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. 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. 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. 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.