June 19, 2015

WHO Reform Strengthens Country Offices Across the World

Indian artist Sudarsan Pattnaik creates a sand sculpture on the eve of World No Tobacco Day at Puri beach some 65 km from Bhubaneswar on May 30, 2015.
Indian artist Sudarsan Pattnaik creates a sand sculpture on the eve of World No Tobacco Day at Puri beach some 65 km from Bhubaneswar on May 30, 2015.

A widespread network provides the World Health Organization a good overview of the health systems in different countries.

When talking about the topics that the World Health Organization (WHO) deals with, it is easy to point out that they cover all aspects of health. Established in 1948, the WHO is the only international organisation that has received from its member states such a broad mandate in the field of health. It is expected to contribute to achieving the highest possible level of health of all peoples. This goal cannot be achieved merely by creating standards and implementing change at the global level; countries must also be supported in dealing with challenges and strengthening health systems. This can best be done via country offices that are familiar with local circumstances and needs. Public health as well as health system’s issues and important topics are somewhat similar in different countries, irrespective of the countries’ income and level of development. At the same time, every country has its own set of problems and challenges, in resolving which international experience as well as the experience of other countries is useful; the WHO’s competence and substantive technical assistance is therefore welcome and provides additional value. Because of this, the WHO has the largest network of representation of all UN organisations.

WHO Country Offices and Adapting Them to Today’s Challenges

In the field of international cooperation, parallels can be drawn between the WHO’s country office and diplomatic representations. However, in the field of health they can also be compared to primary care centres, which deal with diagnosing, counselling on, treating and coordinating health issues on all levels under a family doctors leadership. Hence, a WHO country office deals with assessing the health situation, counselling different stakeholders and strengthening the health system, while also paying attention to the most vulnerable population groups. In addition, WHO country offices provide the member state, UN organisations, international partners, civil society organizations and others the possibility to communicate effectively with the different structures of WHO.
There are WHO country offices in 29 European countries, plus an office in Kosovo. They vary in size and structure according to need, the level of development of a specific country and the intensity of cooperation. The WHO’s diplomatic representations in Europe have been established over recent decades (in the case of Estonia and Moldova, in the first half of the 1990s). There are a few WHO country offices with a longer history; for example, the first country office in Europe was established a little over 55 years ago, in Turkey.
One of the aims of the WHO reform initiated in 2012 was to harmonise the role of all country offices and adapt them according to today’s needs. As a result, their activities focus more on providing policy advice and technical assistance as well as increasing the capacities of countries’ institutions, at both national and local levels. Moreover, besides the ministry of health, it is important to expand the scope of regular cooperation to other ministries and partners from the private and third sectors to include everyone in health development. Among other things, strengthening the teams in country offices and increasing the number of staff rotations between countries has become one of the developing trends.
Today, WHO representations vary from small representative offices, mainly in Eastern Europe, to large ones in Central Asia. For example, most of the countries that joined the EU after 2004—including Estonia—have only small offices with one representative. In crisis hotspots, however, such as Turkey and Ukraine, there are also sub-offices for coordinating and resolving humanitarian crises, including for disease prevention, ensuring basic healthcare services and the availability of medications. Up to 20 specialists work in the larger WHO country offices in Europe. The size of offices in other parts of the world varies—for example, there are offices with more than 100 staff in Latin America, and a centre involving thousands of personnel in India, where the main aim is to strengthen the health system, but also to organise focused programs, such as eradicating polio.
One thing specific to Europe is the direct cooperation between a regional office and a country without a WHO country office. But also the cooperation with EU member states has intensified in recent years; for example, the WHO teams operating in Greece and Cyprus deal with restructuring health systems at national level. In addition to the role of a health-specialised agency, in five EU member states, including Estonia, the WHO is the only UN organisation represented and fulfils a wider remit of coordinating and representing the UN as a whole.

Activities of a WHO Representation

The WHO’s activities across the whole organisation are described using six core functions:
1. providing leadership on matters critical to health and engaging in partnerships where joint action is needed
2. shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge
3. setting norms and standards, and promoting and monitoring their implementation
4. articulating ethical and evidence-based policy options
5. providing technical support, catalysing change, and building sustainable institutional capacity
6. monitoring the health situation and assessing health trends.
Due to the fact that the WHO has a three-layered structure, some of its six main functions (see box) are more centralised than others, but the country offices have a central role in all of them in one way or another. The majority of the work performed by the representations is related to leading and partnerships, providing policy guidance, technical assistance and capacity building. Should the need arise, countries are also supported with expert missions from other levels of the WHO. Nearly 400 expert missions dealing with very different health-related topics were conducted by WHO staff in Europe in 2014. The country offices also have an important role in the event of emergencies and humanitarian crises, when the WHO is responsible for coordinating health-related humanitarian aid (Ukraine is one current example) and supporting the country in dealing with crises as leader of the health cluster in the UN system.
The country offices have an ever-more important role in exchanging experiences between countries and creating networks, including south–south cooperation and three-way partnerships. Several sub-regional structures have been created for this purpose in Europe in recent decades. For example, the Baltic Policy Dialogue has gathered every year since 2004 to discuss the challenges in health systems; the South-east Europe Health Network has competence centres in several countries; and there is a functional health information network in Central Asia. In recent years, similar institutional networks have been established across regions (for example, the Joint Learning Network on Universal Health Coverage). The aim of the various networks is to complement each other, but a future challenge will be to maintain their effectiveness and participation by smaller member countries.
As already mentioned, the size of WHO country offices varies from country to country; so do the scope and methods of their operations. WHO representations in Estonia and Moldova provide a good example. The representation in Estonia—similarly to other representations in the so-called new EU member states—comprises a two-member team: the head of the country office and an assistant. One of its main roles is to identify the need for technical assistance and find the best solution for supporting the country in cooperation with the corresponding field experts from regional office—be it sharing the experience or best practice of other countries, organising training courses and seminars to increase capacities, or providing policy guidance. The country offices are also responsible for conducting independent evaluations and providing suggestions for improving health systems based on assessments. Good examples of the latter are evaluations concerning the arrangements for HIV treatment and care, the sustainability of financing health systems, and the management of non-communicable diseases in the health system.
Due to the flexibility of its operations, the operating area and cooperation of the country office in Estonia is very wide despite its small size, covering a number of topics ranging from environmental health to pharmaceutical policy. Other continuing priorities include tuberculosis and HIV, health system financing and the prevention of non-communicable diseases, with special attention to risk factors such as smoking and nutrition. It is useful to share Estonian knowledge and expertise with other countries, especially the countries of the former Soviet Union, where Estonia’s experience in restructuring the healthcare system and efficient operations in the area of tuberculosis and reproductive health are the most sought-after, but there is also a growing interest in e-health from European and other regions.
The WHO country office in Moldova consists of 15 people, who provide advice in most fields and coordinate the WHO staff and external experts visiting the country. In addition, the team coordinates development aid in the health area and actively promotes policy dialogue on all levels. In recent years, the main priority areas have been the prevention of non-communicable diseases, especially tobacco control (stemming from the WHO Framework Convention on Tobacco Control), and reducing the harmful effect caused by alcohol, developing the health system—including working in areas such as health financing, —addressing the mobility of healthcare workers, structural changes in service provision and the availability of medicines. These areas account for three-quarters of all resources. At the same time, the prevention and control of tuberculosis, as well as other fields agreed upon in the UN Millennium Development Goals, also require attention. Thanks to the WHO’s neutral position and its standards setting function, it has been possible to start a dialogue and share knowledge in several areas in the Transnistria region, for example concerning the prevention and treatment of tuberculosis and HIV, vaccine preventable diseases, maternal and child health, healthcare financing and so on. Since 2012 activity increased in particular region and support for the development of the health system in the whole country is expected in the years to come.

Health, Partners and Diplomacy at the State Level

On a wider scale, there have been two important health-related developments in recent decades that require more and more attention in the WHO’s regular activities. Several new partners have emerged, including funds such as GFATM (which deals with HIV, tuberculosis and malaria), GAVI (which specialises in immunisation), several charitable organisations interested in the health area (Bloomberg, the Bill and Melinda Gates Foundation and others) and non-profit organisations. In addition, health is an important priority for several countries offering development assistance (for instance USAID), and some (such as Norway, the United Kingdom and Switzerland) have clearly stated their positions related to health in their foreign policy. Although the WHO is a normative, standard-setting organisation that does not directly provide financial aid, it has become increasingly necessary to coordinate the limited resources of development assistance effectively and ensure their integration into countries’ health systems.
Internationally, the WHO cooperates with increasing number of partners through different mechanisms and the situation is the same at the state level. Using Moldova as an example, different groups of partners can be involved, with various impacts in the field of health.
The first area is the general coordination of development assistance in health, which involves the largest number of partners; there are 20 organisations, funds or countries active in this field today. The number of partners has increased in recent years (new partners include Estonia, Norway and Japan) or addressing health challenges has received increasing priority for development aid (Switzerland, for example) . In Moldova, various partners provide an additional 15% a year to public-sector health funding.
The second area is other UN organisations, of which ten (including UNICEF, UNFPA, UNAIDS, UNODC, OHCHR, UNDP, IAEA, UNECE and UNESCO) have their own activities in the health area, providing additional knowledge and support. This is integrated into a document summarising UN activities in a country (the UN Development Assistance Framework), but also often requires the coordination of several parties. It is also important to implement at the state level UN resolutions—such as that from 2011 addressing the non-communicable diseases—or global health and foreign policy from 2012, as well as to bring together all UN organisations according to their mandates in health-related topics.
Third, international non-profit and charitable organisations increasingly support countries with their network and activities, and complement local organisations. The role of the WHO at the country level is to ensure the transparency of the coordinated overseas funds and their effective use, and share information to create synergy in cooperation with local health ministries.
Finally, in order to improve people’s health greater cooperation is needed with different sectors within a country, along with promoting the so-called “health in all policies” approach.
Each country office has a different number of partners, depending on the country’s level of development. Unlike Moldova—which is classified by the World Bank as a medium-income country—Estonia (a high-income country), does not have other international organisations or foreign donors as WHO partners. Nevertheless, the continuous strengthening of health systems is important in all countries—this is one of the most important lessons learnt from the Ebola crisis. The WHO’s main partners in Estonia are, first and foremost, government health-related institutions, such as the Ministry of Social Affairs, National Institute for Health Development, Estonian Health Insurance Fund, and Health Board; plus various local health-related non-profit organisations operating in this field and networks promoting health, such as health-promoting hospitals, cities, schools, workplaces, etc., a movement Estonia started in the 1990s. In recent years, a trend stemming from the WHO reform has been to increase cooperation with partners outside the health sector whose decisions have an impact on health. These are mostly in the government sector, such as the ministries of justice, agriculture and the environment, and their agencies. The possible circle of partners changes over time and their number is growing.


Compared to the era when the WHO was found, a number of different parties have appeared on the international health landscape, all of whom fulfil a different role in solving health problems. Nevertheless, there is a continuing need for an independent organisation, unaffected by special interests, to act as a leader and coordinator in health matters and establish evidence-based norms and standards on which participants in the health field can rely in their activities and decisions.
The WHO continues to be an important partner at the state level too, as shown by the wide network of WHO country offices across the world and in Europe. Various countries have expressed the need for the direct technical assistance provided by the WHO and its physical presence, irrespective of the country’s regime, income and level of development. A major factor is undoubtedly the WHO country offices’ flexibility, and the ability to adapt their operations and roles according to a country’s circumstances, needs and relevant health issues, and also according to the partners operating in the health field. In recent decades, while the WHO country offices fulfil a similar role in different countries and the topics they deal with are much the same, the differences lie in the intensity of cooperation and involvement, policy dialogue and readiness for change, the competence of local institutions and experts, and international partners.
Thanks to its widespread network of country offices, the WHO has a very good overview of different countries’ health systems, developments and needs, and different experiences concerning reforms as well as expert knowledge that can be flexibly shared with other countries, adapted to the local context and thus enabling countries to make better decisions. This trend is also supported by the WHO’s reform carried out over recent years, the aim of which is to strengthen the representations even further.
More information about the ongoing reform can be found on the WHO website: www.who.int/about/who_reform/en/

This article expresses the authors’ personal views


This article was published in ICDS Diplomaatia magazine.

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