WHO Governance: From resolutions to results

With none of the health-related Sustainable Development Goals (SDGs) on track and six years to go to their 2030 deadline, its time to rethink WHO’s approach.  Nothing is more fundamental to this rethink than governance.

WHO’s current governance approach is to pass dozens of resolutions — mostly technical and some administrative — at each World Health Assembly.  There is an effort to estimate the resources needed for each resolution and sometimes they come with indicators attached. (Separately, and based on its unique Constitution, WHO’s governance provides a platform to negotiate international treaties, such as the Framework Convention on Tobacco Control, International Health Regulations, or the Pandemic Accord.)

There are strong incentives for the status quo — a resolution economy.  Thirty or so technical departments at Headquarters gain visibility when they propose resolutions that are negotiated and passed.  Countries and staff of Geneva missions gain plaudits for proposing and passing resolutions.  Hundreds of thousands of hours and millions of dollars are used this way across the multilateral system.  Overall, the problem is that talk is fun, results are hard, and people hate accountability.

This approach leads to fragmentation and planning disease — where WHO spends more time on planning than on execution, and results become incidental.

It doesn’t have to be this way.  Imagine a world of no technical resolutions, but rather a governance focussed on execution and results.  This approach, which I have undiplomatically called GSD (Get Shit Done — or more diplomatically, Get Stuff Done), would drive the lagging SDGs.

In addition to being more effective, GSD governance reform would also be more efficient, relieving technical departments from the burden of developing resolutions, and countries from proposing and debating them, and shifting the focus of both groups to results.  As an added bonus, the World Health Assembly could be shorter!

Efforts at governance reform, such as the Agile Member State Task Group, have only scratched the surface, mostly focused on process, like how long people can speak.

The status quo begs the question: what are all these resolutions for?  And more fundamentally, what is the governance of WHO for?

Imagine if resolutions at the World Health Assembly followed five fundamental functions of a governing board (loosely based on the Carver model of non-profit governance). Let’s take each in turn from a results lens.

First, the process for selecting the Director-General was radically changed to a one-country one-vote process just before Dr Tedros’ election, akin to a vote for Security Council membership.  During his term, Dr Tedros has established a philosophy of measurable impact in countries; allocated more money to country offices; and overseen the development of a results architecture with ‘triple billion’ targets and the delivery for impact approach to measuring and managing the Secretariat’s contributions. To build on this and any further accomplishments, the single most important issue going forward is to select in 2027 a Director-General who is relentlessly focussed on results.

Second, on setting strategy, WHO’s 13th General Programme of Work (GPW) focused on measurable impact in countries and introduced the SDG-based triple billion target: 1 billion more people leading healthier lives, 1 billion more people with Universal Health Coverage, 1 billion more people better protected from health emergencies.  As Dr Tedros said recently, “GPW13 was the first of its kind in the history of our Organization, with measurable targets and clear indicators, to support countries on the road towards the health-related SDGs.”  The main gap in GPW 13 was measuring and managing the outputs of the Organization in a way that drives SDGs and triple billion outcomes, as evaluation after evaluation has shown.   Both output and outcome elements are included in GPW 14, but exactly how WHO will accelerate SDG progress remains unclear.  The WHO investment case is more tightly focused — it is a better strategy than the strategy.  (It could still be improved by focusing more on data and delivery and scaling innovation — where WHO’s role should be to take those innovations, especially social innovations, currently reaching millions of people and scale them to reach tens or hundreds of millions.)

Third, measuring progress against strategy has been the Achilles heel of WHO’s governance.  At the beginning of Dr Tedros term, the tools for measuring and managing the Organization’s progress against strategy did not exist; they do now.  Over the past seven years, a system called delivery for impact has been developed to address this problem.  Its origins are in the ground-breaking work of Sir Michael Barber, which was adapted to measure and manage WHO’s outputs.  There has also been progress in measuring how well WHO and other multilateral agencies are working together, through the SDG 3 Global Action Plan. The gap at the moment is incorporating these approaches into WHO’s Programme Budget and especially its governance.

Fourth, progress has been made on ethical limitations, beyond which management cannot go and ensuring these are followed, most importantly on prevention of sexual exploitation and abuse. 

Fifth, on financial sustainability, much progress has been made.  WHO member states have agreed to increase their assessed contributions to 50% of the budget by 2028.  The investment case is now tied directly to WHO’s strategy, and it has measurable outcomes and outputs.  This is good because only through measurable impact can WHO build trust and sustain funding.

In contrast to when Dr Tedros started his term, the tools are now in place to enable a major overhaul of WHO governance that would make WHO more focused on results.  There is no need for constitutional change; WHO could simply change its governance practices as outlined here.  But reform would require Member States demanding measurable results.  Channeling Shakespeare: The fault lies not in our stars but in ourselves.

A earlier version of this post was published in “Health: A Political Choice — Enhancing Resilience and Trust.”