The WHO is critical to global health, but reform is needed

Image credit: Giovanni Maki, Public Library of Science CC-BY

The ongoing Ebola epidemic in West Africa has shone a spotlight on the need for governments, organisations, companies and communities to work in together, with partnerships crossing borders and specialisms in order to make progress. During a session on pandemics at the World Economic Forum in Davos, Wellcome Trust director Jeremy Farrar spoke of the critical need for a unified body, working at the global level to improve global health, but added that it must have strong leadership, and be well funded. Expanding on these thoughts in a comment piece first published in the Wall Street Journal, he explores what needs to happen to enable the World Health Organization to live up to its full potential… 

It killed nearly 300,000 people, but the influenza pandemic of 2009 was a lucky escape. The H1N1 strain of the virus turned out to be milder than initially feared, limiting deaths and severe illness. That was just as well, said an independent review at the time. The report concluded that the World Health Organization was ill-prepared to deal with any global public-health emergency. Among its recommended reforms: an international reserve of responders who could mobilise swiftly against a dangerous epidemic, clear command structures so the WHO could lead this response, and a contingency fund to pay for it.

As the WHO executive board gathers Monday to consider its response to the Ebola epidemic, which has so far claimed 8,500 lives, on the table is a paper whose recommendations will surprise no one who read the H1N1 report. Specifically, the recent paper recognises that in dealing with Ebola the WHO has lacked “the speed, co-ordination, clear lines of decision-making and dedicated funding needed to optimise implementation, reduce suffering and save lives.” These shortcomings have been evident since at least the 2003 SARS outbreak and have been further exposed by emerging threats such as the Middle East respiratory syndrome coronavirus and Southeast Asia’s artemisinin-resistant malaria. Yet while global epidemic surveillance has undoubtedly improved, the capacity to respond quickly and effectively when a threat is detected has not. Ebola has now focused the world’s attention on this critical need.

Yet even if the WHO grasps this historic opportunity, there are fundamental and systemic failings that underlie its inability to learn lessons. This essential organisation, with international legitimacy and respect unmatched in public health, has been held back by deep structural flaws and a chronic refusal to lead.

The abiding problem is illustrated by the executive board itself. This is supposed to be the WHO’s agenda-setting and implementation body. Yet with 34 members it is too big to be anything but indecisive or bound by the lowest common denominators. It can agree more easily on matters of epidemic surveillance, which require light commitments and minimal accountability, than on response, which requires investment and action. This is especially problematic because the WHO’s supreme decision-making body, the World Health Assembly, is even bigger with 194 member states. The assembly is an important source of legitimacy and could be the WHO’s greatest strength, but it must be paired with a streamlined and clear-sighted executive.

It also needs strong and decisive leadership if it is not to be paralysed by consensus. The director general’s mandate, however, is to implement the will of the member states—it is the job description of a manager, not a leader. It must be redrawn. The role’s capacity to act and affect change is further limited by a byzantine division of responsibilities between the WHO’s Geneva headquarters, six powerful regional offices dominated by the larger member states, and more than 150 country offices. This blurs accountability and duplicates functions, and at worst packs important positions with politically appointed placemen who frustrate the efforts of the WHO’s most able people.

These structural constraints have been exacerbated by the excessively narrow way in which the WHO leadership group interprets its mandate. It has chosen to emphasise the technical aspects of its role over the operational direction of epidemic responses. It has been a reluctant leader when eagerness is required.

Leaders of organisations with restrictive governance arrangements, such as most international agencies, have a choice: They can passively follow the wishes of their stakeholders, or they can set a more ambitious agenda that takes a firm position on what action is required and then challenge stakeholders to support it. The WHO needs leadership of the second kind that does not hide behind its mandate but strains against its limits. Gro Harlem Brundtland, the former prime minister of Norway and director general of the WHO from 1998 to 2003, tried to provide such leadership. Frustrated by her inability to win support, she walked away.

Such activist leadership would go well beyond proposing the limited if essential progress that is on the table next week. It would also be seizing the moment to advocate more radical reforms. A recent Chatham House report, for example, argued that the WHO must choose between scaling back the regional division in favour of a unitary structure with a powerful head office, or full decentralisation. With the problem thrown into sharp relief by Ebola, there may never be a better occasion to grasp this nettle.

Reform and proactive leadership is vital to the WHO because the WHO is vital to global health. No other institution has the potential to combine representative legitimacy with the capacity and mandate to act. But if the WHO fails to evolve, others such as the World Bank may feel they have to step in. The result will be Balkanised health governance, when a unified global system is needed. Margaret Chan, the present director general, has another two years in office. Convincing reluctant national governments to embrace real and effective renewal would be a fine legacy.

Details and recordings of the sessions on Global Health Security and Pandemics that Jeremy Farrar took part in at the World Economic Forum  can be found here. This piece was first published in the Wall Street Journal on 23rd January.