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United States Government Accountability Office: 
GAO: 

Report to the Subcommittee on Oversight of Government Management, the 
Federal Workforce, and the District of Columbia, Committee on Homeland 
Security and Governmental Affairs, U.S. Senate: 

July 2012: 

World Health Organization: 

Reform Agenda Developed, but U.S. Actions to Monitor Progress Could be 
Enhanced: 

GAO-12-722: 

GAO Highlights: 

Highlights of GAO-12-722, a report to the Subcommittee on Oversight of 
Government Management, the Federal Workforce, and the District of 
Columbia, Committee on Homeland Security and Governmental Affairs, 
U.S. Senate. 

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. 

View [hyperlink, http://www.gao.gov/products/GAO-12-722]. For more 
information, contact Thomas Melito at (202) 512-9601 or 
MelitoT@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

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

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: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

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

Appendix III: Comments from the Department of State: 

Appendix IV: Comments from the World Health Organization: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: WHO Voluntary Contributions Received from Top 10 Donors, 2010-
2011 Biennium: 

Table 2: WHO Funding by Strategic Objective, 2010 to 2011: 

Table 3: WHO's Areas of Reform and Rationale for Reform: 

Figures: 

Figure 1: WHO Regions, Budgets, and Staffing Levels: 

Figure 2: WHO Biennial Program Budgets, from 2004 through 2011, by 
Funding Type: 

Figure 3: Timeline of WHO Consultations with Internal and External 
Stakeholders, 2011-2012: 

Abbreviations: 

CDC: Centers for Disease Control and Prevention: 

HHS: Department of Health and Human Services: 

JIU: United Nations Joint Inspection Unit: 

NIH: National Institutes of Health: 

PAHO: Pan American Health Organization: 

State: Department of State: 

UN: United Nations: 

UNTAI: United Nations Transparency and Accountability Initiative: 

USAID: U.S. Agency for International Development: 

USUN-Geneva: U.S. Mission to the United Nations in Geneva: 

WHO: World Health Organization: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

July 23, 2012: 

The Honorable Daniel K. Akaka: 
Chairman: 
The Honorable Ron Johnson: 
Ranking Member: 
Subcommittee on Oversight of Government Management, the Federal 
Workforce, and the District of Columbia: 
Committee on Homeland Security and Governmental Affairs: 
United States Senate: 

The World Health Organization (WHO) is the directing and coordinating 
authority for global health within the United Nations (UN) system. In 
this capacity, WHO is responsible for providing leadership on 
important global health matters such as setting standards and 
guidelines for international health, providing technical support on 
public health to countries, and monitoring and assessing global health 
trends. The United States is a key participant in WHO's governing 
bodies and the largest donor to WHO, contributing about $219 million, 
or 22 percent, to WHO's regular, assessed budget for 2010 and 2011, 
[Footnote 1] as well as more than $475 million, or about 16 percent, 
to WHO's voluntary budget.[Footnote 2] 

In January 2010, WHO's Director-General initiated discussions with 
member states on the predictability and flexibility of WHO's financing 
and how its funding could be better aligned with its priorities. 
Through a series of continued consultations and deliberations, member 
states and other stakeholders raised a wide range of other concerns, 
including questions about WHO's core business in an increasingly 
complex and changing global health environment, its role in global 
health governance, and its organizational effectiveness and 
efficiency. Accordingly, WHO developed an agenda that expanded beyond 
financing concerns to address three broad areas of reform: (1) 
priority-setting, to refocus its efforts on what it can do best and 
establish a process to determine its priorities; (2) governance, to 
improve the effectiveness of its governing bodies and strengthen its 
engagement with other global health stakeholders, including 
nongovernmental organizations and private industry; and (3) 
management, to address issues such as human resources, results-based 
planning, and accountability. Implementation of WHO's reform agenda 
remains in the early stages. 

As the largest financial contributor to the UN, the United States 
holds a strong interest in the progress of UN reform initiatives and 
has advocated for comprehensive management reform at UN agencies, 
including WHO. Accordingly, the U.S. Department of State (State) 
developed the United Nations Transparency and Accountability 
Initiative (UNTAI), to promote greater efficiency, effectiveness, 
transparency, and accountability among UN agencies, including WHO. As 
part of this initiative, State developed an assessment tool that it 
uses to conduct annual assessments to measure UN agency performance 
and progress in eight goals related to transparency and 
accountability. Additionally, the U.S. Department of Health and Human 
Services (HHS) is responsible for coordinating U.S. government input 
into the policies and decisions of health-related international 
organizations, including WHO. 

As part of our continuing work on UN management reform,[Footnote 3] 
this report examines (1) the steps 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 address these objectives, we reviewed relevant WHO documents and 
U.S. government data and documents including position papers, talking 
points, and speeches, and met with officials from State and HHS, 
including the Centers for Disease Control and Prevention (CDC), and 
the U.S. Agency for International Development (USAID). We also 
assessed the UNTAI assessment tool, which State uses to measure the 
performance and progress of UN agencies, including WHO, on 
transparency and accountability. In Washington, D.C., and during 
fieldwork in Geneva, Switzerland, in December 2011, we interviewed WHO 
officials and officials at the U.S. Mission to the UN in Geneva (USUN-
Geneva), as well as representatives from 15 other member state 
missions, and a range of other global health stakeholders. In 
addition, we held telephone or in-person meetings with officials from 
each of the six WHO regional offices as well as five country offices. 
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. (see appendix I for further 
details on our objectives, scope, and methodology). 

To improve U.S. assessment of WHO reform, we are recommending 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. 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. State generally endorsed the 
main findings and conclusions of our report. State agreed that its 
process for conducting its assessment for monitoring progress in 
implementing transparency and accountability reforms could be 
strengthened and accepted GAO's recommendation to revise its guidance 
for completing these assessments. State also offered some 
clarifications and additional context regarding its assessments. WHO 
also concurred with the main conclusions of our report and noted that 
the conclusions broadly converge with those of the evaluation 
conducted by WHO's External Auditor. In addition, State, HHS, USAID, 
and WHO provided technical comments that we incorporated into this 
report, as appropriate. 

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.[Footnote 4] 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.[Footnote 5] WHO is staffed by 
approximately 8,000 health and other experts and support staff, 
working at WHO headquarters in Geneva, Switzerland; six regional 
offices;[Footnote 6] 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. 

Figure 1: WHO Regions, Budgets, and Staffing Levels: 

[Refer to PDF for image: illustrated world map] 

Depicted on the map: 

Headquarters; 
Regional offices; 
Country offices; 
Regions: 
Africa; 
Americas; 
South-East Asia; 
Europe; 
Eastern Mediterranean; 
Western Pacific. 

2010-2011 Program budget: 
Headquarters: $1.389 billion; 
Africa: $1.263 billion; 
South-East Asia: $545 million; 
Eastern Mediterranean: $515 million; 
Western Pacific: $310 million; 
Europe: $262 million; 
Americas: $256 million. 

Staffing level (number of positions): 
Africa: 2,482; 
Headquarters: 1,981; 
Eastern Mediterranean: 899; 
South-East Asia: 754; 
Western Pacific: 636; 
Europe: 571; 
Americas: 165. 

Source: GAO analysis based on WHO data; Map Resources (map). 

Notes: The Pan American Health Organization (PAHO), which serves as 
the WHO regional office for the Americas, receives funding directly 
from WHO, in addition to collecting its own assessed and voluntary 
contributions as a function of its separate role as a public 
international health organization for the Americas. The budget and 
staffing figures above indicate the portion of the WHO budget and 
staff allocated to PAHO. However, PAHO's budget also includes funds 
collected directly from member states in the Americas. 

Staffing data are as of December 31, 2011, and do not include 329 
staff who work on WHO special programs and collaborative arrangements. 

[End of figure] 

WHO Budget: 

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 figure 2). 

Figure 2: WHO Biennial Program Budgets, from 2004 through 2011, by 
Funding Type: 

[Refer to PDF for image: stacked vertical bar graph] 

Year: 2004-2005; 
Budget: $3.032 billion; 
Voluntary contributions: 69%; 
Assessed contributions: 31%. 

Year: 2006-2007; 
Budget: $3.670 billion; 
Voluntary contributions: 75%; 
Assessed contributions: 25%. 

Year: 2008-2009; 
Budget: $4.227 billion; 
Voluntary contributions: 77%; 
Assessed contributions: 23%. 

Year: 2010-2011; 
Budget: $4.540 billion; 
Voluntary contributions: 79%; 
Assessed contributions: 21%. 

Year: 2012-2013; 
Budget: $3.959 billion; 
Voluntary contributions: 76%; 
Assessed contributions: 24%. 

Source: WHO. 

[End of figure] 

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).[Footnote 7] 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). 

Table 1: WHO Voluntary Contributions Received from Top 10 Donors, 2010-
2011 Biennium: 

Donor: United States[A]; 
Voluntary contributions: $475 million; 
Percentage of total: 15.5%; 
Cumulative percentage: 15.5%. 

Donor: Bill & Melinda Gates Foundation; 
Voluntary contributions: $467 million; 
Percentage of total: 15.2%; 
Cumulative percentage: 30.7%. 

Donor: United Kingdom; 
Voluntary contributions: $307 million; 
Percentage of total: 10.0%; 
Cumulative percentage: 40.7%. 

Donor: Canada; 
Voluntary contributions: $181 million; 
Percentage of total: 5.9%; 
Cumulative percentage: 46.5%. 

Donor: Rotary International; 
Voluntary contributions: $117 million; 
Percentage of total: 3.8%; 
Cumulative percentage: 50.3%. 

Donor: Norway; 
Voluntary contributions: $116 million; 
Percentage of total: 3.8%; 
Cumulative percentage: 54.1%. 

Donor: United Nations Development Program; 
Voluntary contributions: $110 million; 
Percentage of total: 3.6%; 
Cumulative percentage: 57.7%. 

Donor: The GAVI Alliance[B]; 
Voluntary contributions: $99 million; 
Percentage of total: 3.2%; 
Cumulative percentage: 60.9%. 

Donor: European Commission; 
Voluntary contributions: $97 million; 
Percentage of total: 3.1%; 
Cumulative percentage: 64.1%. 

Donor: Australia; 
Voluntary contributions: $96; 
Percentage of total: 3.1%; 
Cumulative percentage: 67.2%. 

Donor: Other; 
Voluntary contributions: $1.007 billion; 
Percentage of total: 32.8%; 
Cumulative percentage: 100.0%. 

Donor: Total WHO voluntary contributions; 
Voluntary contributions: $3.069 billion; 
Percentage of total: 100%; 
Cumulative percentage: 100%. 

Source: WHO data. 

Notes: Funding data represent actual donor contributions to the WHO. 

[A] U.S. voluntary contributions are primarily provided by USAID and 
CDC. According to USAID and CDC officials, for 2010 through 2011, 
USAID provided about $268 million in voluntary contributions and CDC 
provided approximately $158 million. In addition, the United States 
provides additional voluntary funding to WHO through other offices, 
including State's Bureaus of Population, Refugees, and Migration, and 
International Security and Nonproliferation; the National Institutes 
of Health; and the Food and Drug Administration. 

[B] The GAVI Alliance was formerly known as the Global Alliance for 
Vaccines and Immunization. The GAVI Alliance is a public-private 
partnership focused on saving children's lives and protecting people's 
health by increasing access to immunization in poor countries. 

[End of table] 

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. 

Table 2: WHO Funding by Strategic Objective, 2010 to 2011: 

Strategic objective: Communicable diseases; 
Program budget: $1.268 billion; 
Percentage of program budget: 28%. 

Strategic objective: HIV/AIDS, tuberculosis, and malaria; 
Program budget: $634 million; 
Percentage of program budget: 14%. 

Strategic objective: Enabling and support functions; 
Program budget: $524 million; 
Percentage of program budget: 12%. 

Strategic objective: Health systems and services; 
Program budget: $474 million; 
Percentage of program budget: 10%. 

Strategic objective: Emergencies and disasters; 
Program budget: 364 million; 
Percentage of program budget: 8%. 

Strategic objective: Child, adolescent, maternal, sexual and 
reproductive health, and healthy aging; 
Program budget: $333 million; 
Percentage of program budget: 7%. 

Strategic objective: WHO leadership, governance, and partnerships; 
Program budget: $223 million; 
Percentage of program budget: 5%. 

Strategic objective: Risk factors for health; 
Program budget: $162 million; 
Percentage of program budget: 4%. 

Strategic objective: Chronic noncommunicable conditions; 
Program budget: $146 million; 
Percentage of program budget: 3%. 

Strategic objective: Nutrition, food safety, and food security; 
Program budget: $120 million; 
Percentage of program budget: 3%. 

Strategic objective: Medical products and technologies; 
Program budget: $115 million; 
Percentage of program budget: 3%. 

Strategic objective: Healthier environment; 
Program budget: $114 million; 
Percentage of program budget: 3%. 

Strategic objective: Social and economic determinants of health; 
Program budget: $63 million; 
Percentage of program budget: 1%. 

Strategic objective: Total; 
Program budget: $4.540 billion; 
Percentage of program budget: 100%. 

Source: WHO data. 

Note: Totals may not add due to rounding. 

[End of table] 

Origins of WHO Reform: 

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. 
[Footnote 8] 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. 
[Footnote 9] 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.[Footnote 10] 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 challenges raised by member 
states and other stakeholders.[Footnote 11] WHO 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. 

Table 3: WHO's Areas of Reform and Rationale for Reform: 

Area of reform: Priority-setting; Establishment of organizational 
priorities; 
Rationale for reform: 
* WHO priority-setting has not been sufficiently selective or 
strategically focused. As a result, WHO is overcommitted and works in 
too many global health areas. 

Area of reform: Governance; Effectiveness of WHO internal governance 
structures; 
Rationale for reform: 
* WHO's internal governance structures need to have a more strategic 
and disciplined approach to priority-setting; 
* Oversight of the programmatic and financial aspects of the 
organization needs to be enhanced; 
* The efficiency and inclusivity of the intergovernmental consensus-
building process needs to be enhanced; 
* The duration, timing, and sequencing of the sessions of the WHO 
governing body meetings are not optimal. 

Area of reform: Governance; WHO's engagement with external 
stakeholders; 
Rationale for reform: 
* WHO's role in global health governance needs to be clarified and 
strengthened; 
* The global health community has greatly expanded, leading to a 
number of global health organizations with overlapping roles and 
responsibilities. 

Area of reform: Management; Alignment of WHO headquarters, regional, 
and country offices; 
Rationale for reform: 
* WHO has a decentralized organizational structure, and roles and 
responsibilities of the three levels of the organization need to be 
better defined; 
* Programs and offices tend to work independently of one another. 

Area of reform: Management; WHO financing; 
Rationale for reform: 
* WHO faces a misalignment between what its governing bodies approve 
in terms of strategic direction, the budget for the organization, and 
the resources available; 
* Voluntary contributions, which represent the major source of WHO's 
funding, are often highly specified and not aligned with WHO's program 
budget; 
* The current level of assessed contributions is not sufficient to 
carry out WHO's work; 
* The cost of WHO's administration is not adequately financed. 

Area of reform: Management; Human resources policies and management; 
Rationale for reform: 
* WHO faces a mismatch between its funding and human resources 
policies. WHO's human resources policies focus on long-term employment 
while the organization's funding is largely for short-term projects; 
* The process of recruiting staff is overly complex and lengthy; 
* Performance management tools are not sufficiently used to evaluate 
staff performance. 

Area of reform: Management; Results-based management; 
Rationale for reform: 
* WHO faces challenges in measuring its contributions to health 
outcomes; 
* WHO resources, outputs, and outcomes are not clearly linked. 

Area of reform: Management; Accountability and transparency; 
Rationale for reform: 
* WHO audit and oversight system has limited capacity; 
* WHO lacks timely, validated information about its results and 
resources to provide to member states and governing bodies; 
* Enforcement of WHO's current accountability and transparency 
mechanisms is not robust; 
* WHO's current policies on conflicts of interest and information 
disclosure are insufficient to deal with the growing complexities of 
global health. 

Area of reform: Management; Independent evaluation; 
Rationale for reform: 
* WHO does not have an evaluation policy that has been endorsed by its 
governing bodies, nor does it routinely make its evaluation reports 
public; 
* WHO lacks an established mechanism for oversight of evaluation by 
the governing bodies. 

Area of reform: Management; Strategic communications; 
Rationale for reform: 
* WHO is unable to project a coherent sense of the organization and 
its achievements. 

Source: GAO summary of WHO information. 

[End of table] 

WHO Undertook Consultations in Developing a Reform Agenda that 
Generally Aligns with Challenges Identified by Stakeholders: 

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 
ownership of the change.[Footnote 12] Figure 3 provides a timeline of 
WHO consultations with internal and external stakeholders on its 
reform agenda. 

Figure 3: Timeline of WHO Consultations with Internal and External 
Stakeholders, 2011-2012: 

[Refer to PDF for image: timeline] 

WHO consultation with Internal stakeholders: 

Jan. 2011-May 2012: 6 town hall meetings held with WHO staff. 

Jan. 2011-May 2012: 18 consultations held with WHO senior management; 

June 28-30: First meeting of WHO Task Force on Reform, made up of 
staff from across the organization. 

Sept. 28-30:  Second meeting of WHO Task Force on Reform. 

Nov. 8-10: Consultation with WHO heads of country offices.  

WHO consultation with External stakeholders: 

May 20: World Health Assembly endorsed the direction of WHO reform. 

May 25: Executive Board established consultative process to support 
reform. 

June-Nov.: WHO used feedback from member web consultations to collect 
states on reform agenda.  

July 1: WHO consulted with missions on reform plans  

Fall (Aug.-Oct.): Regional committee meetings served as platforms for 
consultations with their member states. 

Sept.15: WHO consulted with  missions on reform plans.  

Nov. 1-3: Executive Board held a special session on reform and made 
decisions on three areas of reform. 

2012: 

Jan.-Feb.: WHO used web consultations to collect feedback from member 
states on reform agenda. 

Jan. 23: Executive Board made decisions on WHO reform related to 
priority-setting.  

Feb. 27-28: Member state session on WHO priority-setting.  

May 28: World Health Assembly approved components of WHO reform agenda. 

Source: GAO analysis based on WHO documents. 

[End of figure] 

WHO Took Steps to Consult with Internal Stakeholders: 

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.[Footnote 13] 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 Consulted with External Stakeholders through Various Means: 

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.[Footnote 14] According to WHO 
officials, it has also convened three informal dialogues with 
nongovernmental organizations since late 2011. 

WHO Commissioned Independent Evaluations to Provide Input to the 
Reform Process: 

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.[Footnote 15] 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. 

WHO Has Identified Criteria for Establishing Its Priorities: 

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 Some Governance Proposals, although Some Areas 
Require Further Development, Consultation, and Member State Consensus: 

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. 

WHO Management Proposals and Actions Encompass a Wide Range of Areas: 

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.[Footnote 16] 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.[Footnote 17] 

* 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: 

[Side bar: Priority-setting: 
The United States has advocated for WHO to maintain its focus on 
setting standards and guidelines, as well as other global health 
goals. End of side bar] 

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. 

[Side bar: Governance: 
The United States has provided input on WHO proposals. End of side bar] 

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: 

[Side bar: Management Reforms: 
The United States has supported increased transparency and 
accountability and improvements to budgeting and planning at WHO. End 
of side bar] 

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. 

[Side bar: Management Reforms: 
State has developed a tool for monitoring progress in transparency and 
accountability, but lacks sufficient guidance on completing 
assessments. End of side bar] 

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 [hyperlink, 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. 

Sincerely yours, 

Signed by: 

Thomas Melito: 
Director, International Affairs and Trade: 

[End of section] 

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;[Footnote 18] 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. 

[End of section] 

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,[Footnote 19] which requires that the data gathered are clear 
and well defined enough to attain consistent results.[Footnote 20] We 
reviewed the specific benchmarks used in State's UNTAI tool to 
determine potential risks to the accuracy and consistency of the 
resulting assessments.[Footnote 21] 

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 appendix 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. 

[End of section] 

Appendix III: Comments from the Department of State: 

Note: GAO comments supplementing those in the report text appear at 
the end of this appendix. 

United States Department of State: 
Comptroller: 
1969 Dyess Avenue: 
Charleston, SC 29405: 

July 9, 2012: 

Dr. Loren Yager: 
Managing Director: 
International Affairs and Trade: 
Government Accountability Office: 
441 G Street, N.W. 
Washington, D.C. 20548-0001: 

Dear Dr, Yager: 

We appreciate the opportunity to review your draft report, "World 
Health Organization: Reform Agenda Developed, but U.S. Actions to 
Monitor Progress Could he Enhanced" (GAO job Code 320862. 

The enclosed Department of State comments are provided (or 
incorporation with this letter as an appendix to the final report.  
If you have any questions concerning this response, please contact 
Matt Glockner, Program Analyst, Bureau of International Organization 
Affairs at (202)-647-6413. 

Sincerely, 

Signed by: 

James L. Millette: 

cc: GAO — Thomas Melito: 
IO — Esther D. Brimmer: 
State/0IG — Evelyn Klemstine: 

[End of letter] 

Department of State Comments on GAO Draft Report: 

World Health Organization: Reform Agenda Developed, but U.S. Actions 
to Monitor Progress Could be Enhanced (GAO-12-722, GAO Code 320862): 

Thank you for the opportunity to comment on your draft report entitled
World Health Organization: Reform Agenda Developed, but U.S.
Actions to Monitor Progress Could be Enhanced. The Department of State 
has long been an ardent supporter of reform at the World Health 
Organization (WHO) and throughout the wider UN system and has, in 
particular, strongly supported the WHO reform agenda that started in 
earnest in 2010. The GAO's report provides timely and useful 
information on a number of aspects of the WHO reform agenda. 

The Department of State generally endorses the main findings and 
conclusions contained in the GAO report. We are pleased that the GAO 
report found that the United States has advocated for and provided 
input into WHO's reform agenda, particularly in the areas of 
management and improvements to budgeting and planning, as well as 
priority setting, governance, and financing, and that the United 
States established a useful assessment tool to measure progress on 
specific reforms. We are also pleased the report acknowledges that WHO 
has undertaken and continues with an ambitious and comprehensive 
agenda for reforms focused on priority-setting, governance, and 
management reforms and has done so in a consultative manner with its 
Member States and stakeholders. We particularly value that the report 
notes that the long-term success of WHO reform depends on the ability 
of WHO to sustain its efforts through a comprehensive implementation 
plan, and a consensus from internal and external stakeholders. 

The report makes one recommendation, relating to guidance for 
utilizing the Department's assessment tool for monitoring progress via 
the U.S.-sponsored United Nations Transparency and Accountability 
Initiative (UNTAI). We agree that the UNTAI assessment process could 
be strengthened and accept GAO's recommendation to revise guidance for 
completing the annual assessment tool. The Department of State is in 
the process of updating the assessment tool and plans to issue 
expanded guidance prior to the FY 2012 rating. The Department of State 
would also like to make some clarifications and amplifications 
concerning UNTAI. 

First, we would like to emphasize that although GAO's recommendation 
may be directed toward the use of the assessment tool for WHO, UNTAI 
is an effort that involves 24 organizations in the UN system including 
WHO, and as such the recommendation has implications that extend 
beyond the scope of the present GAO report on WHO. We appreciate GAO's 
observations related to WHO's assessment and are studying how these 
might be applied to the broader UNTAI project. 

Second, the assessment tool is not designed to be an audit or 
systematic evaluation of WHO management reforms or those of any other 
UN organization. The annual assessment is a limited scope survey of 
where WHO and other UN organizations stand on various management 
reform goals. While we appreciate the observations generated by the 
involvement of GAO's methodologist, we developed UNTAI as a broad 
assessment tool to identify weaknesses and prioritize our engagement 
on reforms at WHO and elsewhere. We appreciate GAO's acknowledgment 
that UNTAI has helped achieve management reforms at WHO such as the 
establishment of an audit committee. We believe that the assessment 
process will continue to encourage WHO to make progress on 
accountability and transparency reforms. 

Third, we believe that GAO has overstated the need for subject matter
expertise in determining whether some benchmarks on the UNTAI 
assessment tool have been met. The Office of Management Policy and 
Resources in the Bureau of International Organization Affairs designed 
the UNTAI assessment tool in consultation with Missions and other 
relevant offices and bureaus within the Department. The Office 
regularly answers subject matter and agency specific questions on the 
assessments for WHO and other UN organizations. In addition, the 
Office carefully reviews UNTAI reports to help minimize errors, 
omissions, and inconsistencies. We are in the process of developing a 
list of Frequently Asked Questions that will be posted on the 
Department's intranet site for use by Missions. We believe that the 
existing review process combined with planned revisions and 
enhancements to the guidance for completing the assessment tool will 
address GAO's concerns. [See comment 1] 

Finally, the Department would like to stress that it must balance a 
requirement for supporting documentation with the need to minimize the 
burden on Missions, the WHO, and other UN organizations. The UNTAI 
reporting process as it currently stands involves a significant 
investment of staff time by Missions and officers in Washington to 
prepare and review annual assessments. Collection and submission of 
supporting documentation could be beneficial and will be encouraged 
across the board; however, we will not specifically require such 
documentation except for instances where we might have specific 
questions or concerns about a particular benchmark or rating. The GAO 
report cites examples where such follow-up would be useful to better 
enable the Department to monitor the status of WHO reforms and 
advocate for further progress. [See comment 2] 

As the report illustrates, WHO has developed a reform agenda that is 
generally aligned with the priorities of its stakeholders. WHO has 
been taking positive steps to implement reforms in the areas of 
priority-setting, governance, and management. We appreciate the 
report's acknowledgment that the United States has been actively 
involved in shaping and advancing the reform agenda, and particularly 
our vigorous engagement on improving WHO's transparency and 
accountability mechanisms. We remain committed to working with WHO and 
other member states to make further progress on the full range of 
reforms. 

The following are GAO's comments on the Department of State's letter 
dated July 9, 2012. 

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. 

[End of section] 

Appendix IV: Comments from the World Health Organization: 

t.
World Health Organization: 
20, Avenue Appia-CH-1211: 
Geneva 27, Switzerland: 
Tel Central +41 22 791 2111: 
Fax Central +41 22 791 3111: 

Tel direct: +41 22 791: 
Fax direct: +41 22 791: 

Mr Thomas Melito: 
Director, International Affairs and Trade: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, D.C. 20548: 

3 July 2012: 

Dear Mr Melito, 

Response to the United States Government Accountability Report entitled,
"World Health Organization: Reform Agenda Developed, but U.S. Actions to
Monitor Progress Could be Enhanced" by the World Health Organization: 

The World Health Organization (WHO) welcomes the report issued by the 
United States Government Accountability Office (GAO) entitled "World 
Health Organization — Reform Agenda Developed, but U.S. Actions to 
Monitor Progress Could be Enhanced." WHO appreciates the opportunity 
to provide feedback on the report and the United States Government's 
strong interest in the reform of WHO. WHO acknowledges that GAO's 
performance audit included a detailed review of reform-related 
documentation and consultations with Member States and a range of 
global health stakeholders. WHO shares the U.S. Government's interest 
in seeing WHO improve performance and organizational efficiency 
underpinned by principles of accountability and transparency. 

The detailed examination undertaken by GAO provides an important 
framework against which WHO and its Member States can evaluate the 
direction of the programme of reform in the context of current 
challenges facing the Organization. In this regard, WHO particularly 
welcomes GAO's primary conclusions that the proposals which comprise 
WHO's reform agenda respond to the challenges identified by 
stakeholders, and that the process of consultation has been inclusive 
and transparent. WHO notes that these conclusions broadly converge 
with those of the evaluation conducted by WHO's External Auditor. In 
particular both studies stress the importance of improving the 
predictability and flexibility of the Organization's financing, and of 
programmatic reforms that will ensure clear priority-setting. 

As the process of reform moves from development to implementation, WHO 
is focusing on the multiple challenges that might impede progress. Two 
of the specific challenges observed in the GAO report — namely the 
availability of sufficient resources, and the extent of support from 
internal and external WHO stakeholders — are equally of concern to 
WHO. In this regard, WHO is proceeding with measures designed to 
address the funding of reform, and, continuing extensive, internal and 
external consultative processes aiming to guide Organizational changes.
Specifically, as noted in the GAO report, WHO recognizes that the 
development of a detailed implementation plan outlining goals, 
milestones, costs and indicators to monitor and measure the success of 
implementation, will be critical to ensure successful, institutional 
change. WHO welcomes the analysis that the study provides and notes 
that the key U.S. priorities cost effectiveness, efficiency, 
accountability and monitoring and evaluation — underscore and reflect 
the primary objectives of WHO's programme of reform. 

Yours Sincerely, 

Signed by: 

Dr. Margaret Chan: 
Director-General: 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Thomas Melito, (202) 512-9601, or melitot@gao.gov: 

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. 

[End of section] 

Related GAO Products: 

United Nations: Improved Reporting and Member States' Consensus Needed 
for Food and Agriculture Organization's Reform Plan. GAO-11-922. 
Washington, D.C.: September 29, 2011. 

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. 

United Nations: Oil for Food Program Provides Lessons for Future 
Sanctions and Ongoing Reform. GAO-06-711T. Washington, D.C.: May 2, 
2006. 

United Nations: Internal Oversight and Procurement Controls and 
Processes Need Strengthening. GAO-06-710T. Washington, D.C.: April 27, 
2006. 

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. 

[End of section] 

Footnotes: 

[1] WHO's biennial budget is based on a 2-year budget period. 

[2] WHO's budget is comprised of assessed contributions from member 
states, which are based on the assessed dues for each country, as well 
as voluntary contributions provided by member states and other 
entities on a voluntary basis. Voluntary contributions are often 
specified for certain issues such as particular diseases. 

[3] See Related GAO Products at the end of this report. 

[4] "Associate members" refers to territories that are not responsible 
for the conduct of their international relations that may be admitted 
to WHO upon application made on their behalf by the member or other 
authority responsible for their international relations. 

[5] The current Director-General was appointed by the World Health 
Assembly in November 2006, and appointed for a second term at the 65TH 
World Health Assembly in May 2012. Her current term runs through June 
2017. 

[6] WHO regional offices are located in Brazzaville, Congo (African 
region); Cairo, Egypt (Eastern Mediterranean region); Copenhagen, 
Denmark (European region); Manila, Philippines (Western Pacific 
region); New Delhi, India (South-East Asian region); and Washington, 
D.C. (region of the Americas). The Pan American Health Organization 
(PAHO), the specialized health agency of the Inter-American System, 
also serves as the WHO regional office for the Americas as part of the 
UN system. 

[7] Figures are rounded. 

[8] Due to financial concerns, WHO conducted a staffing review in 2011 
that resulted in the abolishment of 200 positions based in Geneva. 
During this period, 43 positions were created in WHO's administrative 
and information technology center in Kuala Lumpur, Malaysia, to 
accommodate functions previously performed in Geneva. WHO expects 
these decisions to result in long-term cost savings. 

[9] Multilateral Organization Performance Assessment Network, Common 
Approach: World Health Organization, 2010, January 2011: and the 
United Kingdom Department for International Development, Multilateral 
Aid Review, March 2011. 

[10] Member states are elected to serve 3-year terms on the Executive 
Board; the United States is currently serving a 3-year term that runs 
from 2010 through 2013. 

[11] WHO's External Auditor, currently the Comptroller and Auditor 
General of India, authored the Evaluation Report of Stage 1 of Reform 
Proposals of WHO, 2012. 

[12] GAO, Results-Oriented Cultures: Implementation Steps to Assist 
Mergers and Organizational Transformations, GAO-03-669 (Washington 
D.C.: Jul. 2, 2003). 

[13] GAO-03-669. 

[14] Nongovernmental organizations in "official relations" with WHO 
are those organizations that fulfill a set of WHO criteria, such as 
having an international scope of work and focusing on development work 
in health and health-related fields. Such organizations have the right 
to appoint a representative to participate, without right of vote, in 
WHO meetings. 

[15] The JIU is the only independent external oversight body of the UN 
system. It is mandated to conduct evaluations, inspections, and 
investigations of the UN system, including the specialized agencies. 
The JIU conducted earlier reviews of WHO's decentralization and 
management and administration issues. See Joint Inspection Unit, 
Decentralization of Organizations within the United Nations system. 
Part III: The World Health Organization (JIU/REP/93/2), and Joint 
Inspection Unit, Review of Management and Administration in the World 
Health Organization (WHO) (JIU/REP/2001/5). 

[16] GAO-03-669. 

[17] WHO's budget for the development phase of the reform is about 
$6.27 million and includes costs for consultations and meetings of the 
governing bodies, secretariat costs, and the independent evaluation. 
According to WHO, member states have provided about $3.04 million in 
funding thus far, resulting in a funding gap of about $3.23 million. 

[18] The GAVI Alliance was formerly known as the Global Alliance for 
Vaccines and Immunization. 

[19] Government Performance: GPRA Modernization Act Provides 
Opportunities to Help Address Fiscal, Performance, and Management 
Challenges, GAO-11-466T (Washington, D.C.: Mar. 16, 2011). 

[20] Auditing and Financial Management: Assessing the Reliability of 
Computer-Processed Data, GAO-09-680G (Washington, D.C.: Jul. 1, 2009). 

[21] Other factors relating to usefulness of information include 
completeness, timeliness, and ease of use. We limit the focus to 
accuracy and consistency because UNTAI is not the only tool State uses 
to monitor management reforms, and because determining whether the 
information produced using UNTAI is complete, timely, or easily used 
depends on the information State may obtain through other methods. 

[End of section] 

[End of section] 

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