With the Covid-19 pandemic beginning to position itself in the rearview, the post-crisis autopsy of the emergency and the actions of the responding parties is well underway. Seeking to better understand where things went wrong and what could be done better in the event of another devastating pandemic, many are very critical of the international body whose very purpose is taking charge of international public health. Like other UN agencies, and even the UN itself, many wonder whether the World Health Organization (WHO) has the governance capacity to fulfill its international duty. Based on its response to Covid, it is clear the WHO in its current form is unable to perform the monumental tasks required of such an important body. As an international organization, it will always be limited in its responses and actions due to the toothless enforcement mechanisms of international law. However, the WHO can be reformed to become much more effective despite these inherent limitations. With such a crucial role in protecting the health of humans across the globe, it is imperative to understand how it can improve itself going forward to prevent millions of deaths and avoid another public health crisis. In order to understand how it can be reformed we must understand its capabilities and limitations based on the frameworks with which it is governed. Analyzing the WHO’s response to Covid-19 will also provide a valuable understanding of its current operations and renewed significance.
Started in 1948, the WHO is the United Nations agency which has a broad mandate to steer and coordinate international health policy. With its current funding, the WHO’s 2022–23 budget is around $6.1 billion with a particular focus on managing the remaining fallout of the COVID-19 pandemic. Only around 16% of this budget comes from mandatory dues assessed to member countries, while the remaining 84% of funding consists of voluntary donations from governments and private donors. With voluntary contributions, the WHO has one of the largest budgets of any UN agency. However, voluntary contributions are regularly appropriated for specific efforts–usually crisis response or in response to outbreaks–which may stray from the delegates’ agenda and hinders the WHO’s ability to autonomously chart its own course. This issue has been exacerbated over the last decade as the WHO has become increasingly dependent on these donations. The primary responsibility of the elected secretary-general is to raise funds from these donors. The top voluntary contributors in recent years have largely been developed countries such as the USA, Germany, and Japan, as well as large philanthropic organizations such as the Bill and Melinda Gates Foundation and GAVI Alliance.
The WHO has experienced profound successes in controlling yellow fever, enacting child vaccination programs, which have contributed to the eradication of smallpox, and bringing about remarkable reductions in polio, as well as many perceived failures such as a delayed response to Ebola in 2014, and now what many believe to be an unsatisfactory response to Covid-19. While criticisms are largely levied by those who feel the WHO is not living up to its lofty goals, many others are simply rooted in politics. Many critics, such as former President Donald Trump, have done both. Even prior to the onset of Covid-19, in a purely political move, Trump threatened to cut US contributions if other member states proceeded with a resolution to encourage breastfeeding as a political act to gratify the powerful US dairy lobbies. Then, amidst the Covid-19 pandemic in 2020, Trump announced he would cut all US relations with the WHO, after many experts raised concerns about the agency’s deference to Beijing and increasing Chinese influence over the institution, claiming WHO officials accepted misinformation from the Chinese government as the outbreak unfolded and waited too long to declare an emergency. While Trump’s actions may have been political retribution directed at China, the criticisms were levied by experts across the map.
In 2005, a legally binding framework coined the International Health Regulations was designed in order to prevent and mitigate health emergencies. Under this framework, WHO member states are required to monitor and report potential crises. Historically, however, countries have been hesitant to report any outbreaks out of fear of economic repercussions such as travel bans, increased regulations and obstructed trade. If a country does report an outbreak, the WHO can declare a “Public Health Emergency of International Concern,” (PHEIC) and issue nonbinding guidance on the responses of member countries. The purpose of this is to encourage countries to report crises in timely manners by preventing countries from overreacting or causing unnecessary economic harm to the country reporting the emergency through mechanisms such as travel bans and trade restrictions. Despite these efforts though, countries continue to be reluctant in reporting crises, and countries continue to respond with travel and trade restrictions on reporting countries.
This issue was illuminated by the Covid-19 crisis. When China alerted the WHO of an outbreak at the end of 2019, the WHO declared a PHEIC a month later and shortly after, 43 different countries imposed travel bans on China. After declaring the PHEIC, the WHO created a playbook that required $675 million in funding for the response. Donors, however were initially slow to act, hamstringing the agency’s efforts in the early days of the pandemic. Throughout the pandemic, the WHO acted as a global coordinator, facilitating data and experts to where they were most needed. Additionally, the issued medical and technical guidance, investigated its origins, monitored new variants and coordinated with world leaders on their national responses. It also provided material support including millions of diagnostic tests, personal protective equipment, and once available, distributed vaccines through the COVAX initiative aimed at providing equitable access to the Covid-19 vaccines.
Many critics have condemned the slow reaction and poor coordination to the outbreak, particularly in the early days of the crisis. These criticisms echoed those of the 2014 Ebola outbreak in which it ignored pleas from other health organizations. In response to this censure, the WHO created a reserve force of public health workers, established a $100 million emergency fund, and added an “incident management system” that allowed it to move medical staff, equipment, and supplies right away while developing a broader response. However, these measures were either insufficient or poorly implemented as the main points of concern ended up being repeated just 5 years later. Another issue illuminated by the Ebola outbreak was political tension between the WHO headquarters and their regional offices. In response, the WHO implemented a system paralleling UNICEF policy, which required staff to rotate posts around the world. With the apparent failure of these reforms to remedy the concerns they were designed to address, many are dissatisfied and Think Global Health’s David P. Fiddler writes that “pleas for strengthening the WHO have remained prominent”. However, there are a number of obstacles in place. Fidler names the most serious obstacles as resistance from China, the Russian war in Ukraine, and weakening US support for expanding authority and thereby funding.
In 2021, a rare special session of the World Health Assembly was convened to initiate the drafting of a global treaty on “pandemic prevention, preparedness, and response,” however these deliberations could take years. Additionally, the Assembly proposed revisions to the International Health Regulations (IHR) to improve future responses, however these amendments did not change substantive obligations nor add new ones, nor did it increase funding or improve the WHO’s capacities. So the lack of meaningful changes begs the question: what meaningful steps can the WHO do to improve its response and shore up funding and authority concerns?
Even prior to Covid-19, the WHO’s staunchest supporters argued that the organization needed more sustainable financing. One such way to do this would be to increasing the assessed contributions that member states must pay under the WHO constitution. Though this would be extraordinarily beneficial to increasing capacity and becoming less reliant on the funding and goals of donors, it is likely to meet opposition from the member states. Despite please for increased assessment dues following the pandemic, the World Health Assembly rejected resolutions to do so in 2020, 2021, and 2022. Therefore this may not be a feasible improvement given the current political climate regarding the WHO and international organizations. There is some hope however, as the Assembly did “request the Secretariat to develop budget proposals … for an increase of assessed contributions to contribute to [the] financial stability of WHO and with the aspiration to reach a level of 50% of the 2022-2023 base budget by the biennium 2030-2031.”
A key argument of opponents to these assessment increases is that they will not increase funding without sufficient institutional reforms. Bureaucrats in the WHO enjoy lucrative benefit packages and thus they rarely dare to speak out or take risks while some of the more committed and capable staff simply leave the organization due to the stultifying effect of the bureaucracy. This bureaucratic structure also limits the WHO’s ability to be proactive, another common critique of the agency. One particular critic succinctly sums up this claim: “At times of crisis, the world doesn’t need file pushers. It needs boots on the ground, whether in fatigues or white coats.” This argument carries immense validity. Communities in West Africa that are being ravaged by Ebola are not concerned with the issuance of a PHEIC or travel bans, they are concerned with getting people on the ground to provide life-saving treatment and interventions. Emphasizing proactivity rather than reactivity would allow the WHO to mitigate crises in earlier stages, likely doing more to limit fallout and saving more lives than issuing guidances and waiting for chaos to ensue before taking meaningful action.
Thus, rather than increase funding, perhaps the WHO needs to reevaluate where it allocates its funding. By redirecting funding from overpaid bureaucrats to doctors and medical teams that can be rapidly deployed to regions in crisis will allow the WHO to take proactive, meaningful measures against public health emergencies without needing to overcome significant political opposition to increased funding. Additionally, the WHO’s global infrastructure of six regional offices and physical presence in 147 countries consumes 70% of their budget. These offices clearly haven’t provided substantive improvements in efficiency or early action, and thus the elimination and consolidation of certain offices could save a tremendous amount of resources that should go towards actual interventions and systems designed to get people on the ground rapidly and save lives. This is not an attempt to discredit the hard-working individuals that compile important data and issue valuable policy guidelines and recommendations, but clearly the WHO’s most lauded successes come when they are actually physically present in an area that needs their help, and their budget and allocation of resources ought to reflect that. The development and distribution of lifesaving vaccines, medicines, and medical care are the measures that save lives and therefore should be the main priority. Strengthening their rapid response teams, getting medications on the ground, and improving the infrastructure for developing and distributing vaccines should be emphasized.
As the executive director of one of the oldest, peer-reviewed, medical journals declared in 2003, “the importance of an international, independent organization that is brave, aggressive, and vocal in its defense of global public health has never been more important,” and this remains true 20 years later. Laid bare by the most devastating pandemic in recent memory, the WHO’s potential for saving human lives is nearly unmatched by any other international organization. However, like other international organizations it is hindered by its own bureaucracy, lack of authority, waste, and inefficiency. There is no better symbol of this wasted potential than the 1 billion H191 vaccines that cost billions of dollars laying unused after the WHO overplayed the danger of the 2009 pandemic. It also doesn’t help that the WHO’s successes limit its capabilities going forward. After eradicating polio, a substantial portion of the international body’s funding dried up as most of it was directed towards polio funding. However, if the WHO is able to reduce its bureaucratic obstructions and free up currently available funds to rapidly and proactively save lives it may demonstrate a more compelling case for its value. This in turn may inspire member states to finally agree to a funding increase, revitalizing the body, limiting its reliance on unsustainable funding sources such as unpredictable donations, and expanding its capabilities to respond to more crises going forward. The WHO must first show it can rise to the occasion before it can expect the full-fledged support of the international community.
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