WHO’s Draft Concept Note: Treating the Symptoms, Not the Causes?

Global health policy enthusiasts will be excited to see that WHO has recently published a draft Concept Note on the 2019-2023 Programme of Work under the stewardship of its new Director-General, Dr. Tedros Adhanom Ghebreyesus (or Dr. Tedros, as he is generally known). The note will doubtless stimulate much discussion within WHO and among its stakeholders and—perhaps inevitably at this stage in the DG’s tenure—much of the detail remains to be filled in. However, the note does have an important role in establishing the key themes for the Organization in the next few years, and as such, it is disappointing that it does not offer a clearer storyline of where WHO wants to go.

We see two glaring missed opportunities: 1) more centrality to universal health coverage (UHC) as an organizing principle for WHO and its work, and 2) more emphasis on enhancing the value for money of public spending on UHC and elsewhere.

Missed opportunity #1: reiterate the centrality of UHC in reaching WHO goals

The first missed opportunity is the failure to reiterate the centrality of UHC to what WHO hopes to achieve. This is surprising as much of the success the WHO has had in recent years in setting the global policy agenda stems from its presentation of the moral and economic case for UHC, particularly in the World Health Report 2010.

By contrast, the treatment of UHC in the current Concept Note is fleeting and superficial. Its opening section “What does the world need?” contains a grab bag of “global health challenges,” leading off with the threat of pandemic flu. This is a missed opportunity to lay out the appeal and power of UHC as an integrative concept. Indeed, the best chance the world has to prevent outbreaks of diseases old and new, to cope with threats to health arising from conflict and natural disasters, to secure financial protection for citizens, to manage and contain the growth in non-communicable diseases, as well as all the other things listed, is if countries move towards sustainable and equitable financing of their health systems through implementing UHC.

The note also begs the question: what exactly would WHO’s role be in supporting countries in their progress towards UHC? Had they been more specific on where WHO can add value in supporting countries to reach their UHC vision, the authors of the draft strategy could be setting out measurable indicators and attributable results of WHO’s activity, which can then be used to inform the outcomes based agenda they advocate. Would WHO be offering advice and setting global norms? Would it be involved in or even leading efforts to devise progress indicators and help collect data and report progress against those as the latest edition of GBD has done? Would it go further and set standards for minimum benefits, populating the famous WHO UHC cube? Would it help countries track expenditure or provide advice on financing and provision arrangements? Would it do even more as suggested and become more operational (and what would this look like in country settings)? And if most or all of the above, where would the capacity come from—and would an alternative not be working with others operating in this space, leveraging already committed resources and expertise in a synergistic fashion? In the spirit of setting priorities and given finite resources, WHO must surely realise that its advocacy, global coordination, and norm-setting role are its real strengths.

What makes this neglect particularly surprising is that UHC is a prominent part of the platform on which Dr. Tedros stood and was elected by the World Health Assembly. Dr. Tedros’ campaign materials prominently list Health for All as the first priority and states clearly that:

“Health for all” must be the centre of gravity for efforts to achieve all of the SDGs … WHO’s top priority must be to support national health authorities’ efforts to strengthen their core responsibilities … Achieving universal health coverage is an ambitious goal, but it is one that can and must be achieved to create a healthier and more equitable world. 

No comparably strong statement appears in the present document which does not get around to discussing UHC directly until page 6, hidden between health emergencies and priority SDGs.

Missed opportunity #2: emphasize value for money in health spending and its uses

The second missed opportunity is about value for money (VfM). The UHC section of the note would be an ideal place to discuss prioritization of spending at country level, based on existing financial envelopes, while also making robust cases to countries’ treasuries for more. Instead we are given a bill: “Achieving the SDG health targets would require new investments increasing over time from an initial US$ 134 billion annually to $371 billion, or $58 per person, by 2030.” There is no mention of the need to spend better, as is clearly set out in WHO’s report on SDGs in Africa; and no mention of the lack of correlation between more spending and better outcomes.

When the note does get around to talking about VfM (on page 9), the discussion seems even more underdeveloped than the discussion of UHC. VfM should be a critical concept for WHO. But the note seems to take the narrowest possible interpretation of value for money, stressing the need for WHO to measure outcomes and operate sound financial management.

Yet as a global normative agency, WHO has a far broader duty—to guide those with the responsibility for managing the world’s health systems to adopt economic appraisal and prudent management practices. A good start would be to declare that WHO will operate on the principle of VfM in all policies, a principle which can be the responsibility of the organisation’s first Chief Economist as Glassman has argued recently.

So, WHO should adopt a reference case for economics to be incorporated into all WHO programmes and all norm setting functions, including new additions to the Essential Medicines List, especially when the new items are: expensive on-patent products; Standard Treatment Guidelines norms in high priority areas such as antenatal care; investment cases for MDG technologies which the Global Fund and UNITAID will go on to purchase at volume; diagnosis and treatment targets such as the 90-90-90 target for HIV; and treatment initiation thresholds for HIV/AIDS. All of this is necessary to ensure that money which flows into health systems is used to the greatest benefit of the target populations and to convince those who fund WHO that it is serious about the VfM agenda. Another important role that WHO could pursue is to promote VfM at the country level especially for transitioning countries—WHA2014 HITA is great starting point. As stated in the Resolution, WHO can help build local capacity for countries to select products, negotiate prices and fees, manage providers through performance contracts where possible, control for and reward quality. Without such capacity the bill for implementing UHC will be much higher and selling the costs to country Ministries of Finance will be harder. Indeed, given the focus of the note on performance indicators for WHO, building in-country capacity is something WHO could be held to account to and that could be linked to better progress towards UHC.

Dr. Tedros himself has said that “the right of every individual to basic health services will be my top priority.” Parsing “basic” as “affordable” puts UHC and VfM at the heart of the DG’s vision. Alas, this clear and compelling vision seems to have got lost in the present Concept Note, which presents a WHO trying to respond to a disparate collection of problems, but with no clear organizing concept of how to tackle the underlying systemic causes of these problems or prioritize competing demands on the Organization’s scarce resources.