W O R L D H E A L T H O R G A N I Z A T I O N
^ ^ ^ ^ O R G A N I S A T I O N M O N D I A L E D E L A SANTÉ
E X E C U T I V E B O A R D F o r t y - t h i r d S e s s i o n A g e n d a i t e m 7 . 1 . 4
E B 4 3 / 4 5 Corr.l 25 F e b r u a r y 1 9 6 9
Л!Г-
，：例，场
C O - O R D I N A T I O N W I T H O T H E R O R G A N I Z A T I O N S A D M I N I S T R A T I V E , B U D G E T A R Y A N D F I N A N C I A L M A T T E R S
R e p o r t s o f t h e J o i n t I n s p e c t i o n U n i t R e p o r t b y t h e D i r e c t o r - G e n e r a l
1 . T h e t e l e x m e s s a g e r e c e i v e d f r o m U N I C E F a n d r e p o r t e d i n P a r t 4 o f d o c u m e n t E B 4 3 / 4 5 h a d w o r d s m i s s i n g f r o m t h e s e c o n d s e n t e n c e i n p a r a g r a p h 4 . 1 " S e c u n d o , r e p a r a 4 " . T h e
D i r e c t o r - G e n e r a l h a s n o w b e e n i n f o r m e d t h a t t h e m i s s i n g w o r d s a r e " o u r o w n " . T h e s e n t e n c e , a s c o r r e c t e d , r e a d s a s f o l l o w s :
，，We w o u l d n o t s e e t h i s p o l i c y a s b e i n g a f f e c t e d b y w h e t h e r f u l l - t i m e o r s h o r t - t e r m e x p e r t s w e r e r e q u i r e d o r w h e t h e r t h e p r o j e c t w o u l d b e s e r v i c e d b y v i s i t s f r o m a W H O r e g i o n a l r e p r e s e n t a t i v e a s w e l l a s t h o s e o f o u r o w n
r e p r e s e n t a t i v e .и.
O R G A N I S A T I O N M O N D I A L E D E L A SANTÉ
INDEXED E X E C U T I V E B O A R D
F o r t y - t h i r d S e s s i o n A g e n d a i t e m 7 . 1 , 4
C O - O R D I N A T I O N W I T H O T H E R O R G A N I Z A T I O N S A D M I N I S T R A T I V E , B U D G E T A R Y A N D F I N A N C I A L M A T T E R S
R e p o r t s o f t h e J o i n t I n s p e c t i o n U n i t R e p o r t b y t h e D i r e c t o r - G e n e r a l
1 • B a c k g r o u n d i n f o r m a t i o n
T h e T w e n t i e t h W o r l d H e a l t h A s s e m b l y ( M a y 1 9 6 7 ) a d o p t e d r e s o l u t i o n W H A 2 0 . 2 21 w h i c h i n t e r a l i a d e c i d e d t h a t " t h e W o r l d H e a l t h O r g a n i z a t i o n s h a l l p a r t i c i p a t e i n t h e J o i n t I n s p e c t i o n U n i t a s s o o n a s a g r e e m e n t o n i t s e s t a b l i s h m e n t h a s b e e n r e a c h e d b y t h e r e l e v a n t i n t e r - a g e n c y b o d i e s a n d t h e U n i t e d N a t i o n s o r g a n s " . I n J u l y 1 9 6 7 , a j o i n t m e e t i n g o f t h e C o m m i t t e e o n P r o g r a m m e a n d C o - o r d i n a t i o n ( e s t a b l i s h e d b y t h e E c o n o m i c a n d S o c i a l C o u n c i l ) a n d t h e A d m i n i - s t r a t i v e C o m m i t t e e o n C o - o r d i n a t i o n ( A C C ) r e a c h e d a g r e e m e n t o n t h e J o i n t I n s p e c t i o n U n i t w h i c h w a s r e p o r t e d t o t h e E c o n o m i c a n d S o c i a l C o u n c i l a n d s u b s e q u e n t l y a p p r o v e d b y t h e E c o n o m i c a n d S o c i a l C o u n c i l a n d t h e G e n e r a l A s s e m b l y o f t h e U n i t e d N a t i o n s .
2 . P r o c e d u r e s r e l a t i n g t o t h e r e p o r t s o f t h e I n s p e c t o r s , a s a g r e e d b y t h e A d m i n i s t r a t i v e C o m m i t t e e o n C o - o r d i n a t i o n i n O c t o b e r 1 9 6 8
2 . 1 T h e a p p r o v e d p r o c e d u r e s r e l a t i n g t o I n s p e c t o r s ' r e p o r t s , a g r e e d u p o n a t t h e j o i n t m e e t - i n g , a r e a s f o l l o w s :
( a ) " • • • t h e I n s p e c t o r s * r e p o r t s s h o u l d b e p l a c e d b e f o r e t h e E x e c u t i v e B o a r d s ,
G o v e r n i n g B o d i e s a n d C o u n c i l s b y t h e D i r e c t o r s - o r S e c r e t a r i e s - G e n e r a l , w h o m a y a t t a c h t o t h e r e p o r t s a n y i n f o r m a t i o n a n d o b s e r v a t i o n s w h i c h t h e y c o n s i d e r a p p r o p r i a t e .и
( b ) " t h e E x e c u t i v e B o a r d s , t h e G o v e r n i n g B o d i e s o r C o u n c i l s w i l l f o r w a r d t o t h e E c o n o m i c a n d S o c i a l C o u n c i l a n d t h e C o m m i t t e e f o r P r o g r a m m e a n d C o - o r d i n a t i o n t h o s e p a r t s o f t h e r e p o r t s w h i c h c o n c e r n t h e c o - o r d i n a t i o n o f t h e a c t i v i t i e s o f t h e i r a g e n c i e s i n t h e e c o n o m i c a n d s o c i a l f i e l d s w i t h t h o s e o f o t h e r o r g a n i z a t i o n s i n t h e U n i t e d N a t i o n s s y s t e m , a n d a l s o i n f o r m a t i o n c o n c e r n i n g m e a s u r e s w h i c h m a y h a v e b e e n t a k e n i n c o n n e x i o n w i t h t h e r e p o r t s . "
2 . 2 . T h e s a m e d o c u m e n t i n d i c a t e d t h a t " w i t h i n t h e f r a m e w o r k o f t h e f u n c t i o n s a n d p o w e r s o f t h e I n s p e c t i o n U n i t # # Ф w o r k i n g a r r a n g e m e n t s a n d p r o c e d u r e s s h o u l d b e e s t a b l i s h e d i n t h e c o u r s e o f t i m e a n d o n t h e b a s i s o f e x p e r i e n c e w i t h a v i e w t o t h e s m o o t h a n d e f f i c i e n t f u n c t i o n i n g o f t h e U n i t " .
2 . 3 A p r o v i s i o n s u g g e s t e d e a r l i e r b y A C C t h a t a c o p y o f I n s p e c t o r s1 r e p o r t s s h o u l d b e g i v e n b y t h e E x e c u t i v e H e a d t o t h e E x t e r n a l A u d i t o r o f t h e o r g a n i z a t i o n c o n c e r n e d w a s w e l c o m e d b y t h e A d v i s o r y C o m m i t t e e o n A d m i n i s t r a t i v e a n d B u d g e t a r y Q u e s t i o n s .
H a n d b o o k o f R e s o l u t i o n s a n d D e c i s i o n s , n i n t h e d i t i o n , p a g e s 4 1 2 - 4 1 3 •
E B 4 3 / 4 5 p a g e 2
2.4 Whereas the initial expectation was that the majority of the InspectorsT reports would, at least in the early stages, address themselves to specific matters in individual organizations, communications from the Inspectors to date have differed widely in nature and in scope. They may be considered to fall in one of the following categories:
(a) a confidential letter to an Executive Head concerning some specific matter or matters which have come to the attention of the Inspectors in the course of an investi- gation. Such letters do not have to be communicated to anyone else but the Inspectors reserve the right to return to the matters raised in an open report if they are not satisfied with action taken as a result of their confidential communication to the Executive Head；
(b) a report on specific matters, it being specifically stated in the covering letter that the Executive Head is free to make such use of the report as he deems appropriate；
(c) a preliminary report on a specific problem requesting further information in response to a list of questions；
(d) a report on one or more specific matters, addressed to an individual organization；
(e ) a report on a matter or matters of concern to most, if not all, organizations in the United Nations system.
2.5 The types of report mentioned in paragraphs (a), (b) and (c) have not given rise to any procedural problems. In these cases it may be possible to take the Inspectors1 comments into account without the need for a report, or before a report is submitted to the governing bodies� While there have so far been no reports of the type mentioned under paragraph (d) no major problem is foreseen in applying the agreed procedure. As regards the type of report described in paragraph (e), however, the ACC believes that considerable confusion might result if
individual governing organs, meeting at different times, were to comment individually and take individual action on Inspection reports dealing with matters of concern to all organizations.
2.6 In order to avoid such an occurrence, the ACC agreed：
(a) that the Inspectors be asked to treat separately 一 either in different reports or in different sections of a report - those matters which concern an individual organization and those which concern more than one organization；
(b) that when reports affecting more than one organization are submitted to governing organs, these reports should be accompanied by the views thereon of the executive heads concerned. To this end, the executive heads have agreed on a standing arrangement whereby they will consult their ACC colleagues on such reports before submitting them to their respective governing organs.
(c) that the ACC Secretariat should be informed of action taken at the Secretariat level or by governing organs of the organizations concerned as a result of the reports, and be responsible for informing the Council and the Committee for Programme and Co- ordination.
3.1 Joint Inspection Unit Report of "WHO Assistance to Developing Countries’'
In accordance with the agreement quoted in 2,1 above, the Director-General is transmitting as Annex 1 a report by the Joint Inspection Unit on "WHO Assistance to Developing Countries"
received by him on 6 February 1969, together with the letter of transmittal from the Chairman of the Joint Inspection Unit.
3.2 Views of the Director-General
The report was prepared after five members of the Joint Inspection Unit had visited Regional Offices and projects in ten countries. They were given all possible assistance in their task of appraising the undertakings of the Organization which they wished to study.
The Director-General is gratified to note that the Joint Inspection Unit was "favourably impressed with WHO assistance programmes,, and that it felt "that in certain important respects the efficiency" of the World Health Organization1 s "operations in the field is
o u t s t a n d i n g� The report then indicates that there are "certain important opportunities for further improvement" and makes relevant observations and suggestions on three points to which the Board will wish to give attention.
3.3 The first point in the report
3.3.1 The first point made by the Joint Inspection Unit is concerned with "the very widespread differences in environment and stages of development among the developing countries,f. In general it can be said that the classification of countries with regard to types of assistance to be provided by the Organization involves the risk of generalization. Clear-cut categories of the type described in the report of the Inspectors cannot be established in terms of the needs and requirements of governments for assistance from the Organization； the differences are sometimes very great even as between contiguous countries. The inspectors, in fact, point out that variations in need range from the "executive" or "орех" type of assignment of WHO personnel, rather than advisers, to the other extreme where "the traditional projects with long-term experts, fellowships and equipment only really fit certain developing countriesM. The Inspectors have also noted "the significant trend in certain semi-developed countries towards much greater use of short-term consultantsM •
3.3.2 As the Board is aware, both headquarters and regional activities are guided by a variety of policy resolutions adopted and modified by the World Health Assembly and the Executive Board over the years with respect to approaches to the technical co-operation activities of the Organization. The Organization1 s obligation to assist governments on request in
strengthening health services is imposed by the Constitution and fulfilment of that responsi- bility in the most effective manner has been the constant preoccupation of the Organization.
The series of relevant resolutions of the Health Assembly and the Board over the past two decades has culminated jn the Report of the Director-General on Policy Governing Assistance to Developing Countries and the resolution of the Twenty-first World Health Assembly on that Report.^ The Director-General is gratified that the Inspectors find themselves "in full agreement with the general assumptions and rationale’， underlying that report.
3.3.3 The Inspectors made the observation that the services of WHO personnel should be
phased out more rapidly. The decision in this case, however, does not rest entirely with the Organization since an important part is played by the national administration of the assisted government. In some exceptional cases, counterparts have been lacking or the incumbent shifted because of factors outside the control of WHO. These exceptional cases apart, it is a guiding principle of the Organization to train counterpart national personnel to replace WHO staff at the earliest possible opportunity. "Traditional projects" are being reduced and being replaced by ad hoc arrangements, mostly short-term consultants. There are certain kinds of programmes, particularly training programmes, which have continued for some years and which are likely to have to be extended well into the future.
1 Off, Rec. Wld. Hlth Org,f 168, Annex 11.
2 Off, Rec. Wld Hlth Org,, 168, resolution WHA21.47, p. 23.
E B 4 3 / 4 5 p a g e 4
3.3.4 The Inspectors have formed an impression that certain countries "often accept experts for a number of projects only because of the technicality that they have to take the experts to get the equipment". The supply and equipment element of projects remains considerably smaller than the other two elements, namely： staff assignments and fellowships. WHO is urged to "review policy on equipment purchases with particular care". The Director-General believes that the policy outlined in his report to the Board on "Policy Governing Assistance to Developing Countries",^ particularly paragraphs 3 and 4 concerning supplies and equipment, adequately safeguards the interest of the developing countries as well as of the Organization.
3.3.5 The Inspectors raised the question of what happens to the traditional project package of experts, fellowships and equipment supplies under the suggestion made in the report on
"Policy Governing Assistance to Developing Countries" and whether the "project-oriented fellowships would become more or less meaningless".
3.3.6 The Director-General considers that the type of projects that could be implemented, would be based upon the specific needs of the health services, and include short or long-term advisers, fellowships and supplies and equipment in any combination necessary to meet the request of a Government, taking into account the availability, both internally and externally, of human and financial resources. The Director-General believes that fellowships for the education and training of health personnel (whether or not such fellowships are connected with specific projects) make an important contribution to the availability of national technical staff.
3.3.7 The report raises an issue with respect to equipment, namely whether WHO "should
get into the business of providing funds for imports of equipment", and suggests that it seems
"more appropriate for any such purchases with real merit to be financed primarily by UNICEF’’，
with WHO funds reserved for additional projects requested by the least developed countries.
They urge WHO to review its policy on equipment purchases.
3.3.8 With respect to the supply of equipment, the approach of the Organization is contained о in the report on "Policy Governing Assistance to Developing Countries' and resolution WHA21.47 Г) of the World Health Assembly. The provision of certain supplies, whether reimbursable
purchases, or from WHO funds is considered an important adjunct to assistance and should be maintained within the limits laid down by the policies of the Board and the Health Assembly.
In this connexion there are certain types of equipment that UNICEF is not in a position to supply as it cannot be expected to meet equipment needs for projects outside its terms of reference (see comments of UNICEF in 4 below).
3.3.9 Questions are also raised with respect to maintenance of equipment# In one region, arrangements have been established under which UNICEF is primarily concerned with repair and maintenance of transport equipment while WHO assumes responsibility for electro-medical instruments. The region concerned is proposing a training course in maintenance and repair for participants from Member States. Another region is preparing a training course for engineers specializing in maintenance of hospital equipment. Preliminary consultations indicate that UNICEF is already taking steps to include repair and maintenance equipment in workshops and maintenance centres in countries where interest has been expressed by the Ministry of Health. Under WHO procedures, Regional Directors have authority to approve the purchase locally of project supplies and equipment, provided that the local cost of items purchased in any one fiscal year for any project does not exceed $ 500. The Director-General will study the question of whether an enlarged delegation of authority to Regional Directors, and. the re-delegation of that authority, would be helpful in solving the problem of spare parts alluded to by the Inspectors.
Off. Rec. Wld Hlth Org., 168, Annex 11.
2 Off. Rec. Wld Hlth Org., 168, Annex 11, pages 47-50 3 Off. Rec. Wld Hlth Org., 168, P. 23.
3.3.10 The report suggests that WHO might explore the possibility of obtaining "experts and personnel provided free of charge by developed cosntries or public institutions". One Regional Office has found that such experts are not in fact free of charge and that it is always expected to pay transportation and per diem and occasionally to pay salary as well.
However, the Director-General will study th© suggestion further.
3.4 The second point in the report
3.4.1 The second point made in the report is concerned with the development of basic health services, particularly in rural areas. The Inspectors state that "they have been impressed by the very widespread view of WHO personnel that single purpose health programmes on a crash basis, particularly in the field of communicable diseases, are often premature'1. The separation of communicable diseases control as a distinct entity from general health service development is somewhat artificial. In every case the health priority of the country should guide the action. In many instances the control of certain communicable diseases becomes the first step in th© process of development of health services. The fact that the gain achieved by single purpose mass campaigns cannot be sustained without concurrent development of permanent health services - particularly in rural areas - has been well recognized by the Organization and is reflected in the recommendations of the World Health Assembly and the Executive Board and in the Organization's work.
3.4.2 Both the Board and the Assembly have, over many years, made the establishment of basic health services an important cornerstone of WHO policy, as is noted in the various programmes of work for specific periods and the proposals made by the Director-General for the First and Second United Nations Development Decades, The decisions of WHO legislative bodies cannot be translated into reality by the activities of the Organization alone, but require the indispensable involvement of governments of Member States to the same end. There is an undoubted trend by governments towards increasing their attention to basic health services and the attention of the Organization is directed towards this end in nearly all aspects of its activities.
3.4.3 While an increased number of countries have recognized the importance of the creation of effective national health systems, actual programmes towards these objectives have been variable. In certain cases the difficulty in proceeding to the early creation of basic health services is intimately linked to the lack of both manpower and training facilities. This fact explains the efforts of WHO to give increased attention to the whole area of education and training as indispensable to the implementation of national health plans and the develop- ment of basic health services. Single purpose communicable disease control programmes are becoming progressively rarer as the acute need for th© control of some of the most widespread diseases is being met and circumstances allow for the development of basic health services.
WHO representatives assigned to most developing countries represent the Organization with respect to the co-ordination of WHO assistance to the country concerned, and because of their intimate contact with the ministries of health, are able to advise and assist the ministry and its senior staff on basic health services and on planning.
3.4.4 The Inspectors have noted that "the trend of WHO expenditures for basic health services has remained about the same during the past few years, as a percentage of total expenditure".
Not infrequently a group of consultants or a WHO representative is in a position to advise governments in respect of the staffing and development of basic health services at a time when national funds are readily available. Furthermore, the realization of this fundamental need has led to the utilization of a substantial part of the malaria funds to support the develop- ment of basic health services without which malaria eradication programmes cannot be success- ful . This can be seen particularly in relation to malaria pre-eradication programmes in th©
African Region. Furthermore, other programmes make an important contribution to the develop- ment of basic health services. It is probable that this question arises as the result of the way in which the activities and obligations of th© Organization are classified in th©
programme and budget as well as in other reports which do not bring out clearly the extent of
E B 4 3 / 4 5 p a g e б
WHO activity concerned with the development of basic health services； the Director-General will review the existing classification to ensure further clarification.
3•5 The third point in the report
3.5.1 The decisions of recent World Health Assemblies regarding the health aspects of
population dynamics (resolutions WHA18.49,1 WHA19.43,1 WHA20.412 and WHA21.433) establish the OrganizationT s policy in this area. The approach to health aspects of population which has developed under these resolutions has been conveyed to every level of the Organization and vigorous attempts have been and are being made to communicate to field staff developments in this area.
3.5.2 WHO is engaged in orientation courses for its own staff as well as advisory services integrated into public health services to countries requesting assistance in this field.
Unifocal programmes suggested by demographers have a different perspective from that taken by health authorities and the Board and Health Assembly have consistently endorsed the public health approach to family planning as the only effective method of fulfilling WHO'S responsibility.
4. Views of the Executive Director of UNICEF
4.1 The Report of the Joint Inspection Unit mentions UNICEF assistance in several paragraphs.
The Director-General has consulted the Executive Director of that Organization； his comments, which were transmitted simultaneously to the Chairman of the Joint Inspection Unit, were received by telex on 18 February 1969 as follows :
"In absence Labouisse, following are my comments which have also sent Macy.
"Primo desire express our appreciation for the close and harmonious collaboration which we have with WHO. We recognize that the advice UNICEF receives from WHO is an essential contribution for a substantial portion of our assistance,
"Secondo re para 4, Board-approved assistance policy is to help projects in function their estimated benefit to children. We would not see this policy as being affected by-
whet her full-time or short-term experts were required or whether the project would be serviced by visits from a WHO regional representative as well as those of (words missing) representative.
Many supplies we give are not at all complicated. Problems of ensuring good use these supplies exceed by far what an individual expert can deal with. They are being tackled by assistance to strengthen supervisory services of ministries, e.g. strengthening of district health offices with respect to their direction and guidance of MCH. In this assistance expert help may well be needed.
"Tertio re para 5, as sound request for UNICEF assistance currently exceed available funds, Board wants us to concentrate on projects having most potential impact on childrens needs across the board, of course including assistance for childrens health. Accordingly in absence substantial additional contributions, we would not finance equipment to save WHO from having to finance it. This is also clear from the fact that W H O' S budget is $ 65 million and UNICEF* s annual income is about $ 45 million of which about $ 15 million goes to childrens health. However we fully appreciate importance of co-ordinating supply function within UN system.
1 Handbook of Resolutions and Decisions, ninth edition, page 100.
2 一 Handbook of Resolutions and Decisions, ninth edition, pages 100-101.
3
O f f . R e c . W l d H l t h O r g . , 168, p a g e s 21-22.
"Quarto re para 6, will be glad try co-operate with others working to help health
ministries set up an equipment maintenance service as we have done for many years in building up vehicles maintenance services.
"Quinto re para 8, we are now assisting projects that go beyond demonstration especially in broad field maternal and child health which has high priority in UNICEF assistance policy.
"Finally believe types of projects benefiting children that UNICEF has mandate to assist could benefit from careful considérât ion of some of the general policy questions raised in report, especially those relating to basic health services and adaptation of forms of assistance to different development stages - Heyward UNICEF".
5. Other Reports received from the Joint Inspection Unit
5.1 The Director-General has also received the following two reports from the Joint Inspection Unit：
(1) "Report on United Nations activities in Turkey" received on 3 September 1968.
(2) "Report on Co-ordination and Co-operation at the Country Level" received on 11 November 1968.
5.2 Both reports affect more than one organization in th© United Nati ons system, and therefore require prior consultation among the executive heads of the organizations concerned, in
accordance with the procedures mentioned in paragraph 2.6(b). Consultations with respect to both the improvement of procedures for dealing with this type of report and the substance of the two reports listed above will be undertaken at th© next session of the Administrative Committee on Co-ordination in April 1969.
5.3 In the circumstances, the Director-General is not now presenting his views on th© two reports pending this discussion and consultation within the Administrative Committee on Co- ordination. He will be reporting on these matters to the Board at its forty-fourth session.
EB43/45 ANNEX 1 N A T I O N S U N I E S U N I T E D N A T I О N S CORPS COMMUN D*INSPECTION JOINT INSPECTION UNIT
Palais des Nations
JIU/69/18 5 February 1969
Dear Dr Candau
I have the honour of transmitting to you herewith a report the Inspectors have prepared on WHO Assistance to Developing Countries based on visits made in 1968 to a number of countries in Africa, Southern Asia, the Middle East and Latin America.
My colleagues and I hope that some of the observations and suggestions we make in this report will be of interest to you and to the WHO Executive Board.
We look forward to receiving your reactions and those of the WHO Executive Board, in due course•
Yours sincerely,
Robert M. Macy Chairman
Joint Inspection Unit
Dr M. G. Candau Director-General
World Health Organization Avenue Appia
1211 Geneva
p a g e 2
REPORT ON WHO ASSISTANCE TO DEVELOPING COUNTRIES Joint Inspection Unit
This is a summary report on WHO assistance to developing countries based largely on visits by several Inspectors to various developing countries in Africa, Southern Asia, the Middle East and Latin America. We have also reviewed certain relevant WHO documents, particularly the resolutions and decisions of the Twenty-first World Health Assembly held in Geneva in May 1968.
We are favourably impressed with WHO assistance programmes, and feel that in certain important respects the efficiency of your operations in the field is outstanding. It is be'ieved, however, that there are certain important opportunities for further improvement, which are presented in this Report.
The first point we want to raise is concerned with the very wide differences in environ- ment and stage of development among the developing countries. At one extreme, there are still
a number of developing countries which cannot meet the traditional counterpart requirements for most projects. What they need in such cases is usually "Орех" or "executive" type assignments of WHO personnel, not advisers. At the other extreme, there are a growing number of ’’semi- developed" countries that have a declining need for the traditional expert under a contract running for several years, but are anxious to have short-term consultants instead in certain areas who are really outstanding in their fields. It seems that the traditional project with long-term experts, fellowships and equipment only really fits the countries in the "middle".
It is our observation that WHO is still trying to meet the needs of developing countries at all three stages of development with the traditional project, and is just starting to tai lor its projects more closely to a particular country's needs. For example, we have noted a significant trend in certain semi-developed countries toward a much greater use of short-term consultants,
We have only recently come across the Director-General's report to the Executive Board at its Forty-first Session (EB41/24 - 5 January 1968), which shows that he already had fully recognized the need for more flexibility in WHO programming in the field, and set forth some interesting proposals entitled "Proposed Forms of Future WHO Assistance", Based on our field observations, we find ourselves in full agreement with the general assumptions and rationale underlying the report. We would however like to offer certain observations and recommenda- tions regarding what he calls "Proposed Forms of Future WHO Assistance".
1. We feel that one of the most important guidelines in implementing technical assistance is the notion that an expert is "supposed to work himself out of a job and go home". We are not convinced that WHO is always fully conscious of this basic principle since it seems to permit projects even in semi-developed countries to run on and on for many years with no concrete time-phased plan for training counterparts and terminating the project. We made some historical studies which revealed that in some countries, terminâted projects were limited
largely to those which provided one-time seminars or training courses, or short-term con- sultants . Termination dates of other projects were repeatedly extended.
2. In the above-mentioned report the Director-General states that "It may be desirable to extend the practice of providing operating personnel more widely than in the past to countries with an acute shortage of staff.". We concur in this statement. He then goes further and raises the question as to where the money would come from for such expanded assistance. It is our view that many WHO personnel are in fact acting in an operating capacity in semi-
developed countries that have local personnel qualified to take over the reins. If these WHO personnel were phased out the necessary funds might then become available. (We recognize that in semi-developed countries new more advanced projects and some large Special Fund Projects can be justified from time to time.)
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3. In the discussion of types of personnel and assistance in the report no reference was made to the possibility of the use of contributions in kind or in the form of experts and personnel provided free of charge by developed countries or public institutions. If this potential source of manpower has not been thoroughly explored by WHO, we suggest that this be done.
4. In paragraph 4.3.1 the Director-General points out the need to shift to shorter assignments of WHO personnel in semi-developed countries. This raises the question as to what happens to the traditional project "package" of experts, fellowships, and equipment and supplies. For example, if a project has only short-term experts, should it include equipment and supplies?
Title has not passed until the project is terminated, so who will instruct the counterparts in the proper use of equipment, and watch to see that it is properly maintained and repaired as needed? Will the concept of project oriented fellowships become more or less meaningless and
future awards be based largely on manpower surveys identifying serious shortages of skills for which no satisfactory training is available locally? We were not able to get satisfactory answers to these questions in the field. These problems become particularly acute when large purchases of medical supplies by UNICEF were involved. The easy way out of course is to con- clude that if only short-term experts are involved, no fellowships or equipment and supplies can be included. A close look at some specific situations, however, may indicate the need for some flexibility on an exception basis.
5. We were interested in the discussion of equipment and supplies in the Director-General * s report, and noted particularly his comments about requests for more equipment and supplies
"over and above the present allocation for specific projects in special circumstances". It has been our experience that this question arises particularly in semi-developed countries which have trained personnel but continuing difficulties in obtaining necessary equipment.
The expression one hears so often in some of the countries is that "their need is more for equipment than advice". There is an impression that they often accept experts for a number of projects only because of the technicality that they have to take the expert to get the equip- ment . This would seem to raise the fundamental policy issue whether WHO should get into the business of providing funds for imports of equipment in those cases, unless the equipment is an integral part of a Regular or TA Project. It would seem more appropriate for any such pur- chases with real merit to be financed primarily by UNICEF. Any excess funds that WHO has for such equipment might b© better spent on additional projects requested by some of the least developed countries but not included in the Director-Generalfs budget proposals. We urge WHO to review its policy on equipment purchases with particular care before reaching a decision.
Our field experience fully supports the Director-General1 s increasing concern over the problems of maintenance and repair of specialized equipment (his paragraph 4.3.5.3). It is our observation that the problems associated with the repair of equipment are particularly acute in th© medical field. We have two suggestions. First, UNICEF and two or three other agencies as well as WHO are starting to move in the direction of training personnel and setting up repair shops for specialized equipment, but these efforts are not always co-ordinated in the
field. It is urged that the agencies involved work together closely on this matter. Second, it is our observation that th© single most frustrating aspect of keeping equipment in good
repair is the lack of delegation of authority down the line in the field to purchase needed spare parts up to a specified dollar amount per item direct from the local agent or factory.
Sometimes this means the difference between having a key piece of equipment out of use for six months rather than two weeks. We were told about instances where the repair and maintenance problem was simplified by procuring equipment manufactured abroad through the local agent, who is then more likely to have spare parts on hand and to respond more quickly to calls for assistance. We suggest that WHO review its procedures regarding delegation of authority to purchase spare parts,
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7. We have not attempted to quantify the above proposals in terms of their effect on WHO's budget, but we believe that they would result in an economical and more effective use of available funds through (a) some shift of funds from the semi-developed to the highly under- developed countries, (b ) a more rapid shift to short-term consultants in semi-developed countries and executive operations type p©rsonn©l in the highly unci©r-developed countries,
(c) more careful administration of the use and maintenance of equipment, (d) a restriction of equipment procured with WHO funds to that for demonstration purposes with additional equipment procured with UNICEF funds, and (e) more severe restrictions on non-project oriented fellow- ships ,particularly in semi-developed countries.
8. We hope that UNICEF would co-operate with WHO in financing equipment and supplies over and above what is needed for demonstration purposes, whose procurement is approved both by WHO and UNICEF. We also urge that UNICEF co-operate fully with WHO in taking feasible steps to ensure that health equipment is kept in repair and properly maintained.
The second point we wish to raise is concerned with the development of basic health
services, particularly in the rural areas. We have been impressed by the very widespread view of WHO personnel that single purpose health programmes on a crash basis, particularly in the field of communi cable diseases, are often premature. For example, WHA21.22 concerned with Malaria Eradication Programme includes the statement that "Recognizing the primary importance of basic health services both as a prerequisite for the starting of programmes and for the maintenance of gains already achieved ••.,’. It is repeatedly emphasized that the backbone of any sound medical programme is a national public health service that provides the basic health services on an integrated basis, even in the more remote rural areas.
In the circumstances, we expected to find much evidence of corrective action under way in the field. We expected to find this experience reflected in discussions of the legislative bodies of WHO, and the budget proposals. ‘ But this was not the case.
For example, in view of the comparatively sophisticated management techniques used by WHO, and the valuable and very widespread experience it has had on the matter of proper time-phasing in the development of health programmes, we expected to find WHO very active» in the health planning field, including the introduction of advanced management tools such as the network techniques which are concerned with the control of time. We find that WHO is requiring net- work analyses in all sub-contracts for UNDP (SF) Projects and is gradually extending these analyses to other types of projects. We hope that this commendable effort by WHO will be extended soon to the health planning field.
We also expected to find a trend toward concentration of assistance in the public health area, and some reorientation by the WHO Regional Offices to focus attention of the developing countries on the objective of establishing basic health services, particularly in the rural areas, as quickly as possible. We note, however, that the trend of WHO expenditures for basic health services, has remained about the same during the past few years, as a percentage of total expenditure. We also find no significant reorientation toward, focusing on basic health services in the Regional Offices visited. One of the Inspectors, however, had noted a
significant reorientation in the Regional Office of WHO at Brazzaville during the 1966-67 period while serving the United Nations in another capacity.
We have been told that in all of the developing world, only Chile, Cuba, and parts of one or two other countries in Latin America have a really integrated national public health service If this approach to health development is so fundamental, why has there been so little progress toward achieving this goal? We have been told that in some countries the local governments are more concerned with help on an immediate problem such as smallpox than on a long range rural health programme. In view of past experience, is this a sufficient answer? Frankly, we inspectors cannot help feeling that an aggressive reorientation within WHO would help to give proper emphasis to this goal of an integrated health service.
E B 4 3 / 4 5 A n n e x 1 p a g e 5 Our final point is concerned with papulation and family planning,
sensitive nature of these topics. We feel that a high priority must be by the UN family, and would like to offer some observations and comments field.
1. There seems to be some lack of clarity among WHO officials in the field as to exactly what is WHO'S position with regard to family planning. It was not clear whether this situation reflected continuing uncertainties in Geneva regarding WHO'S role, or whether local WHO staff had not been fully briefed on headquarters policies and thinking.
2. In view of the very widespread interest and concern with population and family planning by all parts of the UN family, it was assumed that a Regional Office of WHO such as in New Delhi would have a focal point for dealing with these matters on a day-to-day basis. No such point was found.
3• Demographers and other social scientists concerned with population statistics seem to feel that WHO is inclined to move too slowly in the family planning field. On the other hand, WHO officials feel that experience shows that family planning should not be implemented as a separate crash programme, but should be administered through properly staffed rural public health facilities. Thus they argue that the programme cannot move any faster than these basic health services can be established in the rural areas. However, we feel that the position taken by those WHO officials would be a lot more convincing if there were more evidence that money and resources were really being mobilized to push rural public health services•
In closing, the Inspectors would like to thank the Director-General and the many officials of the World Health Organization who have gone out of their way to be helpful in this inspection work. We are most grateful for the full co-operation we have found everywhere.
We recognize the given to this problem on WHOfs role in this
