Transformation of World Health Organization’s management practice and workforce to fit the priorities of African countries

Introduction The WHO Regional Office for Africa developed an evidence-based tool, called the Dalberg tool to guide the functional review and restructuring of the workforce and management of the country offices to better fit the health priorities of Member States. Methods The Dalberg tool was used in conjunction with a series of consultations and dialogues to review twenty-two countries have undergone the functional review. Results: the “core functions” in WHO country offices (WCOs) were identified. These are health coordination, strengthening of health systems, generation of evidence and strategic information management, and preparedness against health emergencies. Results In order to standardize country office functions, categorization of countries was undertaken, based on specific criteria, such as health system performance towards Universal Health Coverage (UHC), health emergencies, burden of communicable and non-communicable diseases, subnational presence and national population size. Conclusion Following the functional review, the staff is now better aligned with country and organizational priorities. For example, the functional review has taken into consideration: (i) the ongoing polio transition planning; (ii) the implementation of the WHO emergency programme in countries; (iii) the investment case for strengthening routine immunization in Africa; and (iv) regional flagship programmes, such as adolescent health and UHC. The delivery of the core functions above will require the hiring of additional capacities and expertise in most country offices if deemed fit-for-purpose.


Introduction
The mandate of the World Health Organization (WHO) is to be a "directing and coordinating authority" in international health rather than a "first responder" agency [1]. Its main functions include: convening health partners; setting norms and standards; monitoring disease trends; conducting research; and providing technical and strategic support to Member States. Weak health systems in most Member States in the African Region have contributed to poor health outcomes (high maternal mortality ratios and child mortality rates, and failure to achieve the Millennium Development Goals (MDGs) and inadequate response to outbreaks and emergencies. In recent years, WHO has struggled to provide high-quality technical and strategic support to Member States, largely owing to funding challenges and also the fact that most country offices are not appropriately staffed [2]. The above issues were clearly evident during the 2014 Ebola virus disease outbreak in West Africa [3][4][5]. Many commentators considered WHO response to the outbreak as inadequate. Indeed, they were of the view that the organization required urgent reform [1,6]. Furthermore, the health profiles of countries vary widely within the Region. In response to some of these criticisms and challenges, the leadership of the WHO in the African Region in 2015 decided to undertake comprehensive reforms aimed at transforming the organization in the region into an accountable one capable of providing efficient and effective strategic and technical support to its Member States, through the Transformation Agenda [7][8][9][10][11].
Realignment of human resource capacity at regional and country levels was identified as a critical component of the Transformation Agenda [10]. The human resources of any organization are its most important assets and the caliber of people working therein is pivotal to the success or failure of the organization [2,[12][13][14][15][16][17][18][19][20]. Schneider developed the attraction-selection-attrition (ASA) model [21] as a useful theoretical framework for understanding how the context, in terms of cultural values and structure, influences and is influenced by the set of human resource (HR) practices an organization adopts.
According to ASA, as values guide judgments and decisions [21] those values and the goals of managers or decision-makers tend to become reflected in the processes, structures and culture that emerge to facilitate the achievement of organizational goals [22].
People within the organization then reflect the broader organizational values and goals [15]. The result is an "organizational logic," or a pull toward internal consistency and a complementary relationship between the culture, vision, structure and practices of an organization, as the individuals hired to work there embody and perpetuate its core values and the practices and processes that support those values [15,23]. Four major conclusions on differentiating HR bundles could be drawn from the literature above: (a) how much is invested in HR; (b) specific focus on certain HR functions; (c) goal or priority to be achieved through HR; and (d) how the workforce is managed.
Indeed, the decision of the WHO Regional Office for Africa to align its workforce with regional and country priorities and commitments is in agreement with existing theoretical perspectives on human resource management. The system's perspective highlights fitting and complementarity issues, which is arguably the most popular approach in the strategic human resource management (SHRM) literature [24][25][26][27][28][29]. Accordingly, SHRM practices must fit into one another, and the desired workforce characteristics and consequent workforce performance are achieved through the entire system of practices and the adequacy of their internal fit [30]. The relationship between SHRM practices and organizational effectiveness, from the human resource viewpoint has been amply demonstrated [31][32][33][34][35].
This view argues that competitive advantage is obtained when human capital resources are valuable, rare and inimitable [30,[36][37][38][39]. It further argues that the critical workforce characteristics in this context are skill/ability, motivation, and resources/opportunity [23,[40][41][42]. (d) improved ways of working to maximize results and staff satisfaction, and meet internal and external expectations. A key guiding principle was the joint management of the review. In other words, the restructuring was jointly led by the WHO regional and country office, with inputs from the WHO headquarters through the steering committee. The rationale for this includes: ensuring country buy-in and responsibility; consistency of the process across countries and adequate support provided to the country offices. Annex 1 highlights the four remaining principles with the rationales.

Methods
Consequently, the "Dalberg evidence-based tool", consultation tools and guidelines were developed by the Regional Office to assess alignment of workforce and operations of WHO with the host countries' health needs and priorities. The desired impact here is to have a WCO workforce that is "fit for purpose", and which provides high quality technical advice and operational support, relevant to the host government and partners. The operational methodology of the functional review consists of establishing the structure of a country office following a multi-level consultative process with the government, United Nations agencies, funds, programmes, and bilateral and multilateral donors. This is followed by an extensive workshop with the respective country offices to enable them to align their operations and structure to country strategic priorities, while

Preparatory phase
Establishment of the steering committee: the first step was the appointment of the oversight and steering committee of the functional review chaired by the Director for Programme Management at the Regional Office, and comprising regional cluster directors, two directors from headquarters, two WHO country representatives, the human resource and programme-budget unit managers, and the project manager of the functional review. Its terms of reference are to: oversee the process and ensuing coherence with the transformation agenda; provide direction and arbitration for the project team; ensure organization-wide consistency; and provide regular updates to the Regional Director.

Review of WHO country offices in the third wave of countries:
in planning the country visits for the third wave of countries, which started after the revision of the operational guidelines, geographical grouping of countries was considered in order to leverage the inherent potential for efficiency gains. Countries without substantive WHO country representative as well as polio high risk countries were placed at the end of the schedule for country visit.
Ethics approval and consent to participate: this is a routine programme activity not a research on human subject, so, we did not obtain any ethical clearance out of which we considered some lessons necessary to be placed in public domain through a scientific peer review journal.
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Results
Results from application of the functional review model: a total of 42 countries had been reviewed (Annex 7). In this paper, we report on the 16 out of 37 countries whose implementation plans have been approved. A number of recommendations were made for each country reviewed. So far, the overall average implementation rate of the functional review recommendations for the approved country restructuring plans ranges between 11% in the Democratic Republic of the Congo (DRC) and 98% in South Africa. The regional average implementation rate stands at 56%. Some of the key findings indicate that governments and other development partners expect WHO to do more in the areas of partner coordination, to achieve better results in the health sector and undertake hands-on capacity-building.  its focus on closing the gaps in this area. As a result of the review, various proposals were made to increase staff and/or cadres, which also will imply budget increases. The additional staff at the WCO also calls for supervisory staff for some positions with clusters/units in the First, the workforce is likely to be pursuing goals and agendas that are incongruent with the needs of the country. Members of staff are likely to be frustrated and demotivated by the tasks assigned, being unskilled for those jobs. As illustrated in the SHRM, the WHO functional review entails ensuring a planned pattern of human resources/workforce and functional deployments and activities designed to facilitate the realization of organizational goals and objectives [5,13,14].

Conclusion
As the priorities are met, the cost of the revision of the workforce will begin to wane. The functional review affords the organization the opportunity to take stock of its human resource profile in the context of the new demands in the countries, and in line with new regional and global targets.