Editor’s Note: This post reflects on a panel that Dr. Jha moderated this January in Washington, DC hosted by The Center for Global Health Science and Security at Georgetown University Medical Center, the Harvard Global Health Institute, and Health Affairs.
The election for the next Director General (DG) of the World Health Organization (WHO) has stirred a quiet but important conversation about the agency’s future role. Yet the two major questions driving this uncertainty—do we really need a WHO and, if yes, what do we need the WHO to do—are often avoided in polite company. The next DG needs to answer both of those questions.
The world has changed since the WHO was founded nearly 70 years ago. The number of organizations engaged in global health was small and the WHO played the central role in cross-national health issues because there were no other obvious entities to do so. Today, the world has become deeply interconnected and interdependent, and the number of organizations engaged in global health has exploded. As Julio Frenk recently noted, 175 new entities, from funders to non-governmental organizations (NGOs), many with a strong focus on global health, have come into existence in just the past decade. In this now crowded stage, critics (from member states to prominent thought leaders) are asking, does the WHO still have a role?
Learning From The Aftermath Of Ebola
In addition to a more developed global health landscape, skeptics are concerned that the WHO often fails to perform when the world needs it the most. There is no better example than the WHO’s recent failures during the 2013-2015 Ebola outbreak in West Africa. While the WHO has many responsibilities (arguably too many), there may be none more important than preventing the spread of cross-national infectious disease outbreaks. The organization was far too slow and ineffective, directly contributing to more than 11,000 preventable deaths. In fact, while the Ebola outbreak continued, new organizations were created to fulfill some of the WHO’s core functions. For example, one of the key jobs of the WHO is coordination, yet the United Nations created the United Nations Mission for Ebola Emergency Response (UNMEER) to expedite the on the ground response to the crisis, presumably because the leadership of the UN did not trust the WHO to play this role.
The WHO has shown little appetite for accountability after the Ebola catastrophe. Very few people lost their job or were otherwise held to account. In most sectors, when organizations fail on mission-critical programs, we expect accountability, a change in leadership, and true “house cleaning.” That has not happened. Of course, the collective failures of the global community around Ebola extend far beyond the WHO, but ultimately, we must hold the WHO accountable for failing to mobilize an effective global response. Critics of the WHO are right to raise the question: if the WHO cannot function effectively when we need it the most, is it time to look elsewhere?
So here is the big question: does the world still need a WHO? The answer is unequivocally yes. While it is true that there are now hundreds of organizations engaged in global health, there is none with the legitimacy of the WHO. And WHO is not just the entity in Geneva. While the WHO’s headquarters may be in Geneva, one of the WHO’s biggest strengths and its most important asset is that the WHO is made up of 194 member states. Only the WHO has the membership (and thus, the legitimacy) to engage in collective action. Under the right leadership, the WHO can stand up to governments, mobilize global opinion on key public health issues, and create political will for action in a way that no one else can.
The WHO is also essential for its work on global public goods. In various areas of public health, we need a neutral, third-party that can set agendas and norms, and coordinate on critical research and development issues. The WHO is the only organization positioned to do this. On these issues, the WHO has done quite a good job. For example, the WHO’s newly created R&D Blueprint lays out a roadmap for priority pathogens. In terms of disease-specific efforts, the WHO launched the Zika Open platform that makes research on Zika more rapidly available for improved global and local learning.
Finally, the WHO receives too little credit for navigating the inter-sectorial nature of global health. Global health is complex, and health outcomes are the product of a number of political and social factors that are not traditional health issues. For example, trade, financial policies, and migration are just a few issues that impact health. There is no other organization that can realistically coordinate with key entities like the World Trade Organization, World Bank, or the United Nations’ High Commissioner on Refugees. Fundamentally, we need an organization that can effectively engage with non-health entities to ensure we consider the health effects of policies.
An Agenda For The Next Director General
Given the central importance of the WHO in ensuring global health, the upcoming election of the next DG is that much more important. The next DG must restore public faith in the WHO. That begins by building real accountability and transparency into the organization. As outlined in prior work, the WHO needs a freedom of information policy that demands that the activities, deliberations, and discussions that occur within the WHO is open to outside scrutiny. Many governments have similar “freedom of information” rules, and the WHO should as well.
To restore public faith, the WHO should create an office of the Inspector General (IG). Independently appointing an IG to ensure that the WHO is meeting its obligations to the global community is a key “good governance” principle. This IG would need to report to the Executive Board of the WHO and to the member states. While the Executive Board technically provides oversight, the board members are country representatives with other responsibilities. They have neither the tools nor the expertise to provide the detailed supervision that an IG can perform.
Finally, the WHO has to make human resources reforms, including the ability to get rid of poor performers. There is far too little turnover at the WHO, and the number of poor performing staff who stay in a single position or sometimes get moved from one area to another is legendary. This creates bureaucratic bloat, making the organization less effective, and donors less willing to provide funds. A new set of HR policies that ensure greater accountability when expectations for high-level performance are not met is critical.
The primary beneficiary of these reforms will be important for the WHO itself. Some WHO defenders argue that the lack of money is the primary reason they are ineffective. At least three major reports assessing the global response to Ebola called out insufficient funds as key to the WHO’s failed response. Indeed, nearly 80 percent of the WHO’s funds are earmarked, giving the organization relatively little flexibility. This funding structure is a symptom, not a cause, of the WHO’s problems. By undertaking substantial reforms, the WHO will restore trust and begin to have a realistic conversation with member states about increasing funding and making those funds more flexible.
We are at a critical moment in global health and a critical moment for the WHO. The anti-globalization forces are gaining strength, arguing that every country should only think about itself. We must counter these arguments with facts that show that a closed border approach will not work. This is the task of the next DG, who will have a short window of time to implement the kinds of reforms needed to make the WHO more effective again. If the DG is successful in implementing reforms, the global community will give the WHO more time and more resources to prove that it can lead. Instead of choosing between a dysfunctional WHO or no WHO at all, the world needs and deserves an effective WHO.