Independent Oversight and Advisory Committee for the WHO Health Emergencies Programme Turkey Mission Report 2–6 November 2019 Dr Felicity Harvey Professor Hiroyoshi Endo Mrs Precious Matsoso ACKNOWLEDGEMENTS The Independent Oversight and Advisory Committee (IOAC) for the WHO Health Emergencies Programme is grateful to the Government of the Republic of Turkey for hosting the visit of the IOAC delegation during 2–6 November 2019 and to the WHO Secretariat at Headquarters (HQ), the Regional Office for Europe (EURO), the Regional Office for the Eastern Mediterranean (EMRO), and the Country Office in Turkey for facilitating the field missions. Special thanks go to the participants for graciously accepting the invitation to meet with the IOAC delegation and providing important insights into WHO’s work on country preparedness and the current response to the Syrian crisis. I. INTRODUCTION 1.1. Context The Republic of Turkey is a transcontinental country with a population of 82 million and shared borders with eight countries including Iraq, Iran and Syria. Owing to the 9-year conflict in the Syrian Arab Republic, which threatens the lives of an estimated 4 million people in the northwest of the country, around 3.67 million Syrians are thought to be living in Turkey, including 2.3 million who are registered under Temporary Protection. This represents the largest number of refugees hosted in any country in the world.1 The critical needs of this large population have placed enormous pressure on the existing infrastructure and services in Turkey, particularly health services. Turkey is located on the transit route to Europe from Asia and Africa and more than 200 million people per year are expected to travel via the new international airport in Istanbul starting from 2030. Turkey is prone to natural disasters such as floods, cyclones, earthquakes, tsunamis, landslides, and droughts, which could worsen in view of climate change. The country is also subject to outbreaks and epidemics of infectious diseases, as well as emerging and re-emerging diseases such as polio and measles. The complex geopolitical situation of the country, and the involvement of multiple actors across sectors, makes country preparedness and response capacity even more important. 1.2. Mission objectives and activities carried out The mandate of the IOAC is to provide independent scrutiny of the WHO Health Emergencies (WHE) Programme and to monitor WHO’s performance in health emergencies. The objective of the Turkey visit was to review WHO’s work in assisting the Government’s response to the Syrian crisis and in strengthening country preparedness in Turkey. WHO established a Country Office in Ankara in 1959 and a field office for covering cross-border operations into Syria in Gaziantep in 2014. The IOAC took a field trip to Gaziantep and met with the WHO team in charge of the cross-border operation in the northern part of Syria. During the visit to Gaziantep, the IOAC interviewed the Deputy Regional Humanitarian Coordinator for the Syrian Crisis, and the Director General for the European Civil Protection and Humanitarian Aid Operations (DG, ECHO), representatives of the International Organization for Migration (IOM), the UNHCR, the Organisation of Islamic Cooperation (OIC), UNICEF, Syria Relief & Development, and the WATAN Organization. In Ankara, the IOAC delegation met with the Deputy Minister of Health; the Directors-General of the respective Ministry of Health (MOH) divisions for migration, emergency health care services, and public health directorates; the Director-General of foreign affairs; and the President of the national disaster management authority for Turkey. The IOAC delegation also consulted the UN Resident Coordinator and representatives of partner agencies. The mission included a site visit to one of Ankara’s refugee health training centres to appraise the effectiveness of WHO’s support of the Government’s approach to 1 Source : https://www.unhcr.org/globaltrends2018 1 providing access to quality and equitable health care for the Syrian people living in Turkey. During the training centre visit, the delegation interviewed the head of the centre, Syrian health-care workers, Syrian patients, and the implementing partner ASAM (Association for Solidary with Asylum Seekers and Migrants). See annex for visit programme. II. SPECIFIC FINDINGS AND OBSERVATIONS 2.1. WHO Country Office in Turkey and the WHE Programme The IOAC was briefed by the WHO Representative in Turkey that clear guidance was received from the Regional Office for Europe (EURO) regarding implementation of WHE Programme reform in 2016 and that the Country Office organigram is currently being adapted to the strategic directions of the 13th General Programme of Work (GPW13) under EURO guidance. The IOAC noted that the Country Business Model was used as a benchmark in defining the Country Office’s structure but that the Regional Office adopted a flexible approach to meet country-specific needs, giving due weight to emergency preparedness activities across the European Region, as well as response to emergencies. The key areas of work with which the Country Office is supporting the MOH include non-communicable diseases (NCDs) and health promotion, mental health, migration and health, and refugee health and health security. The IOAC observed that there is fluid collaboration and support among the different units in the Country Office for its various projects and that the clear mandate for the WHE Programme has strengthened linkage among programmes. Finance and resource mobilization The WHO Country Office in Turkey holds the largest budget in the European Region, i.e. one third of the total budget, with $43.5 million of funding for 2019. Only $1 million of this was funded by assessed contributions and the rest was covered by voluntary contributions, which are being mobilized in-country in line with the Regional Office’s strategic direction. The IOAC commends the WHO Representative’s leadership in effectively engaging with in-country donor representatives: 65% of funding is raised at Country Office level, compared with 25% from HQ and 10% from EURO. For the cross-border operations in Gaziantep, HQ has played a key role in fundraising within the framework of the Whole of Syria approach. The IOAC noted that the Country Office raised more than 90% of funding from in-country donors in Turkey. Fundraising for the Whole of Syria approach has been done in a coordinated manner among HQ, EMRO, EURO, Country Offices and operational hubs, with an agreed internal funding allocation of 67% (Syria hub), 30.6% (Gaziantep hub), and 2.4% (Amman hub until closure of operations in Amman during 2018) for unearmarked funding; this is being adjusted as per the changing operational requirements and decided by consensus among all hubs. In 2019 a total of US$44 million was received for the cross-border operations in Gaziantep from 11-12 donors including the UK, USAID, OCHA and Japan. This figure indicates that WHO’s performance with respect to the Syria 2 crisis has gained credibility year by year, reflecting sustained confidence from donors. The initial budget of the office was $2.4 million in 2014, and the budget increased to $32 million in 2018. Commendably, more than 80% of the Whole of Syria budget has been used for activities. In managing financial uncertainty, WHO has shown the flexibility of constantly reviewing the organigram in Gaziantep as well as on a regular basis through Whole of Syria Strategic and Operational Reviews every 2–3 months. During its mission to Turkey, the IOAC witnessed the critical role of the Country Office and the importance of the delegation of authority for the WHO Representative in mobilizing and deploying resources at the country level. The Country Office has successfully raised US$3 million for health security between 2018 and 2021 and is pushing the agenda for country preparedness. While welcoming the Transformation Agenda, staff noted that resource mobilization should be done in a coordinated manner and that the WHO Country Office is best placed to liaise with in-country donors. The IOAC is pleased to see that the Country Office’s fundraising authority has increased, but is concerned that the additional workload and potential risks of handling funds could be a disincentive for WHO Representatives. The WHO Representative took the initiative to provide staff with training for project management to reduce risk and increase management of the donor funds through the WHO online learning platform ilearn, but there is no systematic career development programme to incentivise such training. The IOAC recommends that WHO empowers WHO Representatives and acquires adequate capacity for resource mobilization, and programme and risk management skills training at the country level. HR management In the Country Office in Ankara, there are 38 positions: 21 national staff, nine international staff and eight non-staff (those on Special Service Agreements, consultants and volunteers). As well as noting the great diversity of staff in the Country Office, the IOAC observed that the proportion of staff working on the WHE Programme is high, owing to cross-border operations and the donor-funded programmes on refugee health and health security. Out of 38 positions based in Ankara, 24 positions have been allocated to the WHE Programme. The field office in Gaziantep is run by a team of 26 staff including 17 professional positions. The IOAC noted an issue related to the HR policy to support staff working on emergencies from non-hardship duty stations. Cross-border operations in response to the Syria crisis are managed by the office in Gaziantep. But since Turkey is classified as a non-hardship duty station according to the UN hardship classifications, the staff in Gaziantep are not entitled to R&R or other packages for hardship duty stations set by the International Civil Service Commission.2 The IOAC recommends that WHO reviews the degree of hardship in offices working on emergencies, especially those carrying out cross-border operations (e.g.