- The WHO is the UN agency responsible for coordinating international health efforts.
- The agency has undergone some reforms in recent years, but still faces criticism over budget constraints and slow responses to health emergencies.
- President Biden reversed his predecessor’s move to withdraw the United States from the WHO amid the COVID-19 pandemic.
The World Health Organization (WHO) is the UN agency charged with spearheading international public health efforts. Over its nearly seventy-five years, the WHO has logged both successes, such as eradicating smallpox, and perceived failures, such as its delayed response to the Ebola outbreak in 2014.
In response, the WHO has undertaken reforms to improve its ability to fight future epidemics and boost the health of the hundreds of millions of people still living in extreme poverty. However, the WHO is in an uphill battle to loosen its rigid bureaucracy and it faces an increasingly troublesome budget. The COVID-19 pandemic has proved to be another monumental challenge for the health agency, sparking fresh debate over its effectiveness.
Why was the WHO established?
Created in 1948 as part of the United Nations, the WHO has a broad mandate to guide and coordinate international health policy. Its primary activities include developing partnerships with other global health initiatives, conducting research, setting norms, providing technical support, and monitoring health trends around the world. Over the decades, the WHO’s remit has expanded from its original focus on women’s and children’s health, nutrition, sanitation, and fighting malaria and tuberculosis.
What does the WHO do?
Today, the WHO monitors and coordinates activities concerning many health-related issues, including genetically modified foods, climate change, tobacco and drug use, and road safety. The WHO is also an arbiter of norms and best practices. Since 1977, the organization has maintained a list of essential medicines it encourages hospitals to stock; it has since made a similar list of diagnostic tests. The agency also provides guidance on priority medical devices, such as ventilators and X-ray and ultrasound machines.
Some of the WHO’s most lauded successes include its child vaccination programs, which contributed to the eradication of smallpox in 1979 and a 99 percent reduction in polio infections in recent decades, and its leadership during the 2003 severe acute respiratory syndrome (SARS) epidemic. The agency has the exclusive authority to declare global health emergencies, which it has done several times since its members granted it the power in 2007. At present, the WHO’s work includes combating the COVID-19 pandemic and other emergencies, as well as promoting refugees’ health.
In its 2019 strategy, the WHO identified three priorities [PDF] for its work over the next five years:
- providing health coverage to one billion more people;
- protecting one billion more people from health emergencies such as epidemics; and
- ensuring another one billion people enjoy better health and well-being, including protection from non-infectious diseases such as cancer.
The WHO’s strategic priorities are rooted in the United Nations’ Sustainable Development Goals, a set of seventeen objectives for ending poverty by 2030.
How is the WHO governed?
The WHO is headquartered in Geneva and has six regional and 150 country offices. It is controlled by delegates from its 194 member states, who vote on policy and elect the director general. Tedros Adhanom Ghebreyesus, previously Ethiopia’s foreign minister, was elected to a five-year term in 2017 and reelected in 2022. He is the WHO’s first leader from Africa, and his election was the first time all WHO countries had an equal vote.
WHO delegates set the agency’s agenda and approve an aspirational budget each year at the World Health Assembly. The director general is responsible for raising the lion’s share of funds from donors.
What is the WHO’s budget?
The current two-year goal (2022–23) is about $6.1 billion [PDF], with a sharp focus on managing consequences of the COVID-19 pandemic. Roughly 16 percent of the budget comes from mandatory dues paid by members; the rest is made up of voluntary donations from governments and private partners. In recent years, the top voluntary contributors have included Germany, the United States, the United Kingdom, and the Bill and Melinda Gates Foundation. Unlike dues, voluntary contributions are often earmarked for specific initiatives, which can complicate the WHO’s ability to set its own course.
Over the past decade, the WHO has become increasingly dependent on voluntary contributions, which puts pressure on the organization to align its goals with those of its donors. For instance, President Donald Trump reportedly threatened to cut U.S. contributions in 2018 if other member states proceeded with a resolution to encourage breastfeeding. And in 2020, amid the COVID-19 pandemic, Trump announced he would cut all U.S. ties with the WHO, arguing it failed to take steps to reduce China’s influence over the body. Usually the top contributor, the United States fell to the second-largest donor, providing $680 million in 2020–21, or about 12 percent of the WHO’s budget. However, upon taking office in 2021, President Joe Biden issued an executive order to halt the withdrawal and reengage with the agency.
Some experts argued that the Trump administration’s moves seriously threatened the body’s effectiveness and cited budget cuts as a major factor in the WHO’s slow response to outbreaks. The eradication of polio could also place financial stress on the WHO, whose budget has for decades been bolstered by polio funding, and on lower-income countries that rely on international funding to keep up surveillance and immunization efforts.
How does the WHO fight global health emergencies?
Under the International Health Regulations (IHR), a legally binding framework drawn up in 2005 to prevent and mitigate health emergencies, WHO member states are required to monitor and report potential crises. Countries have historically been hesitant to report outbreaks, often because they’re fearful of economic repercussions. In 2003, for example, China denied for months that it was suffering an outbreak of the infectious disease that was eventually identified as SARS. Before the WHO declared China free of SARS in 2004, the disease killed more than three hundred people. In Ethiopia, Tedros himself was accused of downplaying cholera outbreaks while he was the country’s health minister; he denied these claims.
In an extraordinary crisis, the WHO can declare a public health emergency of international concern (PHEIC), which it has done six times: during the 2009 swine flu (H1N1) epidemic; in reaction to a reversal of progress in eradicating polio in 2014; amid the 2014 Ebola outbreak in West Africa; during the 2016 Zika virus outbreak in the Americas; once the ongoing Ebola epidemic reached the city of Goma in the Democratic Republic of Congo in 2019; and amid the global outbreak of the new coronavirus in 2020.
During a PHEIC, the WHO issues nonbinding guidance to its members on how they should respond to the emergency, including on potential travel and trade restrictions. It seeks to prevent countries in the surrounding region and beyond from overreacting and inflicting undue economic harm on the country in crisis. The WHO has hoped this would encourage affected countries to report outbreaks in a timely manner. However, experts say that, despite the WHO’s guidance, many countries continue to impose damaging travel and trade restrictions, a problem that was laid bare during the Ebola and COVID-19 crises. In an emergency, the WHO also spells out treatment guidelines and acts as a global coordinator, shepherding scientific data and experts to where they are most needed.
Additionally, the WHO provides guidance and coordination for emergencies that don’t rise to the level of a PHEIC. But declaring a PHEIC can help speed up international action and often encourages research on the disease in question, even if there is little risk of a pandemic. This was particularly true for the 2014 declaration for polio. At the same time, PHEIC declarations are contentious, and some argue that they can exacerbate ongoing outbreaks.
How has the WHO responded to COVID-19?
China alerted WHO officials of a growing outbreak in the city of Wuhan on December 31, 2019. The WHO declared a PHEIC one month later and drew up a strategic preparedness and response plan that initially called for $675 million in funding from donors, though it struggled to get contributions at first. (By late 2020, it had received $1.5 billion for its pandemic response fund, close to 90 percent of its goal for the year.) In March, after the virus had spread to more than one hundred countries, Tedros announced that the outbreak had reached pandemic levels. While such a designation generally does not affect how the WHO addresses a crisis, it amplifies the call for countries to develop their own emergency response plans.
As it has done in past health crises, the WHO has provided medical and technical guidance as its experts investigate the virus, particularly new variants, as well as coordinated with world leaders on their national responses. It has also distributed critical supplies to member states, including millions of diagnostic tests and personal protective equipment for health-care workers. Additionally, it has helped to lead the global vaccination effort: the WHO partnered with the Coalition for Epidemic Preparedness Innovations (CEPI) and Gavi, the Vaccine Alliance, to launch COVAX, a global initiative aimed at providing equitable access to COVID-19 vaccines. By mid-2022, COVAX had delivered about 1.5 billion doses, falling short of its goal to distribute 2 billion by the end of 2021.
However, the WHO’s response has been the subject of controversy. Many experts have raised concerns about the agency’s deference to Beijing and increasing Chinese influence over the institution. Among other criticisms, they say WHO officials accepted misinformation from the Chinese government as the outbreak unfolded, waited too long to declare an emergency, and have shunned Taiwan because of bias toward China. Trump was particularly critical of the agency and in May 2020 he announced an end to the U.S. relationship with the WHO. (Biden reversed course on the U.S. exit immediately after taking office.) In January 2021, a delegation of WHO scientists traveled to Wuhan to investigate the virus’s origin, though its findings were inconclusive and critics say Beijing constrained the group’s work. The WHO has since established a new advisory group to continue research on the issue.
What reforms has the WHO made?
Many critics have faulted the WHO for slow and poorly coordinated responses to outbreaks. That includes the 2014 Ebola outbreak, in which it waited five months before declaring a PHEIC, despite pleas from groups such as Doctors Without Borders. Responding to these criticisms, the organization instituted several reforms intended to improve its responses, including the creation of a reserve force of public health workers and a $100 million emergency fund. The WHO also added an incident management system that allows it to place medical responders, equipment, and supplies such as medicines on the ground right away while it coordinates a broader response.
Under Tedros, the WHO has tackled another of its most enduring problems: political friction between its headquarters and its six regional offices, which critics say have enjoyed too much autonomy. Some say that tension between Geneva and the WHO’s Africa office, in Brazzaville, Republic of Congo, contributed to the agency’s poor response to the 2014 Ebola outbreak. To assert its authority over these regional power bases, the WHO has begun requiring staff to rotate among posts around the world, similar to a policy at UNICEF. While some observers paint this and other changes as merely cosmetic, others have applauded the reforms. “There is much greater cooperation than there was in the past,” global health expert Ilona Kickbusch said at a 2020 CFR meeting.
More recently, the COVID-19 crisis has prompted calls for major reforms. In a rare special session of the WHO’s World Health Assembly in 2021, delegates initiated the drafting of a global treaty on pandemic prevention, preparedness, and response. The proposal for a pandemic treaty has sparked debate, however, and the deliberation process could take years. At the 2022 assembly, countries agreed on a U.S.-led proposal to strengthen the IHR by increasing member states’ accountability around disease outbreaks, though no changes have been formally approved.
“Pleas for strengthening the WHO have remained prominent,” writes CFR’s David P. Fidler for Think Global Health. “However, this goal faces serious obstacles,” Fidler says, namely resistance from China, Russia’s war in Ukraine, and a lack of strong U.S. support for expanding the body’s authority and funding.
On The President’s Inbox podcast, CFR’s Stewart M. Patrick lays out what the WHO can and cannot do.
For Think Global Health, CFR’s David P. Fidler looks at the World Health Assembly’s slow steps toward global health reforms.
This CFR Independent Task Force report argues that the WHO has an important leadership role in public health emergencies but lacks the geopolitical heft to address their broader implications.
In Foreign Affairs, Laurie Garrett examines the WHO’s mishandling of the 2014 Ebola outbreak.
Plagues and the Paradox of Progress, a 2018 book by CFR’s Thomas J. Bollyky, discusses the WHO’s attempts to improve itself after the Ebola crisis.
This CFR Backgrounder describes ongoing global efforts to eradicate polio.
Mia Speier contributed to this report.