including the ambiguous rationale for State’s scores in particular areas and the lack of clarity in the definitions of certain benchmarks. Therefore, ensuring that the performance information resulting from the UNTAI assessment is useful and accurate is crucial for State’s ability to continue advocating for improvements at WHO and monitor WHO reform implementation in certain areas of management reform.

Recommendation for Executive Action

To improve U.S. assessment of WHO reform, we recommend that the Secretary of State enhance its guidance on completing State’s assessment tool for monitoring WHO’s progress in implementing transparency and accountability reforms by including, for example, a requirement to collect and submit supporting documentation with completed assessments.

Agency Comments and Our Evaluation

We requested comments on a draft of this report from the Departments of State and HHS, USAID, and WHO. State and WHO provided written comments that are reprinted in appendixes III and IV of this report. HHS and USAID did not provide written comments on this report.

State generally endorsed the main findings and conclusions of our report and concurred that WHO has undertaken an ambitious and comprehensive agenda for reform. State also agreed that the United States has advocated for and provided input into WHO’s reform agenda, particularly in the areas of management, budgeting and planning, priority setting, governance, and financing. State agreed that its process for conducting its UNTAI assessment could be strengthened and accepted our recommendation to revise its guidance for completing these assessments. State noted that it is in the process of updating its assessment tool and plans to issue expanded guidance prior to the fiscal year 2012 ratings. State also clarified the context regarding its assessments. State noted that we overstated the need for subject matter expertise in determining whether some benchmarks on the UNTAI assessment tool have been met. We recognize that some officers in the field completing the assessment may benefit from the expertise of those in the Bureau of International Organization Affairs. However, we maintain that the UNTAI tool does not provide sufficient guidance to reviewers to assist in making these judgments and that this could lead to potential data reliability concerns. Furthermore, according to an official at USUN-Geneva, improved guidance would be welcome and would help officials in the field complete the assessment tool. In addition, State mentioned the need to balance the requirement for supporting documentation with the need to minimize the reporting burden on missions, WHO, and other UN organizations. We recognize State’s concern about overburdening missions with reporting requirements and maintain that revised guidance would benefit both the missions and officers in Washington in preparing and reviewing these assessments.

In its comments, WHO concurred with the main conclusions of our report and stated that our review provides an important framework against which WHO and its member states can evaluate the reform’s direction. WHO agreed that the reform proposals respond to the challenges identified by stakeholders, and that the consultation process has been inclusive and transparent. In addition, WHO noted that our conclusions broadly converge with those of the evaluation conducted by WHO’s External Auditor. WHO also recognized that the development of a detailed implementation plan will be critical to ensure successful institutional change.

State, HHS, USAID, and WHO also provided technical comments that we have incorporated into this report, as appropriate.

As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to interested congressional committees, the Secretaries of State and HHS, the Administrator of USAID, the U.S. Permanent Representative to the UN in Geneva, the Director-General of WHO, and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-9601 or melitot@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in appendix V.

Appendix I: Scope and Methodology

This report examines (1) the steps the World Health Organization (WHO) has taken to develop and implement a reform agenda that aligns with the challenges identified by the organization, its member states, and other stakeholders; and (2) the input the United States has provided to WHO reforms.

To assess the steps that WHO has taken to develop and implement a reform agenda that aligns with the challenges identified by the organization, its member states, and other stakeholders, we conducted interviews in Washington, D.C., and in Geneva, Switzerland, with WHO officials, representatives of member states to the WHO, and a range of WHO stakeholders. We obtained their views on the challenges WHO faces and whether these challenges align with those addressed in WHO’s reform agenda. We also solicited their views on the steps WHO has taken to consult with internal and external stakeholders in developing and implementing its reform agenda. We interviewed WHO officials based in its headquarters office, six regional offices, and five country offices, including representatives of WHO’s reform team, task force on reform, and headquarters staff association. We interviewed officials from the U.S. Departments of State (State), Health and Human Services (HHS), Centers for Disease Control and Prevention (CDC), U.S. Agency for International Development (USAID), and officials representing 15 other member states to WHO. We interviewed representatives from institutions such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the GAVI Alliance; nongovernmental organizations, such as Doctors without Borders and the Institute of Medicine; and the Bill & Melinda Gates Foundation, one of the largest donors to the WHO. We also met with representatives of UN agencies, such as UNAIDS and the United Nations Development Program; private sector entities, including U.S. and international pharmaceutical research associations; and two research centers that review global health issues. In addition, we reviewed WHO documents on its reform agenda and process, including its evaluation plans and its implementation and monitoring framework for reform.

To examine U.S. support for WHO reforms, we met with officials from State, HHS, CDC, and USAID. We also conducted field work in Geneva, Switzerland, to meet with officials from USUN-Geneva, WHO, and other member state missions to learn about U.S. participation in WHO reform discussions and collaboration with other WHO member states. We collected and reviewed relevant U.S. government documents, including budget documents, strategies, position papers, talking points, and speeches. Based on interviews with U.S. government officials and U.S. government documents, we conducted an analysis to identify possible U.S. government priorities for WHO reform. We also collected and analyzed data from State, HHS, CDC, and USAID on U.S. funding contributions to WHO. We determined that these data were sufficiently reliable for the purposes of presenting specific agency contributions to WHO.

To examine State’s United Nations Transparency and Accountability Initiative (UNTAI) tool to measure the performance and progress of UN agencies, including WHO, on transparency and accountability, we interviewed State officials at State’s Bureau of International Organization Affairs, which developed and uses the assessment tool. To examine the results of State’s assessment of WHO using the UNTAI tool, we interviewed officials at USUN-Geneva who are involved in completing the assessment of WHO. We also systematically reviewed State’s WHO UNTAI report to verify the basis for State’s determinations on each benchmark. Specifically, we examined State’s assigned score for each benchmark against the information WHO provided, noting benchmarks where the support for State’s determination was not clear. In addition, we reviewed the specific benchmarks used in State’s UNTAI tool to determine potential threats to the accuracy and consistency of the resulting assessments. To do so, we developed definitions of the types of judgment necessary to implement the tools, and two analysts independently applied those definitions to each benchmark. They then met to compare and resolve any differences. The two analysts agreed upon resolutions until there was 100 percent agreement on the coding. Finally, we met with officials from State’s Bureau of International Organization Affairs about the results of our review of the benchmarks and our analysis of WHO’s assessment results.

We conducted this performance audit from August 2011 to July 2012 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Appendix II: GAO Assessment of State’s UNTAI Assessment Tool

We performed a review of State’s United Nations Transparency and Accountability Initiative (UNTAI) assessment tool to better understand its potential usefulness for supporting State’s monitoring of management reforms. The usefulness of the data collected by the tool is affected by the degree to which the resulting data are complete and accurate, which requires that the data gathered are clear and well defined enough to attain consistent results. We reviewed the specific benchmarks used in State’s UNTAI tool to determine potential risks to the accuracy and consistency of the resulting assessments.

GAO’s Assessment Methodology

In conducting our analysis, we developed a methodology for determining if the benchmarks in the assessment were clear and sufficiently defined to yield similar results when applied by different individuals. We found that the largest area of concern resulted from the judgment required when evaluating benchmarks. (A full description of our coding methodology and analysis can be found in app. I).

We identified the following two types of judgment necessary to implement the tool for 15 UNTAI benchmarks: 1. Subject matter expertise - Benchmarks that require an understanding of a specific area of knowledge to make an accurate determination. These are benchmarks for which professional judgment is necessary to accurately determine if the benchmark has been met. For example, one benchmark related to the training and qualification of procurement officials would require subject matter expertise in procurement to understand what qualifications or training might be appropriate for procurement professionals. 2. Definitional judgment - Benchmarks that require a determination of scope, size, or meaning. These are benchmarks in which ambiguous terminology or imprecise terms are used, which the assessor must define to assess whether the benchmark has been met. For example, this benchmark would require definitional judgment to determine if the level of qualifications and training would make an individual “qualified and trained.” Definitional judgment would also be needed to determine the proportion of the total number of professionals who must be “qualified and trained” for the agency to meet that benchmark.

Judgment Is Needed for 15 of 50 Benchmarks in State’s Assessment Tool

We determined that 35 of the 50 benchmarks in UNTAI (70 percent) require neither subject matter expertise nor definitional judgment. Of the remaining 15 benchmarks, 5 (10 percent) require both definitional judgment and subject matter expertise to be assessed, 4 (8 percent) require subject matter expertise, and 6 (12 percent) require definitional judgment, which may affect the accuracy and consistency of the results for those benchmarks.

Of the nine benchmarks where subject matter expertise was required, we found knowledge would be needed in five relevant areas to complete the assessment: training and development, acquisitions and procurement, UN policies and practices, auditing and evaluation, and accounting standards. The accuracy and consistency of the individual determinations will depend, in part, on the assessors’ expertise in these five areas, and on their definitional judgment relative to other assessors. For example, one benchmark asks whether “funding arrangements facilitate effective and independent evaluations of the organization’s activities.” This benchmark requires subject matter expertise related to auditing and evaluation and definitional judgment about effectiveness to accurately assess the relevant UN agency. This judgment creates the potential that two assessors with different levels of subject matter expertise and who apply different definitional judgments could rate the same program differently. The potential variation in judgment and knowledge of the assessor could make the overall score of the UN agency vary from 2 to 5 points on UNTAI’s 5-point scale. Guidance on how to assess each of these benchmarks would serve to mitigate the need for judgment and reduce the risk of inconsistency in the assessments.

Appendix III: Comments from the Department of State

GAO Comments

1. We recognize that some officers in the field completing the assessment may benefit from the expertise of those in the Bureau of International Organization Affairs. However, we maintain that the UNTAI tool does not provide sufficient guidance to reviewers to assist in making these judgments and that this could lead to potential data reliability concerns. Furthermore, according to an official at USUN-Geneva, improved guidance would be welcome and would help officials in the field complete the assessment tool. 2. We recognize State’s concern about overburdening missions with reporting requirements and maintain that revised guidance would benefit both the missions and officers in Washington in preparing and reviewing these assessments.

Appendix IV: Comments from the World Health Organization

Appendix V: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Joy Labez (Assistant Director), Diana Blumenfeld, Debbie Chung, Lynn Cothern, Karen Deans, Mark Dowling, Etana Finkler, Emily Gupta, Steven Putansu, Jena Sinkfield, R.G. Steinman, Teresa Tucker, and Sarah Veale made key contributions to this report. Gifford Howland and Kara Marshall provided additional technical assistance.

Related GAO Products

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UN Internal Oversight: Progress Made on Independence and Staffing Issues, but Further Actions Are Needed. GAO-11-871. Washington, D.C.: September 20, 2011.

United Nations: Management Reforms and Operational Issues. GAO-08-246T. Washington, D.C.: January 24, 2008.

United Nations: Progress on Management Reform Efforts Has Varied. GAO-08-84. Washington, D.C.: November 14, 2007.

United Nations Organizations: Oversight and Accountability Could Be Strengthened by Further Instituting International Best Practices. GAO-07-597. Washington, D.C.: June 18, 2007.

United Nations: Management Reforms Progressing Slowly with Many Awaiting General Assembly Review. GAO-07-14. Washington, D.C.: October 5, 2006.

United Nations: Weaknesses in Internal Oversight and Procurement Could Affect the Effective Implementation of the Planned Renovation. GAO-06-877T. Washington, D.C.: June 20, 2006.

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United Nations: Funding Arrangements Impede Independence of Internal Auditors. GAO-06-575. Washington, D.C.: April 25, 2006.

United Nations: Lessons Learned from Oil for Food Program Indicate the Need to Strengthen UN Internal Controls and Oversight. GAO-06-330. Washington, D.C.: April 25, 2006.

United Nations: Procurement Internal Controls Are Weak. GAO-06-577. Washington, D.C.: April 25, 2006.

United Nations: Preliminary Observations on Internal Oversight and Procurement Practices. GAO-06-226T. Washington, D.C.: October 31, 2005.

United Nations: Sustained Oversight Is Needed for Reforms to Achieve Lasting Results. GAO-05-392T. Washington, D.C.: March 2, 2005.

United Nations: Reforms Progressing, but Comprehensive Assessments Needed to Measure Impact. GAO-04-339. Washington, D.C.; February 13, 2004.

United Nations: Reform Initiatives Have Strengthened Operations, but Overall Objectives Have Not Yet Been Met. GAO/NSIAD-00-150, Washington, D.C.; May 10, 2000.