World Health Organization (WHO)
WHO’s establishment in 1948 marked a new era for global health. With a shared purpose of “Health for All,” WHO remained a prominent actor in global health governance for decades, coordinating worldwide efforts against smallpox, handling international reporting, and managing disease outbreaks through the International Health Regulations (IHR). Today, the global community still expects WHO to solve global health governance problems. However, WHO is a beleaguered institution. On a theoretical level, WHO lacks a substantive justice oriented conception of international institutional legitimacy. On a more pragmatic plane, WHO is riddled with budgetary weaknesses, power politics and diminishing reputation and effectiveness. Many questioned its capacity to deal with pandemics, given its role in the 2014 West African Ebola pandemic and 2019-2022 COVID-19 pandemic.
International institutional legitimacy is a key to evaluating an international institution’s right to rule or exercise power. WHO was founded by a United Nations treaty, based on a social contract conception of legitimacy. Its structure also incorporates procedural legitimacy through self-determination, and equal participation through the state consent and World Health Assembly (WHA) process. However, the institution still does not meet the standard of legitimacy the Provincial Globalism (PG) and Shared Heath Governance (SHG) require. As a social contract, it only includes the states that are contracting parties and is unable to demand recognition by non-state actors, like the Global Fund, the Gates Foundation, and Gavi Alliance. It also fails to directly ground its accountability to individual persons or substate groups. This leaves WHO policies limited in scope vis-a-vis nonstate and substate actors.
WHO also lacks a substantive moral foundation for legitimacy. Without a moral foundation undergirding social contracts and procedures, power politics prevails, and bias is unstrained. For example, a justice-based legitimacy would have made WHO more robust against corruption and held more legitimacy to coordinate substate or non-state parties.
Additionally, current WHO fails in the coordination of diverse actors and mutual collective accountability. Though WHO has a mandate to coordinate efforts in global health (Chapter II, Article 2, a, b), it has not been able to fulfil this charge effectively in a context of autonomous states and many new non-state actors. The current constitution makes coordination arduous, requiring a two-thirds majority for approval of many WHO relations with other organisations (Chapter XVI, Articles 69–70, 72). It renders WHO efforts to coordinate and involve other organizations difficult, if not ii possible. Another problem is that WHO does not have enforcement powers to solidify coordination. Without a credible compliance mechanism, other global health actors can and do ignore WHO.
In addition to WHO’s constitutional design, its own lack of transparency and accountability pose other problems in executing its objectives, particularly in obtaining investments from and coordinating global health actors.In its handling of H1N1, WHO came under sharp criticism for bowing to commercial interests and for its procedural opacity. Some experts advising WHO had financial ties with pharmaceutical companies producing antivirals and flu vaccines, and the ‘emer- gency committee’ created to advise Dr Chan on the pandemic declaration timing (which has financial implications for the pharmaceutical industry) did not deliber- ate publicly and WHO had not revealed the identities of its members.
WHO’s inability to coordinate global health actors contributes to other governance problems. For programmes or projects under a given actor’s direct control, the actor remains accountable, but many global heath efforts involve multiple actors, and a lack of coordination blurs lines of responsibility, thus leading to accountability failures. Mutual collective accountability, described elsewhere, is a more comprehensive solution; expecting better WHO accountability to solve all GHG accountability issues is unrealistic.
Finally, the WHO has failed to establish functional independence in either the sci- entific or coordination realms. The WHO needs to be more independent from its powerful member states; WHO must redesign its components and procedures to minimise influence.The WHO should be pared down and ren- dered a more purely executive and technical agency, leaving the legislative functions to the WHA where member states gather to decide on resolutions.
WHO’s performance thus fails under the scrutiny of the PG/SHG framework. We cannot rely on WHO alone to promote human flourishing. The real issue is less WHO’s problems, and more today’s GHG requirements. While WHO reforms may improve its operational capabilities in the future, the global health governance system needs a new vision, based on a substantive conception of justice and legitimacy, and broader restructuring to serve GHG functions effectively and efficiently. Without a broader vision and structure, we will not achieve global health equity, diminish worldwide contagions, or resolve cross-border issues. The global health enterprise needs an institution arching over WHO: a Global Health Constitution (GHC). It must specify WHO functions and articulate the roles and duties of other entities.