There are probably three main things which are widely known about the World Health Organisation. First, it led the way in the global eradication of smallpox, the near-eradication of polio and the international battle against HIV-AIDS.

Second, it is funded by governments and major donor organisations. And third – rather more embarrassingly – it planned to make Robert Mugabe a WHO Goodwill Ambassador in 2017. Oops.

Beyond that, there is a vague awareness that the WHO, like many international organisations, comes in for a lot of stick (something to do with kowtowing to China? Inadequate expectations? A tendency to bureaucratic inertia?). If you want a primer on the longstanding criticisms levelled at the organisation, try this piece by Fiona Goodlee, the editor of the British Medical Journal.

It should be self-evident that the battle against Covid – including the global vaccination strategy championed by Tortoise in #TheArmsRace campaign – depends to a considerable extent upon the WHO’s efficiency, focus and vigour. So let us scroll back and ask what it does (and doesn’t) do; and then explore ways in which it might heal itself.

What, WHO and why?

Established in 1948 as the successor body to the Health Organisation of the League of Nations, the WHO became the first specialised agency of the United Nations to which every member country subscribed. 

Contrary to popular assumption, it is not primarily a “doing” organisation. Its broad mandate includes campaigning for universal healthcare, monitoring public health risks, coordinating responses to health emergencies, and generally promoting human health and wellbeing.

Its first major priority is the setting of norms and regulations. The WHO is the ultimate custodian of global health rules (declaring an international health emergency, setting international standards for air and water quality, listing essential drugs). It also collects data on global health via the World Health Survey, publishing the annual World Health Report, and providing a forum for summits and discussions on health issue.

Its second primary function is local. The WHO has 150 national offices in its six different regions: principally in low and middle-income countries. These offices are run by non-nationals, and provide technical assistance, acting as the primary adviser to each country’s government on matters of health and pharmaceutical policy.

And – as has become clearer than ever during the pandemic – the WHO also has a central role in health emergencies. This aspect of its work is governed by a legal framework: the International Health Regulations. 

As the Economist observed last year: “[t]hey spell out how public-health emergencies should be handled. They set the rules for how nations should behave. And they constrain the WHO. Member states are bound to report outbreaks of diseases as soon as they can, but if they fail to do so, or delay as China did with Covid-19, the organisation has no way of compelling them”.

Alongside member states, the WHO works with a range of partner organisations that provide significant funding, including the World Bank, the European Commission, the Bill & Melinda Gates Foundation, the Rockefeller Foundation, Rotary international and GAVI (the vaccines alliance). 

The WHO and the World Bank constitute the core organising and convening alliance responsible for administering the International Health Partnership (IHP+): a group of partner governments, development agencies, civil society groups, and other bodies committed to improving the health of citizens in developing countries.

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The Covid report card

In conditions of extraordinary stress and pressure, the WHO has played a major role in the response to the pandemic, helping to coordinate global initiatives to develop treatments and vaccines, working with pharmaceutical companies and manufacturers to expedite their work.

It is also a key player in the oversight of Covax – the initiative to distribute 2 billion doses of vaccine this year – alongside the Coalition for Epidemic Preparedness Innovations, Gavi and Unicef.

Inevitably, Covid has shone a bright and unforgiving light upon the WHO, revealing, simultaneously, its strengths and weaknesses. Structurally, it stands between a rock and a hard place: balancing its advisory role, urging nations to raise their game, with the need for diplomacy and strategies tailored to the specific sensitivities and cultures of individual member states. 

In particular, its relationship with China has been the subject of criticism. To this day, Tedros Adhanom Ghebreyesus, the WHO’s Director-General, stands by its original warm praise of China’s response to the original outbreak in Wuhan. Yet as the BBC (alongside many other news platforms) reported, “others – including medics in the country – described how their early concerns about the virus were silenced by the Chinese authorities”. 

In his defence, the WHO’s Director-General argued that China’s strategy had helped to slow the initial international spread of Covid, buying the rest of the world time to prepare, and – no less important – had voluntarily shared the virus’s genetic code promptly, enabling the global scientific community to develop better diagnostic tests and (most spectacularly, and in record time) effective vaccines.

But Tedros has not been able to shake the impression that the investigation in January by WHO-appointed scientists into the origins of Covid in Wuhan was, at best, inadequate, and, at worst, something close to a whitewash. In this respect, the Biden administration had not held back in its criticisms. 

So what to do? Martin McKee is Professor of European Public Health, London School of Hygiene and Tropical Medicine, and the director of the European Health Observatory, in which capacity he works with the WHO. 

As McKee puts it: “I think we’d all accept that very few places handled the Covid-19 pandemic very well. The WHO, like the governments of its member states, is no exception to that. 

“The International Panel for Pandemic Preparedness and Response (IPPPR) evaluated the world’s response to the Covid-19 pandemic. That recently published report, with recommendations for WHO reform, is significant.

“And it’s important these are followed through. As we think about how the WHO needs to change, you always have to remember that, while the WHO is headquartered in Geneva, its six regional offices have equally important roles. The international expertise and connections in Geneva are key, but the regional offices are much closer to their member states, which is a real strength at times of global crisis”.

With that in mind, here’s a ten-point plan for WHO reform:

1. Don’t waste the Covid crisis

“You never want a serious crisis to go to waste. And what I mean by that [is] it’s an opportunity to do things that you think you could not before”.

Rahm Emanuel, Wall Street Journal interview, 2008

One of the WHO’s manifest difficulties is that it functions in a crowded space. Its remit overlaps at many points with those of the World Bank, the International Labour Organisation, GAVI vaccines alliance, the Organisation for Economic Co-Operation and Development, the International Monetary Fund, development banks, and other technical institutions. And that’s before we get to the cacophonously crowded world of donors, foundations, charities and other providers of aid for healthcare. 

This alphabet soup makes it very hard for the WHO to seem – and indeed to be – truly distinctive. As far as its identity is concerned, it suffers death by a thousand cuts.

How can it give itself a stronger sense of institutional vigour, clarity of mission and a sharper public presence?

2. Fix the finances

The WHO relies on contributions from member states (both assessed and voluntary) and from private donors. Its total approved budget for 2020–2021 is over $7.2 billion, of which the majority is accounted for by voluntary contributions from member states.

Among the largest contributors were Germany (which contributed 12.18 per cent of the budget); the Bill & Melinda Gates Foundation (11.65 per cent); and the United States (7.85 per cent). 

The straightforward budgetary problem faced by the WHO is that its funding has been frozen for years – not even increased to take account of inflation. If ever there was a moment for this shrinkage to be reversed, it is surely now. 

The extent to which the WHO lives hand to mouth is under-appreciated. In emergencies it has often been forced to ask its most significant funders for more cash. (In the middle of the 2018-19 Ebola outbreak in Congo, it actually ran out of money.) 

According to the Economist, only 20 per cent of its funding is guaranteed and comes without strings. The remainder is accounted for by around 3,000 unpredictable and voluntary contributions: many are earmarked for specific projects, and almost half are below $500,000.

As Tedros has quite reasonably remarked, such subsidies are “messy, difficult to manage and fragment the organisation”. To address this challenge, he has created the WHO Foundation as a first step towards financial stability, and asked member states for more unconditional funding. 

There is more direct contact now with heads of government rather than finance ministers. This is a start. But it is only a start. The nations of the world need to step up to the plate in preparation for the next health emergency which the WHO will have to face.

3. From WHO to Global Health Board?

The costs to the global economy of the pandemic have been estimated at $10 trillion: the WHO’s annual budget is $7.2 billion.

Juxtaposing those two figures makes a pretty robust case for increased investment in the WHO and a genuinely systematic fiscal approach to global health crises. For this, there is recent precedent: after the 2008-9 financial crisis, central governments rapidly embraced the case for greater economic liquidity, and the need to deploy strong powers of intervention collectively. The G20 became the principal institutional focus of that spirit of recognition.

So: it is not unreasonable to argue that the WHO, in response to the pandemic, should be reimagined and relaunched as a fully-fledged Global Health Board – with greater status, much more secure funding and the natural gathering point for heads of government and their ministers before and during health crises. If we need Nato or the G20 or the IMF, we need such a body.

4. Health as investment

The methods by which we record health expenditure data should also be radically modernised, to draw a much clearer distinction between consumed health expenditure and genuine investment. 

The latter category would include measures to reduce health threats, to bolster early warning systems and to scale up systems to respond to future crises. And please note: such measures must include dramatically enhanced health system surveillance powers for the WHO, not least so the organisation can carry out regular assessment of emergency and pandemic preparedness around the world.

5. Accelerate leadership reform

Tedros, as the first director-general to be elected by a secret ballot of all member states, believes that this mandate gives him greater independence. Previously, the WHO’s executive board (a small sub-group of members) was in charge of electing the D-G.

But there is a strong case to go further. Those close to the WHO suggest that each D-G should have a single seven-year, non-renewable term, rather than the current five years – at the end of which re-election is presently a possibility. This would give the holder of the office longer to pursue a coherent strategy; but also stop them using their first term as an extended re-election campaign.

6. Don’t be bashful about success – or speaking the truth

The fact is that the WHO has done a lot of things rather well. It’s just bad at telling people about them. You’d think, for instance, that an organisation of its kind should really have been warning about the risks of a novel pandemic.

And – as it happens – it did. In 2015, the WHO published this list of the emerging diseases considered most likely to cause major epidemics. In 2018, the WHO warned of “Disease X”, an illness caused by a pathogen never seen before in humans, that would cause the next pandemic and wreak havoc. Indeed, Tedros set up a new division to prepare for it. 

Unfortunately, we have learned the hard way that many countries barely heeded this warning. The reconstructed WHO needs to be much more aggressive in its communications strategy and be more vocal about the problems it sees on the horizon. 

Polite press conferences and old-school websites are not enough. The organisation needs to be a much more nimble, familiar and engaged presence on the world stage, offering clear advice to the global population as well as to governments and making imaginative use of social media to get across the urgency of its message.

7. Regionalise

There are obvious governance and representational complexities facing the regional divisions of the WHO; naturally, tensions also arise between local offices and the organisation’s headquarters. 

Yet one of the clear lessons of the pandemic is that local knowledge and expertise is treasure in the fight against a pathogen like Covid. Big organisations exercise a big gravitational pull to the centre. But the WHO’s regional offices and regions would be better advised to promote bottom-up and community-led approaches to health improvement and prevention. 

A potential model in this respect is the Grameen bank, the community development organisation founded in Bangladesh in 2006, which promotes collateral-free microfinancing by granular collaboration with local communities.

8. Take “One Health” seriously

“One Health”, an idea that has gathered pace in the last decade, refers to developments at the interface of human, animal, and environmental health policy. In the jargon, it is a “multidisciplinary, and multi-agency approach to designing and implementing programmes, policies, legislation and research to deliver better population and public health outcomes”.

In short, it is an umbrella term for the interaction of environment, animals and human beings – particularly relevant to the control of diseases that can spread between animals and humans, such as coronaviruses; to combating antibiotic resistance; and to food safety.

Recognising the interconnection and interdependence between people, plants, animals, and their shared environment is not, of course, a new concept. But it has not driven much appreciable policy or practice to date. In his recent lecture, Lord Jim O’Neill argued that we may need to look more widely at UN architecture, and the role of “One Health” within it. 

At the risk of proposing too much institutional upheaval: there is at the very least a case for a new “One Health” organisation, which would bring together much of what the WHO, Food and Agriculture Organisation (another UN sub-body), World Organisation for Animal Health do at present, integrating these tasks in one agency.

9. Inspections with bite

China’s delay in initially notifying the world of Covid-19 and its subsequent attempts to frustrate the WHO-appointed investigative team mean that the WHO requires much stronger inspection powers. 

Some countries, including Russia, simply do not accept this. But any new pandemic treaty that emerges from the Covid crisis will be pointless without such authority being granted to the WHO. 

The diplomatic battle to secure such rights needs to start immediately. Biosecurity should be a matter of legitimate international concern in exactly the same way that the development of weapons of mass destruction preoccupies weapons inspectors. 

Pathogens do not respect borders. This means that, when it comes to WHO inspection, national sovereignty cannot be the last word.

10. Reform – not replace

For all its flaws, the WHO still has a vital mandate, and employs a great many brilliant people. If you abolished it, you’d have to reinvent it. And the world does not have the time for that. 

We are still in the midst of a global pandemic. We urgently need to vaccinate the poorer nations of the world. Let us not accept the counsels of despair about the world’s leading health authority – but, instead, resolve to make it radically better, and urgently so. 

Andy Cowper is the Editor of Health Policy Insight.