SIPR Chae

The global response to the COVID-19 pandemic has been subpar. As some national leaders downplayed the danger of the virus, the number of COVID-19 cases and deaths mounted. Amidst this global confusion, the World Health Organization (WHO), as the “directing and coordinating authority on international health work,” has undertaken some crucial tasks to counter the threat of the virus.[1] This included convening experts in February to “establish priorities and timelines for COVID-19 research,” disseminating research on COVID-19, and urging national governments to enhance testing.[2]

Yet the World Health Organization has been criticized for what is perceived as a delay in responding to the COVID-19 pandemic. Notably, the WHO delayed declaring COVID-19 a Public Health Emergency of International Concern (PHEIC) until late January and did not classify it as a pandemic until mid-March. In July, U.S. President Donald Trump responded by withdrawing the United States from the WHO, accusing the organization of failing to implement long-due reforms in its priorities and structure.[3] We cannot outright reject such an accusation given the WHO’s past shortcomings. For instance, the WHO failed to accurately report the severity of the 2009 H1N1 influenza outbreak and effectively coordinate vaccine distribution.[4] Furthermore, during the 2014 Ebola outbreak, the WHO withdrew its team prematurely from the disease epicenter in Sierra Leone, was slow to disclose the severity of the outbreak to the international community, and failed to quickly marshal international support,[5] leading Professor Ashish Jha, the director of Harvard Global Health Institute, to describe WHO’s response as an “egregious failure.”[6]

In light of these events, it is crucial to reform the WHO now. This is necessary not only to prevent future health emergencies, but also to secure the survival of the WHO as an organization. As the world faces new health challenges like COVID-19 and existing ones like influenza, it needs a transparent leader in setting global benchmarks and responding to crises in global health.[7] But the WHO remains poorly financed and overstrained as new institutions have challenged the WHO’s leading role in global health.[8] Organizational inefficiency, unclear priorities, and subpar financing have left the WHO as an agency with many responsibilities but diminished power.[9] The WHO must, therefore, conduct a rigorous self-examination of what it can and cannot perform.[10] Organizational reform will not only better prepare the WHO for future health emergencies, it will help the WHO to regain the public’s trust as facilitator of global public health and provider of scientific expertise. The following are recommendations for possible reforms.

1. Prioritize Collaboration and Coordination in Global Health

The WHO has too much on its plate. Its constitution lists 22 functions towards its objective of “the attainment by all peoples of the highest possible level of health.”[11] However, many of these functions overlap with other organizations’ activities, such as UNICEF’s function of promoting maternal and child health and welfare, a mandate which overlaps with the WHO’s function (L) in Article 2 of the WHO Constitution.[12] The WHO should instead focus on the activities that it has comparative advantage over other bodies, such as establishing global health standards and providing advice to national governments on public health measures.[13] The WHO has historically had success in what are called ‘normative functions’—technical guidance, information collection and dissemination , alerting the international community to an epidemic’s threat, and facilitating national governments’ implementation of its advice, such as in the global drive towards eradication of smallpox in the mid-20th century.[14]

To ensure that the WHO does not remain overstretched, the WHO should better coordinate with other agencies in global public health. In deciding which functions to collaborate on, the WHO’s leadership must consider whether it effectively fulfills such functions and whether others can achieve them more readily.[15] For instance, the growing call to establish a WHO medical corps could be satisfied by existing organizations like Doctors Without Borders (MSF).[16] Outsourcing functions such as medical personnel deployment would improve overall efficiency by utilizing other agencies’ comparative advantage.[17] In return, these agencies could be compensated or be recognized as the global leader in those functions. In coordinating with other agencies, the WHO should clearly delineate its responsibility from those of other organizations and eliminate redundancies. As Laurie Garrett, a senior fellow for global health at the Council on Foreign Relations suggested in 2015, the WHO and the World Bank might better coordinate their respective roles as advisors and financiers when handling outbreaks of infectious disease.[18] Overall, this approach would be more efficient than the WHO having overlapping roles with other agencies.[19]

2. Engage Non-state Actors

The exclusion of non-state actors from the WHO’s work hinders its ability to carry out its primary functions of directing and coordinating international health work. The leadership of the WHO must recognize that national governments are no longer the only important actors in addressing global health challenges.[20] Unlike fifty years ago, the field of global health now has a variety of contributors, such as the Global Fund and the Bill and Melinda Gates Foundation.[21] This has created what Professor of Public Health Kelley Lee calls a “market-driven global health environment,” in which different initiatives compete for donors’ funding to achieve the same goal, wasting valuable resources.[22] The contributions from non-state actors cannot be ignored in performing the WHO’s functions.

The WHO should thus advocate for including NGOs, private donors, and civil society groups in its governing body, the World Health Assembly (WHA). A potential model to emulate is the tripartite structure of the International Labor Organization (ILO) that involves representatives from states, labor force, and businesses, thereby integrating both “non-state actors and state actors within its decision-making body.”[23] WHO might consider allocating more votes per state representatives to persuade member states that are reluctant to cede influence to non-state actors. Achieving a more integrative leadership structure can be accomplished by amending the WHO Constitution to enlarge the composition of the WHA, which requires a supermajority vote in the WHA.

3. Rejuvenate the Funding Structure

The WHO’s budget is another concern. For one, it is too small for the WHO’s responsibilities. The WHO’s budget is only one-third the U.S. Centers for Disease Control and Prevention’s budget yet had a similar number of responsibilities in the 2015 fiscal year.[24] The composition of WHO’s budget poses an additional challenge, as funding is often distributed regardless of programmatic need. For instance, in the 2014-15 budget cycle, funding for noncommunicable diseases increased by 21 percent while funding for outbreak response dropped by 51.4 percent.[25] The drop in outbreak response funding led to budget cuts in the WHO’s emergency response units and left the organization with only one technical expert on Ebola.[26] The poor Ebola response is indicative of larger problems stemming from the WHO’s ineffective financing structure. As member states have resisted increases to their mandatory membership dues for many years,[27] the WHO has relied on voluntary contributions from member states and private donors, which now make up more than 80 percent of its overall budget.[28] Dependence on voluntary contributions has left the WHO vulnerable to the whims of private organizations,[29] since donors usually earmark their contributions to be used for specific purposes, which may or may not be aligned with the WHO’s global health priorities.

To decrease dependency on private donors, the WHO should consolidate its financing structure. The WHO leadership should discourage private donors from earmarking their voluntary contributions for specific purposes through continued campaigning. The WHO should also consider expanding the Contingency Fund for Emergencies (CFE), a separate fund for rapid responses to pandemics established after the 2014 Ebola outbreak. An expanded CFE could help the WHO in quickly distributing information and resources during pandemics. In addition, the WHO leadership should continue to make use of the WHO Foundation, an independent grant-making agency established in May 2020 to finance the WHO. Consolidating the WHO financing structure will help the WHO mitigate its perennial funding problem and give the organization more leeway to direct funds where needed the most.

4. Strengthen the International Health Regulations (IHR) Framework

In addition, the WHO, the WHA, and the constituent member states should reform the dysfunctional IHR regime, a legal instrument that defines the rights and responsibilities of WHO member states during epidemics. The IHR framework “asks member states to prepare for public health threats according to standards set by the WHO and to report any outbreaks.”[30] It also requires them to “develop public health capacities to detect and respond” to Public Health Emergency of International Concern (PHEIC),[31] a designation that the WHO can declare over member states’ objection.[32] Once the WHO declares an outbreak to be a PHEIC, IHR calls for “the least intrusive measures possible and strong protection for freedom of movement and other human rights.”[33] However, the WHO cannot enforce the IHR. Without member states’ consent, the WHO cannot deploy international assistance inside a state’s borders,[34] force states to act on its advice,[35] or compel governments to share information.[36] In fact, in the past, triggering PHEIC led member states to defy WHO’s advice. For instance, during the Ebola outbreak, national governments instituted travel bans, which deterred valuable information transfers and hindered crucial medical supply lines.[37]

To reform the IHR, the WHO could allow the IHR secretariat to control its own budget and possess an internal information-gathering unit, using its network of national health ministries and regional offices. IHR reforms would ensure that the IHR does not solely rely on information from member states and is protected from political considerations that can interfere with science-based decisions.[38] Moreover, the WHO could consider collaborating with the UN Security Council to give the IHR more gravitas on the international stage. For instance, the Security Council could issue resolutions in support of the WHO when the WHO declares PHEIC in the future, “which would bolster the WHO by giving greater … force to its actions.”[39] The Security Council can issue resolutions by interpreting its mandate more broadly to “encompass human security.”[40] Such an interpretation would be less controversial than vesting the WHO with new regulatory powers that could encroach on national sovereignty. Furthermore, such a measure has precedent. During the Ebola epidemic, the Security Council called for further engagement from the international community, which raised Ebola’s profile and ushered in more assistance.[41]

Conclusion

The World Health Organization must adapt to the changing realities of the world, as the handling of the COVID-19 pandemic underscores. Outsourcing duplicate functions and including the leadership of non-state actors would improve the organizational efficiency of the WHO. Revitalizing the funding structure and enlarging the existing Contingency Fund for Emergencies would help the WHO to financially prepare for outbreaks. Finally, strengthening the IHR framework would support the WHO in advising member states more effectively on sound public health measures. These reforms will ensure that the WHO remains a global coordinator of public health for years to come.