Content » Vol 41, Issue 10

Original report

Chapter 5: Organizational structures suited to ISPRM’s evolving role as an international non-governmental organization in official relation with the world health organization

Per M. von Groote, MA1,2, Jan D. Reinhardt, PhD1,2,3, Christoph Gutenbrunner, MD4, Joel A. DeLisa, MD, MS5,6, John L. Melvin, MD, MMSc7, Jerome E. Bickenbach, PhD, LLB1,2,8,9 and Gerold Stucki, MD, MS1,2,3,10

From the 1Swiss Paraplegic Research, Nottwil, Switzerland, 2ICF Research Branch of WHO FIC CC (DIMDI) at SPF Nottwil, Switzerland and at IHRS, Ludwig Maximilian University, Munich, Germany, 3Seminar of Health Sciences and Health Policy, University of Lucerne, Switzerland, 4Department for Rehabilitation Medicine & Coordination Center for Rehabilitation Research, Hanover Medical School, Hanover, Germany, 5Department of Physical Medicine and Rehabilitation, UMDNJ – New Jersey Medical School, Newark, NJ, 6Kessler Foundation Research Center, West Orange, NJ, 7Department of Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA, 8Queen’s University, Department of Philosophy, Kingston, Ontario, Canada, 9World Health Organization, Geneva, Switzerland and 10Department of Physical and Rehabilitation Medicine, Munich University Hospital, Ludwig Maximilian University, Munich, Germany

Summary

International non-governmental organizations (NGOs) in official relation with the World Health Organization (WHO) face organizational challenges against the background of legitimate representation of their membership and accountable procedures within the organization. Moreover, challenges arise in the light of such an international NGO’s civil societal mandate to help reach the “health-for-all” goals as defined by WHO and to facilitate the implementation of the United Nations (UN) Convention on the Rights of Persons with Disabilities. The objective of this paper is to examine how such an international NGO using the International Society of Physical and Rehabilitation Medicine (ISPRM) as a case in point can address these challenges. The specific aims are to analyse ISPRM’s structures and procedures of internal organs and external relations and to develop solutions. These possible solutions will be presented as internal organizational scenarios and a yearly schedule of meetings closely aligned to that of WHO to facilitate an efficient internal and external interaction.

INTRODUCTION

As an international non-governmental organization (NGO) of physicians in official relation with the World Health Organization (WHO), the International Society of Physical and Rehabilitation Medicine (ISPRM) clearly has a humanitarian or civil-societal, a professional, and a scientific mandate to address the obstacles to realizing the right to health (1).

Until now ISPRM has focused on the fulfilment of its professional and scientific mandate. Its current organizational structure was sufficient and well suited to serving these specific aims. However, in the process of achieving its goals (2) a set of challenges has arisen. They include the limits of volunteer commitment, economic resources, resources available to the central office, membership growth, and questions surrounding the regional representation and the congress bidding system (2). These challenges, seen from an internal perspective (1), imply that their solution might be found in a review of ISPRM’s organizational procedures and structures.

From an external perspective, ISPRM is expected to live up to the civil-societal mandate it has been granted by WHO. As an international NGO in official relation with WHO, ISPRM has a set of rights and responsibilities (3) that directly translate to a range of challenges to its organizational procedures and structures (1). ISPRM could review these with respect to legitimacy, accountability and effectiveness of policy processes. The organizational structures may then be aligned with good governance principles of WHO as well as ISPRM’s evolving role, as described elsewhere (4). Procedures must, in any case, be clearly defined and self-explanatory to avoid their perpetual iteration, which can only reduce the time available for content discussions. Yet, there is no perfect solution to every challenge – arguments in favour and against can always be found.

The objective of this paper is to analyse how ISPRM can develop its organizational structures and procedures suited to enhance ISPRM’s legitimacy, downward accountability, and policy process effectiveness.

The specific aims of this paper are to review the current structures, procedures and challenges of accountability in light of ISPRM’s civil-societal mandate and of legitimacy management. Furthermore, this paper aims to present suggested modifications and possible new scenarios of ISPRM’s organizational structures. Moreover, the current external liaison structures of ISPRM and respective challenges will be outlined, and future perspectives of ISPRM’s external policy relations and suggested adaptations, drawn from current findings, will be presented.

ISPRM’S ORGANIZATIONAL STRUCTURE: CURRENT SITUATION, CHALLENGES, FUTURE PERSPECTIVES AND SUGGESTED ORGANIZATIONAL SCENARIOS

ISPRM’s achievements rest on an organizational and procedural structure not unknown in the realm of international professional health societies (5, 6). In fact, ISPRM, as is the case for every NGO in official relation with the WHO, is required to have a form of constitution clearly stating the organization’s structures and procedures (3).

Current internal organizational and governance structure

ISPRM defines its internal organizational structures and procedures as stated in the By-Laws and Policy and Procedures Document (7, 8). These laws and regulations state the rights and responsibilities of elected officials and bodies.

The organizational structure of ISPRM (Fig. 1) includes the President’s Cabinet, the Executive Committee, the Board of Governors and Regional Vice Presidents. Other committees are assigned to special fields of expertise or operational tasks, such as the Nominating Committee or the By-Laws Committee.

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Fig. 1. Internal organizational and governance structure of the International Society of Physical and Rehabilitation Medicine (ISPRM) (7).

The President’s Cabinet recommends nominees to the Nominating Committee. It has the authority to act on issues that need immediate attention and can pass this ad hoc authority to the President. He is to act as determined by the Cabinet, until the next meeting of the Executive Committee and/or Board of Governors.

The members of the President’s Cabinet are also automatically represented on the Executive Committee. They are joined by the Executive Director (ex-officio), the Regional Vice Presidents, one representative at large for the individual members and one representative at large for the national societies. The Executive Director is responsible for the overall operations of ISPRM, whilst the Secretary and Treasurer have special duties.

ISPRM’s Board of Governors is the main legislative body of the society. It consists of the Executive Committee, one representative for each member nation nominated by the national societies and the same number of representatives of the individual members.

The Board of Governors elects candidates to ISPRM’s governing bodies. It decides on suggested amendments to the By-Laws, i.e. the constitutional framework of the organization which is binding for its members, with a simple majority of its quorum.

Challenges to ISPRM’s internal organizational and governance structure

ISPRM’s organizational structure and dependant procedures are deliberate, but complex, and arguably unclear in parts.

An international NGO’s organizational structure needs to be rooted in 2 underlying themes of designated good governance – legitimacy and accountability. Legitimacy refers to the authority to speak for a constituency based on equity in elections and some form of expertise, or practical legitimacy to advise or help others (9). Downward accountability (10) is an intra-organizational trait resulting from good governance. In addition, accountability is a managerial prerequisite of a professional organization in terms of capacity, efficiency, standards and anti-corruption (11).

ISPRM’s past experience has shown that further organizational development must be centred on the enhancement of sustainable capacities in terms of personnel, funds, bureaucracy, and membership representation (2). Volunteer leadership and engagement can only carry an organization as far as the leadership reaches. The focus of control resting on few can pioneer rapid growth. Yet, this leadership has to be able to pass its legacy down to accountable others, who are willing to implement and live ISPRM’s decisions, not just in zones of indifference (12), but as a matter of conviction. Sustainable growth needs economic resources as much as these are needed to uphold a legitimate and accountable organizational structure for a growing global membership and the organization’s mandates. The challenge lies in bolstering internal participatory structures, when higher degrees of professionalization, centralization, and bureaucratization – elementary for the survival of a voluntary, non-profit NGO – seem to pull in other directions (13).

The organizational challenge of individual member representation and suggested solutions. The electoral process to the Board of Governors and consequently its proportionate composition could be revised to better define the roles and constituencies of its members.

To start, the term Governor in the name Board of Governors could be seen as inappropriate. The current Board is so large and meets so infrequently that it does not serve the roles usually assumed by a Board of Governors. An orientation towards WHO’s terminology seems better, i.e. the Assembly of Delegates.

The National Societies are to individually nominate candidates to be elected later to the Board to represent them. Although the procedures in Appendix III of the Policies and Procedures (8) outline a process for the open nomination of individual members, nominating committees have, at times, not communicated clearly to the members how they might exercise these rights. However, the membership in the past has submitted very few nominations for any of the ISPRM positions even when asked explicitly to do so in the News and Views. Thus, they have been nominated out of the overall membership by a Nomination Committee comprised of already elected members. This can lead to a limited selection and exclusion of lesser known individuals.

Also, national societies that pay a lump sum for all their members may have additional leverage when it comes to voting through influencing their individual members.

Possible organizational solutions are presented in Table I. All members of the Council of Presidents could be assigned to the Nomination Committee, thus limiting the number of Executive Committee members with approval and disapproval rights of nominations. The Council of Presidents could itself elect a chair and co-chair to co-ordinate and guide toward the new duties. The Nomination Committee would only review and approve or disapprove nominations. The Board of Governors would then nominate candidates directly itself, rather than having its representatives on the Nomination Committee suggest nominees. Also, all other members willing to hold office should be able to be candidates if approved of by the Nomination Committee.

Table I. The International Society of Physical and Rehabilitation Medicine (ISPRM)’s internal organizational challenges and suggested solutions

Challenge

Suggested solution

Pro/Contra

Representation of individual members

Election of representatives of individual members to the Assembly of Delegates

Plus in legitimacy and downward accountability

Technical/resource challenges

Composition of the Nomination Committee

All members of the Council of Presidents alone assigned to Nomination Committee

Nominations to be placed directly by Assembly of Delegates

Review of nominations by Nominations Committee

Prevents self-selection

Plus in legitimacy and downward accountability

Election of the ISPRM President and the role of the ISPRM Vice President

Election of President Elect by Assembly of Delegates or General Assembly

President Elect serves a 2-year term to become ISPRM President for 2 years

The post of ISPRM Vice President is to be faded out

Presidential post is more directly accountable

Technical challenge

Quicker turnaround of terms is more flexible and appropriately fit to new agenda

Less confusion about Vice Presidencies

In terms of recognition of all member votes, a web-based absentee balloting solution could be discussed. Not all members are able to participate in all meetings and congresses to vote. It should, however, be mentioned that these digital voting systems have been proven to be problematic in some elections (14). Also, a postal vote system needs to be reviewed in light of resource limitations in many parts of the otherwise under-represented developing world.

This, perhaps initially daunting, task could be handled professionally and efficiently by an enlarged central office.

Organizational challenges regarding the Presidency and suggested modification. The electoral process to the presidency could be discussed and potentially revised. The Vice President, elected by the Board of Governors, succeeds the President Elect after a 2-year term to become ISPRM’s President for the following 2 years. This accession process over 2 legislative periods means the Board of Governors elects a President that will not serve during its term, thus reducing its direct influence on the President. Also, because of the selection process of the individual members on the Board, the process of choosing a President may lack the input of less well-known or active members. The Vice President’s role is not clearly defined in the By-Laws, although his or her term in office as Vice President serves as a learning period for the future President to gain familiarity with the governance of the organization through participating in key committees. Also, the election of ISPRM’s Regional Vice Presidents by the Board of Governors is challengeable. Persons with limited influence in the regions they are to represent may be elected to the Executive Committee.

To meet these challenges the post of Vice President could be faded out of the present system in favour of shorter, more directly accountable terms of the Presidency. The constitution does not state what role the Vice President has. His post can also be confused with the Regional Vice Presidents, who in future are to play a more prominent role (1, 4). The electorate would thus vote on the President to first become President elect for 2 years. Those favouring this approach believe the term would allow the President Elect to prepare his Presidency in full and assist the President at the same time. The enlarged Central Office (4), when implemented, could compensate for the loss of institutional memory by this reduction in personnel.

Also, the ISPRM Regional Vice Presidents need to be selected or elected by the Regional Societies (4), to be then approved by Board of Governors. It would then not be the other way around as in the present system.

Future perspectives – suggested organizational scenarios

ISPRM’s internal policy structures and procedures, as stated above, could be more democratic in terms of representation and decision-making. On the one hand, to demand a complete, democratic regime (15) to be put in place would exaggerate the point. On the other hand, an NGO reaching out to the world should strive to be as inclusive as possible (13). In order for ISPRM to be seen as a legitimate representative of regional, national and individual PRM voices, the organization may consider modifying its structures and procedures to hear the whole choir and facilitate more participation (16, 17).

The current political organizational system has many concepts well suited to the time in which it was designed. It was especially beneficial in realizing ISPRM’s achievements, as described in an accompanying paper (2). However, no system is immune to changes in demands set by time and a dynamic world societal agenda (1). Organizations must evolve over time just to survive – a fact ISPRM’s leadership has acknowledged by appointing an Organizational Structure Task Force. The scenarios outlined below are aimed at differing stages of ISPRM’s perceived future position in world health polity to accommodate this gradual evolution over time.

The underlying structural principles of the following possible scenarios are already incorporated in the current system. These are in particular: (i) the integration of all world levels through Regional Vice Presidents, (ii) parity in occupancy of governing bodies between representatives of individual and national members; (iii) the accession process in the presidency to allow the accumulation of institutional memory (18); and (iv) the democratic foundation to all structures.

Many elements presented below are well known from the present system, for instance the Executive Committee, the Board of Governors and the Nomination Committee. The 2 suggested scenarios incorporate these elements with alterations to their election, composition and responsibilities.

The proposed changes within the present system apply mainly to the relations between the elements. Furthermore, innovative ideas are introduced (Figs. 2 and 3).

The reward of organizational change to ISPRM will be an increase in structural and procedural legitimacy. In other words, ISPRM will be perceived as the appropriate society to do the job from an internal and external perspective (9). The challenge will be to gain these perceptions and yet develop a structure that is effective and efficient within the resources, human and monetary, available to ISPRM at any given moment in time.

For clarity, from here on we refer to the Board of Governors as the Assembly of Delegates and to the By-Laws and Policy and Procedures document as the Constitution. Furthermore, when mentioning the regions and ISPRM Regional Vice Presidents we are referring to the current and the envisioned ISPRM regions as outlined in an accompanying chapter of this special issue (4).

The following 2 scenarios incorporate the above-suggested modifications to the present system. The composition of the Executive Committee and the President’s Cabinet is only changed in relation to the expiring Vice Presidency. The duties of the Treasurer, the Secretary and the Executive Director, as well as those of standing committees, special committees or task forces, are not discussed here. Their role, like that of the Membership Committee, could be discussed after agreement on the general organizational structures.

Two-level transitional scenario

This first scenario is designed to serve ISPRM in a transition phase between the present and the three-level, best case, scenario described below. It has a two-level structure now of interest to us (Fig. 2). The lower level is composed of the Assembly of Delegates; the upper level is represented by the Executive Committee.

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Fig. 2. Two-level scenario.

National and regional societies are automatically represented in the Assembly of Delegates and eligible to vote. Each national society can send one representative to the Assembly of Delegates and each regional society can send 2 representatives. This is to ensure that the few regional societies gain more leverage in terms of voting in relation to a potentially large number of national societies. Whoever is present at the Assembly can vote.

The individual members, however, vote on representatives to the Assembly of Delegates then eligible to vote. Their number is not to exceed those of the national and regional representatives. No more than 5 individual representatives are to be from 1 single country. Their eligibility to hold office should by then have been reviewed in the membership application process by the Secretary as in the old system. The dotted line in Fig. 2 indicates that the individual members form a kind of virtual assembly. This is a first reference to the lowest level of the three-level scenarios, to be described next.

The Assembly of Delegates nominates and elects all candidates to hold office, be they the presidential candidate, the Treasurer or other Executive Committee or President’s Cabinet members. The legitimacy and accountability of the elected is thus assured. The nominees are reviewed and approved by the Nomination Committee. The ISPRM Regional Vice Presidents appointed by the regional societies ascend to the Executive Committee after approval by the Assembly of Delegates. This approval process replaces the electoral process of the Regional Vice Presidents to the current Board of Governors, because the Regional Vice Presidents are already elected officials of their regional societies. This mechanism allows ISPRM to adhere to the WHO’s requirements of the integration of regional organizational structures.

Three-level best case scenario

The two-level scenario is complemented in this case by a third and lowest level (Fig. 3), best designed to incorporate all requirements derived from ISPRM world societal mandate (1) and an envisioned membership growth. This lowest level is to ensure a more legitimate and organizationally manageable transmission of membership rights to their representatives’ powers to govern ISPRM. Also, an adjusted and more appropriate electoral process from a managerial perspective at the same time enhances downward accountability (10) and democratic legitimacy towards the member and non-member constituency.

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Fig. 3. Three-level scenario.

One representative of every national and 2 of every regional society jointly form the Assembly of National and Regional societies. On the same level all individual members form the Assembly of Individual Members. Both chambers would be chaired by members of the Council of Presidents. These bodies are virtual assemblies in so far as they only meet on special occasions. Elections could be administered by the central office by means of an electronic and postal ballot system. A scheduled meeting, however, could be devised in order for individual members to put questions to the President’s Cabinet and discuss policies and procedures. Such a meeting could be convened at a scientific Physical and Rehabilitation Medicine (PRM) congress (4).

In this scenario both chambers together form a General Assembly, which jointly elects the President Elect. The chambers each elect 15 representatives to the Assembly of Delegates, one level above. On the one hand, the limit to 15 candidates for each chamber is to ensure that the governing Assembly of Delegates is still manageable when ISPRM’s membership grows. Imagine 60 member countries and, respectively, 60 individual member representatives voting on a policy item – one on an agenda of 20! On the other hand, a certain number of delegates is needed to fully reflect ISPRM’s global diversity in membership (19). The special representation of the regional societies by means of 2 representatives sent to the Assembly of Delegates is not incorporated in the three-level scenario. However, the Regional Vice Presidents are still sent to the Executive Committee after approval of the Assembly of Delegates. As do their colleagues on the Nomination Committee, the Assembly chairs screen and approve nominations to the Assembly of Delegates one level above outside of the executive structure.

Such a more inclusive three-level system toward the incorporation of a broad-based and global membership, equipped with the power to vote on issues and people, enhances the stability of ISPRM’s internal and external policy. On the one hand, the more veto players are in place the less likely it is that radical shifts in the direction of ISPRM’s policies occur (20). On the other hand, a less accountable leadership can be pioneers in erecting structures not yet in place (21). This is especially needed in countries where there are no PRM societies. In the long run, however, policy structures need to incorporate pluralism and democratic parity to uphold sustainable policies. The success of external activities lies in dependable policies born out of accountable organizational structures and procedures.

EXTERNAL RELATIONS AND LIAISON STRUCTURES: CURRENT SITUATION, CHALLENGES, AND FUTURE PERSPECTIVES

ISPRM’s external relations and liaison structures are equally important to ISPRM’s further development. They are, in fact, primarily responsible for ISPRM’s organizational structures and procedures (1). To be able to respond to external impulses directed at organizational change and adaptation are favourable attributes of a flexible and capable international NGO (1, 22).

Current external relations

ISPRM has official working relations with WHO’s Disability and Rehabilitation (DAR) team in Geneva. A collaboration plan is in place and regular formal meetings are held (23). ISPRM is also part of a group with the other professional rehabilitation organizations, including the World Federation of Occupational Therapists (WFOT) and the World Confederation of Physical Therapists (WCPT) that meets for consultations with WHO (24).

Challenges within ISPRM’s external relations

The challenges within the collaboration with WHO (23) involve: (i) the development of a systematic representation of ISPRM during the World Health Assembly (WHA) in May every year (3); (ii) the assemblies of the WHO regional meetings; and (iii) the systematic input by ISPRM delegates with respect to activities across WHO secretariats relevant to rehabilitation and PRM. Obviously, meeting these challenges creates new coordinative challenges, which may be beyond the powers of an organization run by individual members. As outlined in an accompanying paper, it is of utmost importance that ISPRM expands its Central Office (4). This expansion may include the employment of an officer responsible for coordinating the activities with WHO and United Nations (UN) systems.

Since WHO is emphasizing the work within the WHO regions and since much relevant action is taking place in the regions, ISPRM may want to further systematically develop its presence with the regional WHO offices, e.g. by holding ISPRM sessions at regional conferences (4) and by monitoring and contributing to the development of policies relevant for rehabilitation on the regional level. The current WHO/ISPRM collaboration plan provides the “names of the Regional Vice Presidents of ISPRM who can serve as regional advisors to DAR” (23). The role of these regional points of contact with WHO offices and collaboration centres and the inclusion of lower, national and local levels could be discussed (1, 22).

ISPRM currently has no formal mechanism to work with regional societies with which it shares its constituency, and it is thus challenged to define its position in relation to them (2). The WHO principles governing relations with NGOs explicitly states that an NGO in official relation with WHO “shall represent a substantial proportion of the persons globally organized for the purpose of participating in the particular field of interest in which it operates.” (3). Thus it seems that regional societies must be able to become ISPRM members representing their whole region. Since the interests of a whole region may collide with the particular interests of all national societies within that region, it makes sense, as described above, to have representatives for whole regions as well.

Furthermore, negotiating the relationship terms, such as the principle of subsidiarity, between allies and partners, is necessary to avoid future conflict (25). In turn, this dialogue can be used to incorporate regional societies’ experience into ISPRM’s policy agenda (22), which can lead to influence legitimacy more by addressing then common goals (9). It would thus seem important to invite regional societies to ISPRM venues in a call to openly discuss interests and expectations of possible future membership relations.

Challenges to ISPRM’s organizational structures regarding external relations

ISPRM’s official relation status to WHO implies a set of rights and responsibilities (3) that entail managerial and organizational consistency with WHO governing principles. Most importantly, the membership of such an NGO in official relation must be able to vote on Policies and Procedures. WHO’s scrutiny of all official relations is not only directed at reviewing organizational efficiency and fiscal accountability. The bodies of the UN system and its partners are more crucially questioning the legitimacy of an organization to act on its behalf (1, 22). This suggests that international NGOs affiliated with the WHO should strive to represent their membership as accurately as possible. The outlined organizational scenarios aim to take these arguments into consideration.

Similarly, a non-profit NGO’s role in advising the provision of publicly funded services once delivered by states to its own citizens could be subject to some controversy (13). This holds especially true in light of the fact that an NGO may pursue activities in states with non-democratic regimes. The NGO may soon itself become a political space (26), preferably cultivating democratic values, procedures and skills. Its potential to act as a bridge between allies and partners of varying resources and interests requires maintaining its legitimacy, including representation of its vision through the process of participatory governance (13).

Other external organizations (1) are themselves bound by codes of conduct and, in most cases, international law. This holds true for nation states and international governmental organizations in or outside the UN system as well as other international NGOs. These possible partners and allies are thus very sensitive to ISPRM’s legitimacy. Private companies approached to become possible sources of funds are equally interested in a partner’s practical and moral legitimacy (9, 27), even more so in view of shareholder interests. In light of increasing activities in potentially culturally sensitive contexts (28) ISPRM must be aware of other professional watchdog NGOs. A good public image is an extremely valuable asset in times of global mass media (1, 22).

Future perspectives of ISPRM’s external relations

The future development of the field of PRM and worldwide implementation of programmes and initiatives to meet “health-for-all” goals, as set out by WHO (29, 30) gives exceptional opportunities to ISPRM. The implementation process of the UN Convention on the Rights of Persons with Disabilities gives guidance on what challenges need to be addressed where.

Collaborative initiatives in the form of global public-private partnerships are only one of many policy tools the organization can utilize to help meet those challenges (22, 27, 31). The other professional rehabilitation organizations are hereby valuable allies to ISPRM.

A good example of a collaborative WHO effort involving a governmental agency, a consumer organization, a trust, a university and a professional organization is the WHO publication Guidelines on the provision of manual wheelchairs in less resourced settings (32). ISPRM has also proven its capability to consult WHO both on technical guidelines (2) and other publications (33). The society could now focus on bringing such partners together and on initiating, leading and helping implement guidelines and standards in its field of competence (31).

Toward an organizational development and enlargement, ISPRM could consider using so called bridging groups, which may be developed into strategic alliances (22). These would be comprised of members of existing ISPRM national or regional societies and of other members from relevant organizations, such as development agencies. They would first serve as a basis for information exchange and basic networking between participating organizations. In a second step the group could, for example, utilize its combined resources to reach out to regions where no PRM organization or even network exists.

One possible scenario may be to send ISPRM representatives into the advisory or supervisory boards of other organizations, such as globally active corporations in rehabilitation technology (22). Conversely, ISPRM may decide to create an advisory or supervisory board inviting representatives of relevant intergovernmental organizations (IGOs), other international NGOs and corporations relevant to PRM. This will provide for a continuous formal and informal flow of information and gradual allocation of funding means.

Also, the Executive Committee could decide to assign an existing or create a new standing committee on strategies to expand and grow the field of competence outside of areas of strong ISPRM membership. A standing committee could look outside of the field at ways one can influence global health policy as outlined in accompanying papers (1, 22). It, or another task force, should monitor the work of the WHO Standing Committee on NGOs to keep track of amendments to rules, regulations and the official relation status of other NGOs after review by WHO (34). Also, relations could be established with the UN Non-Governmental Liaison Service (NGLS) in Geneva (1, 35).

Lastly, when the time comes to amend its current By-laws, a policy agenda item (31) for ISPRM could be added with a vision statement that takes into account the UN Convention on the Rights of Persons with Disabilities (36), the ICF (37), the WHA’s Resolution on Disability and Rehabilitation (38), and finally the vision and mission of the DAR team at WHO (39).

A possible starting point in finding ways to meet the challenges within ISPRM’s external relations may be to look at the sequel of relevant yearly events. ISPRM may want to more closely monitor the world health agenda as defined within WHO governing body sessions (40). To achieve this aim, ISPRM could review its yearly meeting schedule and seek to align it to that of WHO.

Therefore, the next step is to outline ISPRM’s yearly timeline in relation to the meeting agenda of the WHO Executive Board and of the WHA with suggested adaptations.

SUGGESTED TIMELINE OF YEARLY EVENTS CONSIDERING INTERNAL AND EXTERNAL RELATIONS

Depicted in Fig. 4 is the yearly schedule of WHO meetings responsible for shaping ISPRM’s agenda. Congresses and PRM venues other than the ISPRM World Congress are not included. This is to avoid distractions from central correlations.

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Fig. 4. World Health Organization (WHO) and International Society of Physical and Rehabilitation Medicine (ISPRM) timeline.

ISPRM’s meeting schedule should be influenced by two factors. Firstly, there are ISPRM’s own organizational prerequisites to meet and consult regularly. All world levels need to be involved in the consultation and implementation of ISPRM’s agenda (22). As outlined in an accompanying paper (4) a joint ISPRM scientific committee could, for instance, be created to ensure ISPRM’s involvement in the envisioned yearly congress organization and the development of a congress topic list. Also, the above suggested internal electoral system needs to be scheduled.

Secondly, ISPRM’s meeting schedule is influenced by WHO’s meeting schedule, by which the consultations on the world health agenda are coordinated. ISPRM can utilize its dependency on WHO agenda setting power by shadowing WHO’s meeting timeline. This would ensure a timely and effective deployment of ISPRM’s own policy tools (22, 31) to efficiently influence the world health agenda.

WHO meeting schedule

The WHO Executive Board meets in January to revise the WHO’s Medium-term Strategic Plan and the proposed Program Budget. The revised documents are handed to the Director General (DG), who then incorporates suggested amendments by member state governments. The DG recommends the revisions to the documents at the World Health Assembly (WHA), as may be necessary. After the WHA the Executive Board meets for its second session of the year. The Executive Board gives effect to decisions and policies of the WHA. During the later part of the year the Medium-term Strategic Plan is implemented and continually revised at the WHO’s Regional Committee meetings. The draft Strategic Plan is then again passed to the Executive Committee for revision at its first session of the following year. The specific functions of the WHA and the Executive Board are stated in Table II.

Table II. Functions of the World Health Assembly (WHA) and the World Health Organization (WHO) Executive Board (40)

Functions of the WHA

Functions of the WHO Executive Board

Article 18

The functions of the Health Assembly shall be:

(a) to determine the policies of the Organization;

(b) to name the Members entitled to designate a person to serve on the Board;

(c) to appoint the Director-General;

(d) to review and approve reports and activities of the Board and of the Director-General and to instruct the Board in regard to matters upon which action, study, investigation or report may be considered desirable;

(e) to establish such committees as may be considered necessary for the work of the Organization;

(f) to supervise the financial policies of the Organization and to review and approve the budget;

(g) to instruct the Board and the Director-General to bring to the attention of Members and of international organizations, governmental or nongovernmental, any matter with regard to health which the Health Assembly may consider appropriate;

(h) to invite any organization, international or national, governmental or non-governmental, which has responsibilities related to those of the Organization, to appoint representatives to participate, without right of vote, in its meetings or in those of the committees and conferences convened under its authority, on conditions prescribed by the Health Assembly; but in the case of national organizations, invitations shall be issued only with the consent of the Government concerned;

(i) to consider recommendations bearing on health made by the General Assembly, the Economic and Social Council, the Security Council or Trusteeship Council of the United Nations, and to report to them on the steps taken by the Organization to give effect to such recommendations;

(j) to report to the Economic and Social Council in accordance with any agreement between the Organization and the United Nations;

(k) to promote and conduct research in the field of health by the personnel of the Organization, by the establishment of its own institutions or by co-operation with official or non-official institutions of any Member with the consent of its Government;

(l) to establish such other institutions as it may consider desirable;

(m) to take any other appropriate action to further the objective of the Organization.

Article 28

The functions of the Board shall be:

(a) to give effect to the decisions and policies of the Health Assembly;

(b) to act as the executive organ of the Health Assembly;

(c) to perform any other functions entrusted to it by the Health Assembly;

(d) to advise the Health Assembly on questions referred to it by that body and on matters assigned to the Organization by conventions, agreements and regulations;

(e) to submit advice or proposals to the Health Assembly on its own initiative;

(f) to prepare the agenda of meetings of the Health Assembly;

(g) to submit to the Health Assembly for consideration and approval a general programme of work covering a specific period;

(h) to study all questions within its competence;

(i) to take emergency measures within the functions and financial resources of the Organization to deal with events requiring immediate action. In particular it may authorize the Director-General to take the necessary steps to combat epidemics, to participate in the organization of health relief to victims of a calamity and to undertake studies and research the urgency of which has been drawn to the attention of the Board by any Member or by the Director-General.

This consultation cycle is open for contributions by external allies and partners, such as ISPRM. The agenda of the WHA, the Medium-term Strategic plan and the Program Budget are published in advance of sessions and revised throughout the year. ISPRM can thus easily recognize points of interest and adjust its own strategies accordingly.

ISPRM’s meeting schedule

As shown in Fig. 4, it is suggested to hold an additional ISPRM Executive Committee meeting in February of each year. This way, last minute changes to the WHA agenda or network constellations could be acknowledged. Memoranda that the Assembly of Delegates has voted upon the year before could thus be amended appropriately. Also, activities to form coalitions with member states and other international NGOs at the WHA could be coordinated and ISPRM representatives briefed.

It is further suggested to coordinate ISPRM regional and national working groups or task forces to participate in WHO regional consultations. These working groups could be chaired by the Regional Vice Presidents. The working groups would send reports to the Executive Committee in preparation of the WHA in May and of the ISPRM congress in June. The task forces and working groups could reconvene a day or so before the ISPRM congress to evaluate progress. If necessary, they should then recommend amendments to their own mandate and plan of action to be voted on by the Assembly of Delegates.

The biennial electoral process to the Assembly of Delegates and the Presidency could be held in June to correlate with ISPRM scientific meetings.

CONCLUSION

The above outline serves to show that ISPRM is in a unique position to be the leading international, non-governmental PRM actor. Its official relation status to WHO empowers ISPRM to actively participate together with many possible allies and partners in the fulfilment of “health-for-all” goals as envisioned by the world health policy agenda (1, 3).

However, the current internal structural situation seems to be inefficient and not well suited to this task. Moreover, ISPRM may be inadequately equipped to utilize its full potential. In light of major future challenges, modifications to its current policy structures may become increasingly relevant. These even seem mandatory against the background of: (i) an envisioned growth of membership and the implications for manageability, accountability and legitimacy; (ii) the self-imposed vision and mission as outlined in the By-Laws; (iii) and ISPRM’s duties toward the WHO and the global PRM constituency.

Sowing the seeds of change necessarily involves strong regional and national societies willing to take leadership in the implementation of ISPRM policy agenda. They are the cornerstones of sustainable growth and influence – notably in regions where no PRM society exists. Externally, ISPRM must be conscious of the rights and possibilities it already has with WHO and must foster new alliances within the world political system of IGOs and international NGOs.

Additionally, it would be of great advantage to appreciate fully WHO’s schedule of yearly organizational meetings on all world levels. Aligning ISPRM’s own meeting schedule to that of WHO would significantly improve ISPRM’s influence on, and ability to react to, world health policy.

Finally, the possible solutions to ISPRM’s perceived challenges outlined in this paper are not to be misunderstood as being ISPRM’s official position or that of its individual bodies. The main purpose of this paper is to stimulate discussion of the introduced arguments and suggested scenarios in the appropriate ISPRM bodies.

REFERENCES

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