The World Health Organisation’s (WHO) General Program of Work (GPW) is the Organisation’s main strategy document that describes its health priorities, strategic objectives, health outputs, and an indicative budget (or ‘financing envelope’) for a multi-year period. The 13th GPW had been extended to 2025 but, because of various finance-related reforms, the 14th GPW which would have started in 2026 has been brought forward a year to cover the period 2025-28. A couple of consultation papers have been circulated to “key constituencies” to gain their perspectives. Unlike many high level negotiations going on at the moment, this document is not receiving much attention despite its strategic importance. A draft document will be discussed at the Executive Board in January 24 and a revised version presented to Member States of WHO at the World Health Assembly in May 24. In this post, I pick out a few key points that I think deserve further scrutiny. It’s a long post so, for the TLDR community, I provide a bulleted summary first before wading into the deep.
- Framework. The draft 14th GPW currently has a ‘5Ps’ framework comprised of 3 programmatic priorities or goals (promotion, provision and protection) and 2 enabling priorities (powering and performing).
- Objectives. It has six objectives, the first of which is climate change and health – described in the draft as “the greatest health threat of the 21st century”. This is a very welcome development, but will this objective be adequately funded? The other five objectives are: [1] Root causes of ill-health; [2] PHC and essential health systems capacities; [3] health services coverage and financial protection; [4] prevent, mitigate and prepare for “rapid and ongoing demographic, epidemiological, environmental, political, and economic changes worldwide”; [5] rapidly detect and sustain effective response to “the rapid and alarming increase in the number and scale of complex health emergencies globally”.
- Functions. the draft describes what it counts as WHO’s 6 core functions (but which are actually 11): Leadership and coordination; research; norm setting and standards setting; policy development; technical support; monitoring, evaluating, and reporting.
- Themes. The 2nd consultation document (responses to which are due by 6th December) identifies (some might say prematurely) five “recurring themes” from “consultations with Member States, partners and key constituencies” which are “central to the success of this common agenda and achieving measurable impact on health and wellbeing over the next four years”. Putting aside the fact that feedback into this second consultation document does not inform the theme identification, there is also no account of the methodology underpinning the thematic analysis.
- All health players. There is – as expected – much emphasis in the draft of the need for an ‘all health players’ approach to decision-making. For me, this point makes me ask ‘Whose GPW have we really got here’? Under the guise of inclusivity, non-state actors (which include civil society groups, but also the commercial and pharmaceutical sectors, the banking sector and partnerships such as GAVI) are being given an opportunity to influence WHO’s long-term strategy documents. This is highly problematic for reasons discussed later in this and previous posts.
- Financing. The “indicative financial envelope” for the base segment of the program budget and “emerging priorities” for the period 2025-28 is $11.2bn. It looks very much as though the freeze on increases to the base segment will continue for the biennium 2026-27, and possibly beyond. This would be a retrograde step as it represents a reduction over time of the amount of funding we would expect the base segment to attract.
- Framing. A new phrase is introduced in the draft – “the global health ecosystem”. As colleagues from G2H2 have noted, this phrase makes it seem as though WHO must operate within a naturally emerging system rather than a system that is the result of deliberate (but mutable) political and economic decisions. Similarly, as G2H2’s submission to the consultation points out, framing WHO’s contribution in terms of its “added value” to the ecosystem implies that the Organization has to justify its position even though it has a mandate to act as the world’s leading global health authority.
The Five Ps Framework
Three “programmatic priority areas” (promotion, provision, protection) and two “enabling priorities” (powering and performing) frame the draft 14th GPW. The 5 ‘P’s – as this framework may be described in the future – attempts to capture the triple billion targets of the 13th GPW although, apparently, “work is already underway with Member States to recalibrate the triple billion indices and refine impact measurement for the 2025-2028 period”. Clearly, there is still much work to be done and there have been reassurances that further consultations will be considered. But, and given that the external evaluation of GPW 13 is still underway, I get the feeling that the Secretariat is having to rush this consultation through in order to get something out for the Jan EB and May WHA.
The draft explains that the terms ‘promote’, ‘provide’ and ‘protect’ derive from previous work (EB150/29 and A75/8), but this is a bit of a stretch: promotion is most obvious in these documents (being wrapped into UHC) but protection is mainly in terms of financial protection and health emergencies. Provision doesn’t jump out of either document. Powering is especially vague, and also an ugly example of that grating habit of verbing a noun. Performing has, of course, the unfortunate connotation of ‘performing’ for entertainment, and probably not a word you’d use to frame strategy. Overall, it feels like the writers are deliberately looking for a catchy alliteration of Ps.
Complexity and turbulence
Yes, the world is complex. But is it really increasingly complex? How would you quantify that? Personally, I think the draft GPW 14 deliberately over-emphasises complexity (and also turbulence) to justify other elements of the draft, particularly the need for “a health agenda for all health players”. It’s also an invitation for WHO to review its functions and, potentially, farm some of them off to other actors. But maybe I’m reading too much into this!
All health ‘players’
“Players” because ‘all the world’s a stage’? The draft refers to “all health players” and, later, extends the cast list to include various non-health sector actors. Here’s an example of how the draft describes WHO’s relationship with these characters: “GPW 14 will see a marked increase in the Organization approaches to and engagement with crucial health-related sectors”. It is very important to explain what the word “engagement” means here, as there is concern that the commercial and financial sectors are being brought into decision-making at this strategic level under the cloak of ‘inclusivity’.
Alignment
I’ve written about alignment in the context of sustainable funding in previous posts. As expected, it makes an appearance in the draft 14 GPW:
To achieve these ambitious strategic objectives, GPW 14 will drive for an unprecedented alignment and coordination of the extraordinary number of health and health-related players at national, regional and global levels.
The writers of the draft are being clever here in the way that they weave a logic into the narrative when there is no logic. For example, as with the above quote, you don’t necessarily have to drive for alignment in order to achieve your objectives. That is a decision that has already been made in earlier debates on WHO funding. This document is reinforcing that position. What WHO Secretariat wants to do is to align ‘all the health players’ and is trying to justify wanting to do that by claiming that it is necessary. Obviously, it is an impossible ask to align the ‘extraordinary number’ of players. So why aim to try to do that? Furthermore, the suspicion will be that you are looking to appease rather than align in order to attract funding.
Engaging the perspectives of major implementing partners and the broader global health community on the GPW 14 outcomes will strengthen alignment with Member State priorities and further improve the Organization’s shift towards becoming more impact oriented.
What does ‘engaging’ mean in this context? For what it’s worth, I think it is a really bad idea to ‘engage’ major funders in discussion at the strategic level because they will (unsurprisingly) attempt to shape WHO’s priorities and bend them towards their own. It’s bad enough that this already happens in the relationship between WHO and its wealthier MS, but bringing non-state commercial, finance and philanthropic ‘players’ into the discussion will impact negatively on WHO’s ability to independently set priorities. It could increase (not decrease) the suspicion (justified or not) that WHO is unduly influenced by them.
Goals, aims and objectives
I find it hard to believe that the consultations and written feedback alluded to at the beginning of the second consultation document “have established broad concurrence for the context and overarching goal for GPW14, the direction of the strategic objectives, and, most recently, draft outcomes”. There would need to be more transparency in order for anyone to be reassured that this was indeed the case. Will the written submissions from those consulted be publicly accessible?
It is good to see that WHO’s country and regional presence is being prioritised. But it is worth, recalling a recommendation of the independent evaluation of RBM for WHO’s secretariat to ensure that “there is transparency over senior level staff appointments”. No need to remind everyone of the controversy surrounding the recent election of the new Director of SEARO RO.
I think it’s great that the first aim of the draft is to “achieve transformative action on climate change and health”, but it will be hard to demonstrate that in reality. What, for example, does ‘transformative action’ actually look like? What will WHO do that will be substantively ‘transformative’? And it is essential that this aim is budgeted appropriately so that people know how much money is being devoted to this priority area. This will provide transparency and allow others to determine how seriously WHO is actually taking the issue.
Some of the aims described in the draft seem very optimistic. In some cases, you wonder whether WHO is being set up to fail. For example, “ensure every country is fully prepared to prevent and mitigate emerging health risks due to epidemics, pandemics and other hazards”. That aim, surely, is unachievable? If someone were to ask in years to come how many countries WHO ‘ensured’ were “fully prepared”, surely the only honest answer would be zero? WHO has a role to play in ensuring this outcome, for sure, but MS should bear primary responsibility for that, shouldn’t they?
Financing
The “indicative financial envelope” for GPW 14 is approx $11.2bn. Below is the table from the 2nd consultation document. The $2484 figure for the base segment (top line) is the annual amount derived from the biennial budget of $4964. This was the approved budget for 2022-23 and for the draft budget 2024-25. It now looks as though that ‘freeze’ is continuing for the next couple of biennia. The table provides ‘indicative’ figures, so maybe this will change. Historically though, we have tended to see a $300m increase for each biennium. So, you would expect the base segment to increase to at least $5268 for the 26-27 biennium ($2634 for 2026 and $2634 for 2027) and to $5568 for the 28-29 biennium ($2784 for 2028 and 2029). So, the base segment is a bit short.
This shortfall is surprising, especially given the emphasis in GPW 14 on the huge amount of work the WHO has to do, and the increasing complexity and turbulence of the world it has to respond to. For example:
Countries face a worsening environment for achieving better health outcomes due to: climate change; ageing populations; food insecurity; the growing burden of mental health conditions and noncommunicable diseases (NCDs); unfinished communicable disease agendas; new infectious and natural hazards; growing inequities; urbanization; shrinking fiscal space, including debt burdens; and migration. Furthermore, the risk of new health emergencies is increasing owing to the climate crisis, escalating environmental degradation, geopolitical instability, and conflict.
p2, 2nd Consultation Document
The apparent decision to continue to freeze the base segment is very controversial and would need some explanation/justification. I would really like to know how the Secretariat makes this decision; how does it decide the size of the envelope? It has an opportunity at the moment to push for more money. It even has Mazucatto writing economic reports with her ‘moonshot’ and ‘mission-oriented’ approaches. So, really, the Secretariat should be thinking big and expecting much more money from its donors (especially if WHO is going to take its promise of transformative action to respond to climate change seriously).
Ok, that’s more than enough from me! As ever, I admire the huge amount of work required to put these reports together. Hats off to the writers. It must be dispiriting to do that and then get people like me carp about them from the wings. Most likely, I have misinterpreted their work. If so, apologies!
Andrew
