The following is a guest post by my colleague Miles Kahler, senior fellow for global governance at the Council on Foreign Relations and distinguished professor at American University’s School of International Service.
The World Health Organization (WHO) is a canary in the coal mine (no climate change analogy intended!) of global governance. Its sector (or regime complex, to use the scholarly term of art) has grown rapidly over the past two decades, as new actors—nonstate actors such as the Bill & Melinda Gates Foundation and nongovernmental organizations (NGOs), as well as national agencies, such as the U.S. Centers for Disease Control and Prevention—have entered the field, bringing large-scale resources with them. In this crowded field, the WHO faces the same challenge as other global multilaterals: defining its unique contribution among well-funded and energetic competitors. For the World Bank, competition lies largely with new multilateral development banks, such as the Asian Infrastructure Investment Bank (AIIB); the International Monetary Fund (IMF) confronts similar issues with regional financial mechanisms and private finance.
Like the other global multilaterals, however, the WHO possesses one asset that others cannot claim: legitimacy born of its nearly universal membership and close ties with member governments, including both the most powerful states in the system as well as the smallest and poorest. Its representative character gives its consensus statements both weight and publicity (consider the attention given to its recent advice on red and processed meats). On the other hand, the sources of its legitimacy are limited by a funding structure that has skewed toward two dominant governments (the United States and the United Kingdom) and the Gates Foundation. And even if its process legitimacy remains high, its outcome legitimacy—the WHO’s ability to produce the outcomes desired by its members and other stakeholders in an efficient and timely fashion—is in question.
The WHO’s performance during the latest outbreak of Ebola in West Africa produced a new round of questions regarding its effectiveness (and ultimately, its outcome legitimacy). Explanations given for its shortcomings during the epidemic differ, but its performance suggests that promoting the WHO as a central actor in emergency response, a role that would guarantee its place in the new global health order, will require significant changes in both structure and personnel. “Nimble” is rarely the first adjective used to describe multilateral organizations, and the WHO is no exception. Emergency response to epidemics will require a rethinking of its regionalized structure (perhaps the most widely held diagnosis of its poor performance in the face of Ebola) and its concentration of professional staff in the medical professions (when a different mix of skills may be required). A more realistic future might place the WHO as a central coordinating node in a larger network designed for emergency response, rather than aiming to become an actor that would have a direct field presence. Others—such as NGOs like Médecins Sans Frontières—are better equipped to carry out such interventions with greater speed and effectiveness. Whether the WHO can build the authority to exercise such a dominant role within a complex network is uncertain.
The debate over the WHO’s response to the Ebola outbreak misses strengths that the WHO could exploit, however: its relations with member governments and the trust that those members have in the organization. Outbreaks of infectious diseases parallel the growing number and intensity of wildfires in the American West. Firefighting budgets go up; more and more firefighters lose their lives (just as health workers died fighting Ebola); demands for more effective response increase as the effects of wildfires spread to rich neighborhoods. Although an immediate response is necessary on both political and humanitarian grounds, firefighting alone sidesteps the underlying cause of the wildfires: climate change and poor forest management over past decades.
In similar fashion, the global health sector concentrates on outbreaks of infectious disease without devoting adequate attention and resources to the underlying fragility in national public health systems, not only in poor countries, such as those in West Africa, but in middle-income countries as well. Leaving aside the effects of climate change on the likelihood of infectious disease epidemics, one absolutely predictable trend will render such outbreaks both more common and more deadly: urbanization. Throughout the developing world, populations are on the move from rural villages to urban agglomerations, concentrations that are often ill prepared for their arrival. The WHO could play a central and unique role in promoting best practices in public health systems, practices that could also be tailored to suit local circumstances and needs. Its close relations with member governments would make its advice more palatable, particularly if it is able to mobilize resources on a large scale to support construction of local and national public health capacity. Rather than a crisis manager like the IMF, the WHO would resemble, in one of its roles, the Organization for Economic Cooperation and Development (OECD), developing norms and practices that would speed the critical construction of public health infrastructure in a rapidly urbanizing South. Unfortunately, building such capacity is far less alluring to political leaders than fire-fighting (dealing with epidemics)—and less pressing politically.
Can the WHO successfully assume this role within global health? One prediction can be made with certainty: waiting for new organizational leadership to work miracles is a false hope. Discontent with the current director-general is unlikely to translate into a selection process that will produce a new style of leadership. Reforms in leadership selection have been pressed at other, more prominent multilaterals for years, with little change. Organizational reforms must be undertaken without the certainty that top leadership will provide the magic ingredient for success. Reforms will require concerted action by stakeholders and member states over the longer run. The WHO’s future depends on their willingness to devote attention and resources to reform, whatever the distractions of the next health crisis.