WHO reform: the need for a global mobilisation around the democratisation of global health governance

This paper (December 2016) describes the current program of ‘WHO reform’; identifies the main problems being addressed and evaluates the strategies of reform.  This analysis is contextualised within the contemporary structures and dynamics of global governance. The purpose of this analysis is to inform policy and advocacy around the directions of reform and of global health governance more broadly. 

The role and reach of the World Health Organisation was fiercely debated when it was created in 1948 and has been subject to recurring controversy since then. Current debate around the functions, structures and governance has been focused around the reform program which was launched in 2010 following (yet another) a budget crisis.

Of course, there have been shortfalls in performance; the delay in mounting an effective response to the 2014 Ebola outbreak in West Africa is an undisputed example.  What is contested are the causes and how WHO should be reformed.

At the centre of the debate around WHO reform is the freeze on mandatory contributions by member states (also ‘assessed contributions’ or ACs) and the tight earmarking of voluntary contributions by various national, international and private donors.

Undoubtedly the purpose of the freeze and the tight earmarking is to control WHO; to prevent it from implementing many of the policies and programs mandated by the governing bodies (the World Health Assembly, the Executive Board, and the regional committees). The fig leaf with which the freeze is rationalised is that, because WHO is so inefficient and unaccountable, it cannot be trusted with more than subsistence funding; hence the urgency for ‘WHO reform’ as a precondition for adequate, flexible, predictable funding.

The paradox is that, insofar as WHO is inefficient and unaccountable, the principal cause is the funding freeze and the Organisation’s dependence on donor funding. Of course, there are other less obvious factors contributing to WHO’s disabilities, including dysfunctions associated with WHO’s highly decentralised organisational structure, and the lack of accountability of member states for their contribution to WHO decision making and their implementation of WHO resolutions.

The shortfalls and disabilities of WHO need to be understood in relation to the wider structures and dynamics of global governance; the structures of global power and the drivers of global benefit distribution.  While the battle lines around global health policy vary with the specifics of particular issues, the core debates commonly reflect differences in the perspectives of the rich country governments versus those of low and middle income countries; commonly around the activities and interests of transnational corporations. 

The data for this review are drawn from a close review of the records of WHO’s governing body meetings since the present reform was initiated and from a range of publications dealing with history of WHO and global health since the first international sanitary conferences. The analysis of these data has been framed by models derived from governance theory, political economy, and legitimation theory.

The findings of the analysis are structured around the main elements of the reform program: and encompasses: funds mobilisation, budgeting, evaluation, relationships with non-state actors, relationships within the secretariat (between headquarters, the regions and the country offices), WHO’s role in global health governance, the emergency program and the management of the WHO’s staff.

It is clear from the material assembled in this paper that the struggle over the effectiveness and accountability of WHO remains critical to the project of equitable health development globally. The reform of WHO, to realise the vision of its Constitution, will require a global mobilization around the democratization of global health governance; not separate from, but part of, a global mobilization for a convivial, equitable and sustainable world.

Full paper here.