The COVID-19 pandemic has put a sharp focus on the functioning of World Health Organisation (WHO), a specialised agency of the United Nations (UN) responsible for global health management. From the start of the outbreak, the organisation has been at the centre of many controversies. It has been accused of ‘dereliction of duties’; siding with the Chinese government in their initial-cover ups about the outbreak; delaying the declaration of the epidemic a public health emergency, and its inability to work out a timely coordinated global response to the pandemic. Set up in 1948 with an ambitious mandate of supplying public goods in healthcare, WHO has been a directing and coordinating authority on “international health work”.[i]
Over time, its scope and role have undergone significant changes. In recent decades, however, WHO’s capabilities in coordinating global public health efforts have increasingly weakened due to the rising number of multilateral health initiatives, public-private partnerships, non-governmental organizations, etc. Although the proliferation of actors in the global health governance was meant to strengthen the working of the organisation, but the lack of coordination and incoherent priorities between different actors have somewhat rendered the system ineffective.[ii] Also, WHO’s ability to determine healthcare priorities face challenges from the declining budgetary contributions from member states as well as from private bodies.[iii] For many such reasons, the credibility of WHO as a lead UN agency has come under crisis and compels a re-look at its structure, scope and priorities.
142nd Executive Board Meeting of the WHO
Image Source: https://www.devex.com/news/13-things-to-know-about-who-s-geneva-deliberations-91972
WHO Reforms: An Unfinished Agenda
As the demand for reforms in the WHO are growing intense, it is worthwhile to look into the key reforms that the organisation had undertaken since late 1980s. The first phase starting from 1988 to 1998 was mainly devoted to working towards implementation of the “Global Strategy for Health for All”.[iv] The declaration of the Alma Ata conference in 1978 marked the beginning of “Health for All” movement, which promoted the idea of accessible primary healthcare as essential to everyone and as a key means to attaining the goal of health for all. To achieve these objectives, WHO adopted important constitutional revisions such as increase in membership, special technical assistance to improve the health conditions of member states, and the development of public-private partnership models to meet the demands of health services.[v]
One of the major debates during this period centred around WHO’s three-tier structure (headquarters, regions, countries), and the distribution of power between them. The first phase of reform also coincided with an important period of changes in world politics marked by the end of the cold war, strong emphasis on public health over military spending, and a growing recognition of public health for fostering economic development.
The restructuring initiated by the WHO Director General, Dr Gro Harlem Brundtland,(1998-2003) assumed the second phase of reform. Dr Brundtland’s visionary ideas led to setting new norms and standards of working for WHO. She emphasised on the need to “work on ground” for better implementation of action points and placed heath at the core of development agenda.[vi] In her view, the existence of two types of funds in the WHO (regular budgetary contributions by the member states and extra-budgetary contributions) created two parallel power centres within the organisation, which often worked at cross-purposes. To implement the “One WHO” vision, she carried out budgetary reorganization, reallocation of resources, and the restructuring of review process for effective assessment of managerial performance. Bruntland also contributed to the concept of “sustainable development” and was the first to identify the triangular relationship between heath, economy and environment.[vii]
Under her stewardship, WHO’s six regional offices - Africa, the Americas, South-East Asia, Europe, the Eastern Mediterranean, and the Western Pacific - for the first time came together with the headquarter in Geneva to produce a combined budget.[viii] Bruntland also emphasised on creating stronger networks between member states and other stakeholders such as the private sector, development banks, and the non-governmental organisations (NGOs).[ix] The new programs were followed by a restructuring of the WHO’s senior administration in which scientists or personnel with technical knowledge were recruited in its Cabinet of Executive Directors.
Most importantly, she focussed on areas that had had been neglected since WHO’s establishment.[x] Tobacco being one such area was actively pursued by Bruntland’s leadership, which led to the 2003 Framework Convention on Tobacco Control for banning tobacco use.[xi] The WHO reform entered its third phase in 2005 when Dr. Lee Jong-wook (2003-2006) initiated the revision of the International Health Regulations (IHR). The IHR as a policy instrument had become obsolete in the face of new challenges in global health governance.[xii] However, it was the SARS outbreak in 2003 which pushed the World Health assembly (WHA),[xiii] the supreme decision-making body of WHO, to finalise the IHR revisions. The IHR (2005) reflects the new norms of global health security in which member states acknowledge their obligations and responsibilities for a collective outbreak response.[xiv]
The WHO reforms however saw a substantial shift under the stewardship of Dr. Lee Jong-wook’s successor Dr. Margaret Chan (2007-2017). Dr Chan was critical of the singular focus on one-disease programmes like the HIV/AIDS and called for more synergy between horizontal system, comprising of general services, prevention and care for prevailing health problems and vertical programmes for specific health conditions.[xv] One of her highest priorities was strengthening the health system and she spearheaded the establishment of two new clusters; one dedicated to Health Systems and Services and other to Information, Evidence, and Research.[xvi]
Dr. Chan realised the predictability and stability problems associated with WHO’s financing including the lack of alignment between donors’ preferences and the organisation’s priorities.[xvii] Also, the uncertainty caused by the global financial crisis of 2008 directly impacted the funding levels of WHO and it therefore became imperative for her to undertake realistic planning to ensure effective management within the available finance. However, the reforms undertaken failed to improve WHO’s ability to effectively respond to the Ebola outbreak in 2014.
For instance, the organisation experienced a major shortfall in resources to handle Ebola outbreak.[xviii] Realising the need for a contingency fund, the WHO in 2015 added emergency capacities to finance the Health Emergency Programme.[xix] Furthermore, the Ebola crisis exposed the lack of coordination between WHO’s Africa regional office, and Geneva (WHO headquarter), in which the regional office restricted dissemination of information, essential for emergency preparedness and containment measures. The head of its Guinea office also refused to issue visas to an expert Ebola team and an aid of $500,000 was blocked due to bureaucratic wrangling.[xx] WHO, thus, mishandled its early response and delayed alerting the international community about the outbreak.
COVID-19 and WHO’s Response
Although the COVID-19 is vastly different from the Ebola pandemic in terms of the pathogens, transmission routes, symptoms, fatality rates etc, they bring forth the profound need to reform the WHO. In both the cases, WHO failed to gather initial data about the outbreak, delayed declaring the epidemics a public health emergency of international concern (PHEIC), and lacked the authority to resist politicisation of the pandemic. In fact, the reforms undertaken after the Ebola crisis failed to address the fundamental problems in WHO and they remain relevant during the current pandemic.[xxi]
The first relates to the sharing of data during the COVID outbreak. The organisation only relied on Chinese government for data about the outbreak and did not pay heed to information that came from other sources, leading to mischaracterisation about the severity of the virus in the early days of its spread. According to Article 5 in IHR (2005), "WHO shall collect information regarding events through its surveillance activities, assess their potential to cause international disease spread” and in accordance with Article 11, it “shall communicate information to relevant States Parties as well as intergovernmental organisations that might help them in preventing the occurrence of similar incidents”[xxii].
Although WHO published disease related news titled “Pneumonia of unknown cause – China” in the first week of January this year, it failed to assess the overall risk of the reported pneumonia.[xxiii] Owing to the lack of timely evidence, the organisation could not reach a consensus on declaring it a PHEIC at the Emergency Committee (EC) meeting held on 23rd January this year and delayed alerting the other countries about the outbreak.[xxiv]
Second, the current pandemic like its predecessor throws spotlight on the scope of IHR (2005). For instance, China’s handling of the outbreak raises questions about its compliance with the IHR (2005). This in turn points to the absence of enforcement mechanism of the IHR, due to which countries with particular political and economic influence within the organisation often do not comply with its commitments.[xxv] Another critical area which further narrows the scope of IHR (2005) is the working of the emergency committee (EC) which advises the WHO Director-General (DG), to declare an outbreak PHEIC and to adopt “temporary recommendations” which include health measures, health workforce issues, travel advisories, border/travel screenings etc.[xxvi] As seen in the current and previous crisis, the committee’s reasoning did not align with the IHR (2005) and became prone to political influence. Also, the lack of relative details in the EC reports published in the WHO website, raise doubts on whether the EC members take into account the technical and scientific evidence to define a PHEIC.[xxvii]
At the 146th session of the WHO Executive Board[xxviii] which met in the early weeks of February this year, opinions varied among the members about “necessary and “unnecessary” travel and trade restrictions to China as a response to coronavirus outbreak. While Dr Tedros, the current WHO DG advised the member states not to impose any travel and trade restrictions to China in absence of evidence commensurate with IHR guidelines, countries went ahead and tightened travel restrictions, including mandatory quarantine measures on travellers returning from China.
Third, the current pandemic shows that many countries including the developed and developing ones lack national health capacities to deal with infectious diseases despite being signatories to IHR (2005). Likewise, it also reveals the dearth of visionary leadership in WHO. The transnational corporations and pharmaceutical companies often influence the organisation’s decisions vis-a-vis affordable global health solutions. The private sector take-over not only increases the price of publicly developed drug or vaccine but also leads to delays and decreased access.[xxix] The development of Ebola vaccines is a classic example. For instance, while the Canadian government scientists developed the Ebola vaccine with support from the WHO, its transfer of licence to private firm Merck failed to yield any substantial value-addition and proved inadequate to address public health needs during the outbreak in Congo.[xxx]
Member states, particularly the major contributors to WHO’s funding, failed to display political will and vision to carry out meaningful reforms in the organisation.[xxxi] On the contrary, the organisation has emerged as the new playground of power politics and its increasing dependence on the donors (member states as well as non-state actors) undermines its ability to resist political interference, particularly in its allocation of resources. The reluctance of the WHO member states to increase annual contributions to the organisation renders it under-prepared to respond to international health emergencies.[xxxii]
Finally, the three-tier structure of the WHO further complicates its ability to coordinate international cooperation. Each regional office acts as a sphere of influence in which they elect their own Directors.[xxxiii] These self-governing regional offices make decision making difficult for Geneva and the success of policy outcomes is mostly dependent on the relationship between them. And given their proximity to national ministries of health, they often lack objectivity in their roles and responsibilities.[xxxiv]
Opportunity to Reform the WHO & India’s Role
The COVID-19 pandemic has offered an unprecedented opportunity to reform the WHO and enhance its credibility as the leading UN body. In the current context, India is uniquely placed in terms of bringing in the perspectives from the global south and to redefine WHO’s normative framework. The challenge at hand is to make the organisation’s functioning much more transparent, accountable, and representative of the needs of developing and least developed countries.[xxxv] While the ‘one country, one vote’ formula suggests a level playing field in the WHO, even today many developing countries lack sufficient policy capacities to take the lead in policy interventions, propose public health agendas or in tabling resolutions in the WHA meetings. Being the active proponent of reforms in key multilateral institutions, India therefore has major stakes in WHO’s global health governance.
At the G20 Virtual Summit held on 26th March this year, Prime Minister Modi called for reforming the WHO and underscored the need to revive multilateralism to deal with the devastating effects of the pandemic.[xxxvi] His call comes in the wake of rising tensions between the United States and China which tends to deflect global attention away from the core issues. While the withholding of WHO’s funding by the US has dealt a major blow to the organisation, it also opens-up space for new players like India to rise up to the challenge. With India set to occupy the chairmanship in WHO’s executive board in the coming months,[xxxvii] it will be able to propose key governance reforms in the organisation and to set new priorities in the areas of healthcare, services, R&D and innovation.
India’s ambition in the field can already be gauged from the announcement of creating a COVID-19 emergency fund for the SAARC (South Asian Association for Regional Cooperation) countries. Also, the “WHO India Country Cooperation Strategy 2019–2023” fully aligns itself with the newly adopted WHO 13th General Programme of Work, Sustainable Development Goals and the WHO South-East Asia Region’s eight flagship priorities. [xxxviii] The alignment of priorities will allow India to act as a “shareholder” with genuine stakes in the success of the organisation.
For New Delhi to play an active role in reforming WHO, however, requires improving inter-ministerial coordination especially between the external affairs and health and family welfare (MoHFW) ministries. Developing deeper understanding of the technical issues in the organisation is also key to influencing the health agenda in the WHA meeting.[xxxix] A lot would undoubtedly depend on India’s pro-active and sustained engagement (reciprocal) within the WHO individually and also as a part of coalition of like-minded constituents.[xl] Interestingly, the ancient Indian philosophical ethos rooted in “Vasudhaiva Kutumbakam” (The world is one family) lends greater credence to New Delhi as a key anchor in global health cooperation and in contributing to public goods.
*Dr. Priyanka Pandit is a Research Fellow at the Indian Council of World Affairs, New Delhi.
Disclaimer: The views expressed are that of the Researcher and not of the Council.
[i] Clift, C (2013), “The Role of the World Health Organization in the International System”, Chatham House, URL: https://www.chathamhouse.org/sites/default/files/publications/research/2013-02-01-role-world-health-organization-international-system-clift.pdf, Accessed on 18th April 2020.
[ii] (2020), “What Does the World Health Organization Do?”, Council on Foreign Relations, April 16, URL: https://www.cfr.org/backgrounder/what-does-world-health-organization-do, Accessed on 18th April 2020.
[iii] Huang, Y (2016), “How to Reform the Ailing World Health Organization”, Council on Foreign Relations, May 3, URL: https://www.cfr.org/expert-brief/how-reform-ailing-world-health-organization, Accessed on 14th April 2020.
[iv] Clift, C (2013), “The Role of the World Health Organization in the International System”, Chatham House, URL: https://www.chathamhouse.org/sites/default/files/publications/research/2013-02-01-role-world-health-organization-international-system-clift.pdf, Accessed on 18th April 2020.
[v] WHO Report (1992), “The Work of WHO 1990·1991 Biennial Report of the Director-General to the World Health Assembly and to the United Nations”, URL: https://apps.who.int/iris/bitstream/handle/10665/37646/9241561491_eng_part1.pdf?sequence=2, Accessed on 18th April 2020.
[vi] Yach, D. (2016). World Health Organization Reform—A Normative or an Operational Organization? American Journal of Public Health, 106(11): 1904–1906, doi: https://dx.doi.org/10.2105%2FAJPH.2016.303376.
[vii] Borowy, I (2013), “The Brundtland Commission: Sustainable development as health issue”, Michael Journal, URL: https://www.michaeljournal.no/i/2013/03/The-Brundtland-Commission-Sustainable-development-as-health-issue, Accessed on 29th April 2020
[viii] Lerer, L., & Matzopoulos, R. (2001), “The Worst of Both Worlds”: The Management Reform of the World Health Organization”, International Journal of Health Services, 31(2), 415–438, doi:10.2190/xe6n-xdkk-xy4c-57gv.
[ix] Yach, D. (2016). World Health Organization Reform—A Normative or an Operational Organization? American Journal of Public Health, 106(11): 1904–1906, doi: https://dx.doi.org/10.2105%2FAJPH.2016.303376.
[x] Interview with a Public Health Expert from India.
[xi] Lerer, L., & Matzopoulos, R. (2001), “The Worst of Both Worlds”: The Management Reform of the World Health Organization”, International Journal of Health Services, 31(2), 415–438, doi:10.2190/xe6n-xdkk-xy4c-57gv.
[xii] Sperling, J. (Ed.). (2014). Handbook of governance and security. Edward Elgar Publishing.
[xiii] The WHA determine the policies of the Organization, appoint the Director-General, supervise financial policies, and review and approve the proposed programme budget. The WHA adopts regulations on sanitary and quarantine requirements, nomenclature for diseases, causes of death, and public health practices etc.
[xiv] Harman, S. (2017). “Norms won't save you: Ebola and the norm of global health security”, Global Health Governance, 11(2), URL: http://blogs.shu.edu/ghg/files/2016/04/Ebola-Special-Issue.pdf#page=35.
[xv] Clift, C (2013), “The Role of the World Health Organization in the International System”, Chatham House, URL: https://www.chathamhouse.org/sites/default/files/publications/research/2013-02-01-role-world-health-organization-international-system-clift.pdf, Accessed on 18th April 2020.
[xvii] Busby, J., Grépin, A., & Youde, J. (2016) “Ebola: Implications for Global Health Governance”, Global Health Governance, 10(1), 3-11, URL; http://blogs.shu.edu/ghg/files/2016/04/Ebola-Special-Issue.pdf#page=35, Accessed on 14th April 2020.
[xviii] Moon, Suerie, et al. (2015), "Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola." The Lancet, 386(10009), doi: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00946-0/fulltext.
[xix] Reddy, S. K., Mazhar, S., & Lencucha, R. (2018), “The financial sustainability of the World Health Organization and the political economy of global health governance: a review of funding proposals”, Globalization and health, 14(1), 1-11, doi: https://doi.org/10.1186/s12992-018-0436-8.
[xx] Boseley, S (2014), “World Health Organisation admits botching response to Ebola outbreak”, Guardian, October 17, URL: https://www.theguardian.com/world/2014/oct/17/world-health-organisation-botched-ebola-outbreak, Accessed on 14th April 2020.
[xxi] Clift, C. (2016) “Ebola and WHO reform”, Global health, 10(1), URL: http://blogs.shu.edu/ghg/files/2016/04/Ebola-Special-Issue.pdf#page=35, Accessed on 14th April 2020.
[xxiii] (2020), “Pneumonia of unknown cause – China”, World Health Organisation, January 5, URL: https://www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/, Accessed on 14th April 2020.
[xxiv] (2020), “WHO Timeline - COVID-19”, World Health Organisation, May 8, URL: https://www.who.int/news-room/detail/08-04-2020-who-timeline---covid-19, Accessed on 12th April 2020.
[xxv] Wilson, K., Brownstein, J. S., & Fidler, D. P. (2010), “Strengthening the International Health Regulations: lessons from the H1N1 pandemic”, Health policy and planning, 25(6), 505-509, doi: https://doi.org/10.1093/heapol/czq026.
[xxvi] Mackey, T. (2017), “Lessons from Liberia: Global Health Governance in the Post-Ebola Paradigm”, Global Health Governance, 11(2), URL: http://blogs.shu.edu/ghg/files/2016/04/Ebola-Special-Issue.pdf#page=35, Accessed on 12th April 2020.
[xxvii] Burci, Gian Luci (2020), “The Outbreak of COVID-19 Coronavirus: are the International Health Regulations fit for purpose?”, Blog of the European Journal of International Law, URL: https://www.ejiltalk.org/the-outbreak-of-covid-19-coronavirus-are-the-international-health-regulations-fit-for-purpose/, Accessed on 12 April 2020.
[xxviii] The Executive Board, key decision making body of the WHO, consists of 34 persons who are technically qualified in the field of health, each designated by a Member State that has been elected to serve by the World Health Assembly. It draws up the agenda for the WHA annual meetings, advises, facilitates, and gives direction to the WHA policies.
[xxix] Inputs received from a former Indian Diplomat, 27th April 2020.
Herder, M., Graham, J. E., & Gold, R. (2020), “From discovery to delivery: public sector development of the rVSV-ZEBOV Ebola vaccine”, Journal of Law and the Biosciences, doi: https://doi.org/10.1093/jlb/lsz019
[xxx] Inputs received from a former Indian Diplomat, 27th April 2020.
Graham, J. E. (2019). Ebola vaccine innovation: a case study of pseudoscapes in global health. Critical Public Health, 29(4), 401-412, doi: https://doi.org/10.1080/09581596.2019.1597966
[xxxi] Huang, Y (2016), “How to Reform the Ailing World Health Organization”, Council on Foreign Relations, May 3, URL: https://www.cfr.org/expert-brief/how-reform-ailing-world-health-organization, Accessed on 14th April 2020.
[xxxii] Reddy, S. K., Mazhar, S., & Lencucha, R. (2018), “The financial sustainability of the World Health Organization and the political economy of global health governance: a review of funding proposals”, Globalization and health, 14(1), 1-11, doi: https://doi.org/10.1186/s12992-018-0436-8
[xxxiii] Interview with a Senior Public Health Official from India, April 20, 2020.
[xxxiv] Clift, C. (2016) “Ebola and WHO reform”, Global health, 10(1), URL: http://blogs.shu.edu/ghg/files/2016/04/Ebola-Special-Issue.pdf#page=35, Accessed on 14th April 2020.
[xxxv] Inputs received from an Indian Official.
[xxxvi] Press Release (2020), “Press Release on the Extraordinary Virtual G20 Leaders' Summit”, Ministry of External Affairs, Government of India, March 26, URL: https://www.mea.gov.in/press-releases.htm?dtl/32600/Press_Release_on_the_Extraordinary_Virtual_G20_Leaders_Summit, Accessed on 14 April 2020.
[xxxvii] Gupta, S. (2020), “India set to get lead role in WHO board”, Hindustan Times, April 23, URL: https://www.hindustantimes.com/india-news/india-set-to-get-lead-role-in-who-board/story-SqrQmnyQEqWTDvHUWTN8zH.html, Accessed on 24th April 2020
[xxxix] Inputs received from a former Indian Official.
[xl] Inputs received from an Indian Official.