oversight

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

Published by the Government Accountability Office on 2012-07-23.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             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
                                              July 2012

                                              WORLD HEALTH ORGANIZATION
                                              Reform Agenda Developed, but U.S. Actions to
                                              Monitor Progress Could Be Enhanced
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                        What GAO Found
WHO is the directing and coordinating         In May 2012, 194 member states approved components of the World Health
authority for global health within the        Organization’s (WHO) reform agenda, encompassing three broad areas—
United Nations (UN) system. In 2012,          priority-setting, governance, and management reforms—that generally address
member states approved a reform               the challenges identified by stakeholders. According to WHO officials, member
agenda addressing three areas: (1)            state representatives, and other stakeholders, some of the challenges facing
priority-setting, to refocus its efforts      WHO include its (1) lack of clear organizational priorities; (2) lack of predictable
and establish a process to determine          and flexible financing; and (3) highly decentralized organizational structure. In
priorities; (2) governance, to improve        developing its reform agenda, WHO consulted with member states, employees,
the effectiveness of its governing
                                              and other parties to gather their views and feedback. In addition, WHO has
bodies and strengthen engagement
                                              commissioned three ongoing evaluations to provide input into the reform
with other stakeholders; and (3)
management, including human
                                              process. The first stage of one of the planned evaluations was conducted by
resources, results-based planning, and        WHO’s External Auditor, which concluded in March 2012 that WHO’s reform
accountability. The United States is a        proposals are comprehensive in addressing challenges faced by the
key participant in WHO’s governing            organization. WHO continues to consult with member states on priority-setting
bodies and the largest donor,                 and governance proposals, which generally require extensive deliberation and
contributing about $219 million, or 22        consensus from member states. In November 2011, the WHO Executive Board
percent, to WHO’s assessed budget             approved WHO’s management reform proposals in several areas, and requested
for 2010 and 2011, and more than              further development of proposals in other areas. In May 2012, WHO developed a
$475 million, or about 16 percent, to         high-level implementation and monitoring framework that includes reform
WHO’s voluntary budget. As the                objectives, selected activities, 1-year and 3-year milestones, and intended
largest financial contributor to the UN,      impacts. Certain factors could impede WHO’s ability to successfully implement its
the United States has advocated for           reform proposals, including the availability of sufficient financial and technical
comprehensive management reform               resources and the level of sustained support from internal and external
throughout the UN system, including           stakeholders.
WHO. This report examines (1) the
steps WHO has taken to develop and
implement a reform agenda that aligns         The United States has provided input into WHO’s reform agenda, particularly in
with the challenges identified by             the areas of transparency and accountability, but the Department of State’s
stakeholders and (2) the input the            (State) tool for assessing progress in the area of management reform could be
United States has provided to WHO             enhanced. On priority-setting, the United States has advocated for WHO to
reforms. GAO analyzed WHO and U.S.            maintain its focus on certain functions such as setting regulations and standards
government documents and                      for international health. In consultations on governance, the U.S. delegation to
interviewed officials and stakeholders        WHO has commented on a range of proposals WHO has put forth, including
in Washington, D.C., and Geneva,              those on engagement with other global health stakeholders. On management
Switzerland.                                  reforms, the United States has supported an agenda for greater transparency
What GAO Recommends                           and accountability. The U.S. delegation has advocated for a number of reforms
                                              to improve WHO’s internal and external oversight mechanisms and supported
GAO recommends that the Secretary             reforms in budgeting, planning, and human resources. Additionally, State has
of State enhance State’s guidance on          established an assessment tool to measure progress on transparency and
completing its assessment tool for            accountability mechanisms, which is a useful tool for guiding U.S. priorities and
monitoring WHO’s progress in                  engagement with WHO, and could be helpful for monitoring WHO’s progress in
implementing transparency and                 implementing certain management reforms. However, we found weaknesses in
accountability reforms. State generally       State’s assessment tool, including an unclear basis for State’s determinations on
concurred with GAO’s                          certain elements in its assessment of WHO, as well as a lack of clarity in the
recommendation.
                                              definitions used in the assessment. According to State officials, State provides
View GAO-12-722. For more information,        guidance to officials completing these assessments but acknowledged that the
contact Thomas Melito at (202) 512-9601 or    process does not fully mitigate risks to data reliability.
melitot@gao.gov.

                                                                                       United States Government Accountability Office
Contents


Letter                                                                                            1
                       Background                                                                 3
                       WHO Developed a Reform Agenda that Generally Aligns with the
                         Challenges Identified by Stakeholders                                  11
                       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                 23
                       Conclusions                                                              29
                       Recommendation for Executive Action                                      29
                       Agency Comments and Our Evaluation                                       30

Appendix I             Scope and Methodology                                                    32



Appendix II            GAO Assessment of State’s UNTAI Assessment Tool                          34



Appendix III           Comments from the Department of State                                    36



Appendix IV            Comments from the World Health Organization                              41



Appendix V             GAO Contact and Staff Acknowledgments                                    43



Related GAO Products                                                                            44



Tables
                       Table 1: WHO Voluntary Contributions Received from Top 10
                                Donors, 2010-2011 Biennium                                       7
                       Table 2: WHO Funding by Strategic Objective, 2010 to 2011                 8
                       Table 3: WHO’s Areas of Reform and Rationale for Reform                  12




                       Page i                                   GAO-12-722 World Health Organization
Figures
          Figure 1: WHO Regions, Budgets, and Staffing Levels                                        5
          Figure 2: WHO Biennial Program Budgets, from 2004 through 2011,
                   by Funding Type                                                                   6
          Figure 3: Timeline of WHO Consultations with Internal and
                   External Stakeholders, 2011-2012                                                 15




          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




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          Page ii                                              GAO-12-722 World Health Organization
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, 1 as well as more than $475 million,
                                   or about 16 percent, to WHO’s voluntary budget. 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)



                                   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.




                                   Page 1                                             GAO-12-722 World Health Organization
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, 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



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




Page 2                                            GAO-12-722 World Health Organization
                    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 app. 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   WHO was established in 1948 as the directing and coordinating authority
Governance          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




                    Page 3                                      GAO-12-722 World Health Organization
Health Assembly, WHO’s supreme governing body, to set policy and
approve the budget. 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. 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; 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.




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
                                               th
2006, and appointed for a second term at the 65 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.




Page 4                                               GAO-12-722 World Health Organization
Figure 1: WHO Regions, Budgets, and Staffing Levels




                                       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




                                       Page 5                                                       GAO-12-722 World 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.




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 fig. 2).

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




             Page 6                                                    GAO-12-722 World Health Organization
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). 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

 U.S. dollars in millions
                                                Voluntary Percentage of         Cumulative
 Donor                                       contributions        total         percentage
                    a
 United States                                          $475            15.5           15.5
 Bill & Melinda Gates Foundation                         467            15.2           30.7
 United Kingdom                                          307            10.0           40.7
 Canada                                                  181             5.9           46.5
 Rotary International                                    117             3.8           50.3
 Norway                                                  116             3.8           54.1
 United Nations Development                              110             3.6           57.7
 Program
                        b
 The GAVI Alliance                                        99             3.2           60.9
 European Commission                                      97             3.1           64.1
 Australia                                                96             3.1           67.2
 Other                                                 1,007            32.8          100.0
 Total WHO voluntary contributions                    $3,069             100            100
Source: WHO data.


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




7
 Figures are rounded.




Page 7                                                   GAO-12-722 World Health Organization
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.



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

    U.S. dollars in millions
                                                                                      Percentage of
                                                                         Program           program
    Strategic objective                                                   budget            budget
    Communicable diseases                                                   $1,268                  28
    HIV/AIDS, tuberculosis, and malaria                                        634                  14
    Enabling and support functions                                             524                  12
    Health systems and services                                                474                  10
    Emergencies and disasters                                                  364                   8
    Child, adolescent, maternal, sexual and                                    333                   7
    reproductive health, and healthy aging
    WHO leadership, governance, and partnerships                               223                   5
    Risk factors for health                                                    162                   4
    Chronic noncommunicable conditions                                         146                   3
    Nutrition, food safety, and food security                                  120                   3
    Medical products and technologies                                          115                   3
    Healthier environment                                                      114                   3
    Social and economic determinants of health                                   63                  1
    Total                                                                   $4,540                100
Source: WHO data.


Note: Totals may not add due to rounding.




Page 8                                                      GAO-12-722 World Health Organization
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. 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. 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. 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


                            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.




                            Page 9                                              GAO-12-722 World Health Organization
                      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   The United States has long supported UN reform initiatives and has
Reform                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,


                      Page 10                                      GAO-12-722 World Health Organization
                        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
WHO Developed a         challenges identified by stakeholders. In May 2012, member states
Reform Agenda that      approved components of WHO’s reform agenda, encompassing three
                        broad areas—priority setting, governance, and management reforms—
Generally Aligns with   that generally align with challenges identified by stakeholders. According
the Challenges          to WHO officials, member state representatives, and other stakeholders,
Identified by           some of the challenges facing WHO include (1) its lack of clear
                        organizational priorities; (2) lack of predictable and flexible financing; and
Stakeholders            (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. 11 WHO



                        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.




                        Page 11                                             GAO-12-722 World Health Organization
                                           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                        In May 2012, member states approved components of WHO’s reform
Covers Three Broad Areas                   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                         Rationale for reform
Priority-setting
•    Establishment of organizational   •   WHO priority-setting has not been sufficiently selective or strategically focused. As a
     priorities                            result, WHO is overcommitted and works in too many global health areas.
Governance
•  Effectiveness of WHO internal       •   WHO’s internal governance structures need to have a more strategic and disciplined
   governance structures                   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.
•    WHO’s engagement with external    •   WHO’s role in global health governance needs to be clarified and strengthened.
     stakeholders                      •   The global health community has greatly expanded, leading to a number of global health
                                           organizations with overlapping roles and responsibilities.




                                           Page 12                                               GAO-12-722 World Health Organization
Area of reform                        Rationale for reform
Management
•   Alignment of WHO headquarters,    •   WHO has a decentralized organizational structure, and roles and responsibilities of the
    regional, and country offices         three levels of the organization need to be better defined.
                                      •   Programs and offices tend to work independently of one another.
•   WHO financing                     •   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.
•   Human resources policies and      •   WHO faces a mismatch between its funding and human resources policies. WHO’s
    management                            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.
•   Results-based management          •   WHO faces challenges in measuring its contributions to health outcomes.
                                      •   WHO resources, outputs, and outcomes are not clearly linked.
•   Accountability and transparency   •   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.
•   Independent evaluation            •   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.
•   Strategic communications          •   WHO is unable to project a coherent sense of the organization and its achievements.
                                          Source: GAO summary of WHO information.




WHO Undertook                             WHO’s reform agenda generally aligns with the challenges identified by
Consultations in                          WHO officials, member states, and other global health organizations we
Developing a Reform                       interviewed. According to WHO officials, member state representatives,
                                          and other stakeholders, some of the challenges facing WHO include (1)
Agenda that Generally                     its lack of clear organizational priorities, (2) lack of predictable and flexible
Aligns with Challenges                    financing, and (3) highly decentralized organizational structure. For
Identified by Stakeholders                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



                                          Page 13                                              GAO-12-722 World Health Organization
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. 12 Figure 3 provides a timeline of WHO
consultations with internal and external stakeholders on its reform
agenda.




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




Page 14                                          GAO-12-722 World Health Organization
Figure 3: Timeline of WHO Consultations with Internal and External Stakeholders, 2011-2012




WHO Took Steps to Consult               We previously reported that a successful organizational transformation
with Internal Stakeholders              must involve employees and their representatives from the beginning to
                                        promote their ownership of and investment in the changes occurring in
                                        the organization. 13 We also identified the use of employee teams


                                        13
                                          GAO-03-669.




                                        Page 15                                         GAO-12-722 World Health Organization
                               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    WHO used a variety of means to consult with external stakeholders, such
Stakeholders through Various   as member states, on its reform agenda. As decided at the May 2011
Means                          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. 14 According to WHO officials, it has


                               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.




                               Page 16                                             GAO-12-722 World Health Organization
                              also convened three informal dialogues with nongovernmental
                              organizations since late 2011.

WHO Commissioned              At the November 2011 special session on reform of the WHO Executive
Independent Evaluations to    Board, the Board decided to commission three ongoing evaluations to
Provide Input to the Reform   provide input to the reform process. WHO commissioned a two-stage
Process                       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. 15
                              The objectives of the JIU reviews are to (1) assess the management and


                              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).




                              Page 17                                             GAO-12-722 World Health Organization
                                  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              In May 2012, member states endorsed components of WHO’s reform
Member State                      agenda and requested additional work in certain areas. According to
Consideration Have Been           WHO, some of the reform proposals can be implemented relatively
                                  quickly while others require more detailed consideration and planning.
Developed                         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   According to WHO officials, the organization is trying to identify criteria for
Establishing Its Priorities       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


                                  Page 18                                       GAO-12-722 World Health Organization
                              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        WHO has developed proposals for some of its governance reforms;
Governance Proposals,         however, other areas will require further development, consultation, and
although Some Areas Require   member state consensus. Proposals to improve WHO’s governance are
Further Development,          two-fold and entail (1) improving the effectiveness of WHO’s governing
Consultation, and Member      bodies, including its Executive Board, World Health Assembly, and
State Consensus               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


                              Page 19                                      GAO-12-722 World Health Organization
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.




Page 20                                     GAO-12-722 World Health Organization
WHO Management Proposals       Management reforms encompass a broad range of areas, including
and Actions Encompass a Wide   efforts to (1) improve the predictability and flexibility of WHO’s financing;
Range of Areas                 (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      Multiple challenges could affect the success of WHO reform
Impede the Successful          implementation. WHO developed a high-level implementation and
Implementation of WHO          monitoring framework that included reform objectives, selected activities,
                               1-year and 3-year milestones, and intended results for consideration by
Reform                         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


                               Page 21                                      GAO-12-722 World Health Organization
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. 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. 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.




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.




Page 22                                             GAO-12-722 World Health Organization
                             The United States has provided input into WHO’s reform agenda,
The United States Has        particularly in the areas of transparency and accountability, but State’s
Provided Input into          tool to assess the progress of management reforms could be enhanced.
                             On priority-setting, the United States has advocated for WHO to maintain
WHO’s Reform                 its focus on certain functions such as setting norms and standards for
Agenda, Particularly         international health. On consultations on governance, the U.S. delegation
in Transparency and          has commented on a range of proposals put forth by WHO, including
                             those on engagement with other global health stakeholders. On
Accountability               management reforms, the United States has supported increased
Proposals, but State’s       transparency and accountability mechanisms at WHO; however, State’s
                             tool for monitoring progress in this area could be enhanced.
Tool for Monitoring
Progress Could be
Enhanced

The United States Has        In priority-setting consultations, the U.S. delegation has advocated for
Provided Input on WHO        WHO to maintain its focus on normative functions such as setting
Consultations on Priority-   standards and guidelines, as well as other areas such as health security
                             and communicable diseases. According to talking points used in
Setting and Governance       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.




                             Page 23                                     GAO-12-722 World Health Organization
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.

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.




Page 24                                      GAO-12-722 World Health Organization
The United States Has         The United States has supported an agenda for greater transparency and
Supported a Management        accountability for WHO management reforms. According to State officials,
Reform Agenda for Greater     State’s Bureau of International Organization Affairs takes the lead for the
                              U.S. government on issues related to management reform and is
Transparency and              responsible for pursuing management reforms throughout the UN system,
Accountability, but State’s   including WHO. U.S. officials mentioned a number of U.S. goals in this
Tool to Assess Progress in    area, including improving internal and external oversight mechanisms,
These Areas Could be          budgeting and planning processes, and human resources and
Enhanced                      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


                              Page 25                                    GAO-12-722 World Health Organization
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.

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


Page 26                                       GAO-12-722 World Health Organization
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


Page 27                                      GAO-12-722 World Health Organization
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.



Page 28                                    GAO-12-722 World Health Organization
                     WHO has undertaken an ambitious and comprehensive agenda for
Conclusions          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.


                     To improve U.S. assessment of WHO reform, we recommend that the
Recommendation for   Secretary of State enhance its guidance on completing State’s
Executive Action     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.




                     Page 29                                    GAO-12-722 World Health Organization
                     We requested comments on a draft of this report from the Departments of
Agency Comments      State and HHS, USAID, and WHO. State and WHO provided written
and Our Evaluation   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.


                     Page 30                                      GAO-12-722 World Health Organization
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
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,
Thomas Melito
Director, International Affairs and Trade




Page 31                                     GAO-12-722 World Health Organization
Appendix I: Scope and Methodology
             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; 1 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



             1
              The GAVI Alliance was formerly known as the Global Alliance for Vaccines and
             Immunization.




             Page 32                                           GAO-12-722 World Health Organization
Appendix I: Scope and Methodology




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.



Page 33                                     GAO-12-722 World Health Organization
Appendix II: GAO Assessment of State’s
                   Appendix II: GAO Assessment of State’s
                   UNTAI Assessment Tool



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, 1 which
                   requires that the data gathered are clear and well defined enough to
                   attain consistent results. 2 We reviewed the specific benchmarks used in
                   State’s UNTAI tool to determine potential risks to the accuracy and
                   consistency of the resulting assessments. 3


GAO’s Assessment   In conducting our analysis, we developed a methodology for determining
Methodology        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 app. 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.




                   1
                    Government Performance: GPRA Modernization Act Provides Opportunities to Help
                   Address Fiscal, Performance, and Management Challenges, GAO-11-466T (Washington,
                   D.C.: Mar. 16, 2011).
                   2
                    Auditing and Financial Management: Assessing the Reliability of Computer-Processed
                   Data, GAO-09-680G (Washington, D.C.: Jul. 1, 2009).
                   3
                    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.




                   Page 34                                              GAO-12-722 World Health Organization
                            Appendix II: GAO Assessment of State’s
                            UNTAI Assessment Tool




                            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   We determined that 35 of the 50 benchmarks in UNTAI (70 percent)
of 50 Benchmarks in         require neither subject matter expertise nor definitional judgment. Of the
State’s Assessment Tool     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.




                            Page 35                                     GAO-12-722 World Health Organization
Appendix III: Comments from the
                            Appendix III: Comments from the Department
                            of State



Department of State

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




                            Page 36                                      GAO-12-722 World Health Organization
Appendix III: Comments from the Department
of State




Page 37                                      GAO-12-722 World Health Organization
                 Appendix III: Comments from the Department
                 of State




See comment 1.




See comment 2.




                 Page 38                                      GAO-12-722 World Health Organization
Appendix III: Comments from the Department
of State




Page 39                                      GAO-12-722 World Health Organization
                          Appendix III: Comments from the
                          Department of State




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


               1. We recognize that some officers in the field completing the assessment
GAO Comments   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.




               Page 40                                      GAO-12-722 World Health Organization
Appendix IV: Comments from the World
             Appendix IV: Comments from the World Health
             Organization



Health Organization




             Page 41                                       GAO-12-722 World Health Organization
Appendix IV: Comments from the World Health
Organization




Page 42                                       GAO-12-722 World Health Organization
Appendix V: GAO Contact and Staff
                  Appendix V: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Thomas Melito, (202) 512-9601, or melitot@gao.gov
GAO Contact
                  In addition to the contact named above, Joy Labez (Assistant Director),
Staff             Diana Blumenfeld, Debbie Chung, Lynn Cothern, Karen Deans, Mark
Acknowledgments   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.




                  Page 43                                   GAO-12-722 World Health Organization
Related GAO Products
             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.


             Page 44                                   GAO-12-722 World Health Organization
           Related GAO Products




           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.




(320862)
           Page 45                                  GAO-12-722 World Health Organization
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