Why France and Germany's narrow approach to WHO reform matters

BERLIN — The COVID-19 pandemic has precipitated another round of reforms at the World Health Organization. While the topic did not make it fully onto the agenda of the recent World Health Assembly, France and Germany — which have emerged as unexpected leaders of the effort — made it clear they intend to keep the pressure on. The two countries — particularly Germany — are increasingly stepping into leadership roles on global health, and their proposal for reforming WHO, released earlier this year, offered an early preview into how they might steer the field. It also clearly influenced the European Union proposal for strengthening WHO that was released just before the start of WHA. But at a time when some global health observers are looking for sweeping reforms, the proposal has met with some disappointment. “It does locate the WHO reform agenda within a broader agenda of this global health ecosystem,” said Kelley Lee, a professor of public health at Simon Fraser University and the author of a history of WHO. “But the recommendations stick to a very narrow set of reforms mainly around health emergencies.” Rather than pushing for a more autonomous WHO that could pursue a broad agenda reflecting the disparate needs of all its member states, the French and German agenda seems to prioritize the concerns of rich countries, with a particular focus on preventing future health crises. The reforms could also add an additional layer of bureaucracy at a time when observers suggest the agency needs greater autonomy. German officials caution that the proposal — a “nonpaper,” in diplomatic terms — is only a starting point for discussion and not meant to preempt an evaluation of WHO mandated by the World Health Assembly or other reform proposals. Coming from two emerging global health leaders, though, the proposal carries weight, underscored by the fact that some of its recommendations have already made their way into a recent EU draft on how to fix WHO. Responding to outbreaks The COVID-19 outbreak reexposed weaknesses WHO has been grappling with for decades: The agency has limited authority, including no real ability to enforce the International Health Regulations, which are meant to compel member states to report potential outbreaks and cooperate in responses, and an unreliable funding stream necessitating staffing constraints that hinder its work. That led to a WHA resolution in May for another evaluation of WHO and prompted Director-General Tedros Adhanom Ghebreyesus to appoint an Independent Panel for Pandemic Preparedness and Response. This follows a review of the agency’s halting response to the 2014-2016 West Africa Ebola outbreak and comes on the heels of sweeping structural changes that Tedros has introduced since entering office in 2017. There is some reform fatigue within WHO, Lee acknowledged, but changes are probably needed. “I don’t think reform is unnecessary, but I think it’s the scope,” she told Devex. “It ends up being, ‘Put more money in here,’ or, ‘Create a new program or strengthen a program,’ but we always end up in the same place.” She suggested it was time to consider something more sweeping — a process France and Germany are now in a position to lead. In the wake of U.S. President Donald Trump’s attacks on multilateralism and his decision to withdraw from WHO, France and Germany stepped up their defense of the institution and their financial support. Germany, in particular, raised its announced contributions to the agency for 2020 from €110 million ($130 million) to €500 million. “They are in a position to shape the debate,” Susan Bergner, associate at the German Institute for International and Security Affairs, said of France and Germany. “They are seeing themselves not in comparison but in distinction with old players like the U.S. and seemingly new players like China. They don’t want to cede the floor to them. They want to decide whatever the new global health architecture will look like.” The nonpaper, with its 10-point agenda, offers a preview of what the two countries hope this might look like. The proposal, meant to combine three different reform efforts — of the WHO in general, of the agency’s work in emergencies, and of its work under the IHR framework — is headlined by a demand for budget reform. Instead of relying on voluntary contributions for nearly 80% of its $5 billion biennial budget, the nonpaper echoes calls for increasing member states’ assessed contributions to set the agency on a more secure financial footing. All but one of the remaining action items focus specifically on health emergencies and IHR reforms, in a bid to strengthen WHO’s ability to respond to future health emergencies and overcome a member state’s unwillingness to report an outbreak or cooperate in containing it. “[France and Germany] want to decide whatever the new global health architecture will look like.” --— Susan Bergner, associate, German Institute for International and Security Affairs Even as the nonpaper reflects broader demands for more autonomy for an agency that has been hampered by its obligation to seek permission to act from member states, the nonpaper’s third action item actually appears to add another layer of bureaucracy. It calls for establishing a subcommittee, constituted by regional representatives, that “shall be able to follow crises and emergencies, when necessary, on a daily basis, hold meetings with the emergency committee and provide guidance” to the director-general. Lee said that is moving in the opposite direction of delivering the agency more autonomy. “By creating new mechanisms, it’s like saying it’s WHO that’s acted in a way that wasn’t up to scratch [and] that they need to be more transparent,” she said. “The problem is actually with member states. There’s already so many layers of approval and so on. This is going to tie WHO further to committees.” Need for a broader agenda Overall, Lee said, “it’s hard to say this isn’t important in the midst of a pandemic,” but the nonpaper’s focus on health emergencies is “a really narrow agenda” and leaves out other health priorities championed by Germany and France — including in Germany’s recently released global health policy. Those initiatives appeared to accommodate a truly global agenda balancing higher-income countries’ concerns about health emergencies with the problems dogging lower-income countries, including a rise in noncommunicable diseases and shortages of health workers and infrastructure. The German Health Ministry released the much-delayed strategy last month, announcing the government’s intention to “be at the table helping to shape forward-looking international policies on global health.” It includes pledges to expand vaccination programs, boost efforts to address neglected and poverty-related tropical diseases, and counter the health impact of climate change. And while the strategy does center its calls for WHO reform around improving pandemic preparedness, it also recognizes the need to strengthen the agency’s ability to respond to humanitarian health crises, for instance. Bergner said Germany could have done more to integrate these priorities into the nonpaper, particularly an emphasis on achieving universal health coverage. "I was disappointed when I saw that UHC didn't have a prominent role in the nonpaper," Bergner said. "It had to be Germany that would bring it in, and it didn't push hard enough for UHC. If we have resilient health system structures, we'll be better prepared for the next health crisis." The question of which vision Germany and France are bringing to their efforts to reform WHO is not merely academic. In its current role as president of the Council of the European Union, Germany is trying to shepherd the EU into a greater and more steadfast engagement with WHO specifically and global health more generally. A multi-European country initiative on global health that launched in 2019 is working to put together recommendations due at the end of 2021 that “guarantee coherent and lasting ambitions on the role of the EU in global health throughout changing EU presidencies,” Sabine Weiss, Germany’s parliamentary state secretary for health, said during the recent World Health Summit. And the recommendations in the nonpaper have helped guide some of the early discussions taking place among EU officials, she said. This includes a meeting of the EU Council at the end of October that arrived at draft conclusions on the role of the EU in strengthening WHO. The conclusions end with a list of measures that echo aspects of the nonpaper, such as calls to strengthen the agency’s normative role, including the chief scientist’s office, and to reform WHO’s process of declaring a public health emergency. That proposal is now set to guide the EU’s approach to WHO reform moving forward. So while the nonpaper may have been an exercise in “dipping your toe in the water to get the conversation going,” Lee said, “there’s a lot of work behind it,” adding that “the positioning of issues and countries is going to be very important.”