The World Health Organization (WHO) is the part of the United Nations system designated to "direct and coordinate" international public health efforts. Despite a broad mandate to take on issues ranging from infectious diseases to chronic noncommunicable ailments to public safety, the organization has a limited budget to back many of its recommendations. The 2014 Ebola outbreak in West Africa brought into public view some of the WHO's institutional challenges.
A Broad Mandate
The WHO, created in 1948 as part of the United Nations, is tasked with "directing and coordinating" international health policy. It defines its role in global public health as one of engaging partnerships, conducting research, setting norms, providing leadership and technical support, and monitoring health trends. The organization has limited authority to enforce any of its findings or recommendations, however, and it relies on voluntary contributions for 80 percent of its funding.
The WHO's original programs focused on women's and children's health, nutrition, environmental sanitation, and fighting malaria and tuberculosis. It now monitors and coordinates on many other issues, including safety guidelines for genetically modified foods, adaptation to climate change, tobacco and drug use, and road safety. Some of the WHO's most lauded successes [PDF] are its child vaccination programs and the eradication of smallpox in 1979. Polio infections were reduced by 99 percent in 2006, but in 2014 the agency declared a health emergency when authorities reported an uptick in cases.
Today the agency has six main priorities [PDF]:
- universal health coverage;
- health-related Millennium Development Goals;
- noncommunicable diseases, such as cancer, heart disease, and mental health;
- social, economic, and environmental determinants;
- access to medical products; and
- the International Health Regulations established in 2005.
The WHO comprises six regional offices and 147 country offices. It is controlled by delegates from its 194 member states, each of which has an equal vote on the direction of agency policies. Delegates meet each year at the World Health Assembly (WHA) to discuss the policy agenda; the assembly is tasked with electing the WHO's director-general and approving its budget. The organization's regional offices enjoy a great deal of autonomy and are charged with adapting global health policy to regional circumstances. Member dues account for 20 percent of the WHO's budget, and the rest of the agency's funding come mainly from the governments of the United States and United Kingdom and the Bill and Melinda Gates Foundation.
International Health Regulations
In 2005 the WHO issued a set of International Health Regulations (IHR), a legally binding set of policies for infectious diseases pertaining to all WHO member countries that builds off of regulations first developed in 1969. The IHR require member countries to report extraordinary health events such as disease outbreaks that might constitute an international public health emergency, and to implement measures to prevent and control any disease that presents a "significant harm to humans."
Countries have historically underreported epidemics due to fear of economics consequences. The IHR are designed to reduce the disincentives for countries to report such outbreaks in a timely manner, says CFR's Senior Fellow Thomas Bollyky, by restricting other countries from implementing measures that unnecessarily limit trade or travel or infringe on human rights. The IHR empower the WHO to issue recommendations on appropriate health and travel restrictions that countries may take to respond to an international public health emergency.
Despite the IHR being legally binding, there are few effective provisions for their enforcement, and the IHR have experienced mixed results. On the one hand, Bollyky says, the timely reporting of disesase outbreaks has improved since the revision. However, the WHO has been less successful in preventing countries from implementing uneccesary travel and trade restrictions and in helping middle- and low-income countries to implement health systems better equipped to manage outbreaks. It is these systems that have now collapsed under the weight of West Africa's Ebola outbreak. "The WHO has been pulled in multiple directions," Bollyky says, adding that the agency's "hand would be strengthened on enforcing the IHR if the WHO had more resources to tie to compliance. If the WHO had the money to help countries build the minimum capacity for disease surveillance and control, it could tie further funding to progress and might be able do more."
Global Health Emergencies
When the IHR entered into force in 2007, the WHO was granted authority to declare global health emergencies, or Public Health Emergencies of International Concern (PHEIC). It has done so three times: during the 2009 swine flu (H1N1) epidemic, in reaction to a reversal of progress in eradicating polio in May 2014, and during the 2014 Ebola outbreak in West Africa.
A PHEIC [PDF] is defined as "an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response." The IHR Emergency Committee, a group of "international experts," advises the WHO's director-general, who ultimately decides whether to declare an emergency. Once the WHO declares a PHEIC, it issues temporary recommendations to affected countries and can urge neighboring countries not to economically isolate countries handling epidemics.
The WHO's role in containing and confronting global pandemics was called into question during the 2014 Ebola Outbreak. Director-General Margaret Chan was criticized when in a discussion about the Ebola outbreak in West Africa she said the organization was "a technical agency that provides advice and support" and that governments in West Africa had the primary responsibility to care for victims of the disease.
In 2007, the WHO was granted authority to declare global health emergencies. It has done so three times: during the 2009 swine flu epidemic, in reaction to an uptick in polio infections, and during the 2014 Ebola outbreak in West Africa.
Laurie Garrett, CFR's Senior Fellow for Global Health, has called the WHO response "abysmal," but also said that the WHO has worked decisively in past health emergencies, leveraging its authority to confront pandemics. Citing the 2009 SARS pandemic that originated in China, she says the agency worked "with a combination of public diplomacy and aggressive demands for transparency, corralling an international team of responders to work alongside the local responders to bring the outbreak under control."
Budget Challenges and the 2014 Ebola Outbreak
The agency relies primarily on earmarked donations, and its income from member dues has stagnated since the 1990s. The WHO's two-year budget fell by more than 20 percent, from nearly $5 billion in 2009–2010 to $3.98 billion in 2014–2015. WHO's slow response to Ebola has been attributed to budget cuts, and in 2014 WHO leaders petitioned governments around the world to increase funding to fight Ebola. A New York Times analysis found that the WHO's outbreak and emergency response team was hit particularly hard by cuts; officials in that department estimated their staff had been reduced by 35 percent reduction since 2009. The WHO department charged with emergency response was reduced from ninety-four to thirty-four.
In the meantime, global health initiatives beyond the WHO are enjoying "unprecedented focus and funding," with more than $31 billion in funding in 2013 (up from $5.6 billion in 1990). CFR's Global Governance Monitor found that "more than forty bilateral donors, twenty-five UN agencies, twenty global and regional funds, and ninety global initiatives target health activities and assistance." Organizations like the U.S. Centers for Disease Control (CDC); Doctors Without Borders (MSF); the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the Gavi Alliance; and the Bill and Melinda Gates Foundation are important actors, often with more money and visibility than the WHO. For example, the CDC operates on an annual budget of $6 billion, and in 2010 the Gates Foundation constituted five percent of health funding worldwide. Despite the rise in funding for global health, "inadequate coordination and leadership" threaten these institutions' efficacy, the CFR report finds. In particular, the WHO's struggles to lead the response to the Ebola outbreak have left some experts questioning the agency's future and considering the global response the next time a pandemic strikes.
CFR's Garrett, for one, has said that the WHO's chance to take the lead in fighting Ebola, "has already passed." Still others find that the current crisis may serve as an opportunity for the WHO to demand more funding. In an interview with Vox, Peter Piot, a Belgian microbiologist credited with co-discovering the Ebola virus in 1976, predicted that the outbreak would lead to the agency having "a financially protected team that can deal with outbreaks at the WHO and that there will be massive support to strengthen the health systems and services in these countries."
Despite recent struggles, some experts point to the WHO's vast infrastructure and past successes as reason for more robust funding. "At the end of the day, [the WHO] is an institution with enormous credibility in low- and middle-income countries and there is still no other international health agency that can offer that," Bollyky says. "The Ebola crisis is a wake-up call to make the WHO work better, not to find its replacement."
CFR's Global Governance Monitor discusses the challenges of coordinating global health efforts.
This Washington Post article argues that global response to Ebola lacked leadership and coordination.
Budget cuts at the WHO hampered its response to the Ebola crisis, according to the New York Times.
CFR's Laurie Garrett discusses the leadership vacuum in response to Ebola in this CFR Interview.
CFR's Thomas Bollyky proposes ways to reform the WHO to better address cross-border threats in this Expert Brief.