In 2015, after the World Health Organization’s delayed response to the West Africa Ebola epidemic amplified that crisis, some experts called for dismantling the health agency. Today, the 72-year-old organization’s relevance is once again questioned in the midst of a historic pandemic. The most vocal critic of all, U.S. President Donald Trump, recently decided to withdraw his country from the organization.
COVID-19 is WHO's biggest emergency, but politics is its biggest headache. We ask experts what the world really wants from WHO.
While most of these critiques are nothing more but a veiled attempt to find a scapegoat, the current crisis also reveals serious flaws in our global health governance system.
All existing mechanisms, including the revamped 2005 International Health Regulations — which are focused on global health security and were agreed to by WHO member states — have failed to stop the spread of the SARS-CoV-2 virus. WHO, an underfunded organization with limited political power, has consistently struggled to deliver on its official role of guidance and coordination across its member states. Countries’ responses have, for the most part, been uncoordinated.
When the worst of the crisis is over, the time will come to reflect on these mistakes. While WHO today remains the only truly democratic global health agency, it will have to undertake serious reforms if it wants to retain its legitimacy. Here are five ideas that explore how to reform the institution:
1. Strong sanctions. Unable to assert authority, WHO has to rely on soft power strategies to gain countries’ cooperation, leading to many of the criticisms the organization receives. The International Health Regulations currently mandate that governments report any “public health emergencies of international concern” and cooperate with WHO to take action, but WHO has no legal ability to enforce this. The regulations must be reformed to include enforceable sanctions against countries that fail to comply with their mandate.
Experts often cite the World Trade Organization as an example of an international organization with the ability to impose sanctions on its member countries when they fail to abide by its rules. While the WTO dispute settlement mechanism has worked imperfectly in recent months because of U.S. blockages, it nevertheless remains an important model to explore alongside other mechanisms to allow WHO to assert authority over its member states, especially in moments of crisis.
2. Narrow mandate. WHO’s mandate must be clarified and narrowed. The organization has a very broad scope — in theory, all activities that can improve the health of all populations worldwide are under its purview. Instead, WHO should focus primarily on activities where it can bring the most added value.
A 2013 paper on governance challenges in global health identifies four unique global health functions: the production of global public goods, such as technical guidelines; the management of externalities emerging from situations or decisions originating from one country but with negative global health outcomes; the mobilization of global solidarity, such as technical assistance; and stewardship, or the ability to provide strategic direction at the international level.
These functions should be further fleshed out in the context of WHO for the organization’s strategy to gain coherence, with projects outside of this defined scope cut out.
3. Increased untied funding. Many experts have pointed to WHO’s limited budget, which is less than the budget of many major U.S. hospitals, as the main culprit for its current failings. The share of unearmarked funding is also ridiculously low, with membership dues representing less than 20% of the agency’s total budget.
This limits WHO’s ability to fully control the scope of its work. A downward trend has been observed for decades now, so a simple call for more funding from member states will likely not be sufficient unless a strong coalition of countries emerges.
A wider reflection on the role of WHO is necessary to ensure that the next time a public health threat emerges, the world has a strong global health agency to confront it.—
While the latter should be pursued, WHO must also look into innovative financing mechanisms to raise untied money that is not attached to any specific project.
For example, WHO could explore replenishment mechanisms — such as the ones used by Gavi, the Vaccine Alliance and The Global Fund to Fight AIDS, Tuberculosis and Malaria — or assess how to collect higher taxes on global transactions, like UNITAID does for airline tickets. A bigger, untied budget for WHO would not only sustain important global activities, but would help the organization maintain a narrow, strategic focus rather than pursuing a wide net of funding opportunities.
4. Open governance. Alongside its budget, the governance of WHO must also be reformed to facilitate the inclusion of alternative voices, such as from the civil society, and to better channel the influence of private philanthropists. Again, mechanisms used by other international organizations — for example, The Global Fund or those in the climate change space — should be assessed to broaden the governance base of the organization without losing its democratic focus.
5. Broad technical expertise. Finally, WHO must maintain its technical focus but broaden its expertise to include more input from political scientists, urban designers, lawyers, logisticians, or information technology specialists. While the technical focus of the organization can legitimate its public health recommendations and ensure its diplomatic impartiality, bringing new technical expertise on board can expand the organization’s authority on topics that are outside the public health realm but have a strong impact on it, such as digital technologies or social determinants of health.
None of these reforms will be easy to implement. They will require a strong commitment from and extensive coordination between member states in a time of significant economic recession and increased nationalism. Ministries of health are also likely to experience public backlash for measures taken during the height of the coronavirus crisis and may be weakened as a result.
Unless a strong democratic coalition of countries emerges to push for these reforms, they are unlikely to happen. But a wider reflection on the role of WHO is necessary to ensure that the next time a public health threat emerges, the world has a strong global health agency to confront it. Because the question is not whether another threat will emerge after COVID-19, but when.