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Amanda Glassman on the difficult task of setting priorities at the WHO

17 May, 12 | by BMJ Group

As country delegations prepare for the 65th session of the World Health Assembly next week, the reform of the institution itself is only one topic on a list of 20 agenda items and 52 sub-items to be considered by the organisation’s governing bodies.

Setting priorities and fully funding those priorities has been a challenge for the organization; WHO currently runs 213 projects directed by eight organisational divisions and 15 regional and special offices.  In the context of limited resources with no explicit criteria to prioritize budgetary allocations, and no checks on new resolutions and declarations, underfunded and inadequately staffed “priorities” have multiplied, leading to a widening gap between the organization’s aspirational rhetoric and its capacity to deliver concrete results.

I argued here that the first-order criterion to select a WHO priority is that it be a transnational issue that affects multiple states and requires coordinated action to achieve progress or prevent harm. Global issues are those where there is a collective action failure, where perverse incentives in the global system militate against policies or actions that would ensure greater overall welfare. It is in this global space that WHO has a unique and essential role to play.

Under this definition, NCDs in general do not make the cut, but transnational trade practices that permit or facilitate unfettered LMIC market access to multinational tobacco companies would be included. Under this definition, the implementation and monitoring of the International Health Regulations is included, but not maternal health.

Standard-setting, surveillance, data, essential medicines/devices lists and coordination for communicable disease prevention and control are typical examples of transnational issues requiring WHO.

There is a sub-set of issues that could be termed “shared concerns,” where the “global issues” criteria would not apply, but where global knowledge products, benchmarking and exchange will be helpful for countries, and could generate economies of scale for countries. Topics within maternal health would fall here, MDG might fall here, NCD might fall here. Yet here there are capacity constraints, so the organisation will have to be selective within this category.

By limiting WHO’s space to global and shared concerns as defined, it is possible to distinguish a unique WHO role and, using this unique space, inform priorities.

Further, I suggested that the organisation set clear criteria and a process for assessing proposed priorities against the established criteria.

Most importantly, I suggested that establishing an issue –whatever issue- as a “priority” would mean that it was adequately funded and properly staffed.

WHO reform planners have moved ahead in identifying criteria to guide priority-setting. However, with the exception of the “internationally agreed instruments” criteria, the proposed criteria are too broad and –once again- almost any activity fits in.

There are 17 disease-specific areas named “priorities”.  The draft programme of work notes that “priorities are listed as technical topics without specifying what aspect of the topic constitutes a priority for WHO,” but if this detail is not provided it is difficult to assess what this priority-setting exercise might mean in practice or if it can be reflected in budget allocations.

On the plus side, there are only six core functions established in the reform that would presumably apply to these 17 disease-specific areas: (1) providing leadership; (2) shaping the research agenda; (3) setting norms and standards; (4) articulating policy options; (5) providing technical support and building capacity; and (6) monitoring health trends.

Yet the descriptions of the priorities included in the draft programme of work do not yet reflect these core functions.

Worse still, the consolidated report of the DG to the World Health Assembly states that “the priorities that have been framed using these criteria do not describe everything that WHO does.” Then what does a priority really mean?

There are some positive signs in the latest documentation: a push to make the “financing dialogue” with state and non-state actors open to scrutiny by all member states (why not the public?); an intent to prepare a proposal to increase the predictability of financing and flexibility of income; a contingency fund for public health emergencies; and a formal evaluation policy. 

There is tentative movement towards limiting the number of new resolutions based on “an assessment of their strategic value, financial and administrative implications, and reporting requirements and timelines.” That sounds very good, and would inspire more confidence if the assessment were rigorous and transparent to member states and the public.

Still, the reform seems to have punted on the WHO’s priority-setting problem.

Criteria for priority-setting as proposed in the  draft 12th General Programme of Work 2014-2016

  • Current health situation
  • Needs of individual countries for WHO support
  • Internationally agreed instruments
  • Existence of evidence-based, cost-effective interventions

Amanda Glassman is director of the Global Health Policy Program at the Centre for Global Development, a think tank based in Washington DC.

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