- 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.
- On his first day in office, 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. In its seventy-year life, 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, a rigid bureaucracy and an increasingly troublesome budget could impede reforms. Meanwhile, the 2020 coronavirus pandemic has emerged as a 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 [PDF] 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 emergencies, such as the pandemic of a new coronavirus disease known as COVID-19, and promoting refugees’ health.
In its 2019 strategy, the WHO identified three priorities [PDF] for its work over the next several 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 149 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. 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 (2020–2021) is about $5.8 billion, a $1.4 billion increase from the previous budget, much of which is for the COVID-19 response. About 17 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 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 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 third-largest donor in 2020, providing $594 million, or about 8 percent of the WHO’s budget, in the first three quarters. Upon his 2021 inauguration, however, President Joe Biden issued an executive order to halt the withdrawal and reengage with the agency.
Some experts argued that the Trump administration’s move seriously threatened the body’s effectiveness, and cite recent budget cuts as a major factor in the WHO’s slow response to outbreaks. The near eradication of polio could present another budgetary challenge. Since polio funds cover nearly three-quarters of all WHO employees’ salaries, regardless of whether they work on the disease, its eradication could jeopardize the WHO’s future.
How does the WHO fight global health emergencies?
The WHO relies on its member states to monitor and report crises in a timely fashion. 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 has denied these claims.
In an extraordinary crisis, the WHO can declare a public health emergency of international concern (PHEIC, pronounced “fake”), 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 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 highlighted during the 2014 Ebola and 2020 COVID-19 PHEICs.
In an emergency, the WHO also spells out treatment guidelines, hoping to help prevent panics. It also 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 the coronavirus pandemic?
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, the WHO declared the outbreak a pandemic. 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 is providing medical and technical guidance as its experts continue to investigate the virus, particularly new variants, as well as coordinating with world leaders on their national responses. It is also distributing critical supplies to member states, including millions of diagnostic tests and personal protective equipment for health-care workers. Additionally, it is helping 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 January 2021, COVAX announced plans for its first deliveries as part of its goal to distribute two billion vaccine doses by the end of the year.
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. In January 2021, a delegation of WHO scientists arrived in Wuhan to investigate the virus’s origins, after Chinese authorities repeatedly delayed the mission. The team’s success “depends a lot on how much the government is willing to be cooperative,” CFR’s Yanzhong Huang told CNN.
Trump was particularly critical of the agency, announcing an end to the U.S. relationship with the WHO, though legal experts questioned whether the president had the authority to take such a step without congressional approval. In addition to immediately reversing course on the U.S. exit, Biden vowed to bring the United States into the COVAX initiative.
What are other major criticisms of the WHO?
In addition to increased scrutiny over its role in the coronavirus crisis, many critics have faulted the WHO for slow and poorly coordinated responses to previous 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 some of 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 the broader response.
Under Tedros, the WHO is attempting to tackle 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 said it will require staff to rotate among posts around the world, similar to a policy at UNICEF. Although some critics paint these changes as merely cosmetic, and have pointed out that Tedros has scrapped some reforms launched by his predecessor, others have applauded the reforms. “A whole number of a new kind of consultative structures between headquarters and the regions has been created,” global health expert Ilona Kickbusch said at a May 2020 CFR meeting. “There is much greater cooperation than there was in the past.”
Many experts maintain the importance of the agency, particularly in times such as the COVID-19 pandemic. “It plays an irreplaceable role in global outbreak response and, in the current crisis, it has largely served its purpose well,” write CFR’s Thomas J. Bollyky and Georgetown University’s Jeremy Konyndyk.
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 how the WHO has been at the center of pandemic politics.
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.
The WHO’s 2020–2021 budget [PDF] outlines its goals for the coming years.
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 2014 Ebola outbreak.
This CFR Backgrounder outlines the ongoing global effort to eradicate polio.
Mia Speier contributed to this report.