WHO in many respects provides a test-case for how members of the UN development system (UNDS) can either adapt or wither in the contemporary era of partnerships, new sources of financing, and the crowded institutional terrain. While often praised as among the most competent and essential of UN agencies, it must now emphasize its considerable comparative advantages.
Effective leadership and management rather than just reconciliation of institutional tensions are vital to WHO’s future resilience. The alternative is decline.
A different WHO has an essential role in global politics—in fact, three successive global surveys by the FUNDS project have consistently ranked WHO as the most effective member of the UNDS in supporting the MDGs. As the plethora of shiny new institutions begin to appear less effective and responsive than previously thought, this briefing reviews possible reforms options for WHO.
The Case for Reform
Calls for WHO reform have been a defining feature of global health governance. Institutional tensions abound: between its technical advisory role and its normative advocacy role on a range of global public health issues; between institutional commitments to “health for all” and the interests and influences of private health delivery and progressive rather than absolute universalism; and between its regional bases for operations and the need to have a common global agenda.
Tensions in large international organizations will always exist; the issue is how to manage them. There is a crying need to reform WHO to mitigate these tensions, but in many respects WHO has been complacent about its role in global governance and thus slow to compete in the crowded terrain of global health.
Global health is congested with new financing mechanisms such as UNITAID; new research initiatives such as the GAVI Alliance; and new public-private partnerships such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) that was established with much public ceremony to address the three health scourges associated with MDG 6.
The origins of two glossy institutions—UNAIDS and the Global Fund—reveals the lack of confidence in WHO to address the world’s most pressing health concerns. However, reforming the WHO is now essential as these organizations are beginning to lose their luster. All of the relatively new institutions were built on the wave of HIV/AIDS capital. But, HIV/AIDS financing has been in decline over the last three years and questions abound as to whether it should occupy such an exceptional role in global health.
In 1999, 52% of contributions went to WHO’s core (assessed) budget and 48% were voluntary contributions to specific health concerns. In 2014 the ration will be only 23% in core contributions and 77% in voluntary ones. The reliance on voluntary contributions restricts WHO’s ability to fully plan its operations and makes it ever more reliant on the priorities of its major donors, including the Bill and Melinda Gates Foundation that is now the lead agency in global health.
In short, WHO is increasingly an amalgamation of different global health projects and strategies directed by external actors and decreasingly an independent organization.
The outcome of WHO’s current round of reform will not be visionary but ‘reformlite’: a slimmed-down institution that has more central managerial oversight of its core operations. But such reforms alone will not fix the problems of voluntary contributions or the tensions over the pursuit of health for all and its provision. The future of WHO is not necessarily one of managed decline but of opportunity, in particular the opportunity to put WHO back on the global health agenda at a time when some of the new institutions of global health are wavering.
As the deadline for the Post-2015 development agenda approaches, the fundamentals of development assistance for health are being rethought. A shift towards regional actors and regional thinking and the value of technical knowledge over normative agenda-setting gives WHO a critical opportunity to assert its relevance as one of the few universal-membership organizations with regional expertise and offices. For reform to generate institutional resilience rather than managed decline, WHO should emphasize its technical and research capacities as a basis for greater political leverage.
To do so it requires bolder leadership that combines the idealism of global health advocates to establish a clear mandate for the WHO, while simultaneously recognizing resource constraints. Harnessing the support of global health advocates that are committed to a global institution that promotes public health worldwide could help WHO overcome institutional complacency and reform-fatigue to re-establish itself as the leader in global health.
Sophie Harman is Senior Lecturer in the School of Politics and International Relations, Queen Mary University of London where she teaches and conducts research on global health politics and the governance of international development; she has a regional focus on sub-Saharan Africa. She is the author of Global Health Governance (2012) and The World Bank and HIV/AIDS (2010) and editor of African Agency and International Relations (2013), The Governance of HIV/AIDS (2009), and Governing the World? (2013).