DOCUMENT RESUME

02242 - [A1452432]

U.S. Participation in the World Healt'i Organization Still Needs

Improvement. ID-77-15; B-164031(2). May 16, 977. 52 pp.

Report to Sen. Abraham Ribicoff, Chairman, Senate Committee on

Governmental Affairs; by Elmer B. Staats, Comptroller General.

Issue Area: International Economic and Military Programs (600);

International Economic a Military Programs: U.S.

Development Assistance Overseas (603);Health Progr-.ms

(1200).Contact: International Div.Budget Function: International Affairs: Conduct of Foreign

Affairs (152); Health: Prevention and Control of fHealth

Problems (553).Organization Concerned: Department of State; Department of

Health, Education, and welfare; Agency for International

Develop-ent; World Health Organization.

Congressional Relevance: Senate Committee on GovernmentalAffairs.

An update to a previous report by GAO on U.S.

participation in the World Health Organization (WHO) addressed

the need for clear-cut U.S. policies and objectives on

international health. Findings/Conclusionrs: Former

recommendations b GAO that the two Departments and one Agency

involved should formulate statements of such policies have not

been carried out because of lack of coordination among U.S.

health-concerned agencies. Although there has been some

improvement in U.S. efforts to analyze WHC activities,

information from overseas posts is often of little se because

of inadequate collaboration between U.S. and WHO personnel. WHO

planning and program budgeting procedures have improved, but

there are still shortcomings in the process and in meeting U.S.

needs for information. Current issues affecting WHD are (1) a

proposal of the Geneva Greup to limit budget growth of the U.N.

and specialized agencies; and (2) a 1976 World Health Assembly

resolution to allocate 60% of the Regular Program Budget to

technical cooperation and services by 1980. GAO believed there

was merit in the Geneva Group proposal, but expressed concerns

about the resolution. Recommendations: The Secretary of State

should form an Interagency Committee to (1) de7elop objectives

.ad agroe on a lan to achieve objectives; (2) submit an annual

statement to Congress; (3) give priorities to obtaining better

information; ad (4) provide for U.S. epresentation in budget

formulation. He should improve WHO planning and evaluation by

encouraging financial decisions, formulation of national health

plans by member nations, and complete dissemination of program

information. He should assert that U.N. development should be

channeled through the United Nations Development Program and

financed through voluntary contributions. (HTW)

REPORT TO THE SENATECOMMITTEE ON GO VERN.fMENATAL

,~S!rc, AFFAIRSo0 :w BY THE COMPTROLLER GENERAL

< -- m OF THE UNITED STATES

U.S. Participation In TheWorld Health OrganizationStill Needs ImprovementDepartments of State and Health,Education, and WelfareAgency for International Development

This report describes the activities of theWorld Health Organization, discusses currentissues affecting the Organization, identifiesthe lack of clear U.S. policy objectives in theOrganization, and makes recommendations tothe Secretary of State to improve U.S. partic-ipation.

ID.77-15 MAY 16, 1977

CCJMPT ROLL:R GENERAL OF THE UNITED TATEWAYINwTON. D..

B-164031(2)

The Honorable Abraham RibicoffChairman, Committee on GovernmentalAffairs

United States Senate

Dear Mr. Chairman:

Your letter of July 30, 1976, advised us of the Commit-tee's current examination of the United States involvementin international organizations and asked that our previouswork in this area be updated. This report is in responseto your request for our current views on the World HealthOrganization.

We share your concern about much that still needs tobe done to make U.S. participation in U.N. specializedagencies, such as the Organization, more effective. Wecommented on several financial and program issues currentlybefore the Organization which U.S. officials should act on.The principal concern, however, continues to be a need todevelop clear-cut U.S. policies and objectives on interna-tional health. In this regard, we hope our recommendationswill help you and the other Committee members to carry outyour difficult oversight tasks.

In order to expedite the report, we did not followour usual practice of obtaining written agency comments.We did, however, discuss the report matters with responsibleofficials of the agencies concerned and considered theirviews in finalizing the report.

This report contains several recommendations to theSecretary of State concerning improvements needed in variouspolicy and management areas. As you know, section 236 of theLegislative Reorganization Act of 1970 requires the head ofa Federal agency to submit a written statement on actionstaken on our recommendations to the Senate Committee onGovernmental Affairs and the House Committee on GovernmentOperations not later than 60 days after the date of the re-port and to the House and Senate Committees on Appropria-tions with the agency's first request for appropriationsmade more than 60 days after the date of the report.

B-164031(2)

As agreed with your office, we plan to distributethis report to te agencies involved and other appropriatecongressional committees.

As always, we stand ready to render further assistanceon the matters presented in this report.

Siperely y rs

Comptroller General.of the United States

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COMPTROLLER GENERAL'S U.S. PARTICIPATION IN THE WORLDREPORT TO THE SNATE HEALTH ORGANIZATION STILL NEEDSCOMMITTEE ON GOVERNMENTAL IMPROVEMENTAFFAIRS Department of State

Department of Health, Education,and Welfare

Agency for International Develop-ment

DIGEST

Despice previous GAO report recommendationsthat the three departments or agencieslisted above formulate and publish clearstatements of U.S. policy objectives, prior-ities, and interests in the World ealthOrganization, these actions have not beentaken. Unsatisfactory efforts to formulateclear U.S. international health objectivesare due to the lack of coordination amongthe many health-concerned U.S. agencies.(See pp. 10 and 11.)

MANA',NG US. PARTICIPATION

In order to provide the specific policydirection and guidance needed to manageU.S. interests in the World Health Organi-zation, GAO recommends that the Secretaryof State form an Interagency Committeechaired by him or his designee for thepurposes of

--developing specific objectives for U.S.particir tion and coordinating theseobjectives with all pertinent U.S.groups;

--agreeing on a plan for achieving U.S.international health objectives andimplementing U.S. policy in the Or-ganization;

--submitting to the Congress annually,a statement of specific goals andobjectives together with an assessmentof accomplishments, as part of eachcongressional budget presentation;

ear Sheet. Upon removal. the report ID-77-15cover date should be noted hereon.

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-- giving priority to obtaining better in-formation and providing more independentanalysis of Organization activities atthe regional and country levels; and

-- providing a greater U.S. mpact on theOrganization's budget by having U.S.representatives work with Secretariatofficials during the early stages ofbudget formulation. (See p. 19.)

PREPARING U.S. POSITIONS

U.S. efforts to analyze and evaluate Or-ganization activities are less sketchythan at the time of GAO's 1969 and 1974reports. However, improvements still canLe made. Because collaboration between U.S.and Organization field personnel is, inGAO's view, insufficient, the informationprovided by U.S overseas posts is oftenof little use to agency managers in eval-uating the Organization's programs andpolicies. If better information were pro-vided and improved contacts were made atcountry and regional office levels, U.S.health officials could participate moreeffectively in the Organization. (Seepp. 13 and 14.)

Agency for International Development of-ficials recognize that information fromU.S. sources abroad is limited and theyhave attempted to improve collaborationwith the Organization. (See p. 14.)

PLANNING AND EVALUATION

The Organization's planning and programing,as these relate to U.S. interest and activ-ities, have improved since GAO's previousreports. U.S. officials look forward tomore timely and morn useful informationfrom the Organization on its activities,but further efforts are still needed. Forexample:

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-- The Organization's 6-year General Programmeof Work needs financial decisions that willprovide a better link with its biennialbudgeting. This would provide clear andmore effective medium-range priorities andobjectives and better serve the special in-terests of the U.S. and other major contrib-utors. (See pp. 21, 25, and 26.)

-- Short-term planning--the biennial programbudgeting process--is still too project-oriented and also lacks clear objectives.A lack of national country health planningby most member countries will continue tohamper the Organization's ability to meetthe real health needs of these members andto efficiently plan how to use its limitedresources. (See pp. 22, 27, and 28.)

The Organization's new information reportingand evaluation systems are expected to per-mit more effective evaluation of Organiza-tion activities, not only by the Secretariatitself, but also by the United States andother members. The usefulness of these sys-tems to the United States and other memberswill depend, in part, on how they are used.(See p. 32.)

In order to further improve the Organization'splanning and evaluation, GAO recommends thatthe Secretary of State

-- encourage the Secretariat to includefinancial decisions in its medium-termplanning;

--ask top Organization officials to urgemember governments to formulate nationalhealth plans, thereby providing a clearerbasis for the Organization's short-termplanning; and

-- have U.S. de, es obtain the most com-plete dissem 4 ion possible of programinformation a evaluation for all mem-bers. (See pp. 30 and 36.)

Tear 5heel iii

CURRENT ISSUES

Two issues are having and will probably con-tinue to have considerable impact on theOrganization's activities and on U.S. policytoward the Organization.

One issue is a proposal of the Geneva Groupof major contributors to limit the budgetgrowth of the United Nations and its special-ized agencies. The Group, which was told thatits proposals will not affect the 1978-79 Organ-ization budgets, expects to have an influenceon the 1980-81 budgets. GAO believes thiseffort is a step in the ri 'ht direction andis in the best iterests of both the developedand developing countries. (See p. 37.)

The other issue arose from a 1976 World HealthAssembly resolution directing the Secretariatto allocate 60 percent of the Regular ProgramBudget to technical cooperation and servicesby 1980. U.S. officials are concerned aboutthis, but approve of portions of the resolu-tion calling for streamlining operations andcutting out obsolete programs. The State De-partment is reserving its complete positionon the resolution, pending Secretariat deci-sions on how it will be carried out in the1978-79 and 1980-81 Program Budgets. (Seep. 40.)

GAO believes the current issues before theOrganization also stress the importanceof the United States taking a position thatall U.N. development and technical assistancebe channeled through the United Nations Devel-opment Program. The growing financial andoperating independence of U.N. specializedagencies, such as the Organization, have theeffect of undermining the United NationsDevelopment Program centrrl funding andmonitoring system--a system that the UnitedStates and other countries worked hard to es-tablish. GAO therefore, believes it importantthat U.S. officials renew efforts to bring allU.N. development assistance programs underthe coordinated mantle of the United NationsDevelopment Program. (See p. 44.)

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GAO also believes the decisions of the Organi-zation to finance more development assistancealso focuses attention on a financial issue.That is, that the Organization has been a majorexception to the U.S. Gvernment policy thatU.N. technical assistance be funded from voiun-tary contributions rather than assessed funds.The recent action by the Organization to spendmore of the assessed budgets for technicalprojects calls for the U.S. to reexamine theOrganization's exception to this U.S. policy.(See p. 45 )

Accordingly, GAO recommends that the ecretaryof State

-- express U.S. concern over the trend awayfrom United Nations Development Programleadership and reassert that all U.N.development and technical assistance bechanneled through this Program and

--reaffirm that the proper way to financeU.N. development activities is throughvoluntary contributions.

AGENCY COMMENTS

GAO did not obtain formal, written agencycomments on this report. GAO did discussthe report matters with responsible offi-cials and appropriately introduced theirviews in the body of the report. Agencyofficials generally agreed with our reportpresentation and recommendations.

TerShot'.

Contents

Page

DIGEST i

CHAPTER

1 INTRODUCTION 1Brief description of World HealthOrganization 1

U.S. contributions 1What the Organization does 1Evolving priorities 2

The role of the Organization 3

How the Organization works 4

Finances 4Scope of review 7

2 MANAGEMENT OF U.S. PARTICIPATION 9U.S. policy objectives and priori-

ties 9Ordered priorities still

lacking 10Lack of policymaking mechanism 11

Preparing U.S. positions 13Limited opportunities for analy-

sis 13Other suggestions for improving

effectiveness of U.S. partici-pation 15

Conclusions 17Recommendations 19Agency comments 19

3 THE ORGANIZATION'S PROGRAM PLANNING ANDBUDGETING 20

The programing process 21Medium-term planning 21Short-term planning 22

Budget preparation 24Planning and program budgeting still

need improvement 25U.N. study recommends financialdecisions in medium-termplanning 25

Other proposals and actions toimprove planning 26

Conclusions 29Recommedations 30

CHAPTER Page

4 THE ORGANIZATION'S REPORTING AND EVi'LU-ATION 31

External evaluation 31Internal audit 32New internal information and evalua-

tion systems 32Availability of information to mem-

ber governments 34Reservations about the new system 34Conclusions 35Recommendation 36

5 CURRENT ISSUES 37The Geneva group proposes percentage

limits on the United Nations andspecialized agency budgets 37Subsequent developments 38

The 60-percent resolution 40U.S. views of the resolution 42

Conclusions and recommendations 43

APPENDIX

I Letter dated July 30, 1976, from SenateCommittee on Government Operations 46

II Other U.N. bodies involved in health 47

III Composition of the U.S. delegation atthe 1976 World Health Assembly 50

IV Principal officials responsible for ad-ministering activities discussed inthis report 52

ABBREVIATIONS

AID Agency for International Development

GAO General Accounting Office

HEW Department of Health, Education, and Welfare

OIH Office o International Health

UNDP United Nations Development Program

APTER 1

JDUCTION

BRIEF DESCRIPTION OFWORLD HEALTH ORGANIZATI

The World Health Organization, headquartered in Geneva,Switzerland, is one of several specialized agencies affiliatedwithii the United Nations. It was established in 1948 with thelong-term goal of helping all people attain the highest pos-sible level of health. The Organization has 151 members and2 associate members. 1/ Its estimated expenditures for 1977are approximately $26! million. During 1975 more than 2,200health projects were underway in member countries. Fellow-ships were awarded to 5,082 individuals for studies or par-ticipation in meetings. Seventeen conferences were held and65 new scientific publications were issued.

U.S. contributions

The United States hls been a member of the Organizationsince it began. The U.S. portion of the $147,184,000 totalassessed budget for 1977 is $39,637,540. For the period1948 to 1976, U.S. contributions totaled $349,824,000.

U.S. pledges to the Organization's Voluntary Fund forHealth Promotion in 1975 were $1,574,938. Pledges through1974 totaled $33,158,556. These figures do not includepledges made by private U.S. foundations or individuals.

WHAT THE ORGANIZATION DOES

The Organization's work is divided into several pro-gram areas--research, disease prevention and control, healthmanpower development, environmental health, strengtheningnational health services, and administrative support serv-ices. A variety of activities is included in each program

1/Namibia and Southern Rhodesia, associate members, partic-ipate in the deliberations of the Organization, but arenot permitted to vote.

area.. For example, environmental health covers activitiessuch as helping members plan for safe water supplies andadequate waste disposal facilities; promoting programs forthe early detection and control of pollution (noise, radia-tion, heat, industrial wastes, sewage, etc.); promotingprograms to insure that food is free from germs or othercontamination.

In the area of health services, the Organization'sactivities include helping members to improve their healthplanning, encouraging the provision of basic health careto the underserved, high risk, and vulnerable groups ofpeople; promoting the control of certain nutritional defi-ciencies; promoting the treatment of mental health, includ-ing the prevention of mental diseases, alcoholism, and drugabuse.

The nmber and variety of activities reflect thepriorities of the member States. This comprehensivenesshas been criticized by the Organization's Executive Boardas resulting in "fragmented, unrelated efforts that werescmetimes marginal to the solution of high priority prohblems."

EVOLVING PRIORITIES

Important changes in membership and priorities havetaken place. Today a majority of the Organization's mem-bers are developing countries. With the change in member-ship came a gradual shift in the Orgar;ization's priorities.For a long time, the Organization emphasized health problemswith actual or potential worldwide impact, such as malaria,smallpox, tuberculosis, and sexually transmitted diseases.Although prevention and control of such diseases continue toreceive considerable resources, the health problems ofdeveloping countries have clearly become the Organization'sleading priority.

As a result, there has been considerable reassessmentof traditional programs and approaches. For many yearsconventional wisdom had associated the level of health ina country with such health resources as the number of hos-pitals, doctors, research laboratories, medical schools,etc. However, developing countries generally lack theresources to support sophisticated Western technology.Because of the concentration of health services in urbanareas and their limited availability in general, they wereoften inaccessible to the poor in these countries.

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Responding to the need for greater depth and coveragein health programs in developing countries, the Organizationhas adopted several new programs. For example, particularemphasis has been placed on strengthening the capacity ofmember governments to plan and manage comprehensive nationalhealth services. In this field of "country health program-ming," Organization experts help national health plannersto pinpoint priority health problems, identify areas sus-ceptible to change, and formulate priority programs. TheOrganization stresses that its role in this process is todevelop methodology, stimulate interest, and collaboratewith rather than supplant national efforts.

In addition to developing new areas of activity, theOrganization has also adopted new approaches to existingprograms. For example, since 1948 it has participated inprograms to train health personnel, with the emphasis inprior years on the education of doctors and n ses. Be-cause of the time and expense involved in thi, approach,the Organization is now emphasizing programs to developauxiliary health personnel. After only a few months oftraining, locally selected workers are able to make simplediagnoses, dispense rudimentary treatment, and undertakebasic preventive measures to safeguard health.

THE ROLE OF THE ORGANIZATION

The recent evolution in the Organization's work hasled to a rethinking of its central role. One of its re-cent publications concludes that "technical assistance to.member states appears to have taken precedence over co-ordination in the evaluation of the Organization's pro-gramme." It continues by stating that the goal should beto recognize that current program management is the respon-sibility of member governments and to phase out the Organ-ization's role in implementing health projects. At thesame time, there should be increasing efforts to

--develop national resources through education andtraining,

-- identify and focus attention on high priorityhealth problems, and

-- help members obtain and use external assistance.

The Organization's present role is thus seen as one ofcoordination, that is, to develop rather than to supplantnational capabilities.

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HOW THE ORGANIZATION WORKS

In contrast to other U.N. agencies, the bulk of the

Organization's 5,350 employees are situated in regional of-

fices. The 2.5 to 1 ratio of field to headquarters staff

is indicative of the strong regional orientation of the

Organization. A recently approved resolution appears likely

to further strengthen the regional offices.

The following chart shows how the Organization is

structured and the relationship among member governments,

the Organization's Secretariat, and its various governing

bodies.

The six regional offices play a central role in devel-

oping the projects that make up the overall program. Each

member State belongs to one of these geographic regions.

Health projects are first identified by the member govern-

ments and referred to the appropriate regional office. The

region develops a plan of operation including the project

objective and source of funds. The Proposed project must

fall into one of the Organization's major program areas.

The approved regional program budget--consisting of member

country projects and interregional projects--is forwarded

to the Organization's headquarters. The headquarters

staff--the Secretariat--puts together a consolidated program

budget for the six regions and headquarters. The 30-member

Executive Board reviews the consolidated budget and makes

recommendations to the governing body--the World Health As-

sembly. ll member States are represented in the Assembly

which meets once a year to approve the program budget. 1/

A more detailed description of the process is provided in

chapter 3.

FINANCES

Organization documents show that it has three major

sources of income (1) member assessments, (2) contributions

to the Organization's Voluntary Fund for Health Promotion,

and (3) funds from other U.N. agencies.

Assessments levied against members make up what is

known as the regular budget and account for about two-thirds

l/The United States is a member of both the America's and

Western Pacific regions.

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WORLD HEALTH ORGANIZATION

EACH MEMBER GOVERNMENT

belongs to one of 6BEGIONS

- Regional Off;e staff, in close collaboration with govern-ments, prepares a program budget, approved by Members ofthe region.

-Regional program budgets are submitted to the ...

SECRETARIAT

headed by theDIRECTOR GENERAL

which

reviews and consolidates th 6 regional program budgets andthe headquarters program budget, and submits the consoli-dated program budget to the ...

EXECUTIVE BOARD

consisting of 30 Member governments selected by the WorldHealth Assembly; each gov't. selects individual represen-tatives to serve on the Board.

- Board reviews and makes recommendations on the pro-gram budget to the ...

WORLD HEALTH ASSEMBLY

consisting of 3 delegates from each Member

- Assembly approves the program budget and establishes thepolicies and objectives governing the work of WHO.

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of total resources. 1/ The regular budget for calendar year1977 is $147,184,000.

Since 1950 the Organization's regular budget has in-creased at a rapid rate.

Calendar year Regular budget

1930 $ 7,500,0001960 18,113,7601970 67,650,0001974 106,328,8001977 147,184,000

The Secretariat has estimated that by 1979 the regular budgetwill reach at least $173 million.

Contributions by member States and private groups tothe Organization's Voluntary Fund for Health Promotion makeup another major source of extra-budgetary income. Voluntarycontributions of about $32 million in 1975 were more thandouble those received in 1974. Between the time the Volun-tary Fund was set up in 1960 and the end of 1975, contribu-tions and pledges totaled $115,463,703. Pledges by 92 mem-ber States account for 92.5 percent of this total. Theremaining 7.5 percent came from private foundations and in-dividuals. Contributions to the Voluntary Fund can be undes-ignated or earmarked for 1 of 12 programs such as malariaand smallpox eradication and community water supply assis-tance to the least developed countries.

The other major sourc, of supplementary or extra-budgetaryfunds are other U.N. agencies. The Organization acts as theimplementing agency for health projects financed by a numberof agencies, icluding the U.N. Development Program (UNDP),

1/Resources of the Pan American Health Organization arenot included, as the Organization's regional office forthe America's has sources of income in addition to con-tributions from the Organization's regular budget. Itlevies assessments against members and also receivesvoluntary contributions. Pan American Health Organiza-tion's estimated revenue for 1977--excluding the Organiza-tion's funds--total $36,466,909.

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the U.N. Fund for Population Activities, the U.N. Fund for

Drug Abuse Control, and the U.N. Environment Program. 1/

In 1977 the estimated value of health projects managedby the Organization for these agencies is $44,978,667.

As an example of how the funds were used, the ExternalAuditor reported that the total 1975 approved budget of$119,310,000 was used in the following major program sectors:

Organizational meetings $ 1,678,272Executive management and coordination 5,839,257Research promotion 499,839Strengthening of health services 19,557,394Health manpower development 15,416,590Disease prevention and control 28,615,291Promotion of environmental health 6,896,566

Health statistics and information 12,185,406Personnel and general services 15,431,052Regional program planning activities 13,188,219

Total $119,308,886

This leaves a surplus of $1,114.

SCOPE OF REVIEW

On January 9, 1969, we issued a report entitled "U.S.Participation in the World Health Organization." 2/ In July1976 the Senate Committee on Government Operations asked

that the report be updated to assist the committee in itsreview of American involvement in international organiza-tions.

We made our review in Washington at the agencies having

primary responsibility for management of U.S. participationin the Organization:

1/Other U.N. bodies which contribute to the Organization'sextra-budgetary resources are included in a list of U.N.

organizations involved in health in appendix II.

2/GAO followed up on this and other reports on internationalorganizations in a Jul.y 1974 report "Numerous ImprovementsStill Needed in Managing U.S. Participation in Interna-tional Organizations," B-168767.

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--The Office of Health and Drug Control, Bureau ofInternational Organization Affairs, Departmentof State.

-- The Office of International Health (OIH), U.S.Public Health Service, Department of Health, Educa-

tion, and Wlfare (HEW).

-- The Office of ea;th, ureau of Technical Assistance,Agency for Inteirational Development (AID).

Audit work was also perfcr~n t the Organization'sheadquarters, the U.S. Mission t United Nations, and

other international organizations ,eneva, Switzerland,and the Organization's European reqgjnal office in Copen-hagen, Denmark. We also visited a developing country re-

ceiving assistance.

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CHAPTER 2

MANAGEMENT OF U.S. PARTICIPATION

Overall authority for U.S. relations with the WorldHealth Organization lies with the Secretary of State. Overthe years, the State Department has come to rely upon theDepartment of Health, Education, and Welfare's Public HealthService and the Agency for International Development for muchof the input regarding the technical aspects of internationalhealth, while the State Department retains responsibility forpolitical, financial, and administrative matters. The StateDepartment also has final authority for clearing the positionpapers prepared by the other agencies for U.S. delegates andrepresentatives to the Organization's governing body meetings.(U.S. delegates to the 1976 World Health Assembly are listedin appendix III.)

Our previous reports noted the absence of adequatelydefined policy objectives and priorities to guide U.S. offi-cials in looking after our interests in international health,in general, and regarding our participation in the Organiza-tion, in particular. We believe this lack of direction stillexists and that the efforts of the State Department in coordi-nating U.S. positions and programs in international health arenot yet satisfactory. In fairness, it is also a function ofthe diversity of both U.S. and international health concerns,and the difficulty of rationalizing our own domestic healthneeds with overall world health needs and those of individualmember countries in the Organization.

We have also reported in the past that U.S. efforts toinfluence the Organization's programs and policies were ham-pered by shortcomings in the U.S. system for analyzing andevaluating Organization activities. Although improvementshave been made, our review showed that some problems stillexist: lack of operational and evaluative data from theOrganization itself; insufficient contact between U.S.health officials overseas and the Organization's fieldactivities and the related lack of information from thesesources; and limited efforts to effectively use U.S. over-seas personnel resources to influence the Organization'sactivities.

U.S. POLICY OBJECTIVES AND PRIORITIES

There are various U.S. Government agencies involved ininternational health matters. In addition to the major U.S.agencies (HEW, State Department, and AID), others include the

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Departments of Defense, Agriculture, and Commerce; the PeaceCorps; and the Environmental Protection Agency. Numerousbureaus and divisions within these agencies also have aninterest in the impact on international health matters ofconcern to the United States. Our observations reveal thatthese agencies are dpt to have varying health objectives,priorities, and strategies. For example, EW and AID aresubject to different legislative mandates, and they carry outdifferent responsibilities. Thus, their stracegy and policypapers show 'some basically differing general philosophiesregarding international health matters. HEW is mainly con-cerned with how efforts to combat worldwide health problemsmay have an impact on domestic health concerns, as in thesmallpox eradication program. AID's primary concern, on theother hand, is with the socioeconomic development impact ofhealth improvement efforts in the developing countries, as inits family planning efforts.

Ordered priorities still lacking

One purpose of our review was to attempt to determine towhat extent there is any systematic ordering of these some-times competing priorities, to provide guidance for U.S.officials dealing with the Organization.

We found that there have been numerous general expres-sions of U.S. Government concerns regarding internationalhealth problems and regarding the program direction and poli-cies of the Organization. In his address to the 29th WorldHealth Assembly in May 1976, for example, the U.S. ChiefDelegate spoke of U.S. concern and desire to cooperate withthe Organization regarding the general areas of delivery ofbasic health care to rural areas, communicable disease con-trol, and the impact of environmental conditions on health.Specifics in these areas, such as infant mortality, malnutri-tion, and tropical diseases were mentioned. The U.S. Delegatealso expressed U.S. awareness of the need for the Organizationto join forces with those working in other areas of economicdevelopment. These same concerns--general U.S. objectives andpriorities--have also been expressed in U.S. health agencies'planning and policy documents, such as a nearly completed AIDhealth strategy, and by numerous U.S. health officials.

The question remains, as first noted in GAO's 1969 re-port, whether general statements of U.S. world health con-cerns, and agreement in principle with the equally generalgoals and objectives of the Organization and the internationalhealth community, are sufficient to provide the kind of spe-cific policy direction and guidance needed by U.S. officialsto manage our interest in the Organization.

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Several U.S. health officials indicated to us that U.S.approval of the Organization's medium-term plan, which laysout general policies and objectives for a 6-year period, is,in effect, the only comprehensive statement of U.S. policyregarding the Organization's programs and activities. Asdiscussed in detail in the next chapter, this program is,however, very broad in scope, and whatever the amount of U.S.input into its formulation, it cannot serve as the clearstatement of U.S. policy objectives and priorities that isneeded.

Officials at the U.S. Mission in Geneva have sought morecomprehensive guidance. In April 1976 the Mission prepareda policy statement of Mission goals in order to better focusits efforts to represent U.S. interests in the Organization.The statement says that the fundamental objective of theMission is:

"To attain the most effective possibleparticipation by the U.S. in the budgetary plan-ning and program planning of the World HealthOrganization."

As it goes on to dscuss means to achieve this and other ob-jectives, the statement refers to efforts in terms of "U.S.interests in international health," programs and activitiesto which the U.S. assigns special priority," and "U.S. policyon the WHO (World Health Organization]." The statement doesnot, however, spell out what these interests, priorities, andpolicies are. Mission officials agreed that they need fromthe State Department a clear statement of U.S. policy objec-tives and priorities.

The Mission's draft statement was sent to the State De-partment's Bureau of International Organization Affairs forcomment and approval. It was returned to the Mission withsome suggested changes, but without formal approval of theState Department. Bureau officials said Mission goals werestill in the formative stage as far'as the State Departmentwas concerned and had not become U.S. policy. The State De-partment indicated that the statement is a helpful develcp-ment and has potential; it is not known when a final approvedstatement of policy goals will be forthcoming.

Lack of policymaking echanism

This lack of clear guidance for managers of U.S. inter-ests in the Organization points up the need, in our view, fora formalized interagency committee mechanism for formulating,

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coordinating, and implementing U.S. positions and programsin international health.

This issue was addressed in a July 1974 staff study ofHEW's Office of International Health on a strategy for the

public health service in international health. It calledfor increased coordination with the State Department andother agencies with health concerns in the development ofpolicies and programs. There followed an exchange of lettersbetween the Secretaries of HEW and State.

The Secretary of HEW said that HEW would be pleased tocooperate with State in developing "* * * mechanisms whichwill provide a continuing meanE for joint consideration ofinternational health policy." The Secretary of State re-sponded, suggesting HEW staff people contact State's Bureauof International Scientific and Technological Affairs, nowthe Bureau of Oceans and International Environmental, andScientific Affairs to make the necessary arrangements. OIH'sDirector and the Bureau's Deputy Assistant Secretary met andagreed to form an interagency committee to "advise the Secre-taries of HEW and State on basic policy matters relating tothe conduct of international health."

However, according to an OIH senior official, this 1974

effort to establish a policymaking mechanism did not resultin any formal coordinating group being formed. During our

revie, he said that OIH had backed off on its initiative to'

get all the agencies involved in international health to sitdown formally and determine who should do what, and what theU.S. policy should be.

In spite of this apparent withdrawal of interest, thereis evidence of OIH's continued recognition of problems arisingfrom the lack of coordinated policies and programs. For ex-ample, inconsistencies in U.S. international health activitieswere noted in the OIH mid-1976 planning document, similar tothe earlier strategy paper. It pointed out:

"* * * there are examples of independent actionon the part of AID in international health ac-tivitieF which at times are inconsistent with,for example, basic U.S. Government policy towardWHO [World Health Organization]."

Our review of the OIH paper showed that it does not givespecific examples of the inconsistent and out of phase activi-ties and programs nor does it attempt to detail what basicU.S. Government policy toward the Organization consists of.

12

PREPARING U.S. POSITIONS

Our previous reports stated that U.S. agencies involvedin international health matters did not have sufficient in-formation to analyze and evaluate the efficiency and effec-tiveness of the Organization's ongoing programs, nor did newprogram proposals contain enough information on content, ob-jectives, and criteria to allow for reasonable projections oftheir success. Information received from both the Organiza-tion and U.S. sources overseas were found to be deficient.As noted in chapter 3, the Organization is making efforts toimprove its reporting and evaluation; it remains to oe seenhow effective these efforts will be. At the same time, U.S.analysis and position preparation (discussed below) appear tobe less sketchy than in previous years, although improvementsin procedures and focus can still be made.

Limited opportunitie for analysis

U.S. health officials told us that the information re-ceived from the Organization is not really adequate to makedetailed analysis and evaluation of programs and projects.The documentation provided by the Organization before govern-ing body meetings consists of officiLl documents on programand budget proposals, financial reports, and some technicalpapers. These documents do not contain evaluations of on-going programs. Due to this lack of operational and evalua-tive data from the Organization, U.S. officials can onlyanalyze spending trends in various programs. As discussedin chapters 3 and 4, the Organization is moving to improveits program formulation and evaluation, and this is expectedto provide members with better information on the Organiza-tion's act vities.

Our review indicated that one of the major U.S. effortsis to analyze and evaluate Organization activities at the endof each year, just before the annual January executive boardmeetings at which the Director-General's program and budgetproposals are presented. The United States has only recentlyreceived Organization program and budget documents on anytningapproaching a timely basis--much of the documentation for theboard meeting in January 1976, was received in mid-November1975. In previous years, however, this information was notreceived earlier than mid-December and very often not untilearly January.

As noted in the preceding section on policy objectives,there is no formalized body, such as the suggested inter-agency committee, which meets to determine U.S. policy and

13

positions on Organization programs and activities and U.S.participation in the Organization. We found that the agen-cies involved do, however, meet on an ad hoc basis beforemajor Organization forums such as board and assembly meetings.Agency officials also said they keep in touch during the yearon issues of mutual interest. The ad hoc meetings are usedto determine responsibility for commenting on various agendaitems for upcoming meetings and on the documentation for theitems provided members by the Organization.

Since U.S. health analysts have not received from theOrganization all the information needed to do adequate anal-ysis and evaluation, information from U.S. sources overseasis considered important. The problem is, however, that theonly major reporting received from U.S. sources overseas--the State Department's reporting system--Evaluation of U.N.Assistance Programs--focuses on the United Nations Develop-ment Program. This system only marginally reports on U.N.specialized agencies such as the Organization and then onlyinsofar as they present major problems or bear primarily onUNDP programs. According to the State Department's guidanceto overseas posts, these reports are intended to be of value"as background material for preparation of USG [U.S. Govern-ment] positions in the governing bodies of the [UN] organiza-ticn concerned * * *," and to enable representatives at U.S.Missions to U.N. organizations such as the Organization to"take up appropriate problems with the organization concerned."

These reports are not, however, of notable value, ac-cording to some U.S. officials. These officials said thatthe reports are not useful in evaluating the Organization'sbudget and program proposals or for preparing position papersfor board and assembly meetings largely because in the healthfield, they do not report any detail on a country's totalhealth picture, just AID health projects. According to U.S.officials, the reports are also of little use to the U.S. Mis-sion in Geneva for dealing with Organization matterc, becausethey do not address the kinds of health sector problems in-country which can be dealt with at Organization headquarters.

AID's top officials recognize that information from U.S.sources abroad is limited, and they have attempted to improvecoordination and collaboration between AID and the Organiza-tion. For example, in October 1974 AID set up a mechanismwith Organization headquarters in Geneva for annual jointprogram reviews. Then in June 1975 AID requested all prin-cipal AID country missions to provide information on theexisting status of the Organization-AID relations in eachcountry, and specifically instructed the missions to initiate

14

discussions with Organization representatives on how theymight work together more effectively. The June instructionwas intended both to acquaint the missions with the newarrangement for top level coordination between AID and theOrganization and to seek to extend or expand this workingarrangement to the country and regional levels. Accordingto an August 1976 AID report on this effort, 26 of the58 addressee missions responded to the request. Of these,only 9 reported regular meetings with Organization represen-tatives, while 14 reported ad hoc or informal relationships.

The U.S. AID mission in a country we visited during our

review responded only that while a structured program of co-ordination might be desirable at the headquarters and re-gional levels, such an arrangement was not desirable for thatcountry.

The depth and breadth of existing collaboration withOrganization representatives reported by the missions wasquite limited, with only seven mentioning nutrition, fivemalaria, and four each health planning and low cost healthdelivery systems. These are among the top priorities of boththe Organization and the U.S. Government. It would appearthat the limited amount of contact with Organization activi-ties is not an adequate basis for useful reporting to thoseresponsible for managing U.S. participation in the Organiza-tion.

AID officials felt that the results of the reporting onoverseas coordination efforts were more successful than wecharacterized, They also cited lack of AID personnel assignedoverseas as a factor limiting the response to the reportingrequest.

Other suggestions for improvingeffectiveness of U.S. participation

Other suggestions have been advanced that, if imple-mented, could help to bring about more effective U.S. par-ticipation in Organization planning and implementation.These are in addition to the needs pointed out earlier in

this chapter regarding stated policy objectives, a mechanismfor policy and planning formulation, and improved analysisof Organization activities. Suggestions include (1) assign-ing regional health attaches in selected cities where theOrganization's regional offices are located and (2) deter-mining ways to make meaningful contact with the Organiza-tion's Secretariat earlier in the program formulation process.

15

The regional health attache idea was proposed in 1974 byOIH. The OIH staff study referred to earlier suggested thatsuch positions in some regional oftice cities would allow thegathering of health and biomedical information and providethe opportunity to influence and the ability to coordinateU.S. Government input into health activities around the world.The study said it would provide a mechanism for assuring thatAID country mission programs in the region, Organization ac-tivities, HEW programs, and eventually programs conducted byother U.S. agencies were mutually supportive. It was proposedthat the positions be filled by public health service employ-ees, funded by AID, and administratively supported by theState Department, thus actively committing all three agenciesto the responsibilities and functions of the positions.

AID officials told us that HEW's regional attache pro-posal could not be carried out by AID, because of AID's dif-ferent mandate, priorities, funding availabilities, and lackof resources to devote to this purpose.

r need for some such mechanism, however, can be seenin an example of the lack of collaboration between HEW andAID regarding an Organization project in a country we visitedduring our review. The project, funded by HEW and executedby the Organization, is of particular interest to AID--thedelivery of maternal and child health care services in ruralareas. Yet, we could find no evidence that the AID missionwas consulted-in formulating the project and found that,nearly 4 years after the project began, AID mission officialswere unfamiliar with the project's status and could not deter-mine how it might relate to a proposed AID project for thecountry in family health training.

OIH held some discussions with the State Department andAID regarding the regional attache proposal in late 1974 andseemed optimistic that such a mechanism could be established.Budgetary constraints appear to have caused the idea to re-main just a suggestion, and we could find no evidence thata formal, official proposal for such positions has ever beenmade to the State Department. We still believe, however, thatsome mechanism is required because there is not sufficientU.S. collaboration with the Organization's regional and coun-try officials, nor is the kind of information available thatis needed by HEW officials in Washington.

HEW international health officials still think the re-gional health attache proposal is a good idea because, theysay, improved coordination mechanisms at the regional andcountry levels "* * * represents one of the major needs forU.S. programs to achieve a reasonable degree of success * * *."

16

As we note in the discussion or the Organization'sprograming processes in chapter 3, program budget formula-tion begins nearly 1-1/2 years before the Director-Generalpresents his proposals to the Executive Board. It hastherefore been suggested that member governments determinemeans to have collective input to the budget earlier in theprocess.

Making meaningful contact with the Organization'sSecretariat early in program budget formulation seems to usimportant. Otherwise, there is an apparent lack of immediateimpact members can have on program content and magnitude ofexpenditures once the Director-General completes a biennialprogram budget document. Extensive effort is applied in pre-paring position papers for U.S. representatives to Boardmeetings in January and U.S. delegations to the World Assemblyin May. Yet we found indications that members do not or can-not influence budgets at these sessions. For example, a U.S.delegate t the 1975 Assembly stated that he was "struck bythe lack of detailed discussion on the budget document duringthe review of the programme budget at the Assembly." A seniorOrganization official stated last October and U.S. officialsagreed, that it was then too late for members to interveneregarding budget levels for the 1978-79 program budget whichwas presented to the Board in January 1977 and will go to theAssembly in May.

State Department officials acknowledged that it is true,for the most part, that the budget for that year is fairlylocked in. They added, however, that interventions are valu-able for setting the emphasis in subsequent years and can in-fluence future programing and budgeting.

CONCLUSIONS

Our 1969 and 1974 reports made several recommendationsto the State Department, HEW, and AID for improving our par-ticipation in the Organization. Among these, we ecommendedthat responsible U.S. officials

--develop and promulgate statements of U.S. policy objec-tives and program priorities to guide those managingU.S. interests in the Organization and

-- obtain better information from the Organization andfrom U.S. sources overseas to improve U.S. review andanalysis of Organization policies and programs.

17

We believe that the efforts of the State Department, asthe U.S. agency having overall responsibility for U.S. par-ticipation in the Organization, are not yet satisfactory indirecting U.S. Government activities in international health.The United States does not yet have an adequately definedstatement of policy objectives and program priorities forinternational health in general and towards the Organiza-tion in particular.

This continued absence of clear guidance for managersof U.S. interests in the Organization is due, in our opinion,to the lack of success in establishing a formal mechanism(such as the proposed interagency committee) for joint con-sideration of U.S. international health policy. We find itdifficult to imagine how a comprehensive U.S. Governmentstatement of policy, of practical use to the officials whoplan and implement U.S. international health activities, canbe put together unless the responsible senior officials havethe benefit of a formal coordinating and policymaking body.

Another component of U.S. participation is the qualityof the data on which officials base their evaluations andanalysis of Organization programs and policies. Although itappears that U.S. health officials can look forward to re-ceiving better information from the Organization's Secretariat(see ch. 3), we believe there is still a need for U.S. over-seas personnel to obtain and provide .tore independent analysisof Organizatiorr activities at the regional and country levels.We found indications that coordination between AID missionsoverseas and Organization officials in member countries isnot sufficient to provide useful information for HEW managers.AID officials attributed this largely to lack of adequatestaff abroad to do a more comprehensive job. We believe,however, that the problem is that this matter is not receiv-ing adequate priority rather than a lack of staffing.

We believe that if better information were provided,and improved contacts were made at the country and regionallevels, U.S. health officials could participate more effec-tively in Organization planning and implementation. In addi-tion, we received the impression that by the time members atepresented the details of the biennial program budget, it maybe too late for any member to influence much change. Wetherefore believe that representations to the Secretariatearlier in the programing process are needed. Actions beingtaken along these lines are discussed in chapter 3.

19

RECOMMENDATIONS

To provide the specific policy direction and guidanceneeded to manage U.S. interests in the Organization, we recom-mend that the Secretary of State form an interagency committeechaired by him or his designee for the purposes of

--developing specific objectives for U.S. participationand coordinating these objectives with all pertinentU.S. groups;

--agreeing on a plan for achieving U.S. internationalhealth objectives and implementing U.S. policy in theOrganization;

--submitting to the Congress annually, a statement ofspecific goals and objectives together with an assess-ment of accomplishments, as part of each congressionalbudget presentation;

-- giving priority to obtaining better information andproviding more independent analysis of Organizationactivities at the regional and country levels; and

-- providing a greater U.S. impact on the Organization'sbudget by having U.S. representatives work with Secre-tariat officials during the early stages of budgetformulation.

AGENCY COMMENTS

We did not obtain formal written agency comments; how-ever, we did discuss the report matters with responsibleagency officials and included their views, as appropriate.Agency officials generally agreed with our report presenta-tion and recommendations.

19

CHAPTER 3

THE ORGANIZATION'S PROGRAM

PLANNING AND BUDGETING

In earlier reports we noted that budget and operationaldata furnished to members by the World Health Organizationwas too sketchy and incomplete to allow adequate U.S. assess-ment of the Organization's programs. We recommended thatU.S. officials urge the Organization to develop and dissemi-nate better data on its activities by

-- making program objectives more specific,

-- improving reporting, and

--establishing effective evaluation procedures.

To determine the current status of the Organization's plan-ning, budgeting, and evaluation systems, as they relate toU.S. interests and activities, we met with Organizationofficials in Geneva and Copenhagen and reviewed both Organi-zation and U.S. documents. This chapter describes how theplanning and budgeting systems work, the degree to which theUnited States needs for information are being fulfilled, andcurrent efforts to improve them. Chapter 4 addresses theOrganization's reporting and evaluation systems, again asrelevant to U.S. needs.

The program planning and budgeting system is aimed atconsolidating the broad types of interrelated activitiesdescribed in chapter 1 as constituting the Organization'srole. The Organization will continue its global assessmentsof health needs, while orienting its technical codperationefforts directly toward the needs of individual member coun-tries and in accordance with their specific requests. Weobserved that evaluation of Organization activities hasrecently been receiving increased emphasis, and is viewedas an integral part of program planning.

The complexities of planning for efforts to meet worldhealth problems, while at the same time assisting some150 member States to meet their national but interrelatedhealth needs, were addressed in a 1975 study by the Organiza-tion's Executive Board, to which the U.S. member contributed.The study emphasized the relationships among medium-termplanning, country health programing, project formulation,management procedures, and the development of new information

20

and evaluation s ems. Although the Board acknowledgedimprovements in these areas, it noted suggestions for further

effort.

THE PROGRAMING PROCESS

The Organization's program is developed within the termsof a general program of work approved by the World HealthAssembly for a specific period of time. Within the aims andobjectives of this medium-term plan, biennial programs areprepared.

Medium-term planning

Since 1952, six general progra.ns of work have been for-mulated. The fifth one, covering 1973-77, is now in force.

The sixth, covering the 6-year period 1978-83, was approvedat the May 1976, 29th Annual World Health Assembly, and will

go into force with the second biennial program budget(1978-79), to be reviewed at the 30th Assembly.

According to the Chairman of the Executive Board working

group which prepared the sixth general program of work, it is

not a program, but a plan, on the basis of which the actualprograms are to be formulated. The program lays out the gen-

eral policies and health objectives for the Organization forthe next 3 biennial periods. It outlines the overall priorityareas as being

-- development of comprehensive health services, includingprimary health care delivery and improved nationalplanning;

--health manpower development, with an emphasis on"paramedic" type training;

-- disease prevention and control, particularly tropicalcommunicable diseases;

-- environmental health improvement;

-- biomedical and health services; and

-- program development and support, including integrationof health with overall socioeconomic development.

Our analysis showed that these priorities are notspecifically ordered--though primary health care is generallyconsidered first--and they are not quantified.

21

Short-term planning

Short-term planning is accomplished through the processof formulating the biennial program budget. The development,approval, and implementation of the Organization's programextends over a 3-year period as shown on the following chartand described below. While the general program of work isprimarily related to activities under the regular budget,one of the Organization's major constitutional functions isto act as the directing and coordinating authority on inter-national health work irrespective of the sources of fundswhich may be available for this purpose. Consequently, thebiennial program is formulated to include projects which areexpected to be financed from U.N. Development Program, U.N.Environmental Program, U.N. Fund for Population Activities,funds-in-trust, and other extra-budgetary resources.

The 3-year planning cycle as applied in the Europeanregion is illustrative. In the planning year, the Director-General issues instructions on preparing the program budgetbased on program trends and policy matters from the generalprogram and Board and Assembly deliberations. In Octoberregional health officers put together a rough draft of pro-posals for the European region. Although no dollar amountsare applied to country or intercountry activities, the healthofficers are generally aware of what cost levels will be.

The regional'proposals are then sent to member govern-ments with a request that they comment on specific programsand projects and assign priorities. According to regionofficials, government reactions vary from careful analysisamong several responsible health and development planningofficials in several offices, to a cursory once-over by oneman. It is hoped that they look at the proposals in termsof their awareness of funds to be available.

The following March, regional officials again go overthe proposals with the members' input, this time with re-gional budget and finance officers to firm up the proposalsin terms of funding, administration, etc. Unlike those inOctober, these planning sessions are not technically orientedunless members' comments raise new project proposals. Theoutcome of this March meeting is the biennial program budget,which is then refined for presentation to the regional com-mittee meeting of all members in September. There is a"gentlemen's agreement" that members do not discuss individualcountry projects after they are put into the regional programdocuments; discussion centers, instead, on intercountry andinterregional programs.

22

FLOWCHART SHOWING MAIN POINTS OF ACTION INTHE DEVELOPMENT AND PREPARATION OF WHO'S

ANNUAL PROGRAM AND BUDGET ESTIMA'I ES

(Ya 19756 ud a i n *xaTmp

DIRICTOA4INKRAL

HEAWUOJART 3 /atomE1 YEARAAOkTH

MW'Delb- M A-.t U, 11 r Iwrb

I. ul~ s( I 1 I I IntJ r~lr) Octb..

ComArplErIm ~e19 73

how D&t- a_

Waid' IWd* A|.4 D4 ' 2-

,hrryrD~n Co~e fI*. i_ r Flmw

_ _ni .. I.W Pal.

.~nmP- , --

Dl_4OnA _ _ _

Com id - xur

23lM IE~~~~~lrr I !pOrn

| t I | r -d I I " ~

The regional program proposals are then forwarded to theDirector-General, together with the comments and recommenda-tions of the regional committee. Similarly, the programproposals for central, interregional and other activities(particularly the field of research) are prepared by theresponsible technical units at headquarters, and after reviewby the division directors, submitted to a headquarters programcommittee composed of Assistant Directors-General. Followingthe latter's review, the regional and headquarters programsare consolidated in the Organization's proposed program bud-get.

In the approval year, the proposed program budget is xa-mined in detail by the Executive Board, and in light of thisexamination, the Board submits its conclusions and recommenda-tions on the proposed program budget to the World Health As-sembly. The Assembly reviews the proposed budget and Boardcomments and approves the budget level by a two-thirds major-ity of delegates present and voting and a resolution appro-priating fun¾d for the budget year is approved.

In the year of implementation, the program as approvedby the World Health Assembly and as adjusted to take ac-count of any changes in government priorities is put intoeffect by officials of the Organization and member govern-ments, sometimes with the assistance of other internationaland bilateral agencies.

The program approved for a particular year may be ad-justed within the budget parameters to recognize changesin priorities of either the Organization or of individualgovernments. According to region officials, a member coun-try's Ministry of Health determines how it wants to use moneyapproved by the Assembly for whatever health activity forthat country. These officials say that the Organizationmust go along if the Ministry decides it wants to generalizeapproved specific project funds.

Adjustments can also come as the result of changes inextra-budgetary resources, such as UNDP liquidity crisis,or delays in hiring consultants or awarding fellowships.Such adjustments are made in consultation with the nationalhealth administrations during the preparation of programsto be proposed for the next program budget.

BUDGET PREPARATION

Under the concept of program budgeting, budget prepara-tion is not really separated from short-term planning. Budgetestimates are made concurrently with the biennial programing

24

exercise. Although the Assembly reviews a biennial programbudget, it approves only that portion which corresponds tothe next financial year.

Even though, as discussed, financial decisions are notmade in preparing the medium-term general program, tentativeprojections of estimated obligations, as far forward as4 years, are included in the proposed program budget presentedto members.

In the planning year of the 3-year program budget cycle,the Direct.-r-General makes tentative budget allocations toeach region and to headquarters, within which their programproposals are to be contained.

PLANNING AND PROGRAM BUDGETINGSTILL NEED IMPROVEMENT

Although planning and program budgeting procedures andresults are improving, our review indicates that there arestill shortcomings in the way U.S. needs for informationare being met. Some of the new measures to upgrade theprocess are in early stages of implementation and have yetto be proven effective.

U.N. study recommends financial decisionsTn medium-term plannng

In 1974 a U.N. Joint Inspection Unit Inspector prepareda study of the state of planning and programing in U.N..or-ganizations, including the Organization. The report recom-mended that these U.N. specialized agencies set financialceilings when program objectives and priorities are deter-mined in their medium-term planning. The Inspector statedthat:

"* * * if medium-term plans are to act asinstruments that can really help to define apolicy, they must, together ith the programbudgets, entail financial decisions."

The main thrust of the Inspector's arguments is that ifmedium-term planning, such as the Organization's sixth gen-eral program, is to serve as a rational framework for short-term planning, it must provide not only clear program ob-jectives, but financial objectives and constraints as well.

The Inspector said he did nt mean that such a planneed be a 6-year budget or that biennial program budgetswould give way to the plan as documents with a financial

25

sanction. He emphasized the need for a suitable link betweenthe two decisionmaking processes (i.e., medium-term and short-term planning), aving the former cannot be budgets, but canbe a means of determiii.nq orders of magnitude of financialresources for the medium-term period. Since governments mightbe reluctant to make financial commitments over such a longperiod, he uggested that they could agree to a base yearbudget--for example, that amount most recently approved by theOrganization's governing body--and a percentage level of in-creases over each year or two of the plan period.' The Inspec-tor felt that this way of fixing orders of magnitude would becompatible with the type of decisions taken when biennialbudgets are submitted for approval, an entirely differentexercise which consists of making appropriations of precisedollar amounts for particular programs.

In its review of the report, the U.N. AdministrativeCommittee on Coordination, of which the Organization is amember, did not support the Inspector's recommendation. TheOrganization's Director-General agreed with the Committee.The Committee stated that the Inspector's views were con-trary to the'principles of integrating program and financialdecisions even though there were no financial decisionsapplied to medium-term planning, and said that there arealternative formulae" to the Inspector's suggestions. TheCommittee did not say what these alternative formulae mightbe and how they could be used to include financial decisionsin medium-term lanning. It did acknowledge, however, theneed for improving the link between medium-term plans andbiennial program budgets, at least as it regards the techni-cal aspects of program planning and the documents on whichit is based.

We believe the desirability of establishing financialceilings in medium-term planning may be reflected in currentexpressions of frustration by the major contributors to theOrganization regarding the budget growth of the United Na-tions and specialized agencies. A proposal of the Genevagroup of major contributors, aimed at limiting the increaserin these budgets (see ch. 5 for details), would perhaps nothave been necessary had the Organization and the otheragencies imposed on themselves the appropriations limitssuggested by the Inspector.

Other proposals and actionsto improve planning

As noted earlier, the Organization's general programsof work are more statements of general objectives thanmedium-term programs; indeed each has been more of a plan

26

than a program. This is function of their structure and

content, or lack thereof, as well as the absence of finan-cial decisions discussed in the previous section.

The 1975 Executive Board study indicates that consider-

able improvement has been made since the first general pro-

grams, which were formulated in very broad terms and in

which no real attempt was made at delineating subprograms

likely to serve specific needs of each region. The fifth

general program, for w ich the final year of implementationbegins in 1977, is more explicit in the guidance it offers,

and the sixth shows further progress.

Our review foui.d, however, that the general program

still is considered too broad and lacks sufficiently clear

priorities, objectives, and targets. At the Executive

Board review of the sixth program in January 1976, one Board

member noted that "* * * with 6 major areas of concern,

comprising 17 principle objectives, it would be possible to

include practically any health programs and little guidance

was provided as t, priorities." Another said he would liked

to have seen more specific targets, which should be quanti-

fied and given upper and lower levels.

State Department and HEW officials maintain that the

U.S. member of the Board played a major role in the develop-

ment of the program and that some sections represent the

emphasis and thoughts developed in the Public Health Serv-

ice's Office of Internatizral Health. Nevertheless, the

U.S. position paper prepared for the 29th Assembly meeting

last May, at which the members approved the program, notes

that while the sixth program is more specific than the

fifth, with clearer objectives and priorities, it does

not contain quantifiable criteria for assessing and evalu-

ating programs.

The members of the Board seemed to feel that the gen-

eral program was overall a good medium-term plan. They also

seemed to feel that its shortcomings could be made up for

by (1) increased attention to tightening up objectives,

priorities, and criteria in the biennial program budgetingprocess, (2) increased involvement of the Board in prepar-

ing program budgets, and (3) improved evaluation efforts.(See ch. 4.)

The Board is concerned that the Organization's program-

ing has suffered from a tendency toward the development in

member countries of "separate projects bearing insufficient

relation to national health development as a whole." The

Board also said that efforts need to be increased toward

27

constructing "* * * more rational programmes through constantcollaboration with national health administrations in anal-yzing systematically the country's real priority needs."The basis for this concern was confirmed in the externalauditor's report to the May 1976 Health Assembly. His in-vestigation in one region of project implementation comparedwith original planning and budget estimates showed consider-able deviations. His recommendations to the regional Direc-tor emphasized the need for planning to be program orientedas distinct from project oriented, with a clear definitionof objectives against which evaluation could be made.

Because, as both Organization and U.S. officials haveacknowledged, detailed project planning has taken place toofar in time from implementation of the budget, a majorobjective of biennial budgeting--providing more stability inthe planning process--has not been attained. Therefore, theDirector-General has stated that the Secretariat will submitto the January 1977 Executive Board proposals for a new pro-gram planning procedure to avoid repeated.deviations romthe approved budgets. If then approved by the 30th Assemblyin May 1977, he proposals would be implemented in the pro-gram budgeting cycle leading to the adoption of the 1980-81biennial program budget.

In addition, our review of documents shows that theExecutive Board has taken steps to become more involvedin program planning and at an earlier point in programformulation. Since the last World Health Assembly, theBoard has established a special program committee, made upof nine Board members, which will assist the Secretariat inestablishing priorities and preparing program proposalsto implement the general programs of work, and which willadvise the Director-General on policy and strategy involvedin implementing Assembly resolutions aimed at increasingtechnical cooperation with the developing countries.

Our review work indicated that country health planningor programing may be considered perhaps the key elementin both the overall planning of the Organization and im-plementing its health programs. A Board study in late1975 stated that:

"While the main purpose of country health programingis to strengthen self-reliance and national healthplanning at country level, a valuable by-product ishe increased ability to make the needs of Memberates better known to WHO and multilateral or bi-

lateral aid partners and ensure the unity of pur-pose of international health work."

28

A good country plan should provide a clear picture ofnational priorities, health needs, areas of action, andthose activities most suitable for outside assistance. Al-though the crucial role of country planning has been recog-nized for several years, Executive Board discussions in1975 and 1976 have indicated that progress in implementingplanning principles and in establishing rational priori-ties has been unsatisfactory. Only a few developing coun-tries have health-plans, and not all of these are adequate.

An effect of the lack of country health planning can beseen in the observation by European region officials thatwhere a developing country has no formal health plan,health priorities are determined on an essentially ad hocbasis by the Ministry of Health, although Organization andUNDP o.ficials do have influence through the various pro-graming processes.

CONCLUSIONS

Our previous reports recommended that U.S. officialsurge the Organization to produce and make available tomembers more relevant and reliable data on its activitiesthrough improved and better preparation of program objec-tives.

Our current review of how U.S. needs for timely andadequate data are being met found that the Organization'smedium-term planning has become much more specific andordered over the years, and that U.S. health officialshave had an impact on this improvement. The plan for theperiod 1978-83 contains clearer objectives and prioritiesthan previously, but is still lacking definitive financialtargets that could help the United States and other membersevaluate the Organization's programs over the 6-year period.It has been suggested that financial decisions be made dur-ing the medium-term planning process to provide a betterlink with biennial program budgeting and thus lead the Or-ganization to set clear medium-range priorities and objec-tives for its programs. We believe that the adoption ofthese kinds of financial restraints on the Organization's6-year general programs could not only improve the effec-tiveness of the Organization's activities, but would alsoserve the special interest of the United States and othermajor contributors.

Our analysis indicated that short-term planning--thebiennial program budgeting process--is still too projectoriented, and it still lacks the clear definition of objec-tives that would enable the United States and other members

29

to make useful evaluations. We believe that since the Or-ganiiation's programing must reflect the health prioritiesof member States, the lack of rational country health plan-ning by most members will continue to hamper the Organiza-tion's ability to meet the real health needs of thesemembers and to efficiently plan how to use it limited re-sources.

RECOMMENDATIONS

We recommend that he Secretary of State, through U.S.delegates to Organization forums and representatives deal-ing wi,. Organization officials, urge the Director-Generaland the Executive Board to

--encourage basing the medium-term plan upon the fundsthat may be available and

-- urge member governments to formulate rational coun-try health plans to provide clearer bases for theOrganization's short-term planning.

30

CHAPTER 4

THE ORGANIZATION'S REPORTING AND EVALUATION

Our previous reports noted a lack of systematic pro-cedures for evaluating the World Health Organization'sprojects and programs. We pointed out that efforts fellfar short of what is required b U.S. officials to makeindependent judgments relative to the efficiency and ef-fectiveness of Organization operations. Our current review

found that evaluation, both internal and external, is stillinadequate for these purposes, although the Organizationis developing new information and evaluation systems whichmay prove to be more useful.

EXTERNAL EVALUATION

There are two sources of external evaluations of Organ-ization activities: U.N. Joint Inspection Unit reports andthe annual Report of the External Auditor to the World HealthAssembly.

Our current review found that most U.N. Joint InspectionUnit reports address themselves to U.N. systemwide matters,such as the report on medium-term planning discussed previ-ously, and do not deal directly or in detail with the effec-tiveness or impact of Organization programs or projects. Thefew U.N. Joint Inspection Unit investigations which dealtsolely with the Organization concerned mostly administrativematters and, according to the Director-General, have not hada significant impact.

The reports of the Organization's external auditor repart of the annual financial report submitted by the Director-General to the members. This external audit has in the pastbeen only a traditional financial audit, without evaluation

of program and management impact and effectiveness. At theurging in 1975 of the new external auditor, the latest re-

port contains some information on financial implementationby program sector, program and source of funds, and also data

on the financial implementation of projects. A U.S. delegateto the May 1976 Health Assembly noted U.S. approval of themove toward a management approach in the Organization's finan-cial reporting and this move was an approach long advocatedby his delegation.

The report also contained reference to the managementand program audit work conducted in one region, but the de-tails of this work were not made available to members beyond

31

the auditor's general outline of his recommendations to theregional committee.

INTERNAL AUDIT

The Organization's internal audit unit staff consistsof eight auditors. Staff members told us that its reviewsare primarily financial audits which look at such mattersas asset accountability and protection, internal controls,and compliance with financial policies and procedures. Theyinformed us that the unit also conducts some management re-views, comprising about 15 to 20 percent of its effort.These are defined, however, as efficiency or economy reviewsand make no attempt to measure the effectiveness of programsand projects. These reports are addressed to senior Secre-tariat officials and are not available to members.

NEW INTERNAL INFORMATIONAND EVALUATION SYSTEMS

The shortcomings of the Organization's past and presentevaluation efforts have been clearly recognized, as in the1975 Executive Board Study, which called for a renewed ap-proach to evaluation. It noted that past efforts

"* * * have failed to provide WHO [the World HealthOrganization] with an instrument apt to assess andmeasure the value of its programme as a whole, itsrelevance to country health needs, its efficacyand practical impact."

The report noted that attempts at evaluation had not beencarried to their logical consequ¢.ices--that is, to changesin program design or execution. 21? U.S. member of theBoard meeting which reviewed the report took particularnote of its emphasis on the importance of developing a newprogram information system on which to base evaluation ef-forts.

As pointed out by officials of the regional office forEurope, the Organization has developed over the years in-dependent information and reporting systems for administra-tion and for the various technical areas; the procedures andeven the terminology of these various systems are different.They noted that the existing systems are also inadequate foruse as a management tool, since they are technically orientedand not program oriented.

According to the sixth general program of work (1978-83), evaluation should be an integral component of Organiza-tion activities at all levels. In defining objectives and

32

formulating programs, desired results should be measurablefrom both quantitative and qualitative points of view and,wherever possible, targets should be determined in specificterms. Evaluation should be applied on a continuing basisduring the implementation of a program, so that it can pro-vide a reliable basis for adjusting the approaches andmethods of work adopted.

In conformity with the above principles, the Organiza-tion began about 2 years ago to develop a new system ofevaluation. Officials told us that it is intended to be anintegral part of program planning and delivery--the overalloperation functions--at all organizational levels (country,regional, and headquarters). This system will be used toevaluate the sixth general program of work. It is based inlarge measure on a new information and reporting system whichis also being developed. Reports will focus on progressmade in implementing activities and on the assessment of theeffect these activities are making on attaining the objectivesof the program area concerned. This system of reporting willbe used for both regular budget projects and those fundedfrom other sources.

Under this system each program/project will have a pro-file which will include a description of the activity, ob-jectives/targets, milestones/priorities, participants andcommitments, problem areas, data from various assessmentsreports submitted on the activity, and an evaluation/analysisof the activity. Profile information will be updated andsubmitted emiannually; the evaluation/analysis portion ofthe reporting is to be conducted in close collaboration withthe national health authorities concerned.

As proposed, project managers will report to theirregional office on project particulars (e.g., status, prob-lems encountered, etc.). The regional office will reviewand analyze these reports from the viewpoint of regionalprogram objectives, preparing summaries of the countryproject profiles and preparing and updating additional pro-files on intercountry projects. The regional profiles will,in turn, be summarized at the headquarters, which will alsoprepare and update profiles on interregional activities.The profiles prepared at headquarters and the regions willbe provided to the regional and country level managers,respectively, as one form of feedback. The major form offeedback to the regions and field from headquarters willbe in changes in policy lines resulting from headquartersanalysis of the reporting from all regions.

33

The target date for the completion of the informationand reporting system mechanisms is scheduled for the end of1977; thus, officials believe significant parts of it willnot become fully operational until January 1978. Completeimplementation of the new evaluation system will thereforenot have significant impact on programing until the proposedprogram budget for the period 1980-81.

AVAILABILITY OF INFORMATIONTO MEMBER GOVERNMENTS

According to Organization officials, the system shouldeventually make program profiles available to members, withthe provision that certain information, such as from in-dividual country profiles, is the property of the involvedgovernment. Aggregate information about a ma4or program ora whole region, such as in interregional and intercountryprogram profiles, officials said, would be the property ofthe Organization, and thereby available to members withoutrestrictions.

The officials emphasized that individual country ac-tivities or projects are not "Organization projects," butnational projects, a.d the country involved will have toagree before the country can be identified. They notedthat the Organization is not trying, with the profile con-cept and new infcrmation and evaluation systems, to auditor evaluate the performance of member governments; rather,the aim is to determine what have been the relative successesof a given activity and to assist the Organization andmembers in programing and managing the available health re-sources.

RESERVATIONS ABOUT THE NEW SYSTEM

Headquarters officials recognize that not all pro-grams have quantifiable criteria which can be used tomeasure effectiveness. However, they say an attempt will

be made to set out specific output indicators, milestones,priorities, and criteria so that the Organization can meas-ure the health impact of programs. European regional of-fice officials expressed some reservations about thefeasibility of measuring effectiveness and impact. Theofficials say that the new system is to provide for ad-ministrative evaluations, that is, the efficiency of ac-tivities, comparing results achieved with inputs. This,they noted, does not necessarily constitute an effectivenessevaluation. They point out tnat for marO :,.:.th problems,effectiveness indicators--even in general terms--have yetto be developed, and evaluating impact will depend on

34

separate surveys which will use the information gatheredunder the new system. Headquarters officials also acknowl-edged that ongoing experience with the system will beneeded to prove whether or not the indicators and criteriabeing used are really valid and relevant for reviewing im-pact and effectiveness.

The Executive Board reviewed a report by the Director-General on the development of the evaluation system at itsJanuary 1976 meeting. The Board agreed on the proposedconcept of making everyone involved in the work of the Or-ganization assume responsibility for evaluation, but urgedthat some caution was required if objective evaluation wasto be carried out by the same staff as was involved in theoperation of the activities. A member of the headquarterssystem development staff expressed awareness of this issue,but noted that in the past, program evaluation by personsnot involved had caused the emergence of defense mechanisms,leading even to problems in collecting the necessary infor-mation from those who felt that they, rather than the pro-gram, were being evaluated.

U.S. officials' review of the same Director-General'sreport also raised some reservations about the system. Com-ments in position papers prepared for U.S. representativesat the Board meeting included skepticism as to the expecta-tions for critical review of activities at the country levelin the absence of previous country health programing activityor a sound national plan. The U.S. paper also noted thequestion of political issues involved; members have the rightto solicit the Organization's assistance in whatever proj-ect they deem necessary to their health needs as they seethem--if programs are approved through such a process, is itappropriate to evaluate programs solely on a technical basis?

CONCLUSIONS

Our previous reports recommended that U.S. officialsurge the Organization to improve its reporting and evalua-tion procedures and make this information available tomembers. The Organization is adopting new reporting andevaluation systems which are expected to bring improvements.However, it is not yet clear how this will benefit theSecretariat staff and the United States and other members.Potential benefits will depend, in part, on whether thesystems are used to show planners where they need to makechanges in program design and execution. Both U.S. andOrganization officials are aware that diligence will beneeded o maintain evaluation objectivity, as well as con-tinuing attention to determining and testing evaluation

35

criteria. In the final analysis, however. the effectivenessof the new reporting and evaluation systems--like that ofthe new programing efforts--may depend on the progress ofhealth planning by member governments.

To assist the United States and other members in moreeffective participation in the Organization, we believemembers should see that as much information from the newsystems as possible is made available to them.

RECOMMENDATION

We recommend that the Secretary of State, through U.S.delegates and representatives, work to obtain for all mem-bers the most complete dissemination possible of programinformation and evaluation results.

36

CHAPTER 5

CURRENT ISSUES

We found that there are two major issues which arehaving, and will probably continue to have, considerable im-pact on the World Health Organization's activities and onU.S. policy toward the Organization. The first of these,a budget-limiting proposal was aimed at limiting the growthin budgets of the United Nations and of specialized agencies.The second issue involves the so-called "60-percent resolu-tion" passed at the May 1976 World Health Assembly, whichdirects the Secretariat to insure that, by 1980, 60 percentof the Organization's regular budget will be :-pended onprograms of technical cooperation with and services to thedeveloping countries.

THE GENEVA GROUP PROPOSES PERCENTAGELIMITS ON THE UNITED NATIONS ANDSPECIALIZED AGENCY BUDGETS

The French delegate to the consultative level Genevagroup / meeting in June 1976 introduced a proposal forplacing percentage limits on future increases in U.N. budgetsand its specialized agencies. This proposal expressed con-cern that the continuous and excessive increases in the bud-gets of the U.S specialized agencies are now becoming acritical problem for the major contributors. It noted thatprevious attempts by the major contributors to urge budgetrestraint on the Secretariats have failed to stop yearly in-creases which are, in general, very much in excess of theaverage national budgetary increases of the member States.

l/The Geneva group is an informal body of major donors tospecialized agencies concerned with administrative andfiscal matters relating to those agencies. First con-vened in 1964, it operates on two levels. The consulta-tion level composed of foreign office officials (AssistantSecretaries responsible for participation in internationalorganizations) and budget/treasury representatives, meetonce a year to discuss across-the-board problems. LocalGeneva groups composed of permanent representatives toindividual specialized agencies, such as the Organization,meet on an ad hoc basis both to exchange information andto seek to reach a consensus on financial, budgetary, andmanagement issues.

37

This means that as far as international activities are con-cerned, the major contributors are taxed beyond levels theyimpose on their own citizens.

The proposal stated that even if an organization'sSecretariat attempted to control regular budget increases,the majority nations--the so-called Group of 77, composedof those members who contribute less than 10 percent oftotal regular budget assessments--could reverse any Secre-tariat's austerity decisions through votes in the governingassemblies of the organizations. Urging that the Genevagroup members agree among themselves on a percentage increasein the current year's budget beyond which they would notpay a comparable increase in their assessment shares, theproposal stated this would be a better situation for theSecretariats than if individual national parliaments re-fused to carry out budgetary obligations taken by interna-tional councils that have gone beyond the realms of reason.

The proposal met with widespread support at its initialintroduction, though some members expressed misgivings aboutapplying any arbitrary ceiling on agency regular budgets.They preferred to work with the Secretariats to trim admin-istrative expenditures and economize through more carefulprogram formulation. Concern was also expressed about thetreaty obligations of members to pay whatever amounts areassessed by the governing bodies of the organizations.Group members agreed, however, that the proposal !Meritedfurther study in their respective capitals and that furtherdiscussions at the consultative level should be held inNew York in October, following preparatory discussions inensuing weeks by the Geneva group (General).

Subsequent developments

Our review of State Department reports showed thatduring the 3 months after introduction of the budget-limiting proposal, numerous meetings and discussions wereheld among and between members of the Geneva group. Finally,a special consultative level meeting of the Geneva groupwas held at the U.S. Mission to the United Nations in NewYork, October 6, 1976. Representatives of the followingcountries participated as members: Australia, Belgium,Canada, France, Federal Republic of Germany, Italy, Japan,The Netherlands, United Kingdom, and United States. Rep-resentatives of Sweden and Switzerland participated asobservers.

The purpose of the meeting was to discuss the possi-bility of collective action by the group in the light of

38

the rapid growth of budgets in the U.N. systems, and inresponse to the interest aroused by the French delegate'sproposal to establish a system of budgetary ceilings.

According to State DepartLnent records, the group agreedthat any action short of setting some sort of limit tobudget growth would be no more successful than past effortsof the Geneva goup, no matter what means they might use tosecure its acceptance. It was also agreed that settingsuch a limit should, however, in no way preclude, but shouldbe accompanied by, strengthened efforts along traditionallines to assure greater efficiency within that limit.

Although the problem was reportedly not yet felt tobe acute by many members, the group noted that doing nothingcould lead to situations in which at least some major con-tributors might be forced to take unilateral action detri-mental to both the U.N. system and to other members of thegroup. The suggestion was, therefore, welcomed that theyshould seek to establish target figures or budgets in theU.N. system and that through discussion and persuasion,they should promote the acceptance of these targets as auseful management tool by the Secretariats and other membergovernments.

The State account noted that after lengthy discussionon where and when action might be taken, the group agreedthat a selective and phased approach to the specializedagencies would be appropriate. They felt it was importantto take action at that stage of the budgetary cycle whenthe agency's planning ',as beginning to be formulated as aprogram budget? but before specific figures came out inbudget documents. It was also recognized that differentmethods of approach were required for each agency.

Because specific questions could best be addressedby those who dealt with a particular agency at its head-quarters, the group agreed that the cochairmen (U.S. andUnited Kingdom representatives) should issue instructionsto their representatives in the headquarters city of eachof the four major agencies--United Nations Educational,Scientific and Cultural Organization; the World HealthOrganization; International Labor Organization; and Foodand Agricultural Organization of the United Nations--toconvene the local Geneva groups to prepare recommendationson three basic questions:

1. The desirability and feasibility of establishingindicative target figures for the next budget of

39

each agency and, assuming a positive approach, areasonable figure that might be set.

2. The most suitable tactics to be employed vis-a-visSecretariats and other member States to securegeneral acceptance of these views.

3. The timing of any action.

On the question of including the United Nations in thisbudget concern effort, the group agreed to postpone any de-finitive action.

Actinq on the instructions emanating from the October6 meeting, the Geneva group cochairmen in Geneva met in lateOctober with the budget director of the Organization to ex-press the increasing concern of the group with the escala-tion of budgets in the United Nations. The Organizationofficial was reportedly quite surprised and concerned at thevisit. He said it was too late for any member or group todo anything about the 1978-79 program budget as it was al-ready "put to bed." The cochairmen were unable to obtainany detailed information on the 1978-79 program budget anddid not discuss any specific "indicative target figure"that the group would want the Organization to work within.

The Organization's 1980-81 budget was discussed atthree subsequent local Geneva group meetings held in Novem-ber and December 1976 and January 1977. Target budgetfigures were not established at these meetings, but it wasnoted that discussions would have to be held soon if theGeneva group was to have an influence on the 1980-81 budget.The participants talked about getting a discussion of the1980-81 budget on the agenda of the Organization's January1977 Executive Board meeting; that a Geneva group consulta-tive meeting should be held in early March 1977; and thatthe Geneva group should be prepared to present 1980-81budget target figures at the May 1977 World Health Assembly.

THE 60-PERCENT RESOLUTION

The 60-percent resolution (officially Resolution29.48) was passed at the 29th World Health Assembly on

May 17, 1976. The vote was by a resounding majority of 82to zero, with 26 members, including the Urnited States,abstaining. It quantifies and expands previous efforts ofdeveloping country members (the so-called Group of 77) toget the Organization to place new emphasis on increasedtechnical cooperation with those countries.

40

Specifically, the resolution requests that the Director-General:

"* * * reorient the working of the Organiz ationwith a view to ensuring that allocations of theRegular Program Budget reach the level of at least60% in real terms towards technical cooperation andprovision of services by 1980, by

a) cutting down all avoidable and non-essentialexpenditures on establishment and administra-tion, both at headquarters and in the regionaloffices;

b) streamlining the professional and administra-tive cadres;

c) phasing out projects which have outlived theirutility; (and)

d) making optimum use of the technical and admin-istrative resources available in the indivi-dual developing countries."

In commenting on the resolution, the Director-Generalsaid he welcomed the resolution and stressed that it cor-responsed with his own global philosophy on health. Henoted that many of the Organization's present activitiesare not as relevant to the priorities of the developingcountries as they could be and many could be more produc-tive, but most have been implemented because the Assemblyhad decided so. Declaring that the Assembly had taken oneof the most important political decisions in the history ofthe Organization, he cautioned that he assumed the Groupof 77 did not want cuts that would damage programs fromwhich the entire membership benefits. Secretariat figuresshow 51 percent of regular budget funds already going tomember governments. He also stressed that implementing theresolution would take time and could have only a small im-pact on the 1977 program, and insisted that the ExecutiveBoard would have to share in the responsibility of makingthe necessary, perhaps unpopular, decisions involving cuttingprograms and staff positions.

Proposals aimed at implementing the 60-percent resolu-tion by 1981 were approved by the Organization's ExecutiveBoard in January 1977. The Board reviewed policy and strategyfor developing technical cooperation programs and the budget-ing and financial implications of the 60-percent resolution.Proposed actions included abolishing 363 jobs, mostly at the

41

headquarters level, and transferring the resulting savingsto technical cooperation programs.

U.S. views of the resolution

According to the U.S. Chief Delegate's account of theAssembly meeting, the U.S. delegation abstained in the res-olution's adoption partly out of concern as to the advisa-bility of dividing the work of the Organization without acareful examination of its impact by the Director-Generaland the Executive Board. The abstention was reported to bedue in part to a belief that a fixed percentage could leadto arbitrary, poorly conceived schemes that could detractfrom the Organization's effectiveness. Also, U.S. officialstold us they did not like the intent and tone of the resolu-tion regarding arbitrary percentages and deadlines; anddiscussion cf the resolution in the Assembly has been charac-terized as "somewhat bitter" between developed and developingmembers, indicating a degree of polarization both inappro-priate and unfortunate for an international health organiza-tion.

A State Department account of the U.S. abstention notedsimilar objections; that is, the impact of such a move shouldbe studied first. Both agencies found elements of the res-olution to support, expressing praise for those requestscalling for streamlining of operations and cutting out ob-solete programs. Such measures have reportedly long beenadvocated by U.S. delegations.

There is some difference of opinion among officials inthe concerned U.S. health agencies as to just what the ef-fect of the resolution will be on the Director-General'sexpressed intent to emphasize the Organization's coordina-tion role. One opinion holds that the developing countriesare, in the 60-percent resolution, looking for more direct,donor-type project assistance from the Organization's regularbudget, and that this may have a negative impact on the Or-ganization's efforts to expand its coordinating role. Muchdepends on how technical cooperation is defined by theSecretariat, working with the Executive Board. One Depart-ment of Health, Education, and Welfare official expressedconcern that programs dealing with, for instance, cardio-vascular disease, cancer, and environmental pollution--health areas more of a problem to developed than developingcountries--not be cut drastically, since HEW has pointedto these before the Congress as areas of particular concernto the United States and part of the justification for ourparticipation in the Organization.

42

Others, however, feel there is not as much conflict asmay appear between the need for more coordination and the60-percent resolution. This view emphasizes that the Direc-tor-General must implement the resolution, that he appearsto favor the coordinating/cooperative role, and that he isconsulting with the Board through the new program committeeon how he intends to implement the resolution.

In the final analysis, according to a November 1, 1976,memorandum from the State Department's Bureau of InternationalOrganization Affairs, there is not yet a U.S. Government posi-tion on the resolution, because State does not know how itsimplementation will affect the Organization's program as awhole. A more complete U.S. position on the resolution willdepend on analysis of the Director-General's implementationplans and in preparations for the 1980-81 program budget.For 1978-79 many of the new activities will be funded underglobal and interregional projects, and the Director-General'sand regional Directors' development programs.

CONCLUSIONS AND RECOMMENDATIONS

The major donors to the U.N. system and its specializedagencies, including the Organization, have become increas-ingly concerned about the spiraling increases in their regu-lar budgets. In response to this concern, a proposal wasput forth to the Geneva group of major donors to place apercentage ceiling on budget increases past which these con-tributors would not pay. Due to concerns expressed regard-ing the setting of arbitrary limits and treaty obligations,the group decided to urge some sort of indicative targetfigures for the next budgets of four of the major specializedagencies. Initial approaches have been made to two of theagencies--the Organization and the International Labor Or-ganization--but the group has discovered its efforts canhave little or no effect on he 1978-79 budgets of theseagencies, and they haie ot let decided what the targetfigures should be nor how to concentrate their efforts togain acceptance of their views on budget restraints.

We regard the efforts of the Geneva group as importantand a start in the right direction. In order for the groupto urge indicative target figures there must necessarily bea setting of priorities by both the Secretariat of the Or-ganization and members of the group. Such actions will,in our opinion, assist both the developed countries who arepaying the vast part of the budget and the less developedcountries as well who are the primary beneficiaries of theOrganization's program.

43

There is not yet a firm U.S. position on the 60-percentresolution passed at the last World Health Assembly. TheOrganization's Secretariat has een working to redirectelements of the 1978-79 program to provide more res,urcesat the regional level and for direct cooperation wi.h andservices to developing member countries; the major impactwill be on the 1980-81 program b.idget. U.S. health officialshave indicated to us that they are generally hopeful thatthe resolution can lead to economies of administration inthe Organization and the elimination of programs and projectsthat are not producing.

The current issues before the Organization also stressthe importance of the United States taking a position thatall U.N. development and technical assistance be channeledthrough a central coordinating point, the United NationsDevelopment Program. In this regard we previously reported 1/that:

--U.N. development assistance was being carried outthrough thousands of projects in agriculture,health, education, and other fields.

-- These programs lacked focus and a sense of directionbecause there was no unified system for planning andcoordinating among U.N. agencies and because eachoperated independently.

-- UNDP had the largest single program ut other U.N.agencies, such as the Organization, were conduct-ing their projects outside of and without adequatelycoordinating with UNDP.

The factors summarized above still exist and take onincreased meaning as the U.N. specialized agencies obtainlarger annual budgets and spend increasing amounts of thesefunds for basic assistance to developing countries. Thegrowing financial and operating independence of the U.N.specialized agencies have the effect of undermining UNDPcentral funding and monitoring system--a system that theUnited States and other countries worked hard to establish.Therefore, it is important that renewed efforts be made byU.S. officials to bring all U.N. development assistanceprograms under the coordinated mantle of UNDP.

L/"Action Required to Improve Management of United NationsDevelopment Assistance Activities," ID-75-73, July 3,1975.

44

The Organization's decision to finance more developmentassistance also focuses attention on a parellel financial is-sue. That is, that the Organization has been a major ex-ception to the U.S. Government policy that U.N. technicalassistance be funded from voluntary contributions rather thanassessed funds. This policy follows the logic of U.S. bi-lateral assistance in emphasizing that foreign governmentsreceive such assistance at U.S. discretion and not as aright. The Organization has probably been exempted fromthis policy because of the unique humanitarian appeal ofinternational health programs. However, the Organization'srecent action to spend more of the assessed budgets fortechnical projects calls for the United States to reexaminethe Organization's exception to the U.S. policy of provid-ing only voluntary funds for development assistance.

In summary, the competent performance of U.N. activi-ties is of considerable concern to the Congress and thepublic. Thus, the United States and other member countriesshould look to the U.N. agencies to efficiently and effec-tively use their increasing budgets to alleviate variousinternational problems. Accurdingly, we recommend thatthe Secretary of State

-- express U.S. concern over the trend away fromUNDP leadership and reassert the U.S. positionthat all U.N. development and technical assistancebe channeled through UDP and

--reaffirm that the proper way to finance U.N. devel-opment activities is through voluntary contribu-tions.

45

APPENDIX I APPENDIX I

umV"M. AuN.. WL jM. AWm ..mINE v _NE On eJLAM V. IN.J.U

LAMr. VLLL SULie abEf Asna

PER*A A. week" COMMITTE ON

"W MMe T" Eu1 GOVIRIMENT OPEATIONS

WASHI.NTON.DC. MI0 July 30, 1976

The Honorable Elmer B. StaatsComptroller General of the United StatesU. S. General Accounting Off!.ce441 G Street, N. W.Washington, D. C. 20548

Dear Elmer:

As you know, the Committee on Government Operations is

currently reviewing United States involvement in international

organizations.

We are familiar with the reports the General Accountin3

Office has 'isued, the testimony you have given before various

Congressional committees, and your continuing concern with

improving he management of U. S. participation in international

organizations.

To assist the Committee I would request that GAO update its

previous work by the middle of next February, including an update

of your prior reports on the World Health Organization, the

International Labor Organization. and the Food and Agriculture

Organization. I hope you would be prepared to testify before the

Committee, possibly in the early part of the next session, on your

conclusions.

I would also like to have by next February a report on your

cur,,nt review of employment of Americans by international organ-

izations and a report on the World Food Program and our partici-

pation in it. I would also be interested in any review you can

do of the United Nations Educational, Scientific and Cultural

Organization.

I hope that you can also consider in your work the overall

management and budgetary systems of the U.N., and especially the

status of your efforts to encourage the establishment of inde-

pendent review and evaluation systems in international organiza-

tions.

I look forward with interest to learning your thinking in

this important area.

Sincerely yours,

Abe Ribicofr5

46

APPENDIX II APPENDIX II

OTHER U.N. BODIES INVOLVED

IN HEALTH

African Development Bank

Strengthening of health servicesHealth manpower developmentDisease prevention and controlPromotion of environmental health

Asian Development Bank

Promotion of environmental health

Food and Agriculture Organization of theUnited Nations

Strengthening of health servicesDisease prevention and controlPromotion of environmental health

inter-American Development Bank

Strengthening of health servicesHealth manpower developmentDisease prevention and controlPromotion of environmental health

International Atomic Energy Agency

Disease prevention and controlPromotion of environmental health

International Bank for Reconstruction andDevelopment (Worla Bank Group) -

Strengthening of health servicesHealth manpower developmentDisease prevention and controlPromotion of environmental healthHealth statistics

International Labor Organization

Strengthening of health servicesDisease prevention and controlPromotion of environmental health

47

APPENDIX II APPENDIX II

United Nations Capital De!elopment Fund

Strengthening of health servicesDisease prevention and controlPromotion of environmental health

United Nations Children's Fund

Strengthening of health servicesHealth manpower developmentDisease prevention and controlPromotion of environmental health

United Nations Development Programme

Strengthening of health servicesHealth manpower developmentDisease prevention and controlPromotion of environmental health

United Nations Disaster Relief Coordinator, Officeof the

Emergency and disaster relief

United Nations Educational, Scientific and CulturalOrganization

Strengthening of health servicesPromotion of environmental health

United Nations Emergency Operation

Emergencies

United Nations Environment Programme

Health manpower developmentDisease prevention and controlPromotion of environmental health

United Nations Fund for Population Activities

Strengthening of health services

United Nations Fund for Drug Abuse Control

Disease prevention and control

48

APPENDIX II APPENDIX II

.United Nations High Commissioner for Refugees

Strengthening of health services

United Nations Industrial Development Organization

Disease prevention and controlPromotion of environmental health

United Nations Office for Technical Cooperation

Strengthening of health servicesPromotion of environmental health

United Nations Regional Economic Commissions

Strengthening of health servicesPromotion of environmental health

World Food Programme

Strengthening of health services

49

APPENDIX III APPENDIX III

COMPOSITION OF THE U.S. DELEGATION

AT 1976 WORLD HEALTH ASSEMBLY

Delegates:Dr. Theodore Cooper (Chief)Assistant Secretary for HealthPublic Health ServiceDepartment of Health, Education, and Welfare

Dr. S. Paul Ehrlich, Jr. (Doputy Chief)Acting Surgeon GeneralDirector, Office of International HealthPublic Health ServiceDepartment of Health, Education, and Welfare

Dr. Philip ThomsenPhysicianDolton, Illinois

Alternate delegates:Mr. Robert Andrew

Director, Health and Drug ControlBureau of International Organization AffairsDepartment of State

Dr. Milo D. LeavittDirector, Fogarty International CenterNational Institutes of HealthPublic Health ServiceDepartment of Health, Education, and Welfare

Dr. David J. SencerDirector, Center for Disease ControlPublic Health ServiceDepartment of Health, Education, and Welfare

Congressional advisor:Senator John Durkin

United States SenateWashington, D.C.

Advisors:Dr. Faye Abdellah

Director, Office of Nursing Home AffairsPuolic Health ServiceDepartment of Health, Education, and Welfare

50

APPENDIX III APPENDIX III

Advisors (cont.):Mr. H. Jeffrey Binda (Secretary of Delegation)

International Health AttacheUnited States Mission, Geneva

Mr. Carl GripPolitical OfficerUnited States Mission, Geneva

Mr. Arthur MasonAttorneyBoston, Massachusetts

Dr. Malcolm MerrillSenior Consultant on Health for the Agency for Interna-

tional Development

Dr. David RallDirector, National Institute of Environmental HeelthSciences

National Institutes of HealthPublic Health ServiceDepartment of Health, Education, and Welfare

Dr. Richard B. UhrichAssociate DirectorOffice of International HealthPublic Health ServiceDepartment of Health, Education, and Welfare

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APPENDIX IV APPENDIX IV

PRINCIPAL OFFICIALS RESPONSIBLE

FOR ADMINISTERING ACTIVITIES

DISCUSSED IN THIS REPORT

Tenure of office

- Appointed

DEPARTMENT OF STATE

SECRETARY OF STATE,Cyrus R. Vance Jan. 1977

ASSISTANT SECRETARY OF STATEFOR INTERNATIONAL ORGANIZATION AFFAIRS:

Charles W. Maynes (designee) Jan. 1977Samuel W. Lewis Dec. 1975

DEPARTMENT OF HEALTH,EDUCATION, AND WELFARE

SECRETARY CF HEW:Joseph A. Califano, Jr. Jan. 1977

ASSISTANT SECRETARY FOR HEALTH:James F. Dickson, III, M.D. (acting) Jan. 1977Theodore Cooper, M.D. Feb. 1975

DIRECTOR, OFFICE OF INTERNATIONALHEALTH:

S. Paul Ehrlich, Jr., M.D. Jan. 1973

AGENCY FOR INTERNATIONAL DEVELOPMENT

ADMINISTRATOR:John J. Gilligan Mar. 1977John E. Murphy (acting) Jan. 1977

DIRECTOR, OFFICE OF HEALTH,BUREAU FOR TECHNICAL ASSISTANCE

Lee Howard, M.D. Feb. 1967

52