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

GAO-12-722 Published: Jul 23, 2012. Publicly Released: Jul 30, 2012.
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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.

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.


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.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of State To improve U.S. assessment of WHO reform, the Secretary of State should 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.
Closed – Implemented
State generally endorsed the main findings and conclusions of our report, and 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 officials noted that in response to the issues raised by GAO in the report, State took steps to improve the guidance for completing the UNTAI assessment tool. Specifically, in 2013, State took three main steps to improve the UNTAI tool in response to GAO's findings and recommendation to improve its guidance; State issued (1) a glossary of terms, (2) a list of frequently asked questions, and (3) in November 2013, sent instructions to staff at each U.S. mission to the United Nations on how to complete the UTNAI tool.

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