WHO CVC 2020-2021

Sida assesses that WHO has shown great leadership during the ongoing covid-19 pandemic. As concerns the World Health Emergencies (WHE) programme it is not fit-for-purpose and has not been able to efficiently respond to the crisis at the scale needed, it has however gone through significant changes and the pandemic has identified shortfalls and needs for targeted strengthening of a more strategic response mechanism. The limitations of the WHE programme is linked to the constant underfunding, being one of the three most underfunded areas for WHO. A greater flexibility made possible by larger share of fully flexible contributions enabling WHO to act according to current needs would have created better conditions for a more effective response.  Overall, Sida assesses that WHO has been able to implement the results at a reasonable level for year 2020, results and priorities as per defined in the current biennium programme budget (2020-2021). The level of implementation is deemed acceptable given the particular circumstances during the pandemic which has exposed the danger for WHO in having insufficient amounts of flexible funding (at the current stage 80 per cent of WHO:s total funding is earmarked).  Needless to say, the pandemic has interrupted progress towards achieving WHO:s triple billion targets, as resources such as staff were diverted to a response that mobilized the entire Organisation. Disruptions in essential health services have resulted in interruption of essential health care for millions of people. The pandemic has disproportionately affected already vulnerable populations. Some indications: -people living with NCD's have experienced the highest risk for severe c19 and death. -the disruptions in essential health services in many countries due to c19 are predicted to have caused 254000-1 157 000 additional deaths of children less than 5 years old and 12 000 -57 000 additional maternal deaths accross 118 LMICs. According to the Indepent Panel on Pandemic Prepardness and Response Review which assessed the response of the multilateral system (incl WHO), WHO has lacked both the mandate and the financial resources to efficiently manage the Covid-19 pandemic. During the past year, issues linked to the reform of WHO has been at the top of the agenda and the discussion has centered around the three evaluations ie IPPPR, the evaluation of the WHE and the evaluation on IHR respectively; the recommendations resulting from these evaluations will shape the future of WHO. One example being the recommendations on WHO made by the IPPPR from May 2021 the Secretariat are calculating the financial implications of accommodating the IPPPR-recommendations within the biennium programme budget 2022-2023, a calculation exercise that will be ready by January 2022 and submitted to EB 149 (this means that the biennum budget 2022-2023 adopted by WHA 74 is subject to changes and modiciations at a later stage). The IPPPR-recommendations can be generally described as presenting solutions that are non-sector specific (covid-19 pandemic has affected all sectors hence solutions need to be wide).   The pandemic has underscored the importance and interconnection of the triple billion targets in GPW13. It has shown that healthier, more resilient societies can respond more effectively to health emergencies and that essential health services must be available to all, as the disease spreads along the fault lines of social inequality. It has also made it clear that a broader, whole-of-society approach and global solidarity are essential for the response to COVID-19 and to future health emergencies. Please note that the assessment at hand is an assessment of a mid-term-report. The report for the full biennium 2020-2021 is expected to provide clearer indication of results-achievement, also hopefully as a result of the score-card methodology being put to use to a larger extent.  Examples of results have been clustered according each billion goal as well as some examples of results/updates from the work under WHO's 4th "pillar" ie " a more effective WHO" Example of results: 1 billion more people benefiting from UHC: Covid-19 has pushed health systems capacities to the limit, hampering plans to achieve UHC. WHO has provided leadership, supporting countries' urgent responses while working to maintain essential services and core work to strengthen the safety and quality of services. Some examples: -WHO has tracked the huge disruptions in health service provision and supported 163 countries in assessing the impact and populations at risk. A WHO survey of 105 countries found that services were disrupted in almost every country between March and June 2020. Guidance with input from all disease programmes was widely disseminated and complemented by online WHO-courses and innovative strategies such as eg telemedicine.  - within the new PHC framework (developed by the Secretariat and adopted by all Member states) a large number of countries in the European region were supported by WHO to implement a dual approach ie strengthening PHC to address C19 and at the same time maintaining essential PHC-services.  -WHO's UHC compendium was launched and provided guidance to countries in the identification and composition of basic health care packages (as a means of extending UHC).  -WHO supported training of health workers in C19-related topics. Most of the WHO-regions developed tools for workforce surge capacity for C19. -significant milestones reached such as the SDG target for hepatitis prevalence to less than 1% among children under 5; eliminating malaria in 10 countries and at least one Neglected Tropical Disease in 42 countries. Also 36 countries included NCDs into PHC. -Countries were supported by WHO to improve financial protection. -WHO developed the Health financing progress matrix to qualitatively assess a country's health financing policies and their implementation at a given point in time (piloted in 19 countries).  - ACT accelerator partners are working to make 120 million, c19-tests available for LICs and are analysing over 1700 clinical trials for promising treatments.  -To address AMR the AMR Action fund was launched to invest in developing innovative treatments.  Overall, c19 has highlighted and exacerbated inequities in health within and between countries, hitting poor and marginalized hardest in both livelihoods and lives. Has also revealed the need for more resilient health systems. Sida notes the new framework for follow-up on PHC adopted by WHA in year 2020; now with the renewed committment to PHC offered by the new framework it will be absolutely crucial for Sida to ensure that SRHR are an integral part of intensified efforts on PHC. To this end, Sida shall push for the use of the new UHC-compendium which is deemed to be a valuable tool in formulating health benefit packages inclusive of essential SRH-services. WHO/HRP has developed a guidance note specifically aimed at supporting countries in how to integrate SRH-elements into UHC-benefit package design. More specifically, Sida shall recommend partners to use WHO-tools mentioned. On the issue of vaccine equity the world is experiencing a moral failure as HIC's have secured doses outside COVAX and LICs are lagging behind in accessing vaccines and treatment for c19. WHO's leadership has been a strong voice in speaking out on the alarming situation due to vaccine nationalism and vaccine inequity which puts LICs in a difficult situation but also prolongs the global fight on c19 (according to the motto "no-one is safe until everyone is safe").  More over, since the return of the US to WHO and now with new strong language on SRHR and gender equality from the Biden-administration this could have positive implications on WHO's efforts towards greater fulfillment of SRHR. Both through better possibilities of additional funding, technical support, political support etc.  1 billion more people enjoying better health and well-being: - Healthy environments and lifestyles could prevent half the global burden of disease. WHO has worked for years to reduce preventable lifestyle risks such as smoking, unhealthy diets and physical inactivity; these are linked to both NCDs and c19.  -To build forward a greener future from the pandemic WHO launched a Manifesto for a healthy and green recovery from c19 with six policy prescriptions and 80 specific actions for healthy societies that cover protecting nature, water and sanitation, clean energy, sustainable food systems, polluting activities and healthier cities. WHO was approved as a green climate fund readiness delivery partner in 2020 with the first projects to support countries to build capacity on climate change and health being approved in 2020 ( a regional US$ 1 million project for the Caribbean and one for Argentina. Proposals are being prepared for 12 more countries. The pandemic put a spotlight on air pollution, the most important environmental determinant of health, which caused an estimated 7 million premature deaths in 2020. Evidence is accumulating that fine particulate matter, which is affected by government policies, is a risk factor for severe COVID-19. WHO has stepped up work on air pollution in recent years, with increased leadership, evidence synthesis and monitoring, and is currently updating a global assessment of ambient air quality. More than 280 people trained in climate-resilient, environmentally sustainable health-care facilities. WHO guidance provides a set of interventions to improve climate resilience while decreasing the environmental impact and carbon footprint of health care facilities. Guidance was issued on WASH in health care facilities, in the context of c19. - the tripartite formed between FAO, WHO and OIE was strengthened in 2020 eg through the formation of a One Health Global Leadership group on AMR. The MPTF on AMR granted funding to a series of country projects aimed at country level implementation of National Action Plans on AMR through a One health approach and tripartite cooperation.  -The new Tripartite One health coordination group for Asia and the Pacific will intensify joint efforts to manage zoonotic influenza, rabies, food safety and AMR.  -WASH is mentioned among the areas where major challenges remain and much progress is still needed as well as road safety, air quality, alcohol consumption, unhealthy diets and physical inactivity. Far more investments needed for progress to be made.  During the annual review meeting between Sida and WHO, it was however highlighted by WHO that WASH has been recognized as critical in the battle against COVID19, and how the pandemic has also underscored the importance of healthy lifestyles in the prevention and control of NCDs, as obesity, diabetes and cardiovascular and lung disease increase the risk of serious COVID-19 illness. WHO also stated how the pandemic has shown the importance of health literacy to better understand and comply with public health measures. 1 billion more people better protected from health emergencies -WHO supported countries in preparing and responding to the pandemic and issued the Strategic Preparedness and Response Plan which countries could adapt.  -News of a novel corona-virus in early January prompted enormous scientific collaboration. The R&D -blueprint set a unifying direction to accelerate research, leading to an unprecedented amount of research. Effective vaccine were produced rapidly. With partners WHO led the Solidarity trial for c19 for therapeutics, the largest of its kind.  In April 2020 an unprecedented global partnership was created to help the fair and equitable distribution of critical products for c19: the Access to c19 tools Accelerator (ACT) with its vaccine pillar Covax.  WHO has been at the forefront of the UN-response, coordinating 23 UN bodies and other partners. More digital innovations were used eg to track and resource country plans with donors and partners.  Strategic adjustments to national c19-responses during 2020 were facilitated by WHO's rapid development and roll-out of comprehensive guidance, tools and training for readiness and response.  Although c19 dominated WHO:s work WHO also responded to 53 other graded emergencies in 2020 including an outbreak of Ebola in DRC.  Lessons learned from c19 has been that the world was not prepared for a pandemic which suggests that our very concept of preparedness needs to change. The critical importance of early detection, rapid risk assessment and clear communication was highlighted in the first month of the pandemic. What is clear is the need for greater investments in key areas such as public health functions and capacities for surveillance, laboratory diagnoses and health security. There is clearly a need to change the way we finance preparedness for health emergencies towards a more sustainable funding model.  Important developments in addition to what is being mentioned in the mid-term results report is the adoption of the so called "strengthening resolution" during WHA 74 in May 2021. The resolution which aims at strengthening WHO as a whole is considered a milestone in terms of changing global health architecture and one of the main implications is the establishment of an intergovernmental working group tasked with discussing how WHO's role can be strengthened in view of future crisis. A special WHA-session in November 2021 continued the discussion on how WHO can be strengthened to better respond to future crisis and included discussions on the pros and cons of a Pandemic treaty. A resolution was adopted to develop a pandemic treaty to be further discussed during EB150 and subsequently WHA. It is likely that issues on improved health security will remain at the centre of the global health agenda for years to come.  Pillar 4 "a more effective WHO" The implementation of the transformation agenda  (TA) continued in year 2020 incl new ways of working more seamlessly across the three levels aimed at making WHO more efficient and effective with an increased focus on science, data and innovation. The pandemic has reinforced the value of the transformative work over the past 3 years which enhanced WHO's ability to support the global response. The new entities such as the Science Division and the enhanced partnerships and external relations functions were immediately tasked to operate at scale, validating their importance and capabilities. Starting with c19, the science division established a fast-track review mechanism to ensure timeliness, coherence and quality of all WHO guidance, providing approval or critique within 48 hrs.  New measurement tools have become data driven and demonstrate WHO's accountability for results such as the triple billion measurement system. The new department of digital health is steering work in this field.  A commitment to incorporate transparency and accountability in WHO's work has resulted in a number of new processes such as the Output scorecard delivering value for money as well as the new Partners platform.  The new approach to partnerships has enhanced the c19 response eg through the ACT accelerator and the resource mobilization campaign for SPRP for c19 which was the most successful in WHO's history.  Sida lacks an update on how WHO advancing on UN reform although GHAP, the Global Action Plan on Health and well-being (often seen as one of WHO's most important contributions to the UN-reform) bringing together 13 multilateral agencies on health to help countries to accelerate progress towards SDG3 has expanded to 37 countries across all WHO-regions. According to the mid-term report WHO country offices supported the governments in convening the GAP-partners at country level. However, according to a recent study on stakeholder perspectives on the implementation of the GAP, evidence suggest that implementation has been limited and that the GAP has had limited ability to influence the modus operandi of the signatory agencies and improve coordination among them. More specifically, there has been some progress at global level but limited progress at country level (eg due to the lack of a clear entry point for GAP at country level).    Sexual abuse, exploitation and harrassment: during year 2020 specific attention has been brought to the issue of SEAH given the SEAH-allegations linked to the ebola-response in DRC during 2018. This focus has continued during 2021 and a dedicated process has been set-up to ensure independent investigation and affirmative action. WHO has arranged several MS-briefings on the topic where updates have been provided concerning the progress on implementing an independent commission tasked with investigating the case. WHO management has been very clear that any form of abuse totally incompatible with WHO:s mission and that SEAH-allegations undermine WHO's trust as an org. WHO has provided MS with an overview of actions since the mentioned allegations were made in sept 2020: an independent commission has been established aimed at-Identifying victims and holding perpetrators to account;identify root cause of abuse and recommend systemic solutions. Some Member states have been frustrated by slow of process of carrying out the Investigation. On May 3rd investigations started in DRC (Goma), difficult circumstances (eruptions Goma) Investigation team has received  info from UN office for oversight services.  Investigations will follow  the investigations wherever it takes them . Due to the pressure from WHO to get more info to have full confidence in the investigation WHO will be having monthly updates incl mission briefings plus the WHO secretariat  will also provide quarterly briefings to MS as recommended by the EB148. Much has been done since sept 2020 and more planned for coming months. Importance of working with our UN sister agencies through UN interagency committees. Strengthening country capacities are important. WHO has joined UNFPA and UNICEF in implementing community campaigns on SEAH (eg in DRC) In March 2021 WHO launched new policy on addressing SEAH Programme budget for the next increased budget envelope fr prevention/management SEAH (80 musd). Pending submission of the Independent commissions findings we will take the following measures:-task team established to accelerate progress adopting a holistic approach to SEAH; establish group on external experts (MS have valuable experience that WHO can draw on). Sweden's position on SEAH in general is that we look forward to seeing the requirements to enhance and implement a values-based, ethical and gender-mainstreamed culture and environment at all levels of the Organisation (position in March 2021).  Transformation agenda: Sida is specifically following  the part of the TA that aims at driving impact at country level. The overall TA-reform has been assessed by Member states as being complex and difficult to follow. For Sida, an issue of central importance are the implementation of functional review recommendations (functional reviews carried out in eg AFRO and EMRO).  In terms of the internal enabling functions at the level of country office WHOs leadership at the country level is pivotal to driving impact that is tailored to country context (according to the 2021 Country Presence Report covering 20192020). Further, the report indicates that while a high percentage (89%) of all WHO representative posts were in place as of December 2020, the 11% shortfall at that date shows that vacancies continue to occur, sometimes lasting over one year in a country, which may put WHOs reputation at risk and compromise the Organizations ability to provide leadership at country level. The WHO Secretariat will develop feasible succession plans to ensure uninterrupted country-level leadership. The proportion of women WHO representatives, while up 2% since the 2017 report, is at 38%. Inter-regional mobility has remained a challenge for country-level leadership: three out of the six WHO regions did not meet the recruitment target of 30% of WHO representatives from outside their region of origin. WHO Secretariat will continue to scale up its efforts to ensure gender parity among its representatives and to encourage inter-regional mobility, Given the limited number of WHO staff, especially country-based international staff, in base programmes, there is an opportunity to strengthen technical capacity at country-level through the activation of mechanisms such as the mobility and rotation policies and plans for career pathways. Augmenting WHOs technical staff in countries, including international professional staff, is critical to enhance WHOs effective response to the needs of Member States. Other ways of deploying technical expertise and ensuring enhanced country presence could be explored, for example through virtual country teams, rapid response teams, and WHO collaborating centres. In terms of the TA and more specifically the reform aimed at having Country offices that are more fit for purpose in supporting countries, it is Sida's assessment that WHO/AFRO has taken some quite important steps in the right direction eg by supporting country offices in different functions such as management, communication, grants management etc. Among the remaining challenges are issues of lack of long-term staff (large dependency on consultants working on short-term assignments) as well as lack of flexible funding meaning country offices meet challenges in implementing their CCS according to plan (due to high levels of ear-marking made by donors).  Sustainable financing: during EB 148 in February 2021 there was a decision to establish an open ended working group consisting of member states and tasked with submitting to WHA 75 (May 2022) a proposition for more sustainable financing of WHO's enabling functions. The pandemic has clearly demonstrated the vulnerability of WHO due to lack of sustainable, flexible and predictable financing.