Inside WHO's reforms: Progress, failures, and unfinished business

U.S. President Donald Trump has accused the World Health Organization of failing to adopt much-needed reforms, citing it as one of the reasons why he withdrew the U.S. from the United Nations body. But WHO Director-General Tedros Adhanom Ghebreyesus has shot back and defended the organization, saying it “has implemented the deepest and most wide-ranging reforms in the organization’s history.” Over the past eight years, WHO revamped its organizational structure, introduced new divisions and positions, launched high-profile initiatives, started strengthening its country offices, and pushed for changes in its funding model. In addition, it has pursued nearly 100 reforms to improve WHO’s transparency, efficiency, and effectiveness. Despite these efforts, the organization still falls short of becoming more efficient, agile, and fit for purpose, according to more than a dozen global health experts and current and former WHO staff members interviewed by Devex. They said WHO continues to be top-heavy, and still very much reliant on a few donors for much of its budget. While it has initiated policies to prevent sexual exploitation and abuse, cases continue to rise. Some have also criticized it for being slow and bureaucratic, from hiring to delays in issuing product approvals. A WHO official said that the agency has achieved much in its reform agenda, but also admitted “not all is successful,” and they will continue to pursue reforms. For example, the official thinks the work WHO has done to diversify and widen WHO’s donor base has been a success. However, WHO operates in a challenging geopolitical context and a constrained funding environment. Among Tedros’ biggest priorities is getting WHO sustainably funded through an increase in the agency’s flexible funding. WHO supported the creation of the WHO Foundation, an independent body focused on helping raise funding for the U.N. agency from a wide set of donors, including the private sector and the general public. In 2022, member states agreed to gradually increase their membership dues, and after that, also agreed for WHO to launch an investment round to help raise more flexible and predictable funding for the agency. Yet a big part of WHO’s budget still comes from a small set of donors, making it vulnerable to changes in donor priorities or sudden donor pull-outs, as recently demonstrated by the U.S. government. The impact on the agency is huge — WHO faces a budget shortfall of $600 million in 2025 alone, and is slashing its budget ambitions by a billion dollars in the next two years. Its funding gap is so significant that it is now reviewing its priorities and making plans to reduce its work and workforce. But some see this as an opportunity for WHO to review its work and further define its priorities. Staffing matters Another key pillar of WHO’s reform agenda is having a motivated and fit-for-purpose workforce. WHO has taken steps to support its workforce, including simplifying the internship process and offering flexible working hours to staff. However, the agency has faced internal resistance to its staff mobility policy, which was introduced on a voluntary basis in 2023 with plans to make it mandatory later that year. In response to staff concerns, WHO leadership extended the voluntary phase through 2024. The initiative is currently on hold due to the agency's financial constraints. The policy is meant to ensure staff take on new assignments in different duty stations instead of being entrenched in places like Geneva. “I wouldn't even be able to count the number of people who've said to me, I'm just trying to make it until my retirement age. So, staying in Geneva, getting the benefits, and staying there until they can recoup their pension — which is not the recipe for an efficient and effective institution at all,” said one former WHO official who requested to speak anonymously out of concern that their views might be construed as attacking the institution. WHO’s workforce has also expanded over the years. Data shows the total number of staff across WHO was at 9,473 as of July 2024, from 8,029 in July 2017, with those on fixed-term appointments more than doubling during that period. Consultants and those on special service agreements also grew from 4,705 in 2017 to 10,212 in 2024. The highest concentration of long-tenured staff — those with 15 or more years at the organization — is based at WHO headquarters in Geneva. Despite this, Geneva saw the lowest rates of staff mobility in 2024, with less than 1% of professional-level staff and above relocating to other offices or duty stations. But the issue of staffing is a bit more complex. There’s been a lot of criticism that headquarters has too many staffers when the work of the organization should be focused at the regional and country level. But this bloating isn’t the same across WHO as some departments or units have fewer staff. “Global health problems [have] expanded in scope and impact, but they've also expanded in terms of how challenging they are for developing countries to be able to navigate them.” --— Anonymous WHO member state official There’s also a question of performance. Some experts said there are some very hard-working staff within WHO, but there are also those who are staying just because it’s a high-paying job — and it’s difficult for WHO to let them go. The former WHO official said he had a “very underperforming” staff member who was two years away from retirement, but the official was advised to keep them as it would take longer than two years if they filed a complaint for dismissal. The official clarified, however, that such a problem preceded Tedros and isn’t unique to WHO, but rather cuts across the U.N. system. “You cannot get rid of poor performers and even bad actors within the staff … It's just the structure of the UN's professional staff system,” said the former official. An analysis by Health Policy Watch exposed that senior directors holding D2 positions almost doubled since Tedros took office. As WHO plans to reduce its workforce, some staff are suggesting the elimination of D2 positions and/or relocating such positions to other less costly WHO offices, according to the report. In the middle of a cash crunch, it’s understandable to look at the cost of personnel, especially at headquarters, as it covers a significant portion of the budget, said Peter Singer, emeritus professor at the University of Toronto and former special adviser to Tedros at WHO. But among those holding D2 positions, “there are some that are more effective and some that are less effective at getting results. Focus on that, not just what class they are,” he said. Rising abuse cases WHO was heavily criticized for the sexual exploitation and abuse cases that surfaced in the midst of the 10th Ebola outbreak in the Democratic Republic of Congo. The agency has made several changes since then, including a new policy preventing such behavior. But cases continue to rise, including allegations of harassment and abuse of authority, which jumped from 39 in 2021 to 220 in 2023, and retaliation, which rose from nine to 50 cases in the same period. According to a 2024 internal auditor report, the WHO Office of Internal Oversight Services “is faced with an overwhelming number of reports” on these two issues. WHO told Devex it has put in place policies and carried out activities to prevent such behavior, and said an increase in reported cases of harassment and abuse of authority “is a good thing in itself” because it shows increased staff confidence in the system. When it comes to the duration of investigations, WHO has set a benchmark of 120 days, although it admitted that most investigations take longer. Resolving cases can take up to two years, and staff appear to remain wary of the independence of the internal justice system, with the WHO staff association suggesting a system where staff can report concerns directly to the executive board. Truly independent? Among Trump’s reasons for leaving WHO is its “inability to demonstrate independence from the inappropriate political influence of WHO member states.” While he didn’t specify any country in particular, Trump previously accused the U.N. agency of being a “puppet of China.” Tedros refuted claims that WHO lacks independence. However, as with many U.N. agencies, WHO is heavily reliant on voluntary funding, making it vulnerable to political pressures from its member states. The U.S. government’s questioning of WHO’s independence, however, is a big “hypocrisy,” according to Theodore Brown, professor emeritus of history at the University of Rochester in New York. He said the U.S. “probably has been the most complicit political nation in trying to set the priorities and the agenda and direction of WHO.” He said it was the U.S. that pushed WHO in the 2000s to strengthen the International Health Regulations and make the reporting of emerging outbreaks more extensive. But it also ensured WHO has limited enforcement powers. This backfired during the COVID-19 pandemic, when China delayed releasing information on the coronavirus. “It’s … hypocritical for the United States to say, ‘Why isn't the WHO requiring more robust reporting from China?’ Well, one of the reasons is because … China doesn't have to, by the rules which the United States helped craft in the early 2000s.” Slowly but surely? Experts and WHO officials alike argue that WHO’s work in developing guidelines and prequalifying new innovations is an important part of its core mandate. When a new vaccine is prequalified, it helps speed up its introduction in low- and middle-income countries. But WHO has faced criticism for being slow and risk-averse, particularly when mpox vaccines were not immediately available to affected African countries in 2024 due to the lack of prequalification or emergency approval, as reported by The New York Times. Experts argue that WHO could have acted sooner, especially during the global mpox outbreak in 2022. WHO said it didn’t have the data in 2022 to start the process for issuing emergency usage for the vaccine. And while timely review and decision on the vaccines are a priority, it must be done without compromising the assessment of safety, quality, efficacy, and use of the product on target populations. But the agency is changing its processes to help speed up the introduction of health products. One way is through developing a parallel process for guideline development and product prequalification. “There would be a timetable for delivering the guideline and the prequalification that they would be done in as far as possible in parallel, so that you wouldn't end up in a situation where you had a prequalified product but no guideline to guide its use, and vice versa,” Dr. Jeremy Farrar, WHO chief scientist, told Devex. “That sounds boring, just aligning those two things. But actually it would have a massive impact if [we] were able to achieve that,” he said. Not only would it speed up the procurement and implementation of an innovation, but it would also help manufacturers plan ahead and invest in ensuring the products become available quicker. WHO has kicked off this process for lenacapavir, a potentially game-changing HIV drug that’s been found to be 100% effective in preventing HIV when given just twice yearly to women and girls in clinical trials. WHO hopes to conclude the guideline development and prequalification of lenacapavir within six to 12 months. It is also considering testing the approach for up to five other innovations, which could include vaccines, therapeutics, diagnostics, and even vector-control interventions. Farrar said it’s crucial to institutionalize this system within WHO so it becomes the norm instead of just being applied to a few innovations. Going local Another goal of the WHO transformation is to deliver impact in countries by strengthening its country offices. An Action for Results Group, set up in 2023 and composed of WHO country representatives from each WHO region, created an action plan to accelerate implementation of this goal. That plan includes building the human resource capacities of WHO country offices based on each country's context and needs. This means one country may be vulnerable to conflict and health emergencies and will need both technical and emergency response support from WHO, while others may only require some policy support for specific health issues. The WHO director-general and its regional directors also delegated authority to country representatives and increased the amount of flexible funding given to its country offices, which now account for the largest share of WHO’s flexible funds. But change will take time. WHO will need to create and recruit for the necessary positions at the country level, and ensure it has the finances to implement and sustain those positions. Strengthened accountability measures for how funds are utilized are also needed at the country office level, including for heads of office. WHO also wants to improve the succession planning for WHO country representatives, as well as the pool of candidates for the position, starting with a pilot phase in the coming months in the Eastern Mediterranean region. At present, succession plans for WHO country representatives are complex and take a minimum of nine to 18 months, said Dr. Hanan Balkhy, WHO regional director for the Eastern Mediterranean region, where they need a diverse pool of Arabic-speaking candidates — the common language in the region. Governance challenges Experts and current staff said reforms at WHO should also involve member states. They’re the ones responsible for WHO’s ballooning mandate, and finance the agency in line with their own agendas, leading to some health programs being better funded than others. While WHO reforms have laid the groundwork for a much more results-focused organization, member states often focus on their own priorities, churning out new resolutions every year. “The ultimate responsibility for an organization lies with the board of that organization, the governing bodies. So for member states who say, ‘we want reform, we want a more results-focused organization,’ I'd say, look in the mirror and start with the governance of the organization,” Singer said. A WHO member state official from a high income country acknowledged that every member state believes its priority should be priority number one. “But I think if the membership has a really good overview of the financial and human resource implications of what they're asking for, either they may reassess what they consider a priority or look at better grouping their needs so that you have a bit of administrative cost savings,” the official who spoke on condition of anonymity said. The official added that member states can also be clearer when they’re asking WHO for more transparency and accountability. “It's quite easy to throw those words out without being a little bit more granular on exactly where you see the problems are, where you see the knots that need to be unknotted,” the official added. Another opportunity for reform Faced with massive U.S. funding cuts, WHO is under pressure to significantly cut costs and reduce its work. But amid the financial squeeze comes the opportunity for the organization to make some much-needed reforms, said experts and former and current staff. Some are suggesting shrinking the number of WHO country offices, particularly in high- and middle-income countries. Some said WHO should further define its focus, although there remains a debate on whether WHO should focus on its normative work versus operational — for instance, getting vaccines and other drugs licensed quickly while letting others on the ground finalize the job. “I think it's not our role to be UNICEF, to procure, to have a fleet of cars … [but] if we think that's our role, we need to have a conversation with our humanitarian siblings, and really see how we split the pie there,” one senior WHO official said. Others suggested WHO needs to focus on what it can deliver really well and identify areas where other global health organizations can or are already working on and where WHO can “take a back seat.” If there are teams with just one to five people, “what's the point of resourcing at that level? What impact are you really going to make?” one staff member said. But some are wary of WHO cutting its footprint on critical health issues. “I'm very nervous sometimes when people talk about kind of also cutting down on mandates or that [which is] being imposed from the outside, because needs are increasing. Global health problems [have] expanded in scope and impact, but they've also expanded in terms of how challenging they are for developing countries to be able to navigate them,” said the member state official from a high-income country. “We may need a leaner WHO in terms of efficiencies, but I don't know if we need a leaner WHO in terms of their mandate,” the official added. While infectious diseases remain a big focus of WHO, health challenges are expanding or even shifting in countries, such as dropping fertility rates, increases in noncommunicable diseases, and even mental health issues among youth. One former WHO staffer said there has to be an independent body that looks at the current global epidemiology and helps identify where WHO should focus. Suerie Moon, visiting professor at the Center for Outbreak Preparedness, SingHealth Duke-NUS Global Health Institute in Singapore, said WHO’s mandate expansion over the years is driven by both political priorities of member states and health challenges becoming transnational, such as climate change. She doesn’t think cutting down on issues is the right way for the agency to slim down. But figuring out WHO’s core functions is the job of WHO’s member states. “Some have said, should WHO become less operational? Should WHO focus on its normative work? Should WHO focus on country support? And this is where, again, really, it's member states who should come to agreement on core functions,” Moon said. “But I've never seen them do that, and I don't think they will do that.”