	Background

		WHO Structure and Governance

WHO was established in 1948 as the directing and coordinating authority  on global health within the UN system. 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. According to WHO, the provision of stronger and more effective  support to countries is a key outcome of its management reforms. 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 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. 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. 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. The U.S. delegation has taken steps to advocate for a number of reforms  to improve WHO’s internal and external oversight mechanisms. UNTAI is a useful tool for guiding U.S. priorities and engagement on  certain management issues. 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’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. 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. 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.
Why GAO Did This Study

WHO is the directing and coordinating authority for global health within the United Nations (UN) system. In 2012, member states approved a reform agenda addressing three areas: (1) priority-setting, to refocus its efforts and establish a process to determine priorities; (2) governance, to improve the effectiveness of its governing bodies and strengthen engagement with other stakeholders; and (3) management, including human resources, results-based planning, and accountability. The United States is a key participant in WHO's governing bodies and the largest donor, contributing about $219 million, or 22 percent, to WHO's assessed budget for 2010 and 2011, and more than $475 million, or about 16 percent, to WHO's voluntary budget. As the largest financial contributor to the UN, the United States has advocated for comprehensive management reform throughout the UN system, including WHO. This report examines (1) the steps WHO has taken to develop and implement a reform agenda that aligns with the challenges identified by stakeholders and (2) the input the United States has provided to WHO reforms. GAO analyzed WHO and U.S. government documents and interviewed officials and stakeholders in Washington, D.C., and Geneva, Switzerland.

What GAO Found

In May 2012, 194 member states approved components of the World Health Organization's (WHO) reform agenda, encompassing three broad areas--priority-setting, governance, and management reforms--that generally address the challenges identified by stakeholders. According to WHO officials, member state representatives, and other stakeholders, some of the challenges facing WHO include its (1) 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 was conducted by WHO's External Auditor, which concluded in March 2012 that WHO's reform proposals are comprehensive in addressing challenges faced by the organization. WHO continues to consult with member states on priority-setting and governance proposals, which generally 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 activities, 1-year and 3-year milestones, and intended impacts. Certain factors could impede WHO's ability to successfully implement its reform proposals, including the availability of sufficient financial and technical resources and the level of sustained support from internal and external stakeholders.
The United States has provided input into WHO's reform agenda, particularly in the areas of transparency and accountability, but the Department of State's (State) tool for assessing progress in the area of management reform could be enhanced. On priority-setting, the United States has advocated for WHO to maintain its focus on certain functions such as setting regulations and standards for international health. In consultations on governance, the U.S. delegation to WHO has commented on a range of proposals WHO has put forth, including those on engagement with other global health stakeholders. On management reforms, the United States has supported an agenda for greater transparency and accountability. The U.S. delegation has advocated for a number of reforms to improve WHO's internal and external oversight mechanisms and supported reforms in budgeting, planning, and human resources. Additionally, State has established an assessment tool to measure progress on transparency and accountability mechanisms, which is a useful tool for guiding U.S. priorities and engagement with WHO, and could be helpful for monitoring WHO's progress in implementing certain management reforms. However, we found weaknesses in State's assessment tool, including an unclear basis for State's determinations on certain elements in its assessment of WHO, as well as a lack of clarity in the definitions used in the assessment. According to State officials, State provides guidance to officials completing these assessments but acknowledged that the process does not fully mitigate risks to data reliability.

What GAO Recommends

GAO recommends that the Secretary of State enhance State's guidance on completing its assessment tool for monitoring WHO's progress in implementing transparency and accountability reforms. State generally concurred with GAO's recommendation.