Part of the UN system, the sixty-year-old World Health Organization (WHO) is the world's designated leader for global health issues, particularly in the developing world. At the same time, the WHO's mandate is limited because it can only recommend, not enforce, specific health policies. The organization attracted notice in the spring of 2009 with the onset of the swine flu (H1N1 virus) and its declaration of a growing pandemic for the first time in more than forty years. Some critics say the WHO's focus is too broad (Slate), but global health experts say its mandate reflects the desire for a universal agency. Experts say a big challenge going forward will be maintaining the WHO's global leadership among a crowded field of international health organizations, many of which have more resources at their disposal.
A Broad Health Mandate
The WHO was created in 1948 out of discussions in the nascent United Nations about the need for a global health organization. Headquartered in Geneva, Switzerland, it now has offices in 147 countries and six regional offices. It was not intended to provide health services but rather to be a coordinating body for global health policy implemented by national and international health agencies. The WHO primarily makes recommendations and has no power to directly intervene in national health systems. Scott Rosenstein, global health fellow at the Eurasia Group, a U.S.-based analytical group, says though it was originally intended to be "a big-picture institution," it also has many on-the-ground programs. Its annual budget in 2009 was close to $5 billion.
There is no specific organization that is charged with enforcing international health requirements and the WHO has very little power to get countries to comply with their obligations or to cooperate.
The WHO's original programs included malaria, women's and children's health, tuberculosis, nutrition, and environmental sanitation. It now monitors and coordinates on many other issues, including safety guidelines for genetically modified foods, adaptation to climate change, reducing tobacco and drug abuse, and road safety. It also examines non-health determinants of health such as education, poverty, and infrastructure. Some of the WHO's most lauded successes (PDF) are fighting infectious diseases, including the design of child vaccination programs, the reduction of the crippling skin disease yaws by about 95 percent by 1964, the eradication of smallpox in 1979, and the reduction of polio cases by about 99 percent by 2006. There is ongoing debate on how best to use WHO resources. CFR Senior Fellow Laurie A. Garrett wrote in 2007 in Foreign Affairs that the global health community needs to move away from a disease-specific focus to improving general health systems.
In September 2011, the WHO's mandate widened even further after the UN adopted a declaration on non-communicable diseases calling for coordinated action to lower the incidence of diseases such as cancer, heart disease, and diabetes. The World Health Assembly (WHA) approved a resolution endorsing the initiative in May 2011. The WHO will devise a global monitoring system by the end of 2012 to measure progress on the initiative.
Governing the WHO
The organization is controlled by delegates from its 193 member states, each of which has an equal vote on the direction of WHO policies. The delegates of the WHA, which acts as a legislative body, meet annually to discuss the policy agenda. The WHA is responsible for electing the WHO's director-general and approving its budget.
Similar to the UN General Assembly, the WHA is often subject to global politics. Garrett says the assembly was intended to prevent the WHO from taking sides in the capitalism-communism debate during the Cold War. National and international interests continue to influence WHA decisions. China, for example, has blocked Taiwan's membership to the WHO (Taiwan was allowed observer status for the first time in 2009). Meanwhile, issues such as intellectual property rights for drugs, abortion, and the humanitarian situation in Gaza have generated acrimony.
The organization's regional offices enjoy a great deal of autonomy. Regional directors are elected by regional committees made up of health officials from countries within the region, with final approval given by headquarters. The offices are responsible for adapting global health policy to regional circumstances. Perhaps the most unique regional office is the Pan-American Health Organization (PAHO), which existed about forty years before the WHO was created and has enormous leverage in deciding policy for the region. PAHO gets additional funding from separate dues from its regional members and has programs separate from the WHO, such as its own vaccination-buying fund.
A 2005 report (PDF) from Global Health Watch, a collaboration of community and health advocates, notes regional offices also do not escape politics. The report found that regional directors must contend with a "politically charged environment, the corrosive effects of power and status, and their desire to ensure they are re-elected," all of which can impede efforts to improve performance, though many are originally elected on reform platforms. Membership in a regional office isn't always regional, says PAHO information officer Dan Epstein, but instead based on "patterns of health" and sometimes politics. Israel, he notes, is grouped in the European office based in Copenhagen, in part because of similar health patterns, but also because of the political problems it would cause placing the country in the office with other Middle Eastern nations.
International Health Regulations
In 1995, the WHO began revising the International Health Regulations (PDF), a legally binding policy for infectious diseases for all WHO member countries. The regulations, first developed in 1969, were confined to a few diseases, including cholera, small pox, plague, and yellow fever and the reporting requirement "ultimately failed to generate compliance" by WHO member countries, say health researchers Michael G. Baker and David P. Fidler. After a decade of debate, the WHO issued new regulations in 2005 that are much broader in scope, requiring member countries not only to report but also to prevent and control any disease that presents a significant harm to humans. The new regulations also establish a global surveillance system for possible pandemics (PDF). Scott F. Dowell (PDF), director of the Global Disease Detection program at the U.S. Centers for Disease Control, said the new regulations "are a tremendous step forward."
Beyond the International Health Regulations' requirements for reporting to the WHO on health emergencies of potential international scope and a general requirement for disease containment, policies for intervention at the national level are at the discretion of individual countries. Specific requirements were left out in part because of political wrangling. "The WHA health assembly in past sessions refused to go along with any quid pro quo," CFR's Garrett says, noting that governments aren't required to do anything when a pandemic is declared by the WHO. "The poor countries said 'We can't afford to do anything.' The middle income countries said 'We don't like the rich guys telling us what to do.' And the rich countries said 'We have our own policies, why should we listen to WHO?' So all the policy outcomes were eliminated." The infectious disease management plans of many countries, however, still closely follow WHO recommendations, says Eurasia Group's Rosenstein.
Politics have also affected the implementation of the alert system, which got its first test during the 2009 outbreak of H1N1, also known as swine flu. Since swine flu did not prove to be as deadly as avian flu (H5N1 virus)--a disease which influenced baseline assumptions for the alert system's framework--some members of the WHA during their May 2009 meeting were unwilling to declare a full pandemic, pointing to fears of economic harm (MSNBC) and other global health issues on the table. It took nearly two months of lobbying and a three-day emergency session to get enough members on board for the pandemic declaration, Garrett says.
Since the organization was created, the number of global health bodies has ballooned, including those within the UN framework like UNAIDS and UNICEF, numerous HIV/AIDS programs, large private entities such as the Bill and Melinda Gates Foundation, and nongovernmental organizations.
Meanwhile there is no specific organization that is charged with enforcing international health requirements and the WHO has very little power (PDF) to get countries to comply with their obligations or cooperate. The Indonesian government, for example, has repeatedly refused to provide samples of avian flu for study to create possible vaccines. The government claims "biological sovereignty" over the samples and argues that sharing would only benefit Western pharmaceutical companies that would create drugs the country couldn't afford. Rosenstein notes the WHO has no capacity to create vaccines itself, and all it can do is share protocols for the creation of vaccines. Many global health experts argue international health regulations should give the WHO more leverage during transnational emergencies.
Competing Among Financial Giants
In May 2011, the WHO slashed its budget by $1 billion for the next two years (Reuters) because of ongoing financial troubles in many of the organization's major donor countries. The agency is also expected to cut three hundred jobs. In its budget estimate (PDF), the WHO says it is "prudent to show caution" to ensure it can meet its program needs in an uncertain funding climate. It also says it is taking an opportunity to streamline programs. "[T]he strategic objectives would not be implemented in isolation of one another, but in a synergistic manner," says the WHO budget document. "Public health goals--for example, the Millennium Development Goals, scaling up work on non-communicable diseases, and addressing communicable diseases--are very often achieved through the contribution of a number of interlinked strategic objectives."
Health experts say funding for the organization was already inadequate given the WHO's mandate and that donors target a significant portion of the budget toward particular programs, similar to the earmarking done by the U.S. Congress. WHA members finance the WHO with dues based on their individual gross domestic products. Garrett says this means, in essence, that countries with the greatest health needs have to listen to the countries with the most money. The 2005 Global Health Watch report says the United States, in particular, uses its funding leverage to continually pressure the WHO (PDF) "to steer clear of 'macroeconomics' and 'trade issues' that it says are outside its scope, and to avoid such terminology as 'the right to health.'"
Some experts say the economic climate provides a long overdue chance to narrow the organization's focus. Others say the funding shift will make public-private partnerships more attractive. "The great difficulty facing the cash-strapped institution, of course, is how to make sure that private actors such as Bill Gates do not interfere too much with its health policies," writes Stéphane Bussard.
Since the organization was created, the number of global health bodies has ballooned, including those within the UN framework like UNAIDS and UNICEF, numerous HIV/AIDS programs, large private entities such as the Bill and Melinda Gates Foundation, and nongovernmental organizations such as Doctors without Borders. Experts say the rise of these other organizations, especially those with vastly more resources, is testing the WHO's leadership role. "It's chaos," CFR's Garrett says, adding that WHO's job is sometimes akin to "corralling kittens." The 2005 Global Health Watch report found that "transnational corporations and other global institutions--particularly the World Bank and International Monetary Fund--have a growing influence on population health that outweighs WHO's" and "some of these institutions, the Bank in particular, now operate in direct competition with WHO."
The WHO's funding is overshadowed by that of newly emerging organizations, such as the Bill and Melinda Gates Foundation, the Global Fund for AIDS, Tuberculosis, and Malaria, and PEPFAR (the U.S. President's Emergency Fund for AIDS Relief). The Centers for Diseases Control (CDC), for example, has nearly twice the budget (PDF) of the entire WHO. The Gates Foundation's budget for global health (PDF) is around $2 billion per year, about twice the WHO's core budget.
Experts contend that the WHO, challenged though it might be, is still needed. "There is no alternative to the World Health Organization," says the CDC's Scott Dowell. "We all contribute but we will only succeed if the WHO succeeds." A 2008 report from the British parliament points out that the WHO is still extremely influential among middle- and low-income countries, and has an image of being more neutral than U.S.- or British-based organizations. The report suggests WHO's mission statement be revised to specifically give it a mandate of "preparing a strategy for global health governance." Many health experts suggest Geneva should have more control over the WHO's resources for health programs.